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[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]

      HEALING THE WOUNDS: EVALUATING MILITARY SEXUAL TRAUMA ISSUES

=======================================================================

                             JOINT HEARING

                               before the

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                                and the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 20, 2010

                               __________

                           Serial No. 111-79

                               __________

       Printed for the use of the Committee on Veterans' Affairs

                                  ______

                      U.S. GOVERNMENT PRINTING OFFICE
  57-023                   WASHINGTON : 2010
___________________________________________________________________________
For sale by the Superintendent of Documents, U.S. Government Printing Office, 
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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                                 ______

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                    JOHN J. HALL, New York, Chairman

DEBORAH L. HALVORSON, Illinois       DOUG LAMBORN, Colorado, Ranking
JOE DONNELLY, Indiana                JEFF MILLER, Florida
CIRO D. RODRIGUEZ, Texas             BRIAN P. BILBRAY, California
ANN KIRKPATRICK, Arizona

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               HENRY E. BROWN, Jr., South 
VIC SNYDER, Arkansas                 Carolina, Ranking
HARRY TEAGUE, New Mexico             CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas             JERRY MORAN, Kansas
JOE DONNELLY, Indiana                JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California           GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia               VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                               __________

                              May 20, 2010

                                                                   Page
Healing the Wounds: Evaluating Military Sexual Trauma Issues.....     1

                           OPENING STATEMENTS

Chairman John J. Hall, Chairman, Subcommittee on Disability 
  Assistance and Memorial Affairs................................     1
    Prepared statement of Chairman Hall..........................    23
Hon. Doug Lamborn, Ranking Republican Member, Subcommittee on 
  Disability Assistance and Memorial Affairs.....................     3
    Prepared statement of Congressman Lamborn....................    24
Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
  prepared statement of..........................................    25

                               WITNESSES

U.S. Department of Defense, Kaye Whitley, Ed.D., Director, Sexual 
  Assault Prevention and Response Office, Office of the Under 
  Secretary of Defense for Personnel and Readiness...............    17
    Prepared statement of Dr. Whitley............................    41
U.S. Department of Veterans Affairs:

  Bradley G. Mayes, Director, Compensation and Pension Service, 
    Veterans Benefits Administration.............................    18
  Susan McCutcheon, R.N., Ed.D., Director, Family Services, 
    Women's Mental Health and Military Sexual Trauma, Office of 
    Mental Health Services, Veterans Health Administration.......    20
      Prepared statement of Mr. Mayes and Dr. McCutcheon.........    47

                                 ______

Benedict, Helen, Professor of Journalism, Columbia University, 
  New York, NY, and Author, The Lonely Soldier: The Private War 
  of Women Serving in Iraq.......................................     6
    Prepared statement of Ms. Benedict...........................    27
Disabled American Veterans, Joy J. Ilem, Deputy National 
  Legislative Director...........................................    10
    Prepared statement of Ms. Ilem...............................    31
Iraq and Afghanistan Veterans of America, Sergeant Jennifer Hunt, 
  USAR, Project Coordinator......................................    12
    Prepared statement of Sergeant Hunt..........................    37
RAINN--Rape, Abuse, and Incest National Network, Scott Berkowitz, 
  President and Founder..........................................     8
    Prepared statement of Mr. Berkowitz..........................    28
Service Women's Action Network, Anuradha K. Bhagwati, Executive 
  Director.......................................................    14
    Prepared statement of Ms. Bhagwati...........................    39
Society for Women's Health Research, Phyllis Greenberger, 
  President and Chief Executive Officer..........................     4
    Prepared statement of Ms. Greenberger........................    25

                       SUBMISSIONS FOR THE RECORD

American Legion, Denise A. Williams, Assistant Director for 
  Health Policy, Veterans Affairs and Rehabilitation Commission, 
  statement......................................................    50
American Urological Association, Beth K. Kosiak, Ph.D., Associate 
  Executive Director, Health Policy, statement...................    52
American Veterans (AMVETS), Christina M. Roof, National Deputy 
  Legislative Director, statement................................    53
Brown, Hon. Henry E. Brown, Jr., Ranking Republican Member, 
  Subcommittee on Health, statement..............................    58

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:

  Hon. John J. Hall, Chairman, Subcommittee on Disability 
    Assistance and Memorial Affairs, and Michael H. Michaud, 
    Chairman, Subcommittee on Health, Committee on Veterans' 
    Affairs, to Phyllis Greenberger, President and Chief 
    Executive Officer, Society for Women's Health Research, 
    letter dated June 14, 2010, and Ms. Greenberger's response...    59
  Hon. John J. Hall, Chairman, Subcommittee on Disability 
    Assistance and Memorial Affairs, and Michael H. Michaud, 
    Chairman, Subcommittee on Health, Committee on Veterans' 
    Affairs, to Helen Benedict, Professor of Journalism, Columbia 
    University, NY, letter dated June 14, 2010, and Ms. 
    Benedict's responses.........................................    63
  Hon. John J. Hall, Chairman, Subcommittee on Disability 
    Assistance and Memorial Affairs, and Michael H. Michaud, 
    Chairman, Subcommittee on Health, Committee on Veterans' 
    Affairs, to Joy J. Ilem, Deputy National Legislative 
    Director, Disabled American Veterans, letter dated June 14, 
    2010, and Ms. Ilem's responses...............................    65
  Hon. John J. Hall, Chairman, and Doug Lamborn, Ranking 
    Republican Member, Subcommittee on Disability Assistance and 
    Memorial Affairs, and Michael H. Michaud, Chairman, and Henry 
    E. Brown, Jr., Ranking Republican Member, Subcommittee on 
    Health, Committee on Veterans' Affairs, to Kay Whitley, 
    Ed.D., Director, Sexual Assault Prevention and Response 
    Office, Office of the Under Secretary of Defense for 
    Personnel and Readiness, U.S. Department of Defense, letter 
    dated June 14, 2010, and DoD responses.......................    68
  Hon. John J. Hall, Chairman, and Doug Lamborn, Ranking 
    Republican Member, Subcommittee on Disability Assistance and 
    Memorial Affairs, and Michael H. Michaud, Chairman, and Henry 
    E. Brown, Jr., Ranking Republican Member, Subcommittee on 
    Health, Committee on Veterans' Affairs, to Susan McCutcheon, 
    R.N., Ed.D., Director, Family Services, Women's Mental Health 
    and Military Sexual Trauma, Office of Mental Health Services, 
    Veterans Health Administration, U.S. Department of Veterans 
    Affairs, letter dated June 14, 2010, and VA responses........    74
  Hon. John J. Hall, Chairman, Subcommittee on Disability 
    Assistance and Memorial Affairs, Committee on Veterans' 
    Affairs, to Bradley G. Mayes, Director, Compensation and 
    Pension Service, Veterans Benefits Administration, U.S. 
    Department of Veterans Affairs, letter dated June 23, 2010, 
    and VA responses.............................................    80

 
      HEALING THE WOUNDS: EVALUATING MILITARY SEXUAL TRAUMA ISSUES

                              ----------                              

                         THURSDAY, MAY 20, 2010

             U.S. House of Representatives,
            Committee on Veterans' Affairs,
        Subcommittee on Disability Assistance and  
                                  Memorial Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.
    The Subcommittees met, pursuant to notice, at 10:05 a.m., 
in Room 334, Cannon House Office Building, Hon. John Hall 
[Chairman of the Subcommittee on Disability Assistance and 
Memorial Affairs] presiding.
    Present from Subcommittee on Disability Assistance and 
Memorial Affairs: Representatives Hall, Donnelly, Rodriguez, 
Lamborn, and Miller.
    Present from Subcommittee on Health: Representatives 
Michaud, Snyder, and Perriello.

               OPENING STATEMENT OF CHAIRMAN HALL

    Mr. Hall. Good morning, ladies and gentlemen. Welcome to 
the House Committee on Veterans' Affairs Subcommittee on 
Disability Assistance and Memorial Affairs in a joint session 
with the Subcommittee on Health for a joint hearing on Healing 
the Wounds: Evaluating Military Sexual Trauma (MST) Issues.
    Would you all please rise and join me in the Pledge of 
Allegiance.
    [Pledge was taken.]
    Mr. Hall. Thank you.
    We will try to expedite this hearing because there is, at 
11:00 a.m., a mandatory break for the address to the Joint 
Session of Congress by the President of Mexico, President 
Calderon.
    I am grateful today to have the opportunity to conduct this 
hearing, Healing the Wounds: Evaluating Military Sexual Trauma 
Issues, with my colleagues, Ranking Member Lamborn; the Health 
Subcommittee Chair, Mr. Michaud; and Mr. Brown, the Ranking 
Member of the Health Subcommittee, and am especially 
enthusiastic to recognize the men and women veterans who are in 
this room today, and am looking forward to hearing about their 
experiences with MST.
    The purpose of this hearing today is to evaluate ways in 
which the Veterans Benefits Administration (VBA), the Veterans 
Health Administration (VHA), and the U.S. Department of Defense 
(DoD) can better address veterans who are impacted by military 
sexual trauma or MST and to identify and better prevent, treat, 
and properly compensate them.
    MST refers to sexual harassment and sexual assault that 
occurs in military settings, often in a setting where the 
victim lives and works, which means that the victims must 
continue to live and work closely with the perpetrators.
    MST can also disrupt the career goals of many victims as 
perpetrators are frequently peers or supervisors responsible 
for the decisions on work-related evaluations and promotions. 
This means the victims must choose between continuing their 
careers at the expense of frequent contact with their 
perpetrators or ending their careers in order to protect 
themselves.
    Many victims shared that when they do report an incident, 
they are not believed or they are encouraged to keep silent 
because of the need to preserve organizational cohesion.
    The National Center for Posttraumatic Stress Disorder 
(PTSD) of the U.S. Department of Veterans Affairs (VA) reports 
that in 1995, DoD conducted a large-scale study of sexual 
victimization among its active-duty population. This DoD study 
found that the rates of attempted or completed sexual assault 
were 6 percent for women and 1 percent for men.
    Another study found that rates of sexual assault and verbal 
sexual harassment were higher during wartime than peacetime in 
their sample study population. This suggests that the stress of 
war may be associated with increases in rates of sexual 
harassment and assault.
    The National Center for PTSD also reports that the rate of 
MST among the veteran population who use the VA health care 
system appears to be higher than that of the general military 
population.
    One study found that 23 percent of female users of the VA 
health care system report having experienced sexual assault 
while in the military.
    MST has been a concern among many veterans who have 
continually expressed frustration with the disability claims 
process, especially in trying to prove to the VA that the 
assault ever happened.
    For many women and men, when their disability claims for 
PTSD are related to MST and are denied, they suffer a secondary 
injury, resulting in an exacerbation of PTSD symptoms and, 
thus, they are less likely to file an appeal.
    We cannot allow these things to continue to happen to our 
Nation's veterans who have served so bravely and both VA and 
DoD need to ensure that the proper treatment is available.
    Veterans should be able to access treatment facilities and 
qualified staff with care and benefits delivered by employees 
who are properly trained to be sensitive to MST-related issues. 
These veterans need to be treated with the dignity and respect 
that they deserve.
    I look forward to hearing from our esteemed panels of 
witnesses today and now yield to Ranking Member Lamborn for his 
opening statement.
    [The prepared statement of Chairman Hall appears on p. 23.]

             OPENING STATEMENT OF HON. DOUG LAMBORN

    Mr. Lamborn. Thank you, Mr. Chairman.
    And I, too, welcome our witnesses to this important hearing 
to discuss matters concerning military sexual trauma. 
Occurrences of sexual assault with the ranks of our military 
are totally and completely unacceptable. It distresses me to 
think that anyone who volunteers to protect our Nation through 
service in the Armed Forces would ever have to contemplate much 
less experience being harmed by a fellow servicemember.
    But our military is a microcosm of society and crimes that 
occur in society unfortunately also occur in the military. So 
we must face reality and address the problems that arise.
    First, it should be made clear through training at every 
level and to every servicemember that sexual offenses will not 
be tolerated and that perpetrators will be punished to the 
fullest extent under the Uniform Code of Military Justice.
    Second, the military services should follow through and 
ensure that justice is rendered in cases involving sexual 
assault.
    I would also add that the military must thoroughly 
investigate and prosecute false accusers of sexual assault who 
unfortunately detract from the plight of those who really are 
victims of sexual assault.
    While it is important that we deliberate on the very 
serious topic of military sexual trauma, I want to also make 
very clear that this is not an indictment of our military as a 
whole. The vast majority of the men and women who volunteer for 
military service are honorable and patriotic individuals who 
courageously stand to defend our country and other countries 
from tyranny. They are some of our bravest citizens who abhor 
the type of individuals who would commit such a repugnant crime 
as sexual assault.
    As far as this topic pertains to VA benefits, I believe the 
Department has appropriate rules in place for adjudicating and 
rating sexual trauma cases, but I will be listening for ways 
that we can possibly improve on the existing system.
    I want to thank all of our witnesses for their 
participation and their testimony and I look forward to our 
discussion today.
    Mr. Chairman, I yield back. Thank you.
    [The prepared statement of Mr. Lamborn appears on p. 24.]
    Mr. Hall. Thank you, Mr. Lamborn.
    Mr. Michaud.
    Mr. Michaud. Thank you, Mr. Chairman.
    Due to the President of Mexico addressing the joint 
session, I would ask unanimous consent that my opening remarks 
be submitted for the record so that we can begin hearing from 
the panels.
    Mr. Hall. Without objection, so ordered.
    Mr. Michaud. Thank you.
    [The prepared statement of Chairman Michaud appears on p. 
25.]
    Mr. Hall. Other Members, would you agree to submit written 
opening statements so we can go to the witnesses? Thank you so 
much. So ordered.
    I would also like to recognize Megan Williams from the 
Disability Assistance and Memorial Affairs staff who is leaving 
to go to graduate school in Switzerland and to thank her for 
her work for the Subcommittee.
    The first panel who I will now invite to join us at the 
witness table is Phyllis Greenberger, Chief Executive Officer 
(CEO) and President of the Society for Women's Health Research, 
and Helen Benedict, Professor of Journalism at Columbia 
University, and Author of the book, The Lonely Soldier: The 
Private War of Women Serving in Iraq.
    Welcome, both of you, and your full written statements are 
entered in the record. You will have 5 minutes each to give 
oral testimony starting with Ms. Greenberger.
    You are now recognized.

    STATEMENTS OF PHYLLIS GREENBERGER, PRESIDENT AND CHIEF 
  EXECUTIVE OFFICER, SOCIETY FOR WOMEN'S HEALTH RESEARCH; AND 
 HELEN BENEDICT, PROFESSOR OF JOURNALISM, COLUMBIA UNIVERSITY, 
 NEW YORK, NY, AND AUTHOR, THE LONELY SOLDIER: THE PRIVATE WAR 
                    OF WOMEN SERVING IN IRAQ

                STATEMENT OF PHYLLIS GREENBERGER

    Ms. Greenberger. Thank you.
    Mr. Chairman and Members of the Subcommittees, I want to 
thank you for calling this joint hearing on such an important 
and timely topic.
    As said, I am Phyllis Greenberger, CEO of the Society for 
Women's Health Research, and we are a nonprofit patient 
advocacy organization dedicated to improving women's health 
through advocacy, education, and research of sex and gender 
differences.
    The Society focus is on sex and gender differences and 
research needs to be done to explore conditions that affect 
women differently, disproportionately, or exclusively and to 
identify those differences and understand the implications for 
diagnosis and treatment.
    The pressing issues that bring us here today are the risks 
and ramifications of military sexual trauma or MST. MST victims 
are disproportionately, as you know, and almost exclusively 
women.
    A 2008 VA study reported that 15 percent of military women 
in Iraq and Afghanistan experience sexual assault or harassment 
and 59 percent of those were at higher risk for mental health 
problems. This is just among those cases reported. Many more, 
possibly more than half of all MST cases go undocumented each 
year.
    The ramifications of MST for women persist long after the 
initial assault. While sexual assault in any setting is 
horrific, the combined insult of MST occurring while serving in 
a foreign setting, often in an active war zone, only 
exacerbates the effects.
    By VA estimates, over 70 percent of women in the military 
have been exposed to combat. Further, with most MST assaults 
being orchestrated by military personnel against military 
personnel, the environment of trust among those serving is 
broken and a chain of command that fails to protect from and 
respond to MST further degrades unit cohesion.
    Research in the area of MST and sexual assault has revealed 
some interesting sex-based differences. First, women are more 
likely than men to contract a sexually transmitted infection or 
STI. STIs are more difficult to treat in women and can have 
emotional and mental impacts over a woman's life span. Sexual 
assault can result in an unplanned pregnancy or, conversely, 
leave a woman unable to bear children in the future.
    The impacts of MST are not limited to reproduction. 
Infection with the human papillomavirus after a sexual assault 
can result in cancer decades later.
    Second, sexual assault is a common trigger for post-
traumatic stress disorders months and even years after the 
attack. Scientists are finding that women do not respond the 
same to some of the common medications prescribed for PTSD, 
often faring worse than men taking the same medication for the 
same diagnosis.
    Third, multiple traumas can increase the likelihood of 
developing PTSD and the combined impacts of working in a war 
zone, multiple deployments, MST, and for a disproportionate 
share of female military members exposure to early life trauma 
all raise the risk for an eventual PTSD diagnosis.
    Females in the military have twice the level of PTSD and 
depression as their male counterparts.
    Fourth, research suggests that the ultimate impact of a 
traumatic event on a woman may depend on hormone levels and can 
vary based on where she is in her menstrual cycle and whether 
or not she uses medications that alter hormone levels such as 
birth control.
    The role of cyclical hormonal variations, as well as 
studies finding that during pregnancy PTSD symptoms decrease, 
may offer insight into which women develop PTSD after MST and 
may further help discover more effective PTSD therapies for 
women, therapies that are responsive to sex-based hormonal 
differences.
    More research is critical for moving forward and 
determining targeted treatments for women and men.
    The VA in 2010 is in a unique position to better serve its 
female veterans at the same time becoming a leader in women's 
health and sex-based research. Changes in care can only come 
from sound research and investments in VA research often 
translate into new knowledge, methods, screenings, and 
treatment for women and men, military and civilian.
    The VA system faces staffing, organizational, and 
infrastructure challenges when updating to meet the needs of 
the growing female veteran population. Reports as recent as 
March 2010 still found deficiencies in the availability of 
resources for female veterans.
    From providing gender-specific care at all VA medical 
centers to including female subjects in the VA's health 
services research and development, the VA system with proper 
support and resources hopefully can transform what is needed 
today and what is needed for the future.
    The VA needs to optimize its interactions with female 
veterans by offering women the option to participate in 
research projects. The health information technology 
capabilities that link all VA medical centers and each 
veteran's medical and personnel charts offers unmatched 
capabilities for research.
    Further, increasing collaboration between the DoD and the 
VA would additionally offer an improved continuum of care as 
women transition from active duty to veteran issues. Clearly 
there is a need for more investments in the VA and sex-based 
research and we hope that these recommendations will be acted 
upon quickly.
    I encourage the VA and these Committees to consider the 
potential impact of appropriate research into women's health 
and the wide-reaching results that can improve sex-based 
research as well as mental and sexual health for all.
    I want to thank you again for this opportunity to present 
to the Subcommittees and I would be pleased to answer any 
questions.
    [The prepared statement of Ms. Greenberger appears on p. 
25.]
    Mr. Hall. Thank you, Ms. Greenberger.
    And I would now recognize Professor Benedict.

                  STATEMENT OF HELEN BENEDICT

    Ms. Benedict. Hello, Mr. Chairman. Thank you very much, 
Members of the Subcommittees, for honoring me with the chance 
to testify.
    For 30 years, I have been writing about sexual assault 
culminating in my book, The Lonely Soldier, about military 
sexual assault.
    First, I would like to commend the Caregivers and Veterans 
Act signed by President Obama just last month. It was an 
essential step toward helping female veterans. This Act 
addresses the horrendous problem of military sexual assault by 
requiring the VA to train mental health professionals to care 
for women with sexual trauma. This is progress. Yet, I am 
concerned that the training be done properly.
    For my book, I interviewed more than 40 female veterans of 
our current wars and studied many other surveys. Too often they 
told me that when they tried to report an assault, the military 
and the VA treated them as liars and malingerers. A woman who 
reports a sexual assault should never be treated as a criminal.
    They also told me that their sexual assault response 
coordinators assigned to help them by the military often 
treated them with such suspicion that they felt retraumatized 
and intimidated out of pursuing justice.
    Indeed, the usual approach to a report of sexual assault 
within the military is to investigate the victim, not the 
perpetrator, and to dismiss the case altogether if alcohol is 
involved.
    It is, therefore, essential that the counselors used by the 
military and the VA be trained in civilian rape crisis centers 
away from the military culture that habitually blames the 
victim and that is too often concerned with protecting the 
image of a platoon or commander by covering up wrongdoing.
    These counselors and, indeed, anyone within the military 
charged with investigating sexual assault should be trained to 
understand the causes, effects, and costs of sexual abuse to 
both the victim and society.
    Within the VA, reform is also needed. The process for 
evaluating disability caused by military sexual assault needs 
to be automatically upgraded and victims who were too 
intimidated to report an assault while on active duty should 
never be denied treatment once they come home as they so often 
are now.
    The VA needs to recognize the fact that some 90 percent of 
victims, according to the DoD, never report assaults within the 
military because its culture is so hostile to them.
    The VA must also recognize and address the fact that it can 
take years to recover from sexual assault.
    In light of the new Caregivers Act, I also want to alert 
this Committee to the finding that many of our troops were 
sexually or physically abused long before they enlisted.
    In two studies of Army and Marine recruits conducted in 
1996 and 2005 respectively, it was found that half the women 
and about one-sixth of the men reported having been sexually 
abused as children, while half of both said they were 
physically abused.
    This means that close to half our troops may be enlisting 
to escape violent homes. Thus, we need to provide counselors 
trained not only in military sexual assault but in childhood 
abuse and trauma. These counselors should be available to 
active-duty troops and veterans. They should be imbedded with 
the combat stress counseling teams already deployed.
    This is necessary not only to help troops cope with 
multiple traumas of childhood and military sexual assault, as 
well as combat trauma, but to help prevent further sexual 
violence. Psychologists have long known that an abused boy can 
grow into an abusive man.
    Finally, let us recognize that more effective than any 
rules or laws is the attitude of the commander on the ground. 
Studies have shown that commanders who treat their female 
soldiers with respect and insist that other soldiers do 
likewise reduce sexual persecution. Thus, we must reform the 
culture within officer academies which at the moment is rife 
with brutal hazing, abuse, and rape as the scandals at 
Tailhook, Aberdeen, and the Air Force Academy have too long 
demonstrated.
    This violence drums women out of the service and trains men 
to enact and condone rape and torture.
    All officer training schools for all military branches 
should teach their candidates to understand that rape is an act 
of anger, hatred, and power, not desire, and that sexual 
persecution destroys camaraderie and cohesion.
    Officers should learn to take pride in ensuring their 
troops are safe from disrespect and violence from their 
comrades just as they take pride in bringing them home safely 
from war.

    Thank you.
    [The prepared statement of Ms. Benedict appears on p. 27.]
    Mr. Hall. Thank you, Professor.
    And to both of our witnesses, thank you. Your complete 
written statements are a part of the record.
    Chairman Michaud and I spoke about the time situation 
before and if there is no objection from Members of the 
Subcommittees, we would like to submit our questions in writing 
and for the record and move on to the second panel so that we 
can try to hear as many witnesses as possible.
    Is there objection to that? Without hearing any, thank you 
to our witnesses on the first panel. And we will submit 
questions to you in writing and you are now excused.
    And we will move to our second panel, Scott Berkowitz, 
President and Founder of the RAINN, Rape, Abuse, Incest 
National Network; Joy J. Ilem, Deputy National Legislative 
Director of the Disabled American Veterans (DAV); Jennifer 
Hunt, Project Coordinator, Iraq and Afghanistan Veterans of 
America (IAVA); and Anuradha K. Bhagwati, Executive Director, 
the Service Women's Action Network (SWAN).
    Welcome, all of you, again. As you know, your full written 
statements are made a part of the record, so you each have 5 
minutes starting with Mr. Berkowitz.

 STATEMENTS OF SCOTT BERKOWITZ, PRESIDENT AND FOUNDER, RAINN--
 RAPE, ABUSE, AND INCEST NATIONAL NETWORK; JOY J. ILEM, DEPUTY 
  NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; 
  SERGEANT JENNIFER HUNT, USAR, PROJECT COORDINATOR, IRAQ AND 
  AFGHANISTAN VETERANS OF AMERICA; AND ANURADHA K. BHAGWATI, 
       EXECUTIVE DIRECTOR, SERVICE WOMEN'S ACTION NETWORK

                  STATEMENT OF SCOTT BERKOWITZ

    Mr. Berkowitz. Mr. Chairman, thank you for inviting me 
today.
    My name is Scott Berkowitz. I am the President of RAINN 
which is the Nation's largest anti-sexual violence 
organization. We run the National Sexual Assault Hotline, which 
is a partnership of about 1,100 local rape crisis centers 
across the country. We also run an online hotline and do public 
education.
    When I first testified to Congress on this issue about 6 
years ago, a DoD task force had just published an exhaustive 
study. Unfortunately, at the time, that was a fairly common 
occurrence and about a dozen commission reports that preceded 
it had had very little impact.
    But this report had a different ending. It helped lead DoD 
to step up its efforts and I think it has resulted in some 
tangible progress. That is certainly not to say that the 
problem has been solved--in fact, we are a long way from that, 
as reporting and prosecution rates remain too low and too few 
victims reach out for help. But, at last, we are headed in the 
right direction.
    To put the problem in some context: in one sense, the 
military is not at all unique. About 80 percent of all rape 
victims are under age 30 and so the problems faced by the 
military are very similar to those faced by large universities, 
as both have disproportionately young populations.
    Rape is the most violent and traumatic crime that a victim 
lives to remember. The long-term mental health effects can be 
devastating, leaving victims at higher risk for PTSD, 
depression, substance abuse, and many other issues. 
Embarrassment and shame are almost universal among victims.
    In the civilian world, these reactions help explain why 
victims are so reluctant to report their attack to police, or 
even to their own friends and family. While the civilian 
reporting rate is going up, still about six out of every 10 
victims do not report to police.
    Now, add to this mix that in the military, filing an 
unrestricted report, the kind that can actually lead to a 
prosecution, will mean that everyone on base knows. Add in the 
fear of being ostracized, and the impact it might have on your 
career, and it is clear why so many victims remain reluctant to 
report.
    Of course, there is no single, simple solution. But there 
are a few lessons from the civilian world. One is that much 
research has shown that victims who receive prompt care and 
crisis intervention return to full strength much more quickly 
and, very importantly, they are ultimately much more likely to 
report their attack to law enforcement and to follow through 
with prosecution.
    Of course, more reports to law enforcement means many more 
prosecutions and more prosecutions leads directly to fewer 
assaults. Rapists are serial criminals. We are talking about a 
relatively small group who are committing a large number of 
crimes. And so every time we can convince just one more victim 
to come forward, leading to just one more successful 
prosecution, we are potentially preventing dozens of rapes.
    So how do we get more victims to come forward? The 
guarantee of confidentiality is one big piece. I think DoD has 
made some good progress on this score, with the introduction of 
restricted reporting, which has already encouraged more than 
3,000 victims to come forward, about 15 percent of whom later 
decided to pursue prosecution.
    Still, the safety of a restricted report is incomplete. For 
example, DoD has determined that some State mandatory reporting 
laws for medical personnel in California, for example, 
supersede the protections victims enjoy under restricted 
reporting. And I think that is an issue that needs some 
Congressional study.
    Also, victims to date have not had the guarantee of 
privileged communications with military victim advocates, as is 
the case in most States, though I understand that DoD is in the 
process of implementing that change.
    Another vital part of the solution is to make use of the 
extensive civilian services available, such as the National 
Sexual Assault Hotline and local rape crisis centers. These 
services offer the confidentiality that victims desire and 
deserve while still advancing the military's goal of 
encouraging more victims to report their attack to law 
enforcement. They are by no means a replacement for military-
based services, but they are, I think, a bridge to such 
services.
    While time constraints limit the recommendations I can 
share today, I do want to touch on issues of leadership and 
prevention.
    Without sincere buy-in from leadership, evidence that zero 
tolerance means zero tolerance, any prevention efforts will 
absolutely fail. And so DoD leadership needs to continue to 
find ways to ensure that the commanders who take this seriously 
are recognized and rewarded, and that recalcitrant commanders 
are identified and reformed by training when possible, by the 
threat of poor performance ratings when necessary.
    In this process, we need to ensure that commanders do not 
fear that an increase in rape reports on their base will be 
held against them. In fact, such an increase will most likely 
be a sign that what they are doing is working, that a higher 
percentage of victims are coming forward and reporting, which 
is good news. And so that should be reflected in their 
evaluations.
    I would like to add just one quick point about internal DoD 
management. I have heard reports that DoD is considering moving 
its sexual assault programs to be under its domestic violence 
programs. While that might seem efficient on paper, I think 
doing so has the potential to de-emphasize sexual violence and 
seriously hamper prevention and victim service efforts.
    Now that we have started to make real progress fighting 
sexual violence in the military, I think it would really be the 
wrong time to backtrack by conflating two very different 
issues.

    Thank you.
    [The prepared statement of Mr. Berkowitz appears on p. 28.]
    Mr. Hall. Thank you, Mr. Berkowitz.
    Ms. Ilem, you are now recognized.

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Thank you.
    Chairman Hall, Chairman Michaud, and Members of the 
Subcommittees, thank you for inviting DAV to testify at this 
joint hearing focused on improving treatment and disability 
compensation policies for veterans with conditions related to 
military sexual trauma or MST.
    This hearing takes on a topic that is very personal and 
sensitive to many servicemembers, veterans, and the respective 
departments that are responsible for the safety and well-being 
of their members.
    In most cases, MST profoundly changes the lives of those 
affected. For these reasons, all VHA patients are screened for 
history of sexual trauma and treatment is available for MST-
related conditions at VA medical facilities.
    We acknowledge VHA for providing clear and concise 
information about MST on its Web site and in its written 
materials and, most importantly, information on how and where 
veterans can get help.
    It is clearly noted in these materials that service-
connection is not required for eligibility for this treatment. 
However, if a sexual assault is not officially reported during 
military service, establishing service-connection for a related 
condition can be extremely difficult.
    An area of special concern for DAV relates to collaboration 
between DoD's Sexual Assault Prevention and Response Office or 
SAPRO and VHA. Current DoD policy allows servicemembers to file 
restricted or unrestricted reports of sexual assault.
    In the case of a restricted report, the servicemember opts 
to forgo an investigation but does have the right to have an 
official record of the incident created, receive a forensic 
medical examination, and access to medical and mental health 
treatment as necessary.
    Obviously these records are critical to substantiating a 
disability compensation claim through VBA. For this reason, DAV 
is concerned that VBA policy manuals appear to lack any 
reference to SAPRO in obtaining documentation from restricted 
DoD MST reports.
    In reviewing VA's testimony from this morning, it appears 
that their collaboration with SAPRO has been focused more on 
the VHA side of the house and related more to health care 
providers and treatment issues.
    It is my understanding that VBA and SAPRO officials have 
spoken about the issue, but we are not aware that an official 
policy, process, or Memorandum of Understanding is currently in 
place or being developed to secure restricted MST reports.
    Once a claim is filed, VBA has a number of standard sources 
that it examines for records to support these types of claims. 
It does not appear, however, that these reports are archived in 
the individual's military personnel or medical records for 
purposes of confidentiality. And we have been unable to confirm 
if VBA unofficially searches for restricted reports as an 
alternative evidence source for information to substantiate a 
veteran's claim.
    We also have questions with respect to where the forensic 
sexual assault examination form and subsequent mental health 
treatment records related to a restricted MST report are 
archived by each military branch and for how long.
    We ask that VBA provide the Subcommittees with any 
information it has in reference to materials for claims 
developers and raters that reflect collaboration with SAPRO and 
guidance on how to obtain supporting MST documentation from 
each military service branch including any differences in 
records retention, security, or disposal policies.
    Establishing service-connection for related MST is 
important including financial stability, increased access to VA 
health care, but most meaningful for most MST survivors, being 
rated service-connected for disabilities attributed to the 
trauma represents validation that the event occurred, expresses 
gratitude for their service to their country, and recognizes 
the tribulations they endured while serving.
    One of DAV's central purposes is to aid veterans in 
obtaining fair and equitable compensation for their service-
related disability. In this particular area, however, many of 
our national service officers report they are deeply frustrated 
at the routine occurrence of MST claims being denied for lack 
of evidentiary documentation.
    It seems to DAV that the agencies responsible for 
preventing, monitoring, and reporting on MST and providing 
related benefits and health care services should work in 
concert to lower the burden associated with the claims process 
for these veterans and ensure that both servicemembers and 
veterans are fully assisted by the government in securing the 
benefits they deserve and have earned.
    If VBA does not have a policy in place to secure restricted 
MST reports and related medical records, we believe this issue 
can be resolved internally by the respective agencies through 
an MOU or some other mechanism if they simply agree to work 
together to address the issue.
    Again, we appreciate the Subcommittees' interest in this 
area and efforts to identify ways to improve access to benefits 
and health services related to military sexual trauma. And we 
thank you for the opportunity to testify.
    [The prepared statement of Ms. Ilem appears on p. 31.]
    Mr. Hall. Thank you, Ms. Ilem.
    Ms. Hunt, you are recognized now for 5 minutes.

           STATEMENT OF SERGEANT JENNIFER HUNT, USAR

    Sergeant Hunt. Good morning.
    Chairmen, Ranking Members, and Members of the 
Subcommittees, on behalf of IAVA's 180,000 members and 
supporters, I would like to thank you for giving us the 
opportunity to testify.
    Healing the Wounds: Evaluating Military Sexual Trauma is a 
critically important topic. The issue of sexual assault has 
deeply affected IAVA membership, the military and veterans 
community as a whole, and me personally.
    I would like to point out that my testimony today is on 
behalf of IAVA and does not reflect the views and opinions of 
the United States Army.
    My name is Jennifer Hunt and I am a Sergeant in the Army 
Reserves. I have served two tours in Iraq and Afghanistan. In 
Iraq, I earned a Purple Heart when my Humvee was struck by a 
roadside bomb causing shrapnel injuries to my face, arms, and 
back.
    I also serve as my unit's designated victim advocate as 
part of the Army's Sexual Assault Prevention and Response 
Program. While I am proud to serve in this position, I 
sincerely hope that my duties as a victim advocate are ones I 
will never have to perform, but I am ready should the need 
arise to provide any support necessary to the victim. I know 
firsthand how frustrating that the healing process can be 
having experienced sexual assault as a civilian myself.
    Unfortunately, the reality is that servicemembers have been 
coping with significant and under-reported sexual assault and 
harassment in the military for years. Even in a war zone, 
troops cannot escape the threat of sexual assault. While sexual 
assault disproportionately affects female troops, large numbers 
of male servicemembers have been victimized as well.
    While the number of reported assaults are alarming, they 
grossly underestimate the severity of the issue. According to 
the military, only 20 percent of all unwanted sexual contact is 
reported to a military authority. We must find ways to 
encourage more victims to report sexual assault and harassment. 
More importantly, we must make it so that there are no more 
victims of military sexual trauma.
    Despite the urgency of this issue, it has taken decades for 
the military and the VA to finally respond. In recent years, 
both Departments have taken commendable steps. The military has 
introduced a restricted reporting option that can encourage 
more victims to seek care. It also completed its long-awaited 
review of the issue by the Defense Department Task Force on 
Sexual Assault in the Military Services.
    For its part, the VA began universally screening all 
veterans seeking care at the VA for MST in 1999 and every VA 
facility has a designated MST coordinator who serves as a point 
person for these issues. The VA provides free treatment to any 
veteran experiencing health conditions related to MST. However, 
as is the case with other VA health care, not all veterans have 
access to the care that they deserve.
    These steps are an improvement over the years of inaction, 
but more must be done. Victims deserve the very best treatment 
and support that we can provide.
    In the interest of time, I would like to concentrate on our 
top recommendations for how the Subcommittees can best address 
this important issue. You can also find our recommendations in 
our written testimony that was submitted to the Subcommittees 
and our IAVA issue report on women warriors available at our 
Web site.
    First, the VA must do a better job of advertising its MST 
programs. According to one IAVA member, she did not know until 
3 years after returning from a deployment that the VA provided 
sexual trauma counseling. In her words, it is well hid and not 
talked about at the VA.
    Even the U.S. Government Accountability Office (GAO) had 
problems locating information about the VA's MST program. 
According to the GAO, the VA's Web site did not provide a 
complete list of facilities that have MST-related treatment 
programs.
    IAVA believes that no victim should have to chase after 
their own care.
    Second, the VA must expand availability of its specialized 
sexual trauma treatment in inpatient settings. Less than 10 
percent of all VA medical centers offer inpatient mental health 
treatment for veterans that have experienced MST or other 
traumas. This is simply unacceptable.
    IAVA recommends that every Veterans Integrated Service 
Network (VISN) should offer at least one inpatient setting 
specializing in care for MST victims.
    Finally, the VA must ensure that these victims have access 
to preferred treatment settings and providers. Victims should 
not have to settle for mixed-gender treatment options because 
there are no facilities with separate programs for males and 
females in their area.
    According to the GAO, only nine of 153 medical centers 
nationally have residential treatment programs specifically for 
women suffering from mental health injuries.
    This problem is also evident in outpatient treatment 
programs. According to another IAVA member being treated for 
MST-related conditions, it is difficult to go to appointments 
when you have a full-time job and there are not enough VA 
counselors to care for all of us returning veterans on 
consistent basis.
    These recommendations are urgent and IAVA encourages you to 
work with the rest of your colleagues in Congress to help make 
them happen. Sexual assault is a violation of military values, 
values that I hold dear. It undermines the professionalism, the 
morale, the unit cohesion, and the effectiveness of our men and 
women in uniform.
    Sexual assault is also a crime, a crime that has gone on 
for far too long with too little done to stop it. These victims 
need justice. They need our support and they need the proper 
care for their trauma.
    I am here today on behalf of them all to issue you a call 
to service in their support. Again, I thank you for the time 
that you have given me to testify in front of this Committee 
today and I look forward to any questions that you might have.
    [The prepared statement of Sergeant Hunt appears on p. 37.]
    Mr. Hall. Thank you, Ms. Hunt, and thank you for your 
service to our country and to our veterans.
    Ms. Bhagwati, you are now recognized.

               STATEMENT OF ANURADHA K. BHAGWATI

    Ms. Bhagwati. Good morning, Mr. Chairman and Members of the 
Subcommittees. My name is Anuradha Bhagwati and I am a former 
Marine Corps Captain and Executive Director of Servicewomen's 
Action Network or SWAN.
    SWAN's policy work this year focuses largely on reforming 
DoD and VA's sexual assault and harassment policies and 
educating the public about the epidemic known as MST.
    SWAN's testimony is based on the collective input of over 
120 MST survivors, MST crisis intervention works and VA health 
providers. My own experience filing an equal opportunity 
investigation for sexual harassment and discrimination in the 
Marine Corps, and experiences with both VHA and VBA corroborate 
the input of my colleagues and fellow veterans below.
    Unlike the civilian world, MST survivors do not have the 
option of quitting their jobs. They are often stuck working 
with, nearby, or under the supervision of their perpetrators. 
There is simply no guarantee that the chain of command will 
support survivors if they come forward.
    Commanders have consistently ignored equal opportunity and 
sexual assault policies in order to maintain their personnel at 
full capacity. Additionally, commanders have very little 
incentive to prosecute perpetrators as documented incidents in 
their units reflect poorly on their leadership performance and 
reputations.
    MST survivors who report an incident are likely to face 
isolation, retribution, or accusations of lying, 
irresponsibility, or impropriety. There is no guarantee of 
anonymity from the chain of command or victims' advocates and 
survivors are likely to face the horror of retribution from 
perpetrators and the anguish of being a target of public 
ridicule, scorn, and further harassment in their respective 
units.
    We cannot honestly expect people to come forward to report 
and it is irresponsible for us or for DoD to suggest that 
survivors do so without guaranteeing their protection first. 
DoD's failure to protect our servicemembers ought to be the 
subject for a separate set of hearings as there is far too much 
to say here.
    Suffice it to say that without third-party civilian 
oversight of sexual assault and harassment cases, survivors 
will continue to be punished, taunted, isolated, or intimidated 
by their commands for speaking out and perpetrators will in 
most cases go unpunished.
    MST survivors universally describe the horrors of using VA 
medical centers nationwide. Triggers of one's assault or 
harassment are everywhere from the prospect of running into 
your perpetrator, to being surrounded by male patients who 
routinely engage in sexual harassment of female patients, to 
being improperly treated by staff members who have no knowledge 
about the unique experience of sexual trauma in a military 
setting.
    One survivor said to SWAN, I do not want to be fending off 
advances when I am raw from dealing with my issues in therapy.
    Survivors universally say that if they had health 
insurance, they would definitely use private health care 
instead of the VA.
    Many veterans are ignored, isolated, or misunderstood at VA 
facilities because their PTSD is not combat related. The 
veterans community still primarily considers PTSD to be a 
combat-related condition to the great detriment of MST 
survivors.
    Survivors who have used the VA routinely say they are fed 
up with being given endless prescription medication. One Iraq 
veteran described the experience of her MST treatment as 
nothing but pills and pep talks. Many survivors wish they had 
access to yoga, massage therapy, acupuncture, and gender-
specific MST support groups.
    I strongly recommend that the Committee give MST survivors 
the option of fee-based care for all treatment, not just MST 
treatment. At the same time, VHA cannot be let off the hook. VA 
medical centers ought to have separate facilities for women 
patients generally and easy, safe, and direct access to MST 
treatment areas for both male and female MST survivors.
    With respect to MST residential treatment programs, it 
appears that most MST patients and even many VA providers do 
not know that these programs even exist. Among patients who 
have attended, several have experienced sexual harassment by 
staff or fellow patients.
    Also, several programs are collocated with mixed-gender 
veterans' programs in which MST patients are not guaranteed 
privacy or safety from other patients of the opposite sex. VA 
needs to invest in separate facilities for MST programs and 
guarantee the safety and welfare of all participants.
    Filing for disability compensation for MST is universally 
considered a traumatic, agonizing, and cruel experience. Many 
survivors describe the process of rewriting one's personal 
narrative for a VA claim and being rejected by VBA as just as 
traumatic as the original rape or harassment.
    VA claims officers nationwide have proven themselves 
entirely inept when dealing with MST claims. Claims are 
routinely rejected even with sufficient evidence of a stressor 
and a corroborating diagnosis from a VA health provider. Many 
survivors' claims are rejected outright because of VBA's lack 
of knowledge about sexual violence in general.
    This Committee needs to understand that until it is safe to 
report sexual assault or harassment in the military, the 
majority of incidents will not be reported. This bears directly 
on the unrealistic and biased nature of VA claims against 
veterans living with MST. VA must make up for DoD's failure to 
protect its own by awarding just compensation to survivors.
    Another equal protection issue features prominently in MST 
issues. The do not ask, do not tell policy has allowed 
perpetrators to routinely abuse gays and lesbians who would 
otherwise report harassment or assault. Society has yet to 
measure the mental health impact of this insidious policy on 
our Nation's lesbian, gay, bisexual, and transgender veterans. 
We must guarantee access to quality health care for all 
veterans regardless of sexual orientation or gender identity.
    I must add a special note for our older MST survivors, our 
mothers, fathers, and grandparents who suffered at the hands of 
fellow servicemen decades ago. Much of their trauma continues 
to be unrecognized by VA or society.
    One Vietnam era veteran who described MST to us told us 
please help me feel validated before I die. Please honor and 
validate her service and her life by fixing this broken system 
now.

    Thank you.
    [The prepared statement of Ms. Bhagwati appears on p. 39.]
    Mr. Hall. Thank you, Captain, for your testimony and for 
your service to our country and to our veterans.
    We will, as with the prior panel, submit questions to you. 
If you would be so kind as to answer them in writing, and you 
are excused with our heartfelt thanks for your testimony, which 
we will be working seriously to address. So this panel is 
excused.
    And we would like to call our third panel including Kaye 
Whitley, the Director for Sexual Assault Prevention and 
Response Office (SAPRO), the Office of the Under Secretary for 
Personnel and Readiness, U.S. Department of Defense, 
accompanied by Clarence Johnson, Acting Deputy Under Secretary 
for Plans, Office of the Under Secretary for Personnel and 
Readiness, DoD; Bradley G. Mayes, Director of Compensation and 
Pension Service, Veterans Benefits; Susan McCutcheon, R.N. and 
Ed.D., Director of Family Health and Women's Mental Health and 
Military Sexual Trauma Services, Veterans Health 
Administration, U.S. Department of VA, accompanied by Rachel 
Kimerling, Ph.D., Director, Monitoring Division of the National 
Military Sexual Trauma Support Team of the Veterans Health 
Administration at the VA; Patty Hayes, Ph.D., Chief Consultant, 
Women Veterans Health Strategic Health Care Group of the 
Veterans Health Administration, U.S. Department of Veterans 
Affairs.
    Welcome, all of you, and your complete statements are made 
a part of the record.
    Dr. Whitley, you are now recognized for 5 minutes.

  STATEMENTS OF KAYE WHITLEY, ED.D., DIRECTOR, SEXUAL ASSAULT 
 PREVENTION AND RESPONSE OFFICE, OFFICE OF THE UNDER SECRETARY 
  OF DEFENSE FOR PERSONNEL AND READINESS, U.S. DEPARTMENT OF 
 DEFENSE; ACCOMPANIED BY CLARENCE JOHNSON, ACTING DEPUTY UNDER 
 SECRETARY OF DEFENSE FOR PLANS, OFFICE OF THE UNDER SECRETARY 
  OF DEFENSE FOR PERSONNEL AND READINESS, U.S. DEPARTMENT OF 
 DEFENSE; BRADLEY G. MAYES, DIRECTOR, COMPENSATION AND PENSION 
 SERVICE, VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF 
VETERANS AFFAIRS; AND SUSAN MCCUTCHEON, R.N., ED.D., DIRECTOR, 
  FAMILY SERVICES, WOMEN'S MENTAL HEALTH AND MILITARY SEXUAL 
   TRAUMA, OFFICE OF MENTAL HEALTH SERVICES, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
 ACCOMPANIED BY RACHEL KIMERLING, PH.D., DIRECTOR, MONITORING 
    DIVISION, NATIONAL MILITARY SEXUAL TRAUMA SUPPORT TEAM, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
   AFFAIRS; AND PATTY HAYES, PH.D., CHIEF CONSULTANT, WOMEN 
 VETERANS HEALTH STRATEGIC HEALTH CARE GROUP, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

                STATEMENT OF KAYE WHITLEY, ED.D.

    Ms. Whitley. Thank you.
    Chairman Michaud and Chairman Hall, Ranking Members Brown 
and Lamborn, and Members of the Subcommittees, thank you for 
inviting me today to discuss the progress the Department of 
Defense has made in recent years on caring for victims of 
sexual assault.
    The reason for our commitment is clear. Sexual assault 
levies a tremendous human toll, disrupts lives, and destroys 
the human spirit. In the military, it destroys unit cohesion 
and affects military readiness.
    And as I say at each hearing, we always try to keep in mind 
that behind all of the statistics that you hear, there is 
always an individual, a victim whose life has changed forever.
    I would like to start by mentioning a few issues to ensure 
that my role is clear. The term military sexual trauma was 
created by Congress for the Department of Veterans Affairs to 
address the physical and mental problems stemming from both 
sexual assault and sexual harassment.
    The office I represent is tasked with policy related to the 
crime of sexual assault. Our policy was signed just in 2005. So 
while all reports of sexual assault are of great concern to us, 
we are especially focused on incidents that have occurred after 
2005 so that we can identify any necessary changes for our 
policy.
    In my written testimony, I provided a detailed account of 
our program and our collaboration with civilian and Federal 
partners. And given the scope of the issues faced by your two 
Subcommittees, I want to take this opportunity to highlight our 
collaboration with the Department of Veterans Affairs.
    One of the key areas of collaboration relates to 
documentation. In 2007, we contacted the staff of the Veterans 
Benefits Administration to brief them on our victim preference 
reporting form known as DD-2910. This is the form 
servicemembers use to indicate if they would like to file an 
unrestricted report, which leads to commander notification and 
can initiate an investigation or a servicemember may use this 
form to indicate a preference to file a confidential report 
which allows them access to care without an investigation and 
command notification.
    Based on our discussions with the VBA, servicemembers can 
now use this form as evidence of reporting of sexual assault. 
This is another reason we work tirelessly to reduce the stigma 
of reporting. We want victims to come forward and report so 
that they can get the care as well as have documentation they 
may need later.
    While treatment for sexual assault in a VA facility does 
not require this document, disability evaluations require some 
kind of evidence in the military record. Our form is not 
typically part of the military record provided to the VA for 
disability evaluation. However, it can be submitted by victims 
as part of their paperwork for a disability evaluation process.
    Just as the DD-214 is the main basis for proof of military 
service, we would like the DD-2910 to be universally accepted 
of proof that a victim made a report of sexual assault.
    There is more our two Departments can do together to assist 
victims of sexual assault, but we need assistance in removing 
at least one barrier to collaboration and that is State 
mandatory reporting laws.
    Servicemembers in the State of California do not have the 
option of restricted reporting. We would welcome the 
opportunity to discuss this further with your staff and the VA. 
This is a challenge we need help in resolving.
    I would like to share one last thought. Each day, our 
servicemembers dedicate their lives to protecting our country 
and they deserve no less than the very best care and support in 
return. And that is why it is so important that we work 
together to make this program the best it can be.
    Again, thank you for your time and opportunity to testify 
today.
    [The prepared statement of Dr. Whitley appears on p. 41.]
    Mr. Hall. Thank you, Dr. Whitley.
    Mr. Mayes, you are now recognized.

                 STATEMENT OF BRADLEY G. MAYES

    Mr. Mayes. Chairman Hall, Chairman Michaud, Members of the 
Subcommittees, thank you for providing me the opportunity to 
speak today about how the Department of Veterans Affairs 
assists veterans who have been subjected to military sexual 
trauma while serving their Nation in uniform.
    Dr. Susan McCutcheon, who is sitting to my left, will also 
provide brief oral remarks on this subject. We are accompanied 
by Dr. Rachel Kimerling, Director of the Monitoring Division of 
the National Military Sexual Trauma Support Team in the 
Veterans Health Administration, and Dr. Patty Hayes, Chief 
Consultant for the Women Veterans Health Strategic Health Care 
Group.
    In both civilian and military settings, women and men can 
experience a range of unwanted sexual behaviors. Within the VA, 
these sorts of experiences are described as military sexual 
trauma, the overarching term used to refer to experiences of 
sexual assault or repeated threatening acts of sexual 
harassment.
    It is important to remember that MST is an experience, not 
a diagnosis or a mental health condition in and of itself. 
Given the range of distressing sexually-related experiences and 
crimes that veterans report, it is not surprising that there 
are a wide range of emotional reactions that veterans have in 
response to these events.
    Among users of VA health care, medical record data indicate 
that diagnoses of post-traumatic stress disorder, depression, 
and other mood disorders, psychotic disorders, and substance 
use disorders are most frequently associated with MST.
    Fortunately, people can recover from experiences of trauma 
and VA has services to help veterans do this. Dr. McCutcheon 
will discuss these services in greater detail in her remarks.
    Additionally, VA provides compensation payments for 
service-connected disabilities that are related to MST while 
serving in the military. As previously stated, MST may result 
in a number of disabling physical and mental conditions, but 
with respect to benefit claims most often manifest itself as 
PTSD.
    In order to better assist those veterans with PTSD claims 
based on military sexual trauma, VA promulgated special 
regulations at 38 CFR Section 3.304(f)(4) in 2002. This rule 
change emphasized that if a PTSD claim is based on in-service 
personal assault which includes military sexual trauma, 
evidence from sources other than a veteran's service, 
treatment, and personnel records may corroborate the in-service 
traumatic event.
    The change effectively lowered the evidentiary burden for 
veterans of either sex to prove their PTSD claim based on 
military sexual trauma. This change was made in recognition of 
the fact that oftentimes there is little or no evidence 
specially describing an MST encounter or encounters in the 
military.
    Therefore, we accept markers or indicators that support the 
veteran's contentions. Such evidence may include but is not 
limited to records from law enforcement authorities, rape 
crisis centers, mental health counseling centers, hospitals or 
physicians, pregnancy tests or tests for sexually transmitted 
diseases, and statements from family members, roommates, fellow 
servicemembers, or clergy.
    In addition, evidence of behavior changes following the 
claimed assault constitutes another source of relevant 
evidence. Examples of such behavior changes include but are not 
limited to a request for a transfer to another military duty 
assignment, deterioration in work performance, substance abuse, 
episodes of depression, panic attacks, or anxiety without an 
identifiable cause, or unexplained economic or social behavior 
changes.
    The regulation prohibits the denial of claims for service-
connection for PTSD based on in-service personal assault 
without first advising the veteran that information from 
sources other than the veteran's service records or evidence of 
behavior changes may constitute credible evidence of the 
stressor and allowing the veteran an opportunity to furnish 
this type of evidence or advise VA of potential sources of such 
evidence.
    The regulation also provides that VA may submit any 
evidence it receives to an appropriate medical or mental health 
professional for an opinion as to whether it indicates that a 
personal assault may have occurred.
    VBA field personnel who adjudicate PTSD claims based on MST 
were provided with detailed information on proper claims 
processing methods in a training letter issued in November 
2005. Additionally, all VBA Regional Offices have a woman 
veterans' coordinator who is well versed in MST issues and can 
provide assistance to veterans as necessary.
    These procedural steps taken by VA assure that veterans 
filing claims for their PTSD based on military sexual trauma 
will receive fair and thorough consideration of their claims.
    We recognize the damage that MST can inflict on its victims 
and we have developed policies in response that do make it 
easier to establish entitlement to benefits based on disability 
as a result of MST.
    I believe that there is room for us to make improvements, 
but we have taken steps.
    Mr. Chairman, thank you again for the opportunity to appear 
before you today. And at this time, I will turn to my colleague 
from the Veterans Health Administration who can elaborate on 
their efforts to assist veterans suffering from MST-related 
conditions.
    Mr. Hall. Dr. McCutcheon?

           STATEMENT OF SUSAN MCCUTCHEON, R.N., ED.D.

    Dr. McCutcheon. Good morning.
    Chairman Hall, Chairman Michaud, Ranking Members Lamborn, 
Brown, and Members of the Subcommittees, thank you for the 
opportunity to appear to discuss VA's work in identifying and 
treating veterans for conditions related to military sexual 
trauma or MST.
    Addressing the needs of survivors of sexual assault and 
harassment in the military is a priority for the VA. It is a 
tragic fact that many veterans suffered sexual trauma while 
serving on active military duty.
    Some are still struggling with fear, anxiety, shame, or 
profound anger as a result of these experiences. A number of 
individuals have never discussed their experiences or their 
feelings with anyone and they are understandably reluctant to 
talk about them now.
    MST includes any sexual activity where someone is involved 
against his or her will. He or she may have been pressured into 
sexual activities, may have been unable to consent to sexual 
activities, or may have been physically forced into sexual 
activities.
    Other experiences that fall into the category of MST 
include repeated, unsolicited verbal or physical conduct of a 
sexual nature that is threatening in character.
    If these horrific experiences occurred while an individual 
was on active duty or active duty for training, they are 
considered to be MST.
    It is important to remember that MST is an experience, not 
a diagnosis or a mental health condition in and of itself. 
Among users of VA health care, medical record data indicate 
that diagnoses of post-traumatic stress disorder, depression 
and other mood disorders, psychotic disorders, and substance 
use disorders are most frequently associated with MST.
    Even after severely distressing experiences, there is no 
one way that everyone will respond. For some veterans, 
experiences of MST may continue to affect their mental and 
physical health even many years later.
    Fortunately, people can recover from experiences of trauma 
and VA has services to help veterans do this. All veterans seen 
at a VA facility are asked two questions, one to assess sexual 
harassment and the other to assess sexual assault that occurred 
during their military service.
    Veterans who respond yes to either question are asked if 
they are interested in learning about MST-related services that 
are available. Not every veteran who responds yes needs or is 
necessarily interested in treatment.
    The VA MST screening rates only reveal how many men and 
women that seek VA health care report MST, not the actual 
incidence of sexual trauma among those serving in the military.
    VA data indicates that approximately one in five women and 
one in a hundred men seen in VHA respond yes when screened for 
military sexual trauma.
    Although rates of MST are higher among women, because of 
the disproportionate ratio of men to women in the military, 
there are actually only slightly fewer men seen in VA who have 
experienced MST than women.
    Since 1992, VA has been developing programs to monitor MST 
screening and treatment, providing staff with training on MST-
related issues, and engaging in outreach to veterans who have 
experienced MST.
    VA established a national level MST support team in fiscal 
year 2007 to achieve these objectives and promote best 
practices in care.
    Currently all veterans seen in VA are screened for MST. 
Every VA facility has a designated MST coordinator and has 
providers knowledgeable about treatment for MST. And VA offers 
both inpatient, residential, and outpatient services as needed.
    VA also collaborates with others including the Department 
of Defense Sexual Assault Prevention and Response Office or 
SAPRO to discuss treatment approaches for individual veterans 
and servicemembers.
    At the local level, many VA facilities have established 
partnerships with the local military installations to provide 
additional support and to improve outreach and awareness of 
MST.
    Thank you again for the opportunity to appear. We are now 
prepared to answer any questions you may have.
    [The prepared statement of Mr. Mayes and Dr. McCutcheon 
appears on p. 47.]
    Mr. Hall. Thank you, Ms. McCutcheon.
    Unfortunately, we will have to have you answer those in 
writing because the Joint Session is convening across the 
street.
    Mr. Michaud, you are now recognized.
    Mr. Michaud. Thank you, Mr. Chairman.
    And I, too, want to thank the three panels for your 
testimony this morning. It has been very enlightening. I 
appreciate your coming forward.
    And I want to thank the Chairman as well.
    Unfortunately, because the President of Mexico is here, we 
are not able to ask questions today, but we will be submitting 
for the record several questions for the witnesses. My question 
will be more for DoD since that is where the problem usually 
starts, before veterans end up in the VA system. I am very 
curious about what have been some of the repercussions of what 
the predators have done, whether all they have received is a 
slap on the wrist or whether they have been honorably 
discharged or lose their retirement or another punishment.
    I want to thank all of you for coming today and look 
forward to your response to our questions in writing. And thank 
you for your services to those who have served. And thank you 
to the audience as well, for those who decided to come here 
today. Thank you for your service.
    This is a very serious issue and I know the Chairman and I 
will be taking it very seriously and be looking forward to your 
input as we move forward with legislation to address this 
serious problem. Once again, thank you.
    And I yield back, Mr. Chairman.
    Mr. Hall. Thank you, Chairman Michaud.
    Thank you again to our third panel and all of our panels 
today. I regret that we have to have this hasty process. And 
please do not think that it means that we do not care as deeply 
about this issue as you do.
    I want to acknowledge that we are submitting a statement 
for the record from Denise Williams, the Assistant Director of 
the Veterans Affairs and Rehabilitation Commission of the 
American Legion, and a statement by Dr. Beth Kosiak of the 
American Urological Association for the record of this hearing 
as well all Members having 5 days to revise and extend their 
remarks.
    And we will submit questions for you and look forward to 
receiving your answers in writing.
    So, on behalf of the Subcommittees, thank you for your 
insight and your recommendations.
    And this hearing stands adjourned.
    [Whereupon, at 11:08 a.m., the Subcommittees were 
adjourned.]

                            A P P E N D I X

                              ----------                              

          Prepared Statement of Hon. John J. Hall, Chairman, 
       Subcomittee on Disability Assistance and Memorial Affairs

    Good Morning Ladies and Gentleman:

    Would everyone please rise for the Pledge of Allegiance? Flags are 
located at the front and back of the room.
    I am grateful for the opportunity to be here today for a joint 
hearing entitled, Healing the Wounds: Evaluating Military Sexual Trauma 
Issues, with my colleagues, Health Subcommittee Chairman Michaud, and 
our Ranking Members, Mr. Lamborn and Mr. Brown. But, I am particularly 
enthusiastic to recognize the men and women veterans who are in this 
room today and to hear about their experiences with the Department of 
Veterans Affairs and DoD as it relates to Military Sexual Trauma Issues 
(MST).
    The purpose of this hearing today is to evaluate ways in which the 
Veterans Benefits Administration (VBA), Veterans Health Administration 
(VHA), and the Department of Defense (DoD) can better address the needs 
of veterans impacted by Military Sexual Trauma (MST) and identify ways 
to better prevent, treat and properly compensate them.
    MST refers to sexual harassment and sexual assault that occurs in 
military settings. MST often occurs in a setting where the victim lives 
and works, which means that the victims must continue to live and work 
closely with their perpetrators. MST can also disrupt the career goals 
of many of its victims, as perpetrators are frequently peers or 
supervisors responsible for the decisions on work-related evaluations 
and promotions. This means that victims must choose between continuing 
their military careers at the expense of frequent contact with their 
perpetrators or ending their careers in order to protect themselves. 
Many victims share that when they do report the incident, they are not 
believed or are encouraged to keep silent because of the need to 
preserve organizational cohesion.
    The National Center for PTSD of the Department of Veterans Affairs 
(VA) reports that in 1995, the Department of Defense (DoD) conducted a 
large scale study of sexual victimization among its active duty 
population. This DoD study found that the rates of attempted or 
completed sexual assault were 6 percent for women and 1 percent for 
men. Another study found that rates of sexual assault and verbal sexual 
harassment were higher during wartime than peacetime in their sample 
study population. This suggests that the stress of war may be 
associated with increases in rates of sexual harassment and assault. 
The National Center for PTSD also reports that the rates of MST among 
the veteran population who use the VA health care system appear to be 
even higher than that of the general military population. One study 
found that 23 percent of female users of the VA health care system 
reported having experienced sexual assault while in the military.
    MST has been a concern among many veterans who have continually 
expressed frustration with the disability claims process, especially in 
trying to prove to the VA that the actual assault ever happened. For 
many women and men, when their disability claims for PTSD related to 
MST are denied, they suffer a secondary injury, which results in an 
exacerbation of PTSD symptoms. Thus, they are less likely to file an 
appeal.
    There also has been frustration with the lack of appropriate health 
care providers to treat veterans who have experience working with MST.
    We cannot allow this to happen to this Nation's veterans who have 
served her. VA and DoD need to ensure that the proper treatment is 
available. Veterans should be able to have access to treatment 
facilities and qualified staff with care and benefits delivered by 
employees who are properly trained to be sensitive to MST related 
issues. These veterans need to be treated with the dignity and respect 
that they deserve.
    I look forward to hearing from the esteemed panels of witnesses 
assembled today as we attempt to heal the wounds of these veterans and 
get them the proper treatment and benefits without unnecessary delay.

                                 
  Prepared Statement of Hon. Doug Lamborn, Ranking Republican Member, 
       Subcommittee on Disability Assistance and Memorial Affairs

    Thank you Mr. Chairman,

    I welcome our witnesses to this important hearing to discuss 
matters concerning military sexual trauma.
    Occurrences of sexual assault within the ranks of our military are 
completely unacceptable.
    It saddens me to think that anyone who volunteers to protect our 
Nation through service in the armed forces would ever have to 
contemplate being harmed by a fellow servicemember.
    But our military is a microcosm of society--and crimes that occur 
in society unfortunately also occur in the military--so we must face 
reality and address the problems that arise.
    First, it should be made clear through training at every level and 
to every servicemember that sexual offenses will not be tolerated and 
that perpetrators will be punished to the fullest extent under the 
Uniform Code of Military Justice.
    Second, the military services should follow through and ensure that 
justice is rendered in cases involving sexual assault.
    And I would also add that the military must thoroughly investigate 
and prosecute false accusers of sexual assault who work to the 
detriment of those individuals who really are victims of sexual 
assault.
    While it is important that we deliberate on the very serious topic 
of military sexual trauma, I want to also make very clear that this is 
not an indictment of our military as a whole.
    There are those with anti-military views who would try to use 
incidences involving sexual assault to depict our entire military as a 
bunch of violent misogynists.
    Doing so would be a vulgar smear against the heroes this committee 
serves.
    I'm sure the families of the young men who died in Afghanistan this 
past week during the attack on Bagram (bah-GRAHM') Air Field would find 
such a generalization offensive, and I share their perspective.
    The vast majority of the men and women who volunteer for military 
service are honorable and patriotic individuals who courageously stand 
to defend our country and other countries from tyranny.
    They are some of our bravest citizens who abhor bullies and the 
type of individuals who would commit such a repugnant crime as sexual 
assault.
    As far as this topic pertains to VA benefits, I believe the 
Department has the proper rules in place for adjudicating and rating 
sexual trauma cases.
    Title 38 United States Code section 1154 provides VA the authority 
to give proper consideration to the time, place and circumstances, of 
service when determining eligibility to compensation.
    This means that VA must consider non-specific, but corroborating 
pieces of evidence when considering claims based on sexual assault.
    As some of our witnesses point out--this does not always occur and 
VA should address this shortcoming through training to ensure proper 
consideration is afforded to every claim.
    I appreciate the DAV's point that VA should be able to access the 
restricted DoD records documenting reports of sexual trauma.
    I look forward to learning whether such a policy is in place or 
being established to secure such records.
    I want to thank all of our witnesses for their participation and 
their testimony, and I look forward to our discussion today.
    Mr. Chairman, I yield back.

                                 
            Prepared Statement of Hon. Michael H. Michaud, 
                    Chairman Subcommittee on Health

    Good morning. I would like to thank everyone for attending today's 
hearing on military sexual trauma.
    I am happy to join my colleagues, DAMA Subcommittee Chairman Hall 
and our Ranking Members Mr. Brown and Mr. Lamborn, in holding this 
joint hearing.
    Servicemembers who experience military sexual trauma and are brave 
enough to speak out about their experiences are often marginalized and 
for many, it means the end of their military career while their 
offenders often times remain unscathed. We must do better by the women 
and men who experience military sexual trauma.
    Last May, the House Committee on Veterans' Affairs held a 
roundtable discussion with women veterans representing veteran service 
organizations and their auxiliary organizations. During the roundtable 
discussion, military sexual trauma was a commonly cited concern and the 
participants expressed their frustration with the shortage of 
appropriate health care providers to treat veterans with military 
sexual trauma.
    I am proud to say that just last month, S. 1963, the Caregivers and 
Veterans Omnibus Health Services Act, was enacted as Public Law 111-
163. This landmark legislation included important provisions from H.R. 
1211, the Women Veterans Health Care Improvement Act, which was 
introduced by Ms. Stephanie Herseth Sandlin. Among the key provisions, 
VA would be required to provide training and certification for VA 
mental health care providers on caring for veterans suffering from 
sexual trauma and PTSD.
    As we build a VA for the 21st century, we must ensure that it 
embraces the growing and unique needs of our women veterans. I am 
pleased to join my colleagues in the DAMA Subcommittee to explore ways 
that we can better support veterans with military sexual trauma.
    I look forward to hearing the testimonies of our witnesses today.

                                 
    Prepared Statement of Phyllis Greenberger, President and Chief 
         Executive Officer, Society for Women's Health Research

    Mr. Chairman and Members of the Committees:

    I would like to begin by thanking you for calling this joint 
hearing on Military Sexual Trauma. I appreciate the opportunity to 
address both committees on this important and timely topic. I am 
Phyllis Greenberger, the President and CEO of the Society for Women's 
Health Research. SWHR is a non-profit patient advocacy organization 
dedicated to improving women's health through advocacy, education, and 
research of sex and gender differences.
    SWHR's focus since 1995 has been to clearly demonstrate that sex 
and gender differences exist, and research needs to be done to explore 
conditions that affect women differently, disproportionately, or 
exclusively--to identify these differences and to understand the 
implications for diagnosis and treatment.
    Research into this area comes at a time of great need within the 
Department of Veterans Affairs (VA), as today over 10 percent of the 
military presence in Iraq and Afghanistan is female. As the Department 
of Defense (DoD) continues to work to integrate an ever-larger female 
presence among active military, the VA sees a comparable rise in 
numbers of female veterans seeking care after their time of service, 
for both service-related and non-service-related care. Women are the 
fastest growing sector of VA patients. Over 450,000 women have enrolled 
with VA medical centers for care, and that number is projected to rise 
by 30 percent in the next 5 years.
    The pressing issues that bring us here today are the risks and 
ramifications of military sexual trauma, or MST.
    The statistics on risk are well known. MST victims are 
disproportionately and almost exclusively women. A 2008 VA study 
reported that 15 percent of military women in Iraq and Afghanistan 
experienced sexual assault or harassment, and 59 percent of those were 
at higher risk for mental health problems. This is just among those 
cases reported. Many more, possibly more than half, of all MST cases go 
undocumented each year.
    The ramifications of MST for women persist long after the initial 
assault. While sexual assault in any setting is horrific, the combined 
insult of MST occurring while serving in a foreign setting, often in an 
active war zone, only exacerbates the effects. By VA estimates, over 70 
percent of women in the military have been exposed to combat. Further, 
with most MST assaults being orchestrated by military personnel against 
military personnel, the environment of trust among those serving is 
broken, and a chain of command that fails to protect from and respond 
to MST further degrades unit cohesion.
    Research in the area of MST and sexual assault has revealed some 
interesting sex-based differences:
    First, women are more likely then men to contract a sexually 
transmitted infection, or STI. STIs are often more difficult to treat 
in women and can have emotional and mental impacts over a woman's 
lifespan. Sexual assault can result in an unplanned pregnancy or 
conversely leave a woman unable to bear children in the future. The 
impacts of MST are not limited to reproduction. Infection with HPV 
after a sexual assault can result in cancer decades later in life. 
Scientists studying HIV in women found the virus enters and infects the 
cells of the vaginal wall in a way different from how the virus is 
introduced into male cells.
    Second, sexual assault is a common trigger for post-traumatic 
stress disorder, months and even years after the attack. Scientists are 
finding that women do not respond the same to some of the common 
medications prescribed for PTSD, often fairing worse than men taking 
the same medication for the same diagnosis.
    Third, multiple traumas can increase the likelihood of developing 
PTSD, and the combined impacts of working in a war zone, multiple 
deployments, MST, and for a disproportionate share of female military 
members, exposure to early life trauma, all raise the risk for an 
eventual PTSD diagnosis. Females in the military have twice the levels 
of PTSD and depression as their male counterparts.
    Fourth, research suggests that the ultimate impact of a traumatic 
event on a woman may depend on hormone levels, and can vary based on 
where she is in her menstrual cycle and whether or not she uses 
medications that alter hormone levels, such as birth control. The role 
of cyclical hormonal variations, as well as studies finding that during 
pregnancy PTSD symptoms decrease, may offer insight into which women 
develop PTSD after MST, and may further help discover more effective 
PTSD therapies for women--therapies that are responsive to sex-based 
hormonal differences. More research is critical for moving forward and 
determining targeted treatments for women and men.
    The VA in 2010 is in a unique position to better serve its female 
veterans, at the same time becoming a leader in women's health and sex 
based research. Changes in care can only come from sound research, and 
investments in VA research often translate into new knowledge, methods, 
screenings, and treatments for women and men, military and civilian. As 
discussed before this Committee 1 year ago today, the VA system faces 
staffing, organizational, and infrastructure challenges when updating 
to meet the needs of the growing female veteran population. The VA 
still has a long way to go. Reports as recent as March 2010 are still 
finding deficiencies in the availability of resources for female 
veterans. From providing gender-specific care at all VA Medical Centers 
to including female subjects in the VA's Health Services Research and 
Development, the VA with proper support and resources can transform to 
what is needed today and what is needed for the future.
    SWHR would like to encourage the VA to optimize its interactions 
with female veterans, by offering women the option to participate in 
research projects--receiving a high quality of care while gathering 
information to help other female veterans. The health information 
technology capabilities that link all VA medical centers, and each 
veteran's medical and personnel charts, offers unmatched capabilities 
for research. The VA is to be praised for its electronic medical 
records system, and encouraged to utilize it to its full capacity. 
Further, increasing collaboration between the DoD and the VA would 
additionally offer an improved continuum of care, as women transition 
from active duty to veteran status. A victim of MST during her time of 
service needs streamlined care after she returns, as well as a VA 
system that is equipped to meet her sex and gender specific needs. For 
the female veterans who choose to seek care outside of the VA setting, 
private clinicians also depend on the research and clinical guidance 
only the VA can provide--capturing the nuances specific to military 
service, combat exposure, and MST faced by female veterans. The VA 
alone can pull together these details and offer direction to help all 
clinicians make sound choices for their female veteran patients, and 
all women.
    While I hope that I have made clear the need for more investments 
in the VA and sex based research, SWHR further hopes that these 
recommendations will be acted upon quickly. I encourage the VA and 
these committees to consider the potential impact of appropriate 
research into women's health and the wide reaching results that could 
improve sex-based research as well as mental and sexual health for all. 
The VA today has a unique opportunity to champion the cause of women's 
health research--not only for veterans, but for all patients.
    I want to again thank you for this opportunity to present to the 
Committee. I would be pleased to answer any questions.

                                 
     Prepared Statement of Helen Benedict, Professor of Journalism,
Columbia University, New York, NY, and Author, The Lonely Soldier: The 
                  Private War of Women Serving in Iraq

    Thank you for holding this hearing and honoring me with an 
invitation to testify.
    First, I would like to commend the Caregivers and Veterans Omnibus 
Health Services Act, signed by President Obama just this month, as an 
essential step toward helping female veterans and the families of 
wounded warriors.
    This Act takes an important step toward addressing the horrendous 
problem of military sexual assault by requiring the VA to train mental 
health professionals to care for women with sexual trauma.
    This is progress. Yet I am concerned that the training be done 
properly. For my book, The Lonely Soldier, I interviewed more than 40 
female veterans of our current wars. Too often they told me that when 
they tried to report an assault, the military and VA treated them as 
liars and malingerers.
    They also told me that their Sexual Assault Response Coordinators, 
assigned to them by the military, often treated them with such 
suspicion that they felt re-traumatized and intimidated out of pursuing 
justice. Indeed, the usual approach to a report of sexual assault 
within the military is to investigate the victim, not the perpetrator, 
and to dismiss the case altogether if alcohol is involved. Counselors 
have told me of seeing case after case where a battered and abused 
victim has been told, ``It's your word against his.''
    It is therefore essential that the counselors used by the military 
and the VA be trained in civilian rape crisis centers, away from a 
military culture that habitually blames the victim, and that is too 
often concerned with protecting the image of a platoon or commander by 
covering up wrongdoing. These counselors, and indeed anyone within the 
military charged with investigating sexual assault, should be trained 
to understand the causes, effects and costs of sexual abuse to both the 
victim and to society.
    Within the VA, reform is also needed. The process for evaluating 
disability caused by military sexual assault needs to be automatically 
upgraded. And victims who were too intimidated to report an assault 
while on active duty should never be denied treatment once they come 
home, as they so often are now. The VA needs to recognize the fact that 
some 90 percent of victims never report assaults within the military 
because its culture is so hostile to them. The VA must also recognize 
and address the fact that it can take years to recover from sexual 
assault, and that untreated trauma caused by sexual assault can result 
in depression, homelessness, self-destructive behavior, and suicide. No 
victim of military sexual assault should ever be denied benefits and 
help.
    In the light of the new Caregiver's Act, I also want to alert this 
committee to the finding that many of our troops were sexually or 
physically abused long before they enlisted.
    In two studies of army and marine recruits, conducted in 1996 and 
2005 respectively, it was found that half the women and about one-sixth 
of the men reported having been sexually abused as children, while half 
of both said they were physically abused.i
---------------------------------------------------------------------------
    \i\  L.N. Rosen and L. Martin, ``The measurement of childhood 
trauma among male and female soldiers in the U.S. Army,'' Military 
Medicine 161 (1996): 6, 342-345.
---------------------------------------------------------------------------
    The picture may have shifted lately with the recession driving more 
people into the military. Nonetheless, it looks as if close to half our 
troops are enlisting to escape violent homes.
    Thus we need to provide counselors trained not only in military 
sexual assault but in childhood abuse and trauma. These counselors 
should be available to active duty troops and veterans. They should 
embedded with the combat stress counseling teams already deployed.
    This is necessary not only to help troops cope with trauma, but to 
help prevent further sexual violence. Psychologists have long known 
that an abused boy can grow into an abusive man.ii
---------------------------------------------------------------------------
    \ii\  A. Nicholas Groth and H. Jean Birnbaum, Men Who Rape: The 
Psychology of the Offender (New York: Plenum Press, 1979).
      Jessica Wolfe, Kiban Turner, et al. ``Gender and Trauma as 
Predictors of Military Attrition: A Study of Marine Corps Recruits,'' 
Military Medicine 170(2005): 12, 1037.
---------------------------------------------------------------------------
    I emphasize this because too often the focus when addressing 
military sexual trauma is on women alone, ignoring the fact that men 
cause the problem, and that they, too, are sexually assaulted in the 
military.iii
---------------------------------------------------------------------------
    \iii\  According to a 2008 DoD report, some 27 percent of men in 
the reserves and national guard reported sexual trauma in the military. 
Department of Veterans Affairs, ``Military Sexual Trauma Among The 
Reserve Components Of The Armed Forces.''
---------------------------------------------------------------------------
    Violence is endemic to the military, and little can be done about 
that. But our troops are not supposed to be enacting this violence on 
one another. The last chapter of my book offers a list of suggestions 
for how to at least decrease military sexual violence. These are too 
numerous to list here, but I include some essential examples:

      Promote more women. With more recognition and authority, 
women will help to increase respect for female troops, and respect is 
the single most important weapon against harassment and rape.
      Distribute women more evenly. No women should serve alone 
with all-male platoons, as they sometimes do now, for it leaves them 
isolated and vulnerable to assault.
      Strike the ``Don't Ask, Don't Tell'' policy, which 
encourages persecution of men and women, gay or not.
      Reject recruits with records of domestic or sexual 
violence.
      Hold commanders accountable for assaults that occur in 
their units.
      And reward commanders and officers who pursue justice in 
cases of sexual assault.

    Finally, let us recognize that more effective than any rules or 
laws is the attitude of the commander on the ground. Studies have shown 
that commanders who treat their female soldiers with respect and insist 
that other soldiers do likewise significantly reduce sexual 
persecution.iv Thus we must reform the culture within 
officer academies, which at the moment is rife with brutal hazing, 
abuse, and rape, as the Tailhook, Aberdeen and Air Force Academy 
scandals have too often demonstrated.v This violence drums 
women out of the service and trains men to enact and condone rape and 
torture.
---------------------------------------------------------------------------
    \iv\  Sadler, et al. ``Factors Associated With Women's Risk of Rape 
in the Military Environment.'' (2003).
    \v\  ``Conduct Unbecoming'' by Cathy Booth Thomas, Time magazine, 
http://www.time.com/time/magazine/article/0,9171,428045,00.html.
    ``Military Sex Scandals From Tailhook to the Present: The Cure Can 
be Worse Than the Disease.'' By Kingsley R. Browne, Duke Journal of 
Gender Law & Policy, Volume 14:749 2007.
---------------------------------------------------------------------------
    All officer training schools for all military branches should teach 
their candidates to understand that rape is an act of anger, hatred, 
and power, not desire, and that sexual persecution destroys camaraderie 
and cohesion. Officers should learn to take pride in ensuring their 
troops are safe from disrespect and violence from their comrades, just 
as they take pride in bringing them home safely from war.

    Thank you.

                                 
     Prepared Statement of Scott Berkowitz, President and Founder, 
            RAINN--Rape, Abuse, and Incest National Network

    Good afternoon Chairmen Hall and Michaud, Ranking Members Lamborn 
and Brown, and distinguished Members of the Subcommittee on Disability 
Assistance and Memorial Affairs and the Subcommittee on Health. Thank 
you for the invitation to participate in today's hearing on military 
sexual trauma.
    My name is Scott Berkowitz and I am the founder and president of 
the Rape, Abuse & Incest National Network, or RAINN. RAINN, the 
Nation's largest anti-sexual violence organization, founded and 
operates the National Sexual Assault Hotline. The hotline is a 
partnership of 1,100 local rape crisis centers across the U.S., and has 
provided free, confidential counseling and support to more than 1.4 
million victims of sexual violence. We also run the National Sexual 
Assault Online Hotline, a web-based service that provides help to the 
generation of victims who are more comfortable typing than talking. 
RAINN also educates more than 120 million Americans each year about 
sexual assault prevention, prosecution and recovery.
    When I first testified to Congress on this issue, about 6 years 
ago, a DoD task force had just published an exhaustive study of the 
problem. Unfortunately, that wasn't an uncommon occurrence, as one of 
your colleagues vividly demonstrated when she lined up the reports from 
more than a dozen DoD task forces from the preceding two decades.
    Most of these task force reports had shown an understanding of the 
issue and proposed a number of reforms that would help address the 
problem. And all had been shelved soon afterwards, left undisturbed 
until the next commission was created and its staff started searching 
through the archives. While there were many smart, committed people 
within the military services who had worked for years to address the 
sexual assault problem, they lacked the institutional support, 
leadership commitment and resources to fix it.
    So while we were hopeful about the 2004 report, optimistic that 
this time would be different, the odds weren't on our side.
    The good news is: it looks like this time we may have a chance to 
beat the odds. That's not to say that the problem has been solved--in 
fact, we're a long, long way from that. But over the last 6 years, I 
have been pleased to observe that the Pentagon, led by SAPRO and the 
services, has taken the problem seriously and made some tangible 
progress.
The Problem in Context
    To understand the remaining challenges, we need to understand the 
problem in context. In one sense, the military isn't unique. 
Nationally, about 80 percent of all rape victims are under age 30. So 
the problems faced by the military are, in fact, quite similar to those 
faced by large colleges and universities. It is unfortunate, but, for 
the moment, true:
    Where there are many thousands of young people, there are surely a 
large number of rape victims. While there's no question military 
culture is unique--and presents unusual challenges to providing 
services for victims--that unique culture itself is certainly not the 
cause of the sexual assault problem.
    Much research, and our own experience serving rape victims, has 
shown us that they respond to their crime quite differently from 
victims of other crimes. Mental health professionals widely agree that 
rape is the most traumatic violent crime. The FBI ranks it as the 
second most violent crime, trailing only murder. In other words, it is 
the most violent and traumatic crime a victim lives to remember.
    And remembering comes naturally to victims of rape. Sexual assault 
can be devastating to victims, causing post-traumatic stress disorder, 
depression, eating disorders, sleeplessness and other mental health 
issues. Victims, particularly those who do not get help, are many times 
more likely to become addicted to drugs or alcohol or even to attempt 
suicide. Embarrassment and shame are near universal.
    In the civilian world, these reactions help explain why most rape 
victims are so reluctant to report their attack to police, or even to 
their own friends and family.
    While the percentage of civilian rates that are reported to police 
has increased by one-third in the last 15 years, the majority of 
victims--about six out of 10--still do not report.
    Now, add to this mix the fact that in the military, filing an 
unrestricted report, the kind of report that could lead to prosecution, 
will mean that everyone knows--and I do mean everyone, from your 
superiors to your bunkmates. And add in the fear of retaliation or 
ostracization, and the fear of the impact it might have on your career, 
which only serve to amplify the resistance to reporting. If most 
civilian victims are unwilling to report even without all those extra 
concerns, without the fear of sabotaging their career, it's going to 
remain difficult to get military victims to report.
Lessons from the Civilian World
    Of course, there's no single, simple solution to this problem. But 
we can start by applying a few key lessons we have learned in the 
civilian world.

      Number One: Victims who receive prompt, quality, 
confidential crisis intervention return to full strength more quickly, 
and are ultimately more likely to report their attack to law 
enforcement officials.
      Number Two: More reports to law enforcement leads to more 
prosecutions.
      Three: The result of more prosecutions is fewer sexual 
assaults. Increasingly, the data are clear: Rapists are serial 
criminals. There aren't an enormous number of rapists in our midst, 
inside the military or out. There are a relatively small number of 
rapists, collectively committing an enormous number of rapes. So every 
time we can convince just one more victim to come forward, leading to a 
successful prosecution and serious punishment, we may be preventing 
dozens of rapes down the line.
Victim Services & Confidentiality
    So how do we get more victims to come forward for help? Former 
Congresswoman Tillie Fowler, who chaired the investigation into the Air 
Force Academy, told me at the time that every victim they interviewed--
every single one--told the panel that they would never access help 
without the guarantee of confidentiality. This response matches RAINN's 
own research. In the course of developing the National Sexual Assault 
Online Hotline, the consistent message from victims was that the 
service must guarantee confidentiality, even anonymity. This led us to 
go to great lengths to create a safe technology that victims would 
trust.
    DoD has made some progress on this score, with the introduction of 
restricted reporting, which allows the victim to access services 
without an official report that engages the chain of command. Those we 
have spoken to within the services believe restricted reporting has 
been a qualified success. It has encouraged more than 3,000 victims to 
come forward and get help, about 15 percent of whom later decided to 
make an unrestricted report and pursue prosecution.
    Still, the safety of a restricted report is incomplete. Victims' 
communications with military victim advocates do not enjoy the rape 
crisis counselor privilege that is found in most state laws, leaving 
open the possibility that the victims advocate could later be forced to 
testify against the victim in court. That possibility is sure to 
discourage some victims from coming forward, which is the reason most 
states have passed some kind of rape crisis privilege law. I understand 
that DoD recently submitted this change to OMS for the president's 
approval, and I hope the administration acts swiftly to approve and 
implement the change.
    At the same time, DoD has determined that mandatory reporting laws 
for medical personnel, in California for example, supersede the 
protections victims enjoy under restricted reporting. The result is 
that victims in those states are forced to forego the medical care they 
urgently need--even treatment for major injuries, and testing for STls 
and HIV--unless they're willing to sacrifice the confidentiality 
promised by restricted reporting. If they do choose medical care--and, 
by the way, RAINN strongly recommends that all victims receive a 
medical exam as soon as possible following the crime--they may trigger 
a chain of events that ends in civilian law enforcement informing 
military law enforcement, resulting in the very chain-of-command report 
that restricted reporting was meant to avoid. We encourage Congress to 
investigate this issue and determine whether a federal solution is 
feasible.
    Fortunately, there are steps Congress can take to address these 
remaining barriers to victims receiving confidential help.
    Another part of the solution is to make good use of the extensive 
civilian services offered by the National Sexual Assault Hotline, the 
Online Hotline, and local rape treatment centers across the Nation. By 
functioning outside the chain-of-command, civilian services can offer 
the confidentiality and security victims desire and deserve, while 
simultaneously advancing the military's goal of encouraging more 
victims to report their attack to military law enforcement. They are by 
no means a replacement for military-based victim services. Rather, they 
are a bridge to such services, and an alternative for those victims who 
are unwilling to ask for help through official channels.
Leadership & Prevention
    While time constraints limit the recommendations I can share 
regarding prevention programs, I do want to mention the most important 
kind of prevention program. The most effective prevention--the one 
without which all other efforts are sure to fail--is discipline and 
leadership.
    To be effective, any prevention program must be able to credibly 
communicate leadership's personal commitment to zero tolerance of 
sexual assault and to the punishment of all who commit such crimes. Our 
soldiers are smart enough to know the difference between orders they 
need to obey and lectures they must endure and then are free to ignore.
    Without sincere buy-in from leadership, without real evidence that 
zero tolerance means zero tolerance, any prevention efforts will fail.
    As you would expect in an institution as large as the U.S. 
military, there are plenty of examples of leadership both good and bad. 
DoD leadership needs to continue to find ways to ensure that the 
commanders who take this seriously are recognized and rewarded.
    And recalcitrant commanders need to be identified and reformed, by 
training when possible; by the threat of poor performance ratings and 
limited upward mobility when necessary.
    If DoD leadership makes it clear that sexual assault is a force 
readiness issue that deserves the time and effort of those in command, 
that attitude will filter down through the commanding officer of a unit 
to the soldiers he or she oversees. Commanders who are vocal about and 
maintain a focus on their commitment to preventing sexual assault will 
positively influence their units.
    This point is highlighted in the DTFSAMS report, which noted that 
commanders themselves identified this as an issue that needed to be 
addressed. According to the report, interviews with commanders 
concluded that they ``need better training on sexual assault prevention 
and response.''
    As continued improvements in prevention programs and victim 
services show results, we all have a duty to ensure that the public and 
the media understand that a higher number of reported rapes in the 
military is almost certainly a sign of success, not of increased danger 
in the ranks. Such an increase is most likely evidence that we're 
successfully increasing the percentage of victims who pursue justice. 
That's also an important point when assessing commander performance. 
Commanders must not fear that an increase in rape reports on their base 
will be held against them. Rather, they should be accountable for 
instituting an effective program that encourages increased reporting.
    I'd like to add one point about process. There have been news 
reports recently about DoD's plan to restructure its personnel office. 
I defer to DoD as to whether that's a good idea. But I am concerned 
about one idea I've heard floating around--the idea of putting DoD's 
sexual assault programs under its domestic violence programs. While on 
the surface it sounds plausible to combine sexual assault with domestic 
violence, or even sexual harassment, the effect of that could be to set 
back efforts to prevent sexual assault and help victims.
    Sexual assault is a very different issue than domestic violence. 
The relationship between attacker and victim is different; the factors 
that influence the decision to get help or report to law enforcement 
are different; the entire nature and cause of the two crimes are 
different. Equating the two issues might seem like an efficiency move 
on paper, but doing so has the potential to de-emphasize sexual 
violence and hamper prevention and victim-service efforts. Now that 
we've started to make progress, it's the wrong time to backtrack like 
that.
    In summary, the problem of sexual assault is not unique to the 
military, nor is the reluctance of victims to report the crime. To 
successfully combat this problem, we must continue to improve services 
on base. We must provide Servicemembers with alternative, confidential 
services off base. We must implement effective prevention and education 
programs on every base. And all this must be backed up by personal 
commitment by base commanders and Pentagon leadership to zero tolerance 
and routine prosecutions. The result will be fewer sexual assaults, 
healthier and safer soldiers, and an improved public image of the 
greatest military the world has ever seen.

                                 
    Prepared Statement of Joy J. Ilem, Deputy National Legislative 
                  Director, Disabled American Veterans

    Messrs. Chairmen and Members of the Subcommittees:

    Thank you for inviting the Disabled American Veterans (DAV) to 
testify at this joint oversight hearing focused on collaboration 
between the Department of Veterans Affairs (VA) and the Department of 
Defense (DoD) to better address military sexual trauma (MST) and to 
identify better ways to treat and properly compensate veterans for 
conditions related to MST. We also continue to express a fervent hope 
that DoD is effectively addressing methods to prevent and in fact 
eliminate the incidence of sexual assaults and harassment within all 
branches of the military services.
    This hearing takes on a topic that is extremely personal and 
sensitive to many servicemembers, veterans and the respective 
Departments that are responsible for the safety and well-being of their 
members. Sexual trauma is not a ``sex crime.'' It is a violent personal 
crime perpetrated against an innocent and unwilling person, and 
attended by both physical and mental legacy wounds. In that sense, the 
title of today's hearing, ``Healing the Wounds,'' is most appropriate. 
When a servicemember is wounded by enemy rifle fire or mortar shrapnel 
on the field of battle, as a society we are shocked and dismayed by the 
sacrifice and loss of our wounded military personnel, but when someone 
is wounded by sexual violence, society responds in a very different 
way. We hope this hearing can begin to heal these deep wounds that are 
often invisible but have profoundly changed the lives of those 
affected.
             MILITARY SEXUAL TRAUMA: AN UPHILL BATTLE FOR 
                       VA DISABILITY COMPENSATION
    An area of concern for DAV relates to veterans' compensation claims 
for disabilities resulting from MST. The prevalence of sexual assault 
in the military is alarming and has been the object of numerous 
military reports, media coverage, and Congressional hearings over the 
past decade and before. Servicemembers who have suffered MST often do 
not report these assaults during their military service, but many do 
experience lingering physical, emotional and psychological scars and 
symptoms following these incidents. Unfortunately, many men and women 
who experience these types of trauma do not disclose them to anyone 
until years after the fact.
    According to VA, during fiscal year (FY) 2009, 21.9 percent of 
women and 1.1 percent of men screened by the Veterans Health 
Administration (VHA) reported MST. We note, however, that the size of 
each VA clinical population gender cohort (women to men) who reported 
military sexual trauma within VA treatment programs is almost equal: 
53,295 women and 46,800 men, respectively.\1\
---------------------------------------------------------------------------
    \1\ Amy Street, PhD., Dept of Veterans Affairs, National Military 
Sexual Trauma Support Team; DVA Response to MST,'' PowerPoint 
presentation for the DCOE Webinar Series, April 22, 2010.
---------------------------------------------------------------------------
    Another VA study found that of 125,000 veterans screened, about 15 
percent of Operations Enduring and Iraqi Freedom (OEF/OIF) women 
veterans who use VA health care, reported experiencing sexual assault 
or harassment during their military service.\2\ VA research also 
indicates that men and women who report sexual assault or harassment 
during military service were more likely to be diagnosed with a mental 
health condition. According to VA, women with MST had a 59 percent 
higher risk for mental health problems, with the risk among men 
slightly lower, at 40 percent.\3\ The most common conditions linked to 
MST were depression, post-traumatic stress disorder (PTSD), anxiety and 
adjustment disorders and substance-use disorders.
---------------------------------------------------------------------------
    \2\ Dept of Veterans Affairs; VA Research Currents. Nov-Dec 2008. 
http://www.research.va.gov/resources/pubs/docs/
va_research_currents_nov-dec_08.pdf
    \3\ Ibid.
---------------------------------------------------------------------------
    Unfortunately, if an assault is not reported by the victim during 
his or her military service, establishing service connection later on 
for disabling conditions related to MST can be daunting. These claims 
are frequently denied by the Veterans Benefits Administration (VBA) due 
to lack of required documentary evidence to support the occurrence of a 
personal assault stressor. Although VHA provides comprehensive 
treatment for nearly 100,000 MST victims, many would be eligible for 
compensation benefits but are unable to support their claims with 
documented evidence of the stressor incidents. According to an 
Institute of Medicine (IOM) National Research Council report on PTSD 
compensation, significant barriers prevent women from being able to 
independently substantiate their experiences of MST, especially in 
combat arenas.\4\ The IOM report concluded that little research exists 
on the subject of PTSD compensation and women veterans specifically. 
The Committee noted that available information suggests that women 
veterans are less likely to receive service connection for PTSD and 
that this is related to being unable to substantiate noncombat 
traumatic stressors such as MST. The Committee further noted that VA 
administrative procedures and rules for adjudicating and rating these 
types of cases address MST related PTSD claims but that little 
attention is paid to the unique challenges of obtaining documentation 
of an in-service stressor.
---------------------------------------------------------------------------
    \4\ Institute of Medicine and National Research Council of the 
National Academies, Committee on Veterans' Compensation for PTSD, Board 
on Military and Veterans Health, Board on Behavioral, Cognitive, and 
Sensory Sciences; PTSD Compensation and Military Service, 2007.
---------------------------------------------------------------------------
    In 2005, the DoD established the Sexual Assault Prevention and 
Response Office (SAPRO). This organization is responsible for all DoD 
sexual assault policy and provides oversight to ensure that each 
military service branch complies with DoD policy. SAPRO serves as a 
single point of accountability and oversight for sexual assault policy, 
provides guidance to the DoD components, and facilitates the resolution 
of issues common to all military services and joint commands. The 
objectives of DoD's SAPRO policy are to specifically enhance and 
improve: 1) prevention through training and education programs; 2) 
treatment and support of victims; and 3) system accountability.
    Under DoD's MST confidentiality policy, active duty victims of 
sexual assault have two reporting options-restricted reporting and 
unrestricted reporting. Restricted reporting allows a sexual assault 
victim to confidentially disclose the details of his or her assault to 
specified individuals and to receive medical treatment and counseling, 
without triggering any official criminal or civil investigative 
process. Servicemembers who are sexually assaulted and desire to file a 
restricted report under this policy may only report the assault to the 
Sexual Assault Response Coordinator (SARC), Victim Advocate or an 
appropriate health care personnel member. According to SAPRO, health 
care personnel will initiate the appropriate care and treatment, and 
report the sexual assault to the SARC in lieu of reporting the assault 
to law enforcement or to the victim's unit commander. Upon notification 
of a reported sexual assault, the SARC will assign a Victim Advocate to 
the victim. The assigned Victim Advocate will provide information on 
the process of restricted versus unrestricted reporting. At the 
victim's discretion, appropriately trained health care personnel will 
conduct a sexual assault forensic examination (SAFE), which may include 
documentation of the injuries and collection of physical evidence. 
According to SAPRO, in the absence of a DoD provider, the servicemember 
can be referred to an appropriate civilian facility for the SAFE 
[examination].
    According to DoD, unrestricted reporting is recommended for victims 
of sexual assault who request an official investigation of the crime in 
addition to treatment and counseling. When selecting unrestricted 
reporting, these victims permit current reporting channels to be used, 
e.g. notifying the chain of command, military police or civilian law 
enforcement, reporting the incident to SARC, or requesting health care 
personnel to notify law enforcement. Upon notification of a reported 
sexual assault, the SARC assigns a Victim Advocate. At the victim's 
discretion, health care personnel may conduct a SAFE examination, with 
similar collection of information and potential physical evidence. 
According to SAPRO policy, personnel access to details regarding the 
incident are limited to those who have a legitimate need to know.
    In FY 2009, DoD reported an 11 percent increase from the prior year 
in all categories of sexual assault reporting. There were a total of 
3,320 reports to DoD in FY 2009, with 2,516 unrestricted and 714 
restricted reports. These reports represent the largest annual increase 
DoD has seen since yearly data collection began. The rise is attributed 
to DoD's release of its MST social marketing campaign last year, and 
SAPRO officials have stated they believe their message appealing for 
more reporting of MST within the ranks of the active force is achieving 
breakthrough and generating this recent jump in reporting. Since June 
of 2005, when the Department implemented the new restricted reporting 
option for victims of MST, SAPRO has documented 3,486 restricted 
reports having been filed.\5\
---------------------------------------------------------------------------
    \5\ Dr. Kaye Whitley, Director, Office of the Sec. of Defense, 
Sexual Assault Prevention and Response Office; Sexual Assault in the 
Military, PowerPoint presentation for the DCOE Webinar Series, April 
22, 2010.
---------------------------------------------------------------------------
    While DoD reports that it prefers complete (meaning, unrestricted) 
reporting of sexual assaults to activate both victims' services and law 
enforcement actions, it recognizes that some victims desire only health 
care and support services, without command or law enforcement 
involvement. The Department states its first priority is for victims to 
be protected, treated with dignity and respect, and receive the best 
possible medical treatment, counseling and care. DAV acknowledges that 
DoD policy, but we also want to protect MST victims' rights and 
benefits when they transition to veteran status.
    DAV's primary concern is that VA be able to access the restricted 
DoD records documenting reports of MST for an indeterminate period. On 
several occasions over the past 2 years, DAV has contacted VBA and 
SAPRO staff to try to verify that the organizations are collaborating 
to ensure access to these records, if authorized by the veteran, in 
support of a VA benefits claim for conditions related to MST. It is my 
understanding that they have spoken but that to date there is not an 
official policy, process or Memorandum of Understanding (MOU) in place 
to secure such records. To establish service connection for PTSD there 
must be credible evidence to support a veteran's assertion that the 
stressful event actually occurred. Once a claim is filed VA has a 
number of standard sources it examines for records to support a claim 
for a condition secondary to personal trauma or MST. However, we do not 
see SAPRO-related reports listed in any of VA's training and reference 
materials/manuals for developing claims for service connection for PTSD 
based on MST. At this juncture we are unable to confirm if VBA 
unofficially searches for ``restricted'' reports as an alternative 
evidence source for information to substantiate the veteran's claim. VA 
does list medical reports from civilian physicians or caregivers who 
treated the veteran immediately after the trauma as alternative 
evidence to seek out in these cases; however, we do not know if VBA 
staff developing these claims are aware of DoD SAPRO policies and would 
contact the veteran to see if a restricted report was in fact filed, a 
physical examination conducted and if follow-up medical or mental 
health treatment records exist.
    To maintain confidentiality in the case of restricted reporting, 
DoD policy prevents release of MST-related records, with limited 
exceptions. Also, VA is not specifically identified as an ``exception'' 
for release of records in DoD's policy, and it is unclear if VA could 
gain access to these records even with permission of the veteran. 
Nevertheless, DoD does list VA as an advisor to the DoD Sexual Assault 
Advisory Council or (SAAC), a council that coordinates policy and 
review of the Department's sexual assault prevention and response 
policies and programs. We also have questions with respect to where and 
how physical assessment records that are completed following the 
assault and subsequent mental health treatment records related to the 
restricted MST reports are kept and for how long. It does not appear 
that these reports, whether restricted or unrestricted, are archived in 
the individual's official military personnel record, even subsequent to 
discharge from active duty. We are concerned that VBA adjudication 
staff may not be aware or attempt to gain access to these records that 
for privacy reasons are being kept separate from victimized 
servicemembers' medical treatment and personnel records. Additionally, 
we are not clear on how each military service branch maintains these 
records. According to DoD policy, physical evidence collected 
associated with a restricted report of the event is destroyed after 1 
year if the servicemember or veteran does not wish to pursue civil or 
criminal sanctions against the perpetrator. However, we are not aware 
of the policies for maintaining DD Form 2911 (Forensic Medical Report 
Sexual Assault Examination form) completed by the examining clinician 
following the reported assault. The information on this form would in 
many cases validate the stressor associated with subsequent PTSD or 
other mental health consequences of MST.
    We hope to confirm with the Subcommittee's oversight that VA is 
indeed fully collaborating with DoD to ensure veterans who have 
suffered MST and have filed claims for benefits for related conditions 
gain VA's full assistance in accessing these important records in 
support of their claims for disability. Additionally, we concur with 
the recommendation made in the 2008 report of the VA Advisory Committee 
on Women Veterans that suggested VBA identify and track claims related 
to personal assault/MST to determine the number of claims submitted 
annually, grant rates, denial rates, and types of conditions most 
frequently associated with these claims. The Committee stated that 
development of tracking systems could further guide studies on research 
on all aspects of MST. Finally, we ask that VBA provide the 
Subcommittees any information it has in its reference materials for 
claims developers/raters that reflect its collaboration with DoD/SAPRO 
and guidance to MST-related claims developers on how to access 
supporting documentation from each military service in the case of both 
restricted and unrestricted reporting options, including any 
differences in records retention, security and disposal policies.
                VBA REQUIREMENTS FOR MST-RELATED CLAIMS
    Establishing a veteran's service connection for PTSD requires: (1) 
medical evidence diagnosing PTSD; (2) credible supporting evidence that 
the claimed in-service stressor actually occurred; and (3) medical 
evidence of a link between current symptoms and the claimed in-service 
stressor.
    However, if the claimant did not engage in combat with the enemy, 
or the claimed stressors are not related to combat, then the claimant's 
testimony alone is not sufficient to establish occurrence of the 
claimed stressors, and his or her testimony must be corroborated by 
credible supporting evidence. If a PTSD claim is based on in-service 
personal assault, evidence from sources other than a veteran's service 
records may corroborate a veteran's account of the stressor incident. 
Examples of such evidence include, but are not limited to: records from 
law enforcement authorities, rape crisis center, mental health 
counseling centers, hospitals, or physicians; pregnancy tests or tests 
for sexually transmitted diseases; and statements from family members, 
roommates, fellow servicemembers, or clergy. Additionally, evidence of 
behavioral changes following the claimed assault is one type of 
relevant evidence that may be found in these sources. Examples of 
behavioral changes that may constitute credible evidence of the 
stressor include, but are not limited to: a request for a transfer to 
another military duty assignment; deterioration in work performance; 
substance abuse; episodes of depression, panic attacks, or anxiety 
without an identifiable cause; or unexplained economic or social 
behavioral changes (title 38 CFR Sec. 3.304(f)(4).)
    Unfortunately, in many cases, even when the veteran has been 
diagnosed with PTSD based in part on claimed in-service sexual trauma, 
his or her claim is denied because there is no independent evidence 
(credible supporting evidence) to corroborate their statements as to 
the occurrence of any claimed in-service stressor. Even in cases where 
a VA physician indicates that a veteran was being followed for symptoms 
of military related sexual trauma, these lay and medical statements do 
not constitute credible supporting evidence. For more information, see 
Moreau v. Brown, 9 Vet. App 389, 396, (1996), wherein the court 
concluded that corroboration of an in-service stressor cannot consist 
solely of after-the-fact medical nexus evidence.
    As noted above, to receive disability compensation from an MST-
related condition, as noted above, the standard of evidence is stricter 
than for combat injuries, or even for military occupational injuries. 
Service connection for a condition related to MST is important on a 
number of levels. Specifically, veterans with service connection have 
improved access to VA health care--for veterans with VA disability 
ratings of 50 percent or more disabling--access to VA health care for 
any condition. Disability compensation can also make a tremendous 
difference in a disabled veteran's financial status. Finally--and most 
importantly for many MST survivors--being rated service connected for 
mental and physical disabilities attributed to MST represents 
validation, connotes gratitude for their service to their country and 
recognizes the tribulations they endured while serving.
          COUNSELING AFTER MST: AN OPEN DOOR FOR VA TREATMENT
    In accordance with section 101 of Public Law 103-452, the Veterans 
Health Programs Extension Act of 1994, any veteran self-reporting a 
history of in-service sexual trauma is eligible for VA health care for 
conditions related to that trauma. In compliance with this mandate, all 
patients are screened for MST, and treatment is available for MST-
related conditions at all VA health care facilities. Service connection 
or disability compensation is not required for eligibility for this 
treatment, and veterans in these MST programs are exempt from co-
payments for care provided.\6\
---------------------------------------------------------------------------
    \6\ Dept of Veterans Affairs, Office of the Inspector General; 
Health Care Inspection, Review of Inappropriate Copayment Billing for 
Treatment Related to Military Sexual Trauma, February 4, 2010. http://
www4.va.gov/oig/54/reports/VAOIG-09-01110-81.pdf.
---------------------------------------------------------------------------
    We congratulate VHA for making available on its Web site, http://
www.mentalhealth.va.gov/msthome.asp, clear and concise information 
related to definition, screening and treatment for MST. VHA notes that 
both men and women have experienced MST during their military service, 
and that all veterans seen in the VA health care system are screened 
and asked about experiences of sexual trauma. VA provides a fact sheet 
to answer commonly asked questions including the commonality of MST and 
ways MST can affect veterans. VA also includes a list of possible signs 
and symptoms survivors of MST may experience, and most importantly, the 
Web site provides information on how and where veterans who experienced 
MST can get help from VA. Information is provided regarding the Women 
Veterans Program Managers, the MST Coordinators and VA's general 
benefit information hotline. VHA's Web site, outreach posters and 
brochures clearly indicate that VA provides confidential counseling and 
treatment for mental health and physical health conditions related to 
experiences of MST, all without copayment. VA also holds that service 
connection or disability compensation is not required to receive VA MST 
treatment, and that a veteran need not have reported the incident, nor 
have documented that it occurred, to obtain these services. In some 
cases a veteran may be able to receive VA MST treatment even if he or 
she is not otherwise eligible for VA care.
    We are pleased that VHA makes a point to convey that recovery from 
personal trauma is possible; and that VA has the resources and services 
to help veterans through this extremely difficult challenge. We 
acknowledge the many experts, specialized research conducted and 
programs that have been established through the VA's National Center 
for PTSD, many of which are focused on MST and its consequences in 
mental health of victims. Nationwide, VA offers specialized MST 
inpatient and outpatient services, and evidence-based treatments and 
counseling by specially trained sexual trauma counselors in its Vet 
Center community-based facilities. Veterans can also request a same-sex 
provider if it makes them feel more comfortable in their counseling 
sessions.
    In testimony before the Health Subcommittee on March 9, 2009, VA 
testified that it had established an MST support team in VA Central 
Office to monitor MST screening and treatment, oversee MST-related 
education and training, and promote best practices for screening and 
treatment.
    Despite this progress, VHA staff across the nationwide system needs 
to be more sensitive and knowledgeable and recognize the importance of 
environment of care delivery when evaluating these veterans for their 
physical and mental health conditions. For years we have encouraged VHA 
to develop a MST provider certification program, guarantee at least 50 
percent protected time for MST coordinators to devote to position 
responsibilities, provide separate and secure women's subunits for 
inpatient mental health and residential services, ensure privacy and 
safety, and improve coordination with the DoD in transition of 
veterans, especially those with complex behavioral health needs related 
to MST. The Government Accountability Office (GAO) released a GAO 
``Watchdog Report #12'' on April 7, 2010, in which GAO's Director of 
Federal Health Care stated: ``One challenge is a [VA] difficulty in 
hiring primary care providers with specific training and experience in 
women's health. For example, officials at many VA facilities we visited 
noted they had difficulty attracting mental health care providers with 
experience in treating post-traumatic stress disorder and military 
sexual trauma, which are prevalent [among] women veterans.'' Based on 
the continuing reports we have received from our National Service 
Officer (NSO) corps and veterans themselves, DAV strongly endorses 
GAO's observation.
    We are pleased that Public Law 111-163, the Caregivers and Veterans 
Omnibus Health Services Act of 2010, recently approved by the 
President, includes a provision to mandate graduate education, training 
and certification for VA mental health providers delivering counseling, 
care and services for MST-related conditions, to ensure veterans have 
access to mental health clinicians with specialized expertise in this 
unique area. DAV urges VA to promptly begin implementation of the MST 
Congressional mandate in Public Law 111-163, to begin to address some 
of these unmet needs.
    In 2007, VA's National Center for PTSD published the first-ever 
randomized controlled trial to assess PTSD treatment for active duty 
women and women veterans. In the study, the women who received 
prolonged exposure therapy had greater remissions of PTSD symptoms than 
women who received present-centered therapy. Additionally, the 
prolonged exposure group was more likely than the present-centered 
therapy group to no longer meet the criteria for a diagnosis of PTSD 
and achieve total remission. However, mental health experts report that 
these case-intensive treatments are not universally available at VA 
medical centers (VAMCs) nationwide. This study documented the 
importance of spreading this evidence-based practice throughout VA's 
system. DAV is pleased that VA has developed a program to train its 
mental health providers to provide the most effective treatment for 
PTSD due to sexual trauma and combat trauma and is examining how best 
to address complex combat and MST issues.\7\ However, further expansion 
of these training programs is still needed.
---------------------------------------------------------------------------
    \7\ Dept of Veterans Affairs News Release; Health Care Report Card 
Gives VA High Marks, June 13, 2008.
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           HOMELESS WOMEN VETERANS AND MST--A SPECIAL CONCERN
    Finally, we note another area in relationship to MST that warrants 
the Subcommittees' attention. VA has excellent programs for homeless 
veterans but women veterans present some unique challenges for VA 
within those programs. Frequently women are reluctant to take advantage 
of VA's stellar programs such as transitional housing, substance-use 
disorder programs and residential rehabilitation and treatment 
programs, due to personal safety concerns and because often they are 
the sole or primary caretakers of minor children. In some facilities VA 
has struggled to maintain a welcoming, secure and safe treatment 
setting especially for women who have serious mental illness and/or 
have been victims of MST.
    According to VA, the overall number of homeless veterans has been 
declining (now approximately 131,000 on any given night), but the 
number of homeless women veterans has nearly doubled to 6,500 over the 
last decade, about 5 percent of the total homeless veteran population. 
In a recent newspaper report, VA was cited as reporting that overall, 
female veterans are now between two and four times more likely to end 
up homeless than their civilian counterparts.\8\ This alarming jump is 
coupled with the report that 1 in 10 homeless veterans under the age of 
45 are women, and as more veterans return from deployments in Iraq and 
Afghanistan, these numbers are expected to rise. Combat-related stress 
and MST are both risk factors for homelessness. These women present 
unique challenges to the VA system, designed for use primarily by men, 
and very few VA facilities have homeless programs designed specifically 
for women, and none are able to accommodate children. It is also noted 
that about 75 percent of these female veterans have been victims of 
sexual abuse and many have substance-use and mental health problems 
that require specialized care. Programs and treatment services for 
mental health, MST, substance-use disorders, and maintaining 
independent housing and gainful employment are all essential to this 
vulnerable population. Therefore, we must ensure that VA programs are 
properly adjusted to meet the unique and growing needs of women 
veterans and ensure that women have equal access to these specialized 
services.
---------------------------------------------------------------------------
    \8\ Bryan Bender, The Boston Globe; More Female Veterans Are 
Winding Up Homeless, July 6, 2009. http://www.boston.com/news/nation/
washington/articles/2009/07/06/more_female_veterans_
are_winding_up_homeless/.
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                                SUMMARY
    In summary, DAV recommends the Subcommittees provide oversight to 
ensure VA, DoD and SAPRO work collaboratively to develop a joint policy 
directive and system for each military service branch to maintain and 
share with VA when needed critical medical records related to MST 
cases; provide servicemembers information on how and where to access 
these records and information about VA benefits and services should 
they decide in the future to file claims for disability compensation 
with VA for conditions related to MST. We also ask that VBA provide the 
Subcommittees any information it possesses in its reference materials 
or guidance for claims developers and raters that reflect VBA's 
collaboration with SAPRO, as well as any guidance to claims developers 
working on MST-related claims on how to access supporting documentation 
from each military service branch in cases of both restricted and 
unrestricted reporting options, including acknowledgements of 
differences in records retention across branches, and security and 
records disposal policies within the DoD service branches.
    Unfortunately, we continue to see increasing numbers of 
servicemembers and veterans who report MST and seek care from VA as 
well as file claims for disability compensation through our NSO corps. 
One of DAV's central purposes is to aid veterans in obtaining fair and 
equitable VA compensation for their service-related disabilities. We 
believe our NSO corps provides a premier service to help veterans 
rebuild their lives, and we have aided millions of veterans since the 
founding of our organization. In this one particular area, however, our 
NSOs are deeply frustrated at the routine occurrence of MST claims 
being denied for lack of evidentiary documentation. For these reasons 
and more, it seems to DAV that the agencies that are responsible for 
monitoring and reporting on MST, and providing benefits and services to 
victims of MST, as well as preventing the problem at its source, to 
work in concert to lower the burden of this claims process and ensure 
servicemembers and veterans are fully assisted by the government and 
their advocates in securing the benefits they deserve and have earned. 
We believe this issue can be resolved internally by the respective 
agencies involved through a memorandum of understanding agreed to by 
both parties, or through some other mechanism short of a new statutory 
mandate, if they simply agree to work in a cooperative spirit on a 
seemingly very solvable problem.
    Finally, we recommend the Subcommittee on Health request VHA 
provide a report to the Subcommittee on its safeguards and efforts to 
ensure all women veterans and especially women veterans with combat-
related stress and/or MST histories have access to secure and safe 
treatment settings in all VA facilities and programs. As indicated 
above, MST is not a ``women's issue'' in VA; however, VA is still 
primarily populated with men and male oriented. As such women's safety, 
security and comfort must remain a special concern.
    Messrs. Chairmen, again we thank you for the opportunity to share 
our views at this important hearing focused on healing the wounds of 
military sexual trauma--and your efforts to identify ways to improve 
treatment and properly compensate veterans for conditions related to 
MST. We appreciate the attention to these issues and hope the 
Subcommittees will consider the issues of concern and recommendations 
we have brought forward in our statement. Thank you once again for the 
opportunity to provide testimony at this hearing. I would be pleased to 
address your questions, or those of other Subcommittee members.

                                 
      Prepared Statement of Sergeant Jennifer Hunt, USAR, Project 
         Coordinator, Iraq and Afghanistan Veterans of America

    Chairmen, Ranking Members, and Members of the Subcommittees on 
Disability Assistance and Memorial Affairs and Health, on behalf of 
Iraq and Afghanistan Veterans of America's one hundred and eighty 
thousand members and supporters, I would like to thank you for inviting 
us to testify today. ``Healing the Wounds: Evaluating Military Sexual 
Trauma'' is a critically important topic. The issue of sexual assault 
has deeply affected IAVA membership, the military and veterans' 
community as a whole, and me personally. I would like to point out that 
my testimony today is on behalf of IAVA and does not reflect the views 
and opinions of the United States Army.
    My name is Jennifer Hunt, and I am a Sergeant in the U.S. Army 
Reserves. I grew up in Shelton, CT and enlisted in the Army Reserves 
shortly after September 11th. I've served combat tours in Iraq and 
Afghanistan as a Civil Affairs Specialist and, in Iraq, I earned a 
Purple Heart when my Humvee was struck by a roadside bomb, causing 
shrapnel injuries to my face, arms and back.
    Whether deployed or drilling stateside, I also serve as my unit's 
designated Victim Advocate, as part of the Army's Sexual Assault 
Prevention and Response program. I sincerely hope that my duties as 
Victim Advocate are ones that I will never have to perform.
    But if I was called upon to serve as a Victim Advocate my official 
responsibilities would include: acting as the first point of contact 
for the victim; counseling them on what their options are for reporting 
the attack; notifying the installation's Sexual Assault Response 
Coordinator; and accompanying victims to medical appointments or 
related meetings. And I am ready, should the need arise, to provide 
personal support to the victim. I know first-hand how difficult and 
frustrating the healing process can be, because I was a victim of 
sexual assault as a civilian.
    Unfortunately, the reality is that servicemembers have been coping 
with significant and underreported sexual assault and harassment in the 
military for decades. While sexual assault disproportionately affects 
female troops, male servicemembers are impacted too. And they may face 
even greater stigma when deciding whether to report it or seek care. In 
FY 2009, there were more than 3,200 reports of sexual assault involving 
servicemembers. Even in the warzone, troops cannot escape the threat of 
sexual assault; there were 279 reported sexual assaults in combat areas 
last year. While these numbers are alarming, they grossly underestimate 
the severity of the issue. According to the Defense Department, only 20 
percent of all unwanted sexual contact is reported to a military 
authority. This must change--and the time is now.
    But despite the urgency of the issue, it has taken several 
congressional hearings, extensive media attention, and the increasing 
number of victims coming forward to share their trauma publicly for the 
military and the Department of Veteran Affairs to finally respond to 
the staggering number of incidents. In recent years, both departments 
have taken commendable steps. The military introduced a ``restricted 
reporting option'' to encourage more victims to seek care and 
counseling and completed its long awaited review of the issue by the 
Defense Department Task Force on Sexual Assault in the Military 
Services.
    MST can lead to the development of major health problems, such as 
depression, eating disorders, miscarriages, and hypertension. Victims 
may also be eligible for disability compensation from the VA. 
Consequently, the VA began universally screening all veterans seeking 
care at the VA for Military Sexual Trauma in 1999 and the VA provides 
care to any veteran who has experienced MST. However, as is the case 
with other VA health care, treatment is inconsistent and not all 
veterans receive the care they deserve. IAVA was extremely concerned to 
learn that the VA's Inspector General had to review the billing 
practices of VA health facilities and clinics after it was revealed 
that patients at one Texas clinic were being improperly charged copays 
for MST-related care. VA hospitals need to be trained in the proper 
treatment of and benefits for MST victims.
    These steps are an improvement over the years of inaction, but much 
more must be done to adequately prevent and respond to Military Sexual 
Trauma. Our women warriors deserve the best treatment and support on 
the planet. Therefore, IAVA recommends the following steps to ``Help 
Heal the Wounds'':
    For the Department of Defense----

      Adequately fund the Department of Defense's Sexual 
Assault Prevention and Response Program (SAPR) to achieve its mission 
of prevention, response, training and accountability. As recommended by 
the DoD's Task Force on Sexual Assault, the Secretary should include 
the SAPR Program in its Program Objective Memorandum budgeting process 
ensuring a separate line of funding is allocated to the services.
      Conduct a study to identify a more comprehensive system 
that will accurately measure the incidence of sexual assault within the 
military--not just reported assaults. DoD should also conduct its 
gender relations survey bi-annually to more accurately assess the rate 
of sexual harassment.
      Require the Secretary of Defense to review sexual assault 
prevention and response efforts in the Reserve Components--which is not 
happening now.
      Require all military installations to have a Sexual 
Assault Response Coordinator (SARC) and deployable SARC on base. SARCs 
must be full-time military or DoD civilian personnel.
      Ensure all servicemembers have access to a restricted 
reporting option, and improve avenues for restricted reporting by 
allowing victims to reserve their right to a restricted report even 
after disclosing an assault to a third party, with the exception of 
chain of command or law enforcement. Additionally, a hotline should be 
established to allow victims to report sexual assault and harassment 
even when in-theatre. And that hotline must be connected with a local 
Sexual Assault Response Coordinator.
      Guarantee that all military personnel have access to 
qualified medical personnel to conduct evidence collection in sexual 
assault cases in a safe, timely, confidential, and gender--unbiased 
manner, even in deployed and remote locations.

    For the Department of Veterans Affairs--

      Expand availability of specialized sexual trauma 
treatment inpatient and residential settings.
      Ensure that victims have access to preferred treatment 
settings and providers. For example, victims should not have to settle 
for mixed-gender treatment facilities because there are no facilities 
with separate programs for males and females in their area.
      Conduct a fully independent review of VA medical 
facilities to assess whether or not they are adequately complying with 
VA standards for safety and privacy for MST victims.
      Ensure the use and implementation of a method 
specifically designated to track MST-related care at all VHA medical 
facilities, so that MST treatment data are readily accessible across 
the VA system, as recommended by the VA's Office of Inspector General.
      Identify, track and report to Congress the outcomes of 
disability claims that involve MST. This will better measure the number 
of MST-related claims submitted annually, length of processing times, 
denial rates, and the types of disabilities that are associated with 
MST.

    These recommendations are urgent. And IAVA encourages you to enlist 
the support of the President and the first lady to help make them 
happen.
    Sexual Assault is a violation of military values and 
professionalism. It undermines unit cohesion, morale and effectiveness. 
The majority of assailants are older and of higher rank than their 
victims. They abuse not only their authority, but the trust of those 
they are responsible for protecting.
    Sexual assault, whether it occurs in the military or in the 
civilian world, is also a crime. It is a crime that threatens the 
individual victim and the strength of the United States military.
    Sexual assault is a crime that has gone on for too long, with too 
little done to stop it. While not all of IAVA's recommendations fall in 
the jurisdiction of these Subcommittees, we look forward to working 
with you to fully address the issue of Military Sexual Trauma. Our 
women warriors have served nobly. And I am here today on behalf them 
all, to issue to you a call to service. We have done our part. Now it's 
time for you to do yours.

    Thank you.

                                 
    Prepared Statement of Anuradha K. Bhagwati, Executive Director,
                     Service Women's Action Network

    Good morning, Mr. Chairman, and Members of the Committee. My name 
is Anuradha Bhagwati. I am a former Marine Corps Captain and Executive 
Director of Service Women's Action Network (SWAN), an advocacy and 
direct services organization for servicewomen and women veterans.
    SWAN's policy work this year focuses largely on reforming DoD and 
VA Sexual Assault and Harassment policy and educating the public about 
the epidemic known as Military Sexual Trauma (MST).
    MST is an intensely personal issue for us and for the veterans we 
represent. This testimony is based on the collective input of over 120 
MST survivors, MST crisis intervention caseworkers and VA health 
providers. My own experience filing an Equal Opportunity investigation 
for sexual harassment and discrimination in the military and the 
unfortunate follow-on experiences I've had with both VHA and VBA 
regarding treatment and benefits corroborate the experiences of my 
colleagues and fellow veterans below.
I.  Department of Defense (DoD):
    Sexual trauma in a military setting is unique and must be 
recognized as such before suggesting appropriate policy remedies. We 
must first understand why a servicemember would choose to stay silent 
after being sexually assaulted or harassed.
    DoD puts MST survivors in an awful predicament in which they are 
likely to be further traumatized if they come forward. Unlike the 
civilian world, MST survivors don't have the option of quitting their 
job; they are often stuck working with, nearby, or under the 
supervision of their perpetrators. There is simply no guarantee that 
the chain of command will support survivors if they come forward. 
Commanders consistently ignore equal opportunity and sexual assault 
policy in order to maintain the personnel in their unit at full 
capacity. Additionally, commanders have little incentive to prosecute 
perpetrators, as documented incidents reflect poorly on their 
leadership performance and reputation.
    MST survivors who report an incident are likely to face isolation, 
retribution, or accusations of lying, irresponsibility or impropriety; 
there is no guarantee of anonymity from the chain of command or Victim 
Advocates, and survivors are likely to face the horror of retribution 
from perpetrators and the anguish of being a target of public ridicule, 
scorn and further harassment in their respective units. We cannot 
honestly expect people to come forward to report--it is irresponsible 
for DoD to suggest that survivors do so, without guaranteeing 
protection.
    Despite overtures by DoD in recent years to prevent sexual assault 
and harassment, nothing on the ground has changed for women and men in 
uniform. DoD's failure to protect our servicemembers ought to be the 
subject for a separate set of hearings, as there is far too much to say 
here. Suffice it to say that without third party oversight of sexual 
assault and harassment cases, a culture of impunity and hatred of women 
within the military makes it almost certain that survivors will be 
punished, taunted, isolated, or intimidated by their commands for 
speaking out, and that perpetrators will in most cases go unpunished.
II. Veterans' Health Administration (VHA):
    MST survivors universally describe the horror of using VA Medical 
Centers nationwide. The climate at VA hospitals is still largely 
unwelcoming to women, but for MST survivors, the experience of going to 
an appointment can be life-threatening--triggers of one's assault or 
harassment are everywhere, from the prospect of running into your 
perpetrator, to being surrounded by male patients who routinely engage 
in sexual harassment of female patients, to being improperly treated by 
staff members who have no knowledge about the unique experience of 
sexual trauma in a military setting.
    One survivor said to SWAN, ``I don't want to be fending off 
advances when I'm raw from dealing with my issues in therapy'' while 
another said, ``I have no [private] health care. I have to use the VA. 
Therefore I have to go through all the embarrassment.'' Survivors 
universally say that if they had health insurance, they would 
definitely use private health care instead of the VA.
    Many veterans are ignored, isolated, or misunderstood at VA 
facilities because their PTSD is not combat-related. The veterans' 
community still primarily considers PTSD to be a combat-related 
condition, to the great detriment of MST survivors.
    Survivors who have used the VA routinely say they are fed up with 
being given endless prescription medication--one Iraq veteran described 
the experience of her VA MST treatment as nothing but ``pills and pep 
talks.'' Many survivors wish they had access to yoga, massage therapy, 
acupuncture, and gender-specific MST support groups.
    Lots of MST patients echo the comments of other veterans 
generally--that a lack of privacy, child care and availability of 
evening or weekend appointments prevents them from accessing care at VA 
Medical Centers.
    I strongly recommend that the Committee give MST survivors the 
option of fee-based care for all treatment. At the same time, VHA 
cannot be let off the hook. VA Medical Centers ought to have separate 
facilities for women patients, and easy, safe, and direct access to MST 
treatment areas for both male and female MST survivors.
    I'd like to say a few words about MST Residential Treatment 
programs. It appears that most MST patients do not know that these 
programs exist, and it's apparent that many VA providers also don't 
know about them. Survivors have mixed reactions to these treatment 
programs. Most describe agonizing wait lists for the programs, along 
with a shortage of VA funding to travel to the program. Among those 
patients who have attended, several have experienced sexual harassment 
by staff or fellow patients. Another disturbing trend is VA's 
integration of residential programs with other mixed-gender veterans' 
programs, in which MST patients are not guaranteed privacy or safety 
from other patients of the opposite sex. VA needs to invest in separate 
facilities for MST programs, and guarantee the safety and welfare of 
all participants.
III. Veterans' Benefits Administration (VBA):
    Filing for disability compensation for MST is universally 
considered a traumatic, agonizing, and cruel experience. Many survivors 
describe the process of re-writing one's personal narrative for a VA 
claim as just as traumatic as the original rape or harassment.
    VBA claims officers nationwide have proven themselves entirely 
inept when dealing with MST claims. Claims are routinely rejected, even 
with sufficient evidence of a stressor and a corroborating diagnosis 
from a VA health provider. Many survivors' claims are rejected because 
of VBA's lack of knowledge about sexual violence. For example, many 
servicemembers have been denied VBA compensation because their job 
performance did not decline after the assault or harassment--which in 
the sexual violence community is a perfectly normal survival reaction 
to a life-threatening situation. Countless more survivors failed to 
report through official channels, or cannot fathom the agony of 
attempting to file a claim when military culture and the VA are so 
rigged against women.
    Current VBA policy is forcing women and men with insufficient 
evidence of their assault and harassment to suffer in silence and 
shame, to numb their pain through use of substances, and to take or 
attempt to take their own lives. This Committee needs to understand 
that until it is safe to report sexual assault or harassment in the 
military, the majority of incidents will not be reported. You cannot 
continue to punish veterans with MST twice. VA must take responsibility 
for DoD's failure to protect its own by awarding just compensation to 
survivors.
    Another equal protection issue features prominently in the work we 
do on MST. The ``Don't Ask, Don't Tell'' policy has allowed gay and 
lesbian servicemembers, as well as those who are perceived to be gay, 
to be systematically sexually harassed and assaulted in uniform. 
Perpetrators have routinely abused gays and lesbians who would 
otherwise report harassment or assault. Society has yet to measure the 
mental health impact of this insidious policy on our Nation's LGBT 
veterans. We must guarantee access to quality health care for all 
veterans, regardless of sexual orientation or gender identity.
    I must add a special note for our older MST survivors, our mothers 
and grandmothers whose sacrifice years ago both on the battlefield and 
in the barracks forged the way for women like us to join the military--
we must not forget them. Many of them suffered at the hands of fellow 
servicemen decades ago, and their trauma continues to be unrecognized. 
One Vietnam-era veteran who survived MST told us, ``Please help me feel 
validated before I die.'' Honor and validate her service and her life 
by fixing this broken system now.

    Thank you.

                                 
      Prepared Statement of Kaye Whitley, Ed.D., Director, Sexual
 Assault Prevention and Response Office, Office of the Under Secretary 
   of Defense for Personnel and Readiness, U.S. Department of Defense

    Chairmen Michaud and Hall, Ranking Members Brown and Lamborn, and 
Members of the Subcommittees, thank you for inviting me today to 
discuss the progress the Department of Defense has made in recent years 
on caring for victims of sexual assault. I would like to focus on the 
efforts of my office, the Sexual Assault Prevention and Response Office 
(SAPRO), working in partnership with the Military Services. As a team, 
we are making great headway to standardize, professionalize, and 
institutionalize our programs. Once we achieve all three, we hope to 
realize our vision: A culture free of sexual assault. Until that time, 
ensuring an effective response for victims is one of our highest 
priorities.
    At the beginning of my testimony, it is important to clarify a few 
issues.

      The Department of Veterans Affairs is tasked by Congress 
to address the physical and mental problems of veterans stemming from 
physical assault or sexual assault or sexual harassment that occurred 
while the verteran was serving on active duty or active duty for 
training. VA utilizes the umbrella term ``military sexual trauma'' to 
refer to these experiences.
      In the Department of Defense, the office that I represent 
is tasked with policy relating to the prevention and response of sexual 
assault. Sexual harassment is addressed by the Equal Opportunity 
Program. Reported incidents of sexual harassment are not included in my 
statistics.
      Finally, I would like to remind everyone that our DoD-
wide sexual assault policy has been in place since 2005. All reports of 
sexual assault are of concern to us, and we are especially concerned 
with reports of incidents that occurred after 2005 in that we want to 
examine them to determine if there are any necessary changes in our 
policy.
Sexual Assault: An Underreported Crime
    One of the challenges facing the Departments of Defense and 
Veterans Affairs is the fact that sexual assault is one of the most 
underreported crimes in our society. National studies indicate that 
most sexual assaults go unreported in the civilian sector--largely 
because victims are fearful of the life-changing events, public 
scrutiny, and loss of privacy that often come with a public allegation. 
The potential medical and psychological costs and consequences of 
sexual assault are extremely high.
    Unfortunately, the military is not immune to the problems faced by 
the rest of American society--and sexual assault is no exception. 
Sexual assault in the military has similar costs and consequences for 
victims--but there are other factors that complicate a victim's 
experience in the military and interfere with reporting. First, sexual 
assault can occur where a victim works and lives. Victims are not 
always able to escape painful reminders that keep them from putting the 
incident behind them. Second, when the perpetrator resides in the same 
unit as the victim, sexual assault sets up a potentially destructive 
dynamic that can rip units apart. Third, recent research has found that 
a history of sexual assault doubles the risk of posttraumatic stress 
when the victim is exposed to combat.\1\
---------------------------------------------------------------------------
    \1\ Smith, et al., (2008). Prior Assault and Posttraumatic Stress 
Disorder After Combat Deployment, Epidemiology, 19, 505-512.
---------------------------------------------------------------------------
    Some victims may not want to come forward to report for many of the 
same reasons cited by their civilian counterparts: DoD studies indicate 
that about eight of ten sexual assaults in the military go 
unreported.\2\ Victims are concerned about losing their privacy, 
fearful about being judged, fearful of retaliation, and afraid that 
people will view them differently. In addition, female and male 
military victims alike mistakenly believe that reporting their 
victimization somehow makes them weak and less of a warrior. They worry 
that their career advancement will be disrupted and their security 
clearances revoked.
---------------------------------------------------------------------------
    \2\ U.S. Department of Defense (2008). 2006 Workplace and Gender 
Relations Survey of Active Duty Members. Washington, DC: Defense 
Manpower Data Center. Retrieved from http://www.sapr.mil/contents/
references/WGRA_OverviewReport.pdf.
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Bringing Sexual Assault Victims into Care
    In order to bring more victims forward, the Department offers two 
reporting options: Restricted and Unrestricted Reporting. The addition 
of Restricted Reporting as an option was critical to our program. 
Restricted Reporting allows victims to confidentially access medical 
care and advocacy services. Although Restricted Reporting does not 
trigger the investigative process, commanders are provided with non-
identifying personal information that allows them to provide enhanced 
force protection. Also, victims who initially make a Restricted Report 
may change their minds and participate in an official investigation at 
any time.
    Restricted Reporting is having the desired effect. At the end of FY 
2009, the Department had received 3,486 Restricted Reports since the 
option was made available in 2005. We believe that number represents 
3,486 victims who would not have otherwise come forward to access care 
had it not been for the Restricted Reporting option. In addition, 15 
percent of those victims who made a Restricted Report converted to 
Unrestricted Reports, allowing us to take action to hold those 
offenders accountable.
    Bringing as many victims forward to report the crime of sexual 
assault is one of our strategic goals. During the past 3 years, reports 
of sexual assault have been increasing by about 10 percent annually. 
While our goal is to decrease sexual assaults, we do want to increase 
the numbers of victims coming forward and are engaging in a variety of 
activities that encourage victims to report. For example, in 2008, the 
Secretary of Defense identified reducing the stigma of reporting sexual 
assault as one of his priorities. Since then, each of the Services has 
taken steps to educate their members that reporting the crime and 
seeking help are a sign of strength, not weakness. In 2009, the 
Department issued a memorandum underscoring that being the victim of a 
crime like sexual assault is not grounds for losing one's security 
clearance. The memo further encouraged all members of the Department of 
Defense, military and civilian alike, to engage care services as soon 
as possible following traumatic events.
Military Sexual Assault Response
    When we created our policy in 2005, we established the framework 
for a coordinated, multidisciplinary response system modeled after the 
best practices in the civilian community. Victim care begins 
immediately upon an initial report of a sexual assault. At the heart of 
our sexual response system are the Sexual Assault Response Coordinator 
(SARC) and Victim Advocates. Servicemembers worldwide have access to a 
24/7 response. Every military installation in the world--both in 
garrison and deployed--has a SARC and Victim Advocates who provide the 
human element to our response. Our SARCs and Victim Advocates will:

      Work with victims to identify and address issues related 
to their physical safety and needs as well as concerns about their 
commander and the alleged perpetrator;
      Listen to victims' needs and then connect them with 
appropriate and necessary resources, including medical care, mental 
health care, and legal and spiritual resources; and
      Connect victims to off-base resources when necessary.

    SARCs and Victim Advocates also work with victims to help them 
decide whether to make a Restricted or Unrestricted Report. In order to 
ensure that victims make an educated decision in which they are fully 
informed of their choices, we developed a Victim Preference Reporting 
Form (called DD 2910) which explains their options. This form is 
completed by the victim with the assistance of the SARC or Victim 
Advocate in every case. In each case, the SARC or Victim Advocate 
emphasizes that the victim should keep a copy of the DD 2910 in his or 
her personal files, as noted on the bottom of the form. (A sample of DD 
2910 is included at the end of my testimony.)
Tracking Victim Care
    The Department believes that comprehensive data collection and 
analysis are vital to policy analysis and program implementation. Thus, 
a Department-wide sexual assault database is currently under 
development. We have secured funding and will be soon awarding a 
contract for development.
Collaborating to Enhance Victim Care
    Effectively preventing and responding to sexual assault are 
demanding undertakings. We know that we cannot do it alone. As a 
result, we have been collaborating with other Federal, state, and non-
profit agencies to maximize our effectiveness. We have been working 
with the Department of Veterans Affairs since the inception of the 
program in 2005. In addition, we have recently begun to meet with a 
variety of veterans groups to identify what gaps there might be related 
to our issue as Servicemembers transition from active duty to veterans 
status. Meeting with non-governmental groups, such as Iraq and 
Afghanistan Veterans of America and the National Organization for 
Women, has helped us gain a fuller understanding of the challenges that 
veterans might be experiencing.
    One of the key areas of collaboration has been related to 
documentation. In 2007, we contacted the staff of the Veterans Benefits 
Administration (VBA) and briefed them on our Victim Preference 
Reporting Form (DD 2910). We forwarded copies of the form to VBA, which 
said that it would agree to accept a copy of the form, signed by both 
the victim and the SARC or Victim Advocate, as evidence of reporting of 
sexual assault. While treatment for sexual assault in a VA facility 
does not require this document, service connection determinations 
require some kind of evidence in the military record. Our form is not 
typically part of the medical record that is provided to VA for service 
connection determinations; however, it can be submitted by victims as 
part of their paperwork for a service connection determination.
    As noted throughout my testimony, reporting a sexual assault can be 
very challenging for a military victim--and many do not want the sexual 
assault in any kind of permanent record until they are ready to 
separate. As a result, corroborative evidence of sexual assault may be 
difficult to come by in a medical chart or other record system if the 
victim never reported the matter or if the member made a Restricted 
Reported and opted to not use medical care. Just as the DD 214 is the 
main basis for proof of military service, we would like the DD 2910, 
the Victim Preference Reporting Form, to be universally accepted as 
proof that a victim made a report of sexual assault.
    Past this coordination on reporting form, let me mention a few 
additional ways we have collaborated:

      A representative from VA participates, per our request, 
on our Sexual Assault Advisory Council, which was the main oversight 
body for the Sexual Assault Prevention and Response program in the 
Department.
      We have teamed with members of VA's Military Sexual 
Trauma Support Team to present our respective programs at national 
conferences.
      Members of my staff have attended VHA's annual training 
conference for Military Sexual Trauma Coordinators and presented on the 
DoD Sexual Assault Prevention and Response Program for the past 3 
years. In addition, my staff has also participated in VA webinars to 
educate VA providers about sexual assault and the DoD and VA programs.
      The MST Support Team and SAPRO often work together to 
ensure that victims of sexual assault are connected with the 
appropriate services. We have referred a number of victims to each 
other's offices for assistance.
Challenges in Caring for Military Victims of Sexual Assault
    In addition to what has been done to date, there is more our two 
Departments can do together to assist victims of sexual assault, but we 
need assistance in removing at least one barrier to collaboration: that 
is, state mandatory reporting laws.
    As I explained previously, prior to the implementation of 
Restricted Reporting, victims could not access medical care or advocacy 
services without the involvement of law enforcement and command. 
Restricted Reporting is critical to reducing the barriers that prevent 
victims from accessing care in the military. Despite all of its 
benefits, Servicemembers in a number of states, including California, 
do not have the option of Restricted Reporting if they wish to access 
medical care for a sexual assault. Victims cannot access private 
medical care and treatment either on or off base. California is an 
example of a state with this type of law. Section 11160 of California's 
Penal Code requires health care practitioners to make a report to law 
enforcement if they provide medical services for a physical condition 
to a patient whom he or she knows or reasonably suspects is a victim of 
various crimes of a sexual nature. That report must include the 
victim's name, whereabouts, and a description of the person's injury. 
There is no discretion on the part of a health care provider; the law 
requires mandatory reporting. Once the health care provider notifies 
civilian law enforcement, we cannot guarantee that they will not notify 
military law enforcement. Once military law enforcement is aware of a 
sexual assault, it must investigate and command must be notified.
    If our active duty members could make Restricted Reports in 
federally funded facilities, such as a VA Medical Center--no matter 
where it is located--we believe this would allow us a wider variety of 
options to offer victims for care. We do not know how many more reports 
we would have received had the Restricted Reporting option been 
available in California. This is a challenge that we need help in 
resolving.
Conclusion
    The Department of Defense and the Department of Veterans Affairs 
have made significant progress since 2005 in assisting victims of 
sexual assault. Both Departments have programs that truly address the 
needs of the victim.
    As I conclude my testimony, I would like to share one last thought. 
Each day, our Servicemembers dedicate their lives to protecting our 
country and deserve no less than the very best care and support in 
return. This is why it is so very important that we work together to 
make this program the best it can be. We can thank our SARCs, Victim 
Advocates, and first responders for dedicating their lives to those in 
need and giving back to those who serve.
    As mentioned earlier, since 2005, 3,486 individuals would not have 
received care and support had it not been for the creation of the 
Restricted Reporting and our program. That's remarkable progress. It's 
up to all of us (Department of Defense, Department of Veterans Affairs, 
and Congress) to continue to take the lead by working together to 
resolve issues so that our policy is effective for all of our 
Servicemembers.
    Thank you for your time and for the opportunity to testify today. I 
would be happy to answer your questions.
                              DD Form 2910

           Prepared Statement of Bradley G. Mayes, Director,
  Compensation and Pension Service, Veterans Benefits Administration, 
                  U.S. Department of Veterans Affairs

    Good Morning, Chairman Hall, Chairman Michaud, Ranking Members 
Lamborn, Brown, and Members of the Subcommittees: Thank you for the 
opportunity to appear to discuss the Department of Veterans Affairs' 
(VA's) work in identifying, treating and compensating Veterans for 
conditions related to military sexual trauma (MST). We are accompanied 
by Dr. Rachel Kimerling, Director of the Monitoring Division of the 
National Military Sexual Trauma Support Team in the Veterans Health 
Administration (VHA); and Dr. Patty Hayes, Chief Consultant for the 
Women Veterans Health Strategic Health Care Group (VHA).
    It is a tragic fact that many Veterans suffered sexual trauma while 
serving on active military duty. Some are still struggling with fear, 
anxiety, shame, or profound anger as a result of these experiences. A 
number of individuals have never discussed their experiences or their 
feelings with anyone, and they're understandably reluctant to talk 
about them now. That is why we would like to thank the Members of the 
Subcommittees for their diligent efforts to address this very important 
issue.
What Is Military Sexual Trauma (MST)?
    In both civilian and military settings, women and men can 
experience a range of unwanted sexual behaviors. Within VA, Veterans 
are likely to hear these sorts of experiences described as ``military 
sexual trauma,'' the overarching term VA uses to refer to experiences 
of sexual assault or repeated, threatening acts of sexual harassment. 
The definition used by VA is from the U.S. Code (1720D of Title 38) and 
is ``psychological trauma, which in the judgment of a VA mental health 
professional, resulted 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 or active duty for training.'' 
Sexual harassment is further defined as ``repeated, unsolicited verbal 
or physical contact of a sexual nature which is threatening in 
character.'' More concretely, MST includes any sexual activity where 
someone is involved against his or her will--he or she may have been 
pressured into sexual activities (for example, with threats of negative 
consequences for refusing to be sexually cooperative or with implied 
faster promotions or better treatment in exchange for sex), may have 
been unable to consent to sexual activities (for example, when 
intoxicated), or may have been physically forced into sexual 
activities. Other experiences that fall into the category of MST 
include unwanted sexual touching or grabbing; threatening, offensive 
remarks about a person's body or sexual activities; or threatening and 
unwelcome sexual advances. If these horrific experiences and often 
criminal acts occurred while an individual was on active duty or active 
duty for training, they are considered to be MST.
How Common Is MST?
    Information about how commonly MST occurs comes from VA's universal 
screening program. Under this program, all Veterans seen at Veterans 
Health Administration (VHA) facilities are asked two questions--one to 
assess sexual harassment and the other to assess sexual assault that 
occurred during their military service; Veterans who respond ``yes'' to 
either question are asked if they are interested in learning about MST-
related services available. Not every Veteran who responds ``yes'' 
needs or is necessarily interested in treatment. It is important to 
note that rates obtained from VA screening cannot be used to make any 
estimate of the rate of MST among all those serving in the U.S. 
military, as they are drawn only from Veterans who have chosen to seek 
VA health care. Also, a positive response does not indicate that the 
perpetrator was a member of the military. Approximately 1 in 5 women 
and 1 in 100 men seen in VHA respond ``yes'' when screened for MST. 
Though rates of MST are higher among women, because of the 
disproportionate ratio of men to women in the military, there are 
actually only slightly fewer men seen in VA who have experienced MST 
than women.
How Can MST Affect Veterans?
    It is important to remember that MST is an experience, not a 
diagnosis or a mental health condition in and of itself. Given the 
range of distressing sexually-related experiences and crimes that 
Veterans report, it is not surprising that there are a wide range of 
emotional reactions that Veterans have in response to these events. 
Even after severely traumatizing experiences, there is no one way that 
everyone will respond--the type, severity, and duration of a Veteran's 
difficulties will all vary based on factors like whether he or she has 
a prior history of abuse, the types of responses from others he or she 
received at the time of the experiences, and whether the experience 
happened once or was repeated over time. For some Veterans, experiences 
of MST may continue to affect their mental and physical health, even 
many years later. Some of the difficulties both female and male 
survivors of MST may have include:

          Strong emotions: feeling depressed; having intense, sudden 
        emotional reactions to things; feeling angry or irritable all 
        the time;
          Feelings of numbness: feeling emotionally ``flat''; 
        difficulty experiencing emotions like love or happiness;
          Trouble sleeping: trouble falling or staying asleep; 
        disturbing nightmares;
          Difficulties with attention, concentration, and memory: 
        trouble staying focused; frequently finding their mind 
        wandering; having a hard time remembering things;
          Problems with alcohol or other drugs: drinking to excess or 
        using drugs daily; getting intoxicated or ``high'' to cope with 
        memories or emotional reactions; drinking to fall asleep;
          Difficulty with things that remind them of their experiences 
        of sexual trauma: feeling on edge or ``jumpy'' all the time; 
        difficulty feeling safe; going out of their way to avoid 
        reminders of their experiences; difficulty trusting others;
          Difficulties in relationships: feeling isolated or 
        disconnected from others; abusive relationships; trouble with 
        employers or authority figures; and
          Physical health problems: sexual difficulties; chronic pain; 
        weight or eating problems; gastrointestinal problems.

    Among users of VA health care, medical record data indicate that 
diagnoses of post-traumatic stress disorder (PTSD), depression and 
other mood disorders, psychotic disorders and substance use disorders 
are most frequently associated with MST. Fortunately, people can 
recover from experiences of trauma, and VA has services to help 
Veterans do this.
How Has VA Responded to the Problem of MST?
    Since 1992, VA has been developing programs to monitor MST 
screening and treatment, providing staff with training on MST-related 
issues, and engaging in outreach to Veterans. More recently, VA's 
Office of Mental Health Services (OMHS) established a national-level 
MST Support Team to support these objectives and promote best practices 
in care. Services available to Veterans include:

      All Veterans seen in VA are asked whether they 
experienced MST and all treatment for physical and mental health 
conditions related to experiences of MST is free for both men and 
women.
      Every VA facility has a designated MST Coordinator who 
serves as a contact person for MST-related issues. This person can help 
Veterans find and access VA services and programs. He or she may also 
be aware of state and federal benefits and community resources that may 
be helpful.
      Every VA facility has providers knowledgeable about 
treatment for the aftereffects of MST. Many have specialized outpatient 
mental health services focusing on sexual trauma. Vet Centers also have 
specially trained sexual trauma counselors.
      Nationwide, there are programs that offer specialized 
sexual trauma treatment in residential or inpatient settings. These are 
programs for Veterans who need more intense treatment and support.
      To accommodate Veterans who do not feel comfortable in 
mixed-gender treatment settings, some facilities have separate programs 
for men and women.
Collaboration
    VA has developed a number of initiatives that promote coordination 
of care for active duty personnel and recently discharged personnel 
more broadly, but most coordination of clinical care for individual 
Veterans and active duty personnel seeking MST-related care happens on 
the local level and depends on the relationships that specific VA 
facilities have negotiated with local military installations. Local MST 
Coordinators often participate in or ensure inclusion of MST-related 
materials in local outreach events, particularly those post-deployment. 
At a national level, the VA MST Support Team has developed an ongoing 
relationship with the Department of Defense's Sexual Assault Prevention 
and Response Office (SAPRO). The OMHS MST Support Team and SAPRO have 
presented at each others' training events in order to share information 
about VA and DoD responses to sexual trauma with frontline clinicians. 
Staff from both the MST Support Team and SAPRO have given informational 
presentations about VA and DoD responses to sexual assault at a 
national VA training conference and at the International Society for 
Traumatic Stress Studies research conference. The two groups also 
communicate as necessary regarding individual Veterans needing 
assistance in locating appropriate services to match their treatment 
needs.
VBA Procedures for PTSD Claims Based on MST
    VA provides compensation payments for service-connected 
disabilities. The VA schedule for rating disabilities is based on the 
average earning loss resulting from the disabilities in the schedule. 
As the role of women in the military has expanded, the number of 
disability compensation claims received by VBA related to MST has 
increased. As you have already heard, MST may result in a number of 
disabling physical and mental conditions, but most often manifests 
itself as PTSD.
    In order to better assist those Veterans with PTSD claims based on 
MST, VA promulgated 38 CFR Sec. 3.304(f)(4) in 2002, which emphasizes 
that, if a PTSD claim is based on in-service personal assault, which 
includes MST, evidence from sources other than a Veteran's service 
treatment and personnel records may corroborate the in-service 
traumatic event. Such evidence may include, but is not limited to: 
records from law enforcement authorities, rape crisis centers, mental 
health counseling centers, hospitals, or physicians; pregnancy tests or 
tests for sexually transmitted diseases; and statements from family 
members, roommates, fellow servicemembers, or clergy. In addition, 
evidence of behavior changes following the claimed assault constitutes 
another source of relevant evidence. Examples of such behavior changes 
include, but are not limited to: a request for a transfer to another 
military duty assignment; deterioration in work performance; substance 
abuse; episodes of depression, panic attacks, or anxiety without an 
identifiable cause; or unexplained economic or social behavior changes. 
The regulation prohibits the denial of claims for service connection 
for PTSD based on in-service personal assault without first advising 
the Veteran that information from sources other than the Veteran's 
service records or evidence of behavior changes may constitute credible 
evidence of the stressor and allowing the Veteran an opportunity to 
furnish this type of evidence or advise VA of potential sources of such 
evidence. The regulation also provides that VA may submit any evidence 
it receives to an appropriate medical or mental health professional for 
an opinion as to whether it indicates that a personal assault occurred.
    This regulation takes into account the sensitive nature of MST and 
the difficulty with obtaining supporting evidence in many of these 
cases when service connection is claimed following the Veteran's 
separation from service. In those cases where PTSD is diagnosed during 
service and the claimed stressor is related to that service, VA 
regulations state that the Veteran's lay testimony alone may establish 
occurrence of the claimed stressor, provided that the claimed stressor 
is consistent with the circumstances, conditions, or hardships of the 
Veteran's service and in the absence of evidence to the contrary.
    VBA field personnel who adjudicate PTSD cases based on MST were 
provided with detailed information on proper claims processing methods 
in a training letter issued in November 2005. Additionally, all 
regional offices have a Women's Veteran Coordinator, who is well-versed 
in MST issues and can provide assistance to Veterans as necessary. 
These procedural steps taken by VA ensure that Veterans filing claims 
for PTSD based on MST will receive a fair and thorough consideration of 
their claims.
CONCLUSION
    VA recognizes the damage that MST can inflict on its victims, and 
it has developed responses that are focused on providing Veterans the 
care and support they need. We have achieved much, and are continually 
evaluating ways to improve. VA's MST Support Team is conducting a 
comprehensive study of providers of MST related mental health care. 
This will help us determine the number of unique providers at each 
facility who deliver MST related care, describe the characteristics of 
these providers, and assess the relationship of provider gender to 
patient gender to determine whether VA can consistently honor patients` 
expressed preferences for providers of a particular gender, as is VA's 
policy. These results will provide important information to help us 
ensure there is sufficient capacity for specialized MST related 
services at each VA facility. We look forward to sharing the results of 
this analysis with Congress when it is ready later this year.
    Thank you again for the opportunity to appear. We are prepared to 
answer any questions you may have.

                                 
Statement of Denise A. Williams, Assistant Director for Health Policy, 
    Veterans Affairs and Rehabilitation Commission, American Legion

    Messrs. Chairmen, Ranking Members and Members of the Subcommittees:

    The American Legion appreciates the opportunity to submit for the 
record our views on this very important issue.
                               Background
    The Department of Veterans Affairs (VA) defines Military Sexual 
Trauma (MST) as sexual assault or sexual harassment that occurred while 
in the military. This includes any sexual activity where someone is 
involved against his or her will. In 1992 P.L. 102-585 authorized VA to 
provide up to 1 year of treatment to women veterans for psychological 
trauma resulting from physical assault, battery or harassment of a 
sexual nature. The Veterans Health Care Extension Act of 1994 (P.L. 
103-452) granted VA the authorization to provide MST counseling to male 
veterans as well. On March 25, 2005 the Veterans Health Administration 
directive 2005-015 mandated that all enrolled veterans be universally 
screened for MST. In addition, the directive mandated that all VA 
medical facilities designate a MST coordinator to oversee MST screening 
and treatment and standardized training materials for MST.
    The VA provides treatment and counseling to all veterans that are 
suffering from MST and any mental and physical conditions related to 
MST. This service is afforded to all veterans free of charge. It is not 
necessary to have reported the incident while in the military or be 
service connected for this condition in order to receive this treatment 
and counseling.
    The Department of Defense (DoD) defines sexual assault as 
intentional sexual contact, characterized by use of force, physical 
threat or abuse of authority or when the victim does not or cannot 
consent. This includes rape, nonconsensual sodomy, indecent assaults, 
or attempts to commit these acts. In 2005, Congress directed the 
Secretary of Defense to develop a comprehensive policy for DoD to 
address the prevention and response to sexual assault involving 
servicemembers. In addition, the law requires that a standard 
definition for sexual assault be developed, DoD submits an annual 
report to Congress on reported sexual assault incidents involving 
servicemembers.
                                 Issues
    VA reported that in FY 2008 a total of 48,106 female veterans (21 
percent) and 43,693 male veterans (1.1 percent) screened positive for 
Military Sexual Trauma. According to the DoD Sexual Assault Prevention 
and Response Office (SAPRO), in FY 2008 there were a total of 2908 
official reports of sexual assault in the United States military; this 
is an increase from 2688 reported in FY 2007. Messrs. Chairmen, these 
numbers are alarming and The American Legion urges Congress, DoD and VA 
to act now to eliminate this disturbing trend.
    In addition to these astounding numbers of MST and sexual assault 
cases, The American Legion is deeply concerned to learn that VA and DoD 
actions to address this dire issue are lagging. In March 2010 the 
Government Accountability Office (GAO) published a final report 
entitled VA Health Care: VA Has Taken Steps to Make Services Available 
to Women Veterans, but Needs to Revise Key Policies and Improve 
Oversight Processes (GAO-10-287). It was based on site visits to nine 
VA medical centers (VAMCs) and ten Community Based Outpatient Clinics 
(CBOC) affiliated with these nine VAMCs, and eight Vet Centers, which 
are counseling centers that help combat veterans readjust from wartime 
military service to civilian life. GAO was asked to examine the on-site 
availability of health care to women veterans, the extent to which VA 
facilities are following VA policies that apply to the delivery of 
health care to women veterans, and key challenges that VA facilities 
face in providing health care to women veterans and how VA is 
addressing these challenges. The GAO report stated that only two of the 
VAMCs that they visited had specialized residential treatment programs 
specifically for women who have experienced MST. Although VA has taken 
steps to inform staff about their various programs offering MST 
treatment and counseling, this information is only available internally 
and VA has not provided this information on their external Web site 
where it can be easily accessed by veterans. The American Legion 
encourages VA to improve their transparency by making this information 
readily accessible to veterans and to also collaborate with the Veteran 
Service Organizations (VSOs) to disseminate this valuable information.
    In order to help address this problem, The American Legion has made 
dealing with such issues with the proper sensitivity a priority in the 
training of its Department Service Officers (DSOs). There are American 
Legion DSO's located in every State. These service officers can assist 
veterans and their families in filing a claim for benefits and gaining 
access to VA health care. DSO's are trained to recognize and handle 
benefits issues, claims and discharge upgrades for women veterans. DSOs 
are also encouraged to increase their own awareness of the available 
resources so as to better assist and inform veterans suffering from MST 
of those resources.
    The American Legion has also made tackling the issues faced by 
women veterans a high priority by conducting seminars and panel 
discussions at various of its national meetings. We publish an annually 
updated guide for Women Veterans that is one of our most sought after 
resources, even used by VA at Vet Centers to inform women veterans of 
the resources available for their specific needs. While The American 
Legion is proud to provide such materials and resources to veterans, VA 
should not lag behind what is offered in the private sector in such 
matters.
    Returning to the GAO study, the report also noted a lack of 
uniformity in the training practices of mental health professionals. VA 
policy on mental health (MH) professionals training is ambiguous and 
does not detail the necessary training for MH professionals who treat/
counsel victims of MST or other sexual trauma. As a result, some VA 
facilities have implemented their own guidance on training and 
experience of MH providers. The American Legion recommends that the 
Secretary of VA intervene and amend the policy to clearly define the MH 
professional's requirement to treat/counsel MST patients. This effort 
would assure that our veterans are not deprived of the best quality of 
care available to them.
    Unfortunately, the prevalence of sexual assault in the United 
States military continues to increase, regardless of the implementation 
of the DoD's Sexual Assault Prevention and Response (SAPR) program in 
2005. In 2008, the Defense Manpower Data Center conducted a Service 
Academy Gender Relations Survey to assess the incidences of sexual 
assault and harassment at the three academies. The report found that 
8.6 percent of women and 0.6 percent of men reported that they 
experienced unwanted sexual contact at the United States Military 
Academy. At the United States Naval Academy, 8.3 percent of women and 
2.4 percent of men indicated they experienced unwanted sexual contact. 
At the United States Air Force Academy 9.7 percent of women and 1.4 
percent of men reported they encountered unwanted sexual contact.
    The American Legion recommends that the Department of Defense 
aggressively enforce sexual assault prevention training on a more 
frequent basis. Additionally, we recommend that all servicemembers be 
educated on the procedures of how to report a sexual assault. 
Servicemembers in leadership positions should be trained on how to 
recognize physical and psychological signs of sexual assault. The 
American Legion declares that DoD has to effectively enforce zero-
tolerance towards sexual assault across the board with no exceptions.
    There is a certain aspect of the military's culture that may 
discourage a victim from reporting their sexual assaults. According to 
the American Journal of Public Health, perpetrators are typically other 
military personnel, and victims often must continue to live and work 
with their assailant daily, which increases the risk for distress and 
for subsequent victimization. Unit cohesion may create environments 
where victims face strong encouragement to keep silent about their 
experiences, having their reports ignored or even being blamed by 
others for the sexual assault. The DoD themselves admitted that only a 
small percentage of sexual assault is reported. The American Legion 
believes that in order to combat this appalling issue, there needs to 
be more involvement from top leadership within the Department of 
Defense.
    To further add to the aforementioned issues, veterans who suffer 
from MST encounter barriers when they file a claim for disability 
compensation through the Veterans Benefits Administration (VBA). The 
veterans are left with the burden to prove that they are eligible to 
receive compensation even though they have a diagnosis of Military 
Sexual Trauma from the Veterans Health Administration. As noted above, 
The American Legion has implemented a mandatory bi-annual training of 
our Department Service Officers to educate them on how to handle women 
veterans' issues and all MST claim cases whether male or female in a 
sensitive manner. We are trying to do our part to assist veterans in 
the handling of these difficult benefits claim cases and with the 
issue, in general. But it is incumbent on all of us, DoD, VA and the 
veterans' advocacy community, to make sustained efforts to deal with 
this growing problem or it will continue to fester. By having this 
hearing today, the Committee is obviously demonstrating its commitment 
to addressing the problem and we very much appreciate it.
    Once again The American Legion thanks you for the opportunity to 
provide our views. We are happy to answer any questions the 
Subcommittees may have and look forward to working with both 
Subcommittees on rectifying this issue.

                                 
   Statement of Beth K. Kosiak, Ph.D., Associate Executive Director, 
             Health Policy, American Urological Association

    I would like to thank the Subcommittee on Disability Assistance & 
Memorial Affairs and the Subcommittee on Health of the House Committee 
on Veterans' Affairs for your invitation to testify about urotrauma, a 
specific battlefield injury affecting a growing number of wounded 
military service personnel. Urotrauma is the term coined to refer to 
physical injury to the genitourinary system.
    We are receiving reports from our physician members, particularly 
from our urologists who have recently served in the armed forces in 
Iraq and Afghanistan, that urotrauma is an increasingly prevalent 
condition among our active military personnel and veterans. An 
escalating number of soldiers suffer extensive, debilitating injuries 
to the genitourinary system. These injuries have far reaching effects 
for years to come--including impaired sexual function and difficulty 
conceiving children. While not as readily apparent as the loss of limb 
or scarring to an exposed area of the body, urotrauma is a serious and 
growing problem.
    Urologists are disturbed that the knowledge and practice base is 
inadequate to meet this challenge. The American Urological Association 
(AUA), on behalf of its concerned surgeons, welcomes the opportunity to 
provide testimony and raise awareness about this condition.
    I am Beth Kosiak, Ph.D., the head of Health Policy for the AUA, a 
member organization that represents over 92 percent of the more than 
10,000 practicing urologists in the United States and over 16,000 
world-wide. The long-standing mission of the AUA is to promote the 
highest standards of clinical urological care through education, 
research, and formulation of health care policy. Urologists are the 
specialists who most often diagnose and treat prostate cancer, the 
second leading cause of cancer deaths among men in the United States. 
In addition, urologists diagnose and manage the care for kidney stones, 
urinary incontinence, urinary tract infections, and benign prostatic 
hyperplasia (BPH), among other conditions.
    There is insufficient data regarding the management of wartime 
genitourinary trauma. Neither a recent comprehensive review that 
examined available data from the 1960s to the present, nor a 1-year 
retrospective review of the United States Army trauma registry revealed 
substantial information on genitourinary trauma. While this latter 
registry provides valuable data on combat injuries, it does not record 
data specific to each genitourinary organ, nor does it detail what 
treatment modalities were used by urologists to manage genitourinary 
trauma.
    This dearth of data presents serious challenges to the appropriate 
diagnosis and management of these injuries.
    As battlefield rescues increase, more returning service personnel, 
particularly those who are victims of Improvised Explosive Devices 
(IEDs), are living with urotrauma injuries. Unfortunately, physicians 
must treat patients without the benefit of knowledge of the most 
effective treatments. Injury to urogenital organs accounts for between 
1 percent and 12.5 percent \1\ of all war injuries and most are 
associated with multiple lesions, especially abdominal.
---------------------------------------------------------------------------
    \1\ The figure of 12.5 percent was most recently supplied to us by 
Michael O'Rourke, head of Health Policy for the Veterans of Foreign 
Wars (VFW) in a personal communication on May 11, 2010.
---------------------------------------------------------------------------
    Most injuries observed during Operation Iraqi Freedom (OIF) and 
Operation Enduring Freedom (OEF) were due to IEDs and other explosive 
ordinance, and gunshot wounds. The extensive soft tissue loss seen with 
blast and high velocity bullet injuries necessitated a staged approach 
to genital reconstruction in many patients.
    More information needs to be gathered on the use of modern body 
armor in the prevention or minimization of genitourinary injury and to 
encourage improvements in the design of body armor to better protect 
the genitourinary area. The Joint Theater Trauma Registry was used to 
conduct a retrospective study of 2,712 trauma admissions to a United 
States Army Combat Support Hospital in Iraq. Casualties wearing body 
armor had a 2.1 percent rate of genitourinary injury versus 3.4 percent 
for those not wearing body armor.
    The Department of Defense (DoD) is sponsoring a major effort to 
focus on traumatic brain injury (TBI), and considers this one of the 
signature military medical challenges facing the Department for years 
to come. The DoD will fully implement a comprehensive TBI registry 
including a single point of responsibility to track incidents and 
recovery and expand corresponding treatment services. This effort 
provides a strong model for genitourinary trauma for which dedicated 
research on prevention and appropriate treatment could minimize long-
term/permanent damage, and encourage the development of more effective 
body armor.
    Given the urgent need for better data, information and clinical 
practice knowledge to treat and rehabilitate servicemen and women who 
experience such injury, the AUA has already taken several steps and 
plans to take more.
    First, and most significantly, we have authored a bill recently 
introduced in the House by Representatives Zack Space (D-OH) and Carol 
Shea-Porter (D-NH), H.R. 5106, which would establish an Interagency 
Commission on Urotrauma, led by the U.S. Department of Defense, to 
investigate and advise on the research and action needed to advance 
treatment of this important condition. The urotrauma legislation 
includes the following key provisions:

      Creation of ``The National Commission on Urotrauma,'' 
which will conduct a comprehensive study of the present state of 
knowledge and research on urotrauma, evaluate existing education and 
research resources, and identify knowledge and programmatic gaps.
      A long-range plan, based on the Commission's 
comprehensive study, for the use and organization of national resources 
to effectively deal with urotrauma, including: (1) researching 
innovations in the care and treatment of persons affected by urotrauma, 
(2) identifying ways to prevent or minimize these types of injuries, 
and (3) improving education and training to medical personnel caring 
for these individuals and raising awareness among the general public.

    Second, we have prepared and asked the Representatives to circulate 
a letter to their colleagues that asks for their support for this bill.
    Third, the AUA regularly produces evidence-based clinical practice 
guidelines which are gaining national attention for their scientific 
rigor, transparent methodology and timeliness. The AUA's Board of 
Directors has approved development of a clinical practice guideline on 
urotrauma; we anticipate that work will begin early in 2011. Our 
guidelines are publicly available on our Web site and are listed on the 
Federal National Guidelines Clearinghouse, sponsored by the Department 
of Health and Human Services' Agency for Healthcare Research and 
Quality (AHRQ). Thus, once completed, the urotrauma clinical practice 
guideline would be similarly available.
    Fourth, we have begun to engage our member urologists, particularly 
those who have served in military theaters, to provide their expertise 
to raise awareness and advance treatment knowledge about urotrauma.
    Finally, we have reached out to the Deputy Undersecretary for the 
Office of Wounded Warrior Care and Transition Policy of the Department 
of Defense, and supplied information in response to their request. We 
plan to contact other organizations and Federal agency offices where 
appropriate, to help educate relevant parties about urotrauma as well 
as offer the expertise of our member surgeons.
    I thank you for the opportunity to submit written testimony on this 
important topic, and offer the services of the AUA and its members to 
the Subcommittees if we can be of any further assistance.

                                 
 Statement of Christina M. Roof, National Deputy Legislative Director, 
                       American Veterans (AMVETS)

    Mr. Chairman, Ranking Members Lamborn and Brown, and distinguished 
committee members, on behalf of AMVETS, I would like to extend our 
gratitude for being given the opportunity to share with you our views 
and recommendations regarding the treatment of military sexual trauma 
within the Department of Veterans Affairs (VA), more specifically the 
Veterans Health Administration (VHA).
    AMVETS feels privileged in having been a leader, since 1944, in 
helping to preserve the freedoms secured by America's Armed Forces. 
Today our organization prides itself on the continuation of this 
tradition, as well as our undaunted dedication to ensuring that every 
past and present member of the Armed Forces receives all of their due 
entitlements. These individuals, who have devoted their entire lives to 
upholding our values and freedoms, deserve nothing less.
    By way of background and clarification, AMVETS understands that 
Military Sexual Trauma (MST) is in no way exclusive to the female 
veterans population, however much of our testimony today will be based 
on specialized treatments for women whom have experienced and are being 
treated for MST.
    Women veterans are the fastest growing subgroup of the American 
military veterans' population today. In fact, 2009 estimates show that 
women compose 14 percent of today's military forces, and within the 
next 10 years this number is expected to nearly double. If those 
estimates hold true than upwards of 30 percent of America's military 
forces and veteran community will be comprised of women. Women are also 
being deployed to combat zones at a rate in which this country has 
never seen and are carrying out vital roles on the frontlines. A 2008 
VA study showed that 45-49 percent of female OEF/OIF veterans were 
enrolled in the VA Health Care System and were using VA provided 
services on a regular basis. This same study also showed that over 50 
percent of the women currently enrolled in the VA health care system, 
46 percent were under the age of 30. Now, more than ever, we must make 
sure that VA is ready and equipped with the necessary staff, 
facilities, and gender specific care programs to offer the best 
available care to today's returning women servicemembers. According to 
VHA officials more than 1,000 new cases involving MST are uncovered 
each month, yet little is known to VHA staff about mental health needs 
of MST-exposed patients, or access to and utilization of services by 
these patients. While AMVETS understands that the VA health system is 
facing a very large endeavor in providing and implementing effective 
care models to their patients regarding MST, we also find self 
proclaimed lack of knowledge on the subject unacceptable. VA's health 
care providers must have the experience and knowledge to treat all 
wounds of war.
    Treatment and care models of MST do not differ so dramatically from 
VHA to care provided by private sector physicians to the extent that 
VHA should be having trouble understanding MST and the related metal 
disorders that often accompany it. There are already many established 
and long used models that can serve as guiding principles for VA in the 
establishment and implementation of care relating to MST. If VHA 
believes they are lacking in the prior experience needed to effectively 
provide care, AMVETS believes VHA may be best served in reaching out to 
private sector or other agency care providers for guidance and 
assistance. In fact, on March 3, 2009, VA's Principal Deputy under 
Secretary for Health, Dr. Gerald Cross, stated ``We believe it is 
essential that our medical professionals across the system be able to 
effectively recognize and treat the manifestations of sexual trauma and 
PTSD,'' further proving VA's agreement with AMVETS on this matter.
    VA defines Military Sexual Trauma as sexual or psychological trauma 
resulting from sexual harassment or abuse that either men or women are 
subjected to while serving in the military. Due to further research by 
AMVETS, we were able to gather a further breakdown of the terms used to 
define MST as recognized by VA. AMVETS research of current VA policies 
produced the following definitions:

    1.  Sexual Assault is defined as intentional sexual contact, 
characterized by the use of force, physical threat, and/or abuse of 
authority when the victim does not consent.
    2.  Sexual Assault is further defined as encompassing force or the 
threat of force, coercion is used, or when the un-consenting party is 
asleep, incapacitated, or unconscious.
    3.  Sexual Abuse is defined as, but not limited to, insistence on 
unwanted touching, forcing of unwanted sexual acts and demeaning 
remarks, treating as a sexual object with no regards to emotional well-
being.
    4.  Sexual Harassment is defined as a form of gender discrimination 
involving unwanted sexual advances, the requesting of sexual acts, and 
any other verbal or physical conduct of a sexual nature when a person's 
job, pay or rank are placed in jeopardy, creates an intimidating or 
hostile workplace, and/or offensive work environment.
    5.  Sexual Misconduct is defined as an act committed without intent 
to harm another and where, by failing to correctly assess the 
circumstances, a person believes unreasonably that effective consent 
was given without having met his/her responsibility to gain effective 
consent. Situations involving physical force, violence, threat or 
intimidation fall under the definition of Sexual Assault, not Sexual 
Misconduct.

    AMVETS believes that it is very important to bring attention to the 
fact that the Department of Defense does not currently include ``Sexual 
Harassment'' in their definition of sexual assault, as VA does. This 
difference of definition poses a problem in itself. AMVETS believes 
there needs to be a single definition on what constitutes ``Military 
Sexual Assault'' used by both VA and DoD to better recognize and treat 
victims of MST, as well as removing any questions regarding reporting 
of sexually related incidents.
    Studies conducted by VHA and private sector organizations from 
2006-2009 show that on average 24 percent of all female veterans 
screened during their initial VA health care assessment displayed the 
criteria necessary for having experienced a MST event during their 
service. One must remember that these numbers were obtained during 
initial screenings and do not factor in the female veteran population 
that were later given a diagnosis of a condition stemming from a MST 
event. Furthermore, with DoD and VA using separate definitions of MST 
it is impossible to know how many veterans have truly experienced a 
sexually traumatic event during their service.
    MST and its correlation to a magnitude of mental health disorders 
has been long documented and accepted within the medical community. 
However, it has not been until recently that women veterans under VA 
care have been specifically studied for the correlations of MST to PTSD 
and other mental health disorders. In 1996, a survey to determine the 
prevalence of physical and sexual abuse experiences, during and outside 
of military service, was conducted among 828 women veterans at the 
Baltimore Veterans Affairs Medical Center. Data collection was through 
an anonymous, mailed questionnaire. Three questions were used to elicit 
histories of physical abuse, sexual abuse, and rape. From the survey, 
429 completed forms (52 percent) were returned. Most of the veterans 
had at least some college education and about 50 percent served 4 or 
more years on active duty. About 68 percent of the respondents reported 
at least one form of victimization, while 27 percent reported to have 
undergone all three forms, of which sexual abuse was the most common, 
followed by physical abuse and then rape. It was during adulthood that 
all three forms of abuse took place, with one-third of the women 
reporting victimization during active duty. Coyle also found that 
single women and divorced women were more likely to report 
victimization than married women. In conclusion, physical and sexually 
abused women veterans were the ones more likely seeking care at the 
center.i
---------------------------------------------------------------------------
    \i\  Coyle BS, Wolan DL, Van Horn AS. The prevalence of physical 
and sexual abuse in women veterans seeking care at a Veterans Affairs 
Medical Center. Mil Med. 1996 Oct; 161(10):588-93.
---------------------------------------------------------------------------
    Research has shown that veterans who have experienced MST are at a 
high risk for developing a range of mental health conditions such as 
PTSD, major depression, anxiety, and panic disorder. MST victims may 
also struggle with other problems, including low self-esteem, 
difficulties with interpersonal relationships, and sexual dysfunction. 
To the best of AMVETS' knowledge, there have only been two 
scientifically valid studies conducted since 2001 that examined rates 
of DSM-IV PTSD diagnoses in women veterans with MST. First, Suris et 
al.,ii using a sample of female Veterans Administration (VA) 
patients, compared rates of PTSD related to two types of civilian 
sexual trauma with PTSD rates related to MST. Suris found that MST was 
more frequently traumatizing than civilian assault. Thus, the data 
indicates that MST is more predictive of PTSD than are other types of 
military trauma or civilian sexual trauma.
---------------------------------------------------------------------------
    \ii\  Suris A, Lind L, Kashner M, Borman PD, Petter F. Sexual 
assault in women veterans: an examination of PTSD risk, health care 
utilization, and cost of care. Psychosom Med. 2004; 66:749-56.
---------------------------------------------------------------------------
    The second study was conducted in 2006 by Dr. Deborah Yaeger. 
Yaeger et al.,iii compares rates of Post Traumatic Stress 
Disorder (PTSD) in female veterans who had military sexual trauma (MST) 
with rates of PTSD in women veterans with all other types of trauma. 
Both studies had findings that suggested that MST is common and that it 
is a trauma especially associated with PTSD. Yaeger's research actually 
showed correlation between the MST group and Other Trauma group (r=.13, 
P=.07) reflected a weak relationship. Dr. Yaeger also conducted a 
logistic regression analysis in which PTSD was regressed on MST and 
Other Trauma. Both the MST group (Wald x2=20.3, df=1, P=.0001) and 
Other Trauma group (Wald x2=5.4, df=1, P=.02) significantly predicted 
PTSD, but MST predicted it more strongly. This finding is significant 
because the number of women positive for MST was less than half of 
those positive for Other Trauma, yet the relationship of the MST group 
with PTSD was stronger.iv This is only one example of data 
showing the almost unquestionable link between MST and PTSD. Finally, 
in 2007, the Medical University of South Carolina wrote an article that 
reviewed the literature documenting the nature and prevalence of 
traumatic experiences, trauma-related mental and physical health 
problems, and service use among female veterans. Existing research 
indicates that female veterans experience higher rates of trauma 
exposure in comparison to the general population. Emerging data also 
suggest that female veterans may be as likely to be exposed to combat 
as male veterans, although not as directly or as frequently. Female 
veterans also report high rates of posttraumatic stress disorder, which 
has been associated with poor psychiatric and physical functioning. USC 
concluded that while sexual assault history has been related to 
increased medical service use, further research is needed to understand 
relationships between trauma history and patterns of medical and mental 
health service use. Researchers also are encouraged to employ 
standardized definitions of trauma and to investigate new areas, such 
as treatment outcomes and mediators of trauma and health.v 
AMVETS believes this review further demonstrates the importance of a 
uniformed definition of MST throughout all agencies, more specifically 
DoD and VA. AMVETS also believes these studies to show the importance 
of integrating mental health care, as outlined by VHA 1160.01, into all 
VAMCs and CBOCs providing primary care.
---------------------------------------------------------------------------
    \iii\  Deborah Yaeger, MD, Naomi Himmelfarb, PhD, Alison Cammack, 
BS, and Jim Mintz, PhD. DSM-IV Diagnosed Posttraumatic Stress Disorder 
in Women Veterans With and Without Military Sexual Trauma. J Gen Intern 
Med. 2006 March; 21(S3): S65-S69.
    \iv\  Deborah Yaeger, MD, Naomi Himmelfarb, PhD, Alison Cammack, 
BS, and Jim Mintz, PhD. DSM-IV Diagnosed Posttraumatic Stress Disorder 
in Women Veterans With and Without Military Sexual Trauma. J Gen Intern 
Med. 2006 March; 21(S3): S65-S69.
    \v\  Zinzow HM, Grubaugh AL, Monnier J, Suffoletta-Maierle S, Frueh 
BC. Trauma among female veterans: a critical review. Trauma Violence 
Abuse. 2007 Oct; 8(4):384-400. Review. PubMed PMID: 17846179.
---------------------------------------------------------------------------
    In 2005, VHA published VHA Directive 2005-015, authorized under 
P.L. 102-85 outlining specific policies, procedures and staffing 
requirements as they relate to the treatment and care of veterans who 
have experienced military sexual trauma (MST). To build upon this 
directive VHA 1160.01, as published in September of 2008, provided even 
more policies and procedures that all Veteran Affairs Medical Centers 
and Community Based Outpatient Clinics should employ when treating 
veterans having suffered MST. These policies and procedures provide 
guidance and outline all legally binding requirements of the treatment 
of veterans having experienced MST by all VAMCs and CBOCs. The measures 
are as follows:

      The constant availability, isolation and safety of 
``women only'' areas in each medical facility treating women veterans.
      That all medical directors ensure that every patient 
receiving care is screened for MST.
      The use of MST software that allows tracking of VA's 
screening of veterans. The Women Veterans Health Program and the Mental 
Health Strategic Work Group utilize the national MST report to respond 
to Congressional inquiries and for expansion of MST programs and 
initiatives.
      Veterans receiving MST-related counseling and treatment 
are not billed for inpatient, outpatient, or pharmaceutical co-
payments; however, applicable co-payments may be charged for services 
not related to military sexual trauma or for other non-service 
connected conditions.
      Scheduling priority for outpatient sexual trauma 
counseling, care, and services is consistent with the VHA performance 
standard of scheduling within 30 days for special populations and 
mental health clinics.
      Accurate documentation of screening, referral, and 
treatment services provided to veterans, aggregated by gender, is 
maintained. This process includes use of the MST software and the MST 
clinical reminder to track and monitor the level of compliance with the 
standard (100 percent of enrolled veterans screened). The nationwide 
tracking system to ensure consistent data on screening and treatment of 
victims of military sexual trauma must be used.
      MST counseling is provided by contract with a qualified 
mental health professional if it is clinically inadvisable to provide 
in Departmental facilities or when VA facilities are not capable of 
furnishing such counseling to the veteran economically because of 
geographic inaccessibility or the inability of the medical center to 
provide counseling in a timely manner.
      Veterans who report experiences of MST, but who are 
otherwise deemed ineligible for VA health care benefits based on length 
of military service requirements, may be provided MST counseling and 
related treatment only.
      The MST software application that activates the MST 
Clinical Reminder within CPRS has been installed at the facility. All 
veterans receiving VHA health care must be screened for MST using this 
clinical reminder.
      Veterans screening positive and requesting treatment are 
provided free care, with no inpatient, outpatient, or pharmacy 
copayments, for mental and physical health conditions resulting from 
their experiences of MST. Determination as to whether care is MST-
related is made by the clinician providing care. All MST-related care 
must be designated by checking the MST box on the encounter form for 
the visit.
      The time frames for evaluations of veterans for possible 
mental disorders resulting from MST must follow the requirements in 
paragraph 13, of VHA 1160.01.
      Evidence-based mental health care is available to all 
veterans diagnosed with mental health conditions resulting from MST.

    While AMVETS does realize that VA has been making efforts to 
provide better care to all women veterans, we were quite troubled by 
two recent GAO reports on the standards of care our female veteran 
population has been receiving at VAMCs and CBOCs, especially in the 
areas of mental health and MST treatments. In March 2010, GAO published 
a report entitled ``VA Has Taken Steps to Make Services Available to 
Women Veterans, but Needs to Revise Key Policies and Improve Oversight 
Processes,'' as a follow up report to the July 2009, GAO report 
entitled'' VA Health Care: Preliminary Findings on VA's Provision of 
Health Care Services to Women Veterans.''
    AMVETS believes that what GAO reported in March 2010 is 
unacceptable and quite negligent by many VAMCs in providing the most 
basics of care to our women veterans. For example, in the 2009 report 
GAO found that none of the facilities they visited were compliant with 
privacy requirements outlined by VA. Regrettably, in the more recent 
2010 report, GAO reported that most facilities still had not improved 
their measures to provide the required privacy to women veterans. 
Another area in need of compliance, as pointed out by GAO numerous 
times, are the requirements for treating veterans who have experienced 
any sort of MST, as outlined by P.L. 102-85 and 38 U.S.C. Sec. 1720D. 
Federal law specifically requires VA to establish a program to provide 
these MST-related services and to provide for appropriate training of 
mental health professionals and such other health care personnel as the 
Secretary determines necessary to carry out the program effectively. 
These laws state that every VA facility to be equipped and able to 
provide immediate care for any veteran who has experienced any 
psychological trauma as a direct result of a physical assault or 
harassment that was sexual in nature during their time in service.
    VA's MST-related policies require that VAMC directors appoint an 
MST Coordinator and that necessary staff education and training be 
provided. The MST coordinators are responsible, among other things, for 
monitoring and ensuring that VA policies related to MST screening, 
education, training, and treatment are implemented at the facility. GAO 
reported that VA had taken some steps internally to make information 
about MST programs more readily available to VA providers. 
Specifically, VA has conducted monthly, nationwide MST conference calls 
which have included basic information on the structure and focus of the 
various residential and outpatient programs offering MST or sexual-
trauma-specific treatment, as well as detailed presentations by key 
providers from several programs. VA also has a list of the various 
programs on its internal Web site, which is accessible by VA providers. 
However, GAO went on to say that VA had not made the same information 
accessible to veterans through VA's external Web sites or printed 
literature accessible to all veterans. As of November 2009, the Web 
site pages reviewed by GAO from VA's national Web site did not provide 
complete lists of facilities that have MST-related treatment programs 
or specialized programs for women veterans. The sites that did list 
specific residential treatment programs usually listed a single 
program, while nine VAMCs have relevant programs. AMVETS is quite 
concerned that VA's outreach to women veterans is falling short. While 
most of us here today are very familiar with VA programs, the average 
veteran is not. It is the responsibility of VA to not only design and 
implement these MST specific programs, but to also educate the veterans 
living in all parts of the country on the services available to them. 
How can a veteran receive the care and assistance they need if they do 
not even know that the care exists?
    It was the understanding of AMVETS that ensuring the privacy and 
integrity of all women veterans seeking care in a VAMC or CBOC was a 
requirement of federal law, not a suggestion. Women veterans seeking 
care for the most private and potentially damaging experiences, such as 
MST, must feel safe and that only their best interests are at hand by 
VA medical providers. What sort of message are we sending our returning 
female servicemembers, who have suffered a traumatic sexual experience, 
when VA is not able to offer them something as simple as an OB table 
facing away from the examine room door or a private and separate 
sleeping area from the male patients? Can VA honestly say, to this 
congressional Subcommittee and to all veterans, that the oversight they 
have exercised over the implementation of these care measures has been 
nothing less than their best? Can AMVETS be assured that every VAMC and 
CBOC is doing everything in their power to correct the deficiencies 
that have been repeatedly pointed out to them regarding the care of 
America's returning war fighters?
    AMVETS offers the following recommendations regarding military 
sexual trauma care and treatment issues:

    1.  AMVETS recommends these Subcommittees set forth a strict 
timeline in which VA will have to report all updates on the 
implementation of MST policies and procedures in every VAMC and CBOC, 
and that the Committee holds VA accountable to a specific date of 
systemwide total implementation. AMVETS further recommends that any 
requests for exception on meeting the specified deadline are required 
to be made in writing directly to the Secretary for final approval.
    2.  AMVETS recommends VA immediately update the information on 
their Web site, as well as written literature, to guarantee that all 
veterans are aware of the services available to them and where they may 
go to receive said services.
    3.  AMVETS recommends these Subcommittees maintain strict oversight 
on the implementation of VHA 1160.01 as it pertains to the availability 
of treatment for MST and all mental health care provided by VA, in 
efforts to implement and maintain uniformed mental health care 
systemwide.

                                 
   Statement of Hon. Henry E. Brown, Jr., Ranking Republican Member, 
                         Subcommittee on Health

    Thank you, Mr. Chairman.

    We are here this morning with our colleagues from the Subcommittee 
on Disability Assistance and Memorial Affairs to discuss issues 
surrounding Military Sexual Trauma (MST).
    Sexual assault and harassment is unacceptable in any sector of 
American society and is a particularly serious matter in our military 
and veteran populations.
    Because it occurs in a hierarchical and highly stressed 
environment, the negative physical and psychological effects of MST can 
be intensified and make one more likely to develop a mental health 
condition. The most common mental health condition observed among those 
veterans who report MST is post-traumatic stress disorder (PTSD).
    It is particularly troubling to me that a servicemember who is a 
victim of sexual assault is often hesitant to disclose their experience 
because they fear negative social stigma, peer pressure, and risking 
their career.
    It is encouraging that VA has come a long way since initially 
establishing a program to provide MST treatment in the 1990's. In 2003, 
VA began screening every patient seeking health care at a VA facility 
for MST and providing those who disclose it with free, confidential 
treatment and counseling. To receive such care, a veteran does not need 
to be service-connected, have reported the incident previously, or have 
documented that it occurred.
    Additionally, each VA facility has a designated MST point of 
contact, coordinated through VA's national MST Support Team. With the 
recently enacted Caregivers and Veterans Omnibus Health Services Act, 
Congress mandated sexual trauma training and certification for VA 
mental health providers to ensure proper provision of the supportive 
services veterans with MST experience need and deserve.
    VA's universal screening program is a good model to promote early 
detection and increase access to mental health care. However, there is 
still a great need to promote and develop effective therapies and 
conduct research to help us learn more about how to successfully treat 
veterans who experienced MST.
    When the men and women of our Armed Forces devote their time in 
service to our country, they knowingly accept the threat of danger from 
America's enemies. But what they should never have to accept is the 
threat of sexual trauma from their fellow servicemembers.
    I look forward to hearing from our witnesses on how we can all do a 
better job of combating MST and supporting the healing of those who 
have tragically experienced it. I thank you all for being here for this 
difficult and important conversation.
    Most importantly, I hope that any servicemember or veteran with MST 
who may be listening today will be encouraged to report their 
experiences and seek help at their local VA. I yield back the balance 
of my time.
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 14, 2010

Phyllis Greenberger
President and Chief Executive Officer
Society for Women's Health Research
1025 Connecticut Avenue, NW Suite 701
Washington, DC 20036

Dear Ms. Greenberger:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittee on Disability Assistance and Memorial Affairs' 
and Subcommittee on Health's joint oversight hearing on, ``Healing the 
Wounds: Evaluating Military Sexual Trauma Issues,'' held on May 20, 
2010. We would greatly appreciate if you would provide answers to the 
enclosed follow-up hearing questions by Wednesday, July 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all full 
committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Jian Zapata by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

John J. Hall
Chairman
Subcommittee on Disability Assistance
and Memorial Affairs
                                                 Michael H. Michaud
                                                           Chairman
                                             Subcommittee on Health

                               __________

        Questions from the House Committee on Veterans' Affairs
 Subcommittees on Disability Assistance and Memorial Affairs and Health
    ``Healing the Wounds: Evaluating Military Sexual Trauma Issues''
                              May 20, 2010
    Question 1: In your opinion, what training is needed to ensure that 
commanders treat military sexual trauma as it is, a crime?

    Response: The Society for Women's Health Research (SWHR) is 
dedicated to improving women's health through advocacy, education, and 
research. We appreciate the opportunity to offer insight into proven 
approaches in responding to sexual assault and to offer suggestions as 
to what we believe needs to be done in order for military sexual trauma 
(MST) to be taken seriously as a crime.
    First, it is clear that a top-down approach needs to be integrated 
into all MST training. Leaders within the military must emphasize that 
MST is not just an acronym--it is rape and it is a crime that affects a 
person both on an emotional and physical level. This must be clearly 
conveyed to those servicemembers that they lead. The actions and level 
of seriousness that leaders take toward MST should be reflected in the 
actions and behavior of those being instructed. By making clear from 
the beginning what is not tolerated or appropriate, leaders will be 
doing their part to foster an atmosphere of zero tolerance for sexual 
harassment and assault.
    SWHR commends the efforts of the Sexual Assault Prevention and 
Response Office (SAPRO) within the Department of Defense (DoD) for 
their efforts educating servicemembers and commanders about MST, and 
for their bystander outreach campaign targeting the vast majority of 
military members who are not sexual offenders. However, according to 
SAPRO reports, almost 100 percent of MSTs occur with the knowledge of, 
help of, or assistance from another individual. By educating what words 
and behaviors to watch for, and learning ways to respond and report as 
a bystander, SAPRO is helping to equip members with information to help 
stop these crimes from happening and to prevent the trauma and 
destruction in the first place. SAPRO has different training programs 
specific for commanders within the military; these programs help to 
educate commanders and leaders on sexual assault and harassment 
throughout their careers. SWHR applauds the leadership SAPRO has taken 
in addressing MST within the military, and hopes that their research 
and reporting on this topic will guide policy decisions that will 
eliminate the risk of MST for those who serve.
    Second, we will not understand the full scope of the problem unless 
better and more complete reporting systems are in place that emphasize 
coming forward for treatment, reduce stigma, and eliminate any threats 
to the victim's career. To ensure MST is treated as a crime, reporting 
of MST must be uninhibited, provide for privacy and be held with the 
highest discretion, and the repercussions must be swift, severe, and 
uniformly applied. According to a Department of Defense (DoD) report in 
2009, only 10 percent or fewer of sexual assaults are estimated to have 
been reported to law enforcement or military Sexual Assault Resource 
Centers. Studies completed by the VA in 2007 conclude that 20-30 
percent of female veterans were raped or assaulted while serving. It is 
likely that there is a higher number of MST survivors not yet accounted 
for, as less than 50 percent of female veterans have come forward to 
claim VA benefits or care, and as a result have not been included in 
the most recent VA surveys.
    Treatment is especially important for female victims of MST because 
of their likelihood to develop subsequent complications, such as 
sexually transmitted infections ((STI) or Post Traumatic Stress 
Disorder (PTSD). Sex-based research has found that women are more 
likely to acquire a STI than a man, and many of these infections can 
have potentially lifelong consequences. Additionally, women are twice 
as likely as men to develop depression and PTSD because of exposure to 
traumas. Prolonged feelings of fear, if not treated, can lead to 
increased levels of stress and anxiety, all with body wide impacts. 
Appropriately timed and sex-based interventions after MST could prevent 
overwhelming mental and physical health burdens on the victim as well 
as an avoidable financial burden to the Department of Veteran Affairs 
(VA).
    One reason why both men and women do not report MST stems from 
threats (explicit or implied) from the person(s) whom harmed them 
sexually and the stigma that comes with reporting being a victim of 
MST. An August 2009 article in The Seattle Times relayed a story from a 
male MST victim and his fear in coming forward because of death threats 
he had received. The men who gang raped him worked alongside him day in 
and day out; because of the close ties and personal connections with 
these fellow military men, he reports he felt lost on how to deal with 
the problem. Victims of MST are often filled with shame and 
humiliation, at a loss for what to do, especially when threatened if 
they speak up about their issues. This case highlights the fact that 
MST can and does happen to both men and women. If both sexes fear 
coming forward after MST because of threats of harm or career loss, 
stigmatization or because of the humiliation they as victims feel, the 
military faces a great challenge in overcoming this atmosphere of shame 
and suffering in silence.
    The VA Web site discusses the fact that victims of MST can 
experience a disturbance in their career goals (delayed promotions, 
demotions or dishonorable discharges) possibly due to factors such as a 
perpetrator who is a superior not recommending her for promotion, or 
because the woman is not performing at her best due to PTSD or avoiding 
certain assignments to avoid her assaulter. This is a great 
disadvantage to those who wish to advance up the ladder, however, 
choose not to once they realize they will be working alongside their 
perpetrator(s).

    Question 2: What training would you recommend for VBA benefits 
staff to ensure that they are properly recognizing the connections 
between MST and PTSD?

    Response: In response to the near doubling of female veterans in 
the past 5 years the Veterans Benefits Administration (VBA) is making 
great strides in improving the resources available to the increased 
number of women veterans. With 45.9 percent of servicewomen surviving 
MST going on to develop PTSD according to the VA's Web site update in 
2009, the connection between MST and PTSD is strong. In order to 
properly recognize, best assist, effectively treat, and ideally prevent 
PTSD in MST victims, a few interventional steps should be taken. The 
VBA will benefit from recognizing the numerous symptoms and side 
effects that can occur in any combination and with varying levels of 
severity; distinguishing the unique stresses and environmental 
triggers, addressing the looming emotional toll, and formulating 
individualized assistance.
    While the VBA coordinates benefits in addition to disability 
payments including reintegration, housing, education and 
rehabilitation, the medical personnel practicing within the VA medical 
centers must also take a multifaceted approach to best serve those 
surviving MST, with or without PTSD, including combining psychotherapy, 
medication and group reinforcement when appropriate.
    Symptoms of PTSD can appear immediately after the trauma, 
relatively late or in fluctuating intervals. The VA reports that while 
94 percent of females suffering from MST will experience some symptoms 
of PTSD within 2 weeks, 30 percent will experience some symptoms nine 
or more months later. With such a great variety in time between the 
trauma and onset of symptoms, and with many women trying to cope with 
MST on their own, it is especially important that all medical personnel 
are actively looking for and using medical questioning and testing to 
highlight any symptoms. Accordingly, the VBA must be flexible in 
designating timelines for claiming PTSD and related assistance. A 
report in July 2010 from the VA discusses the new regulations 
broadening the range of incidents that could cause PTSD and easing 
access to the benefits a veteran could receive. Increased research into 
the different experiences for women after MST, with or without PTSD, 
will help VA and civilian medical providers stand ready to better serve 
all victims with more targeted treatment regimens. Improved sex-based 
responses to MST and PTSD are not only crucial to preventing long term 
consequences of MST and effectively treating PTSD, but also to 
preventing the 13 percent of women suffering from PTSD that are more 
likely to abuse alcohol, the 26 percent of women that are more likely 
to abuse drugs and the countless female veterans that have contemplated 
suicide.
    Triggers, anything from a scent to a situation that causes the body 
to be reminded of the sexual assault, can reinforce PTSD caused by MST, 
enhancing memory consolidation and often causing a woman to react more 
negatively than a man. The case of MST with PTSD is especially unique 
in that the veteran had oftentimes lived side-by-side with the 
aggressor for some period of time, including after the assault. The 
unique stresses and overexposure to environmental triggers greatly 
influence the sufferer's psychological state and tend to have an even 
greater impact on women due to fluctuations in hormone levels and rates 
of memory consolidation. According to Margaret Alternus, speaking on 
the issue of sex differences at a 2008 Society for Women's Health 
Research conference on Posttraumatic Stress Disorder in Women Returning 
from Combat, women tend to react more negatively to interpersonal 
stressors, have a greater frequency and intensity of negative emotions 
due to fluctuating hormone levels, and have a heightened sensitivity to 
the hormone catecholamine, which is key to memory reconsolidation. 
While ultimately the DoD needs to be cognizant of the impact triggers 
may have on a woman who survived MST but continues to serve, it is 
imperative that the VA is equipped with a full scope of sex-specific 
treatment options for all veterans, and the VBA stand ready to provide 
assistance where necessary. Veteran benefits, health care, and 
reintegration efforts all need to coordinate to help the victim regain 
a sense of normalcy and reenter the community after the assault and 
after a tour of duty.
    The psychological ramifications of PTSD take a severe emotional 
toll on the sufferer and influence the ability to maintain conventional 
relationships, even long after the attack. By recognizing any prominent 
or underlying signs of relationship problems in the victim and a 
spouse, child or other immediate family members, a personalized and 
targeted care regimen could be created. A veteran's return to civilian 
life is a difficult adjustment for the individual and family, and the 
VBA is uniquely equipped to aid the veteran and family members during 
the transition with training, compensation, and education benefits. VBA 
should expect that a victim of MST, with or without PTSD, may require 
aid that is different from a servicemember not experiencing MST or 
PTSD. In addition, some regular family counseling should be made 
readily accessible, so that veterans will have a strong, well-informed 
emotional support system.
    The most important aspect to recognizing the connection between MST 
and PTSD and effectively treating it is through individualized 
attention. Flexibility within the VBA structure will allow for sex-
based and individual-based differences in needed assistance. Every 
woman's suffering was caused by a different event, is perpetuated by 
varying triggers, is influenced by unique hormone levels, and is 
characterized by personal combinations of symptoms. By recognizing 
these various factors, whether apparent or concealed, and creating 
individualized treatments, each female veteran has the ability to 
overcome her PTSD.

    Question 3: For female MST victims, you recommend that VA provide 
treatment and benefits that meet their gender specific needs. Do you 
believe that MST related benefit claims should be processes only by VBA 
staff of the same gender as the veteran claimants?

    Response: MST related benefit claims can be processed equitably and 
uniformly by a well-trained VBA staffer of either sex, however, the VBA 
may consider making case review by same-sex staffers an option if 
requested by a veteran.
    While the sex of the VBA staff adjudicating MST and PTSD related 
claims should not make a difference, there are obvious concerns about 
the sex of the health care provider and the participants of group 
therapy within VA medical centers that must be acknowledged and worked 
into VA care models. SWHR strongly believes that the VA should strive 
to provide evidence-based, gender-specific treatment options at each 
level of care. According to a June 2010 article in Time magazine, the 
VA has been working to implement policies to provide and improve sex-
specific care and treatment for veterans. One example includes all-
female therapy groups, especially for those women surviving sexual 
assault. This is a step in the right direction and SWHR hopes to see 
more improvements for veterans through the research and application of 
sex-specific care.

    Question 4: Your testimony discussed the importance of VA working 
with non-VA providers to ensure that veterans receiving private 
treatment for MST issues are nonetheless afforded the highest quality 
of care that meet VA's standards. Please elaborate on how VA can better 
collaborate with such providers to share clinical guidance and other 
important information on the treatment of conditions that result from 
military sexual trauma.

    Response: SWHR has learned through interviews with women veterans 
that a common reason why women seek care with non-VA providers is to 
ensure confidentiality. For the VA to ensure veterans are receiving the 
best care possible within their facilities they should start by making 
their care models more accessible and inviting, while ensuring privacy 
of records and during appointments.
    Another suggestion deals with training for non-VA providers. 
According to an article within The New York Times in July 2010, the VA 
is equipped with its own training programs that help to ensure proper 
treatment and care specifically for veterans. Tom Pamperin, an 
Associate Deputy under Secretary for Policy and Programs at the 
Veterans Department, states ``VA and VA-contact clinicians go through a 
certification process. They are familiar with military life . . .'' The 
VA could consider allowing non-VA providers to take this certification 
course, allowing public or private medical centers an opportunity to 
better ensure that veterans seen in these settings are provided with 
tailored treatment and care that fully meet VA standards. Another 
possibility would include allowing medical groups to model their own 
training session after the VA's model or seek consulting from the VA 
for proper treatment and care. In the setting of rising numbers of 
veterans, the VA may benefit from drawing up well trained non-VA 
providers to help in addressing in a timely fashion the needs of all 
veterans. SWHR supports recent recommendations calling for permitting 
outside clinicians to document PTSD for the purpose of claiming VA 
benefits, given the number of women who feel most comfortable seeking 
non-military assistance in dealing with MST or PTSD related issues.
    Also within The New York Times article, Eric Shinseki, Secretary of 
the VA, states ``This Nation has a solemn obligation to the men and 
women who have honorably served this country and suffer from the 
emotional and often devastating hidden wounds of war''. The VA's new 
policy for veterans with PTSD, easing barriers to claiming 
compensation, is a step in the right direction; however, considering 
the high number of war veterans, both male and female, who have PTSD 
because of MST, the VA should consider additional expansions in care 
and benefits recognizing the unique hardships and challenges faced by 
returning victims of MST.

    Question 5: Do you have suggestions on how the VA and DoD can 
better work together to ensure a smooth transition for servicemembers 
who have experienced a military sexual trauma?

    Response: The efforts of the VA and DoD to implement a mutually 
shared electronic health record is commendable. These advancements in 
technology and communication are establishing an unprecedented path 
towards seamless medical coverage that will certainly improve the 
health care delivered to servicemembers throughout their lifetime. 
Currently, the Virtual Lifetime Electronic Record (VLER) system is 
being strategically implemented, monitored and improved so as to 
facilitate the transition from military to civilian life. With some 
slight modifications, this system can also better monitor the effects 
of MST in the increasing number of female veterans.
    The VLER system right now seems to focus primarily on the sharing 
of medical records pertaining to pharmaceuticals and drug allergies. 
These records should conversely cover all aspects of the medical realm 
so as to allow for the complete interoperability of personal health 
information between the VA and DoD. This might include all the tests, 
screenings and any forms of therapy undergone while in the military. In 
addition, medical records prior to deployment could be scanned into the 
system, providing the most complete picture. This would highlight any 
previous conditions or trauma that might potentially impact a 
servicemember's health or susceptibility to PTSD. By integrating all 
medical records, the DoD and VA would be able to provide seamless 
medical coverage to individuals entering the military, throughout their 
deployment and as a veteran. With their unique access to data 
concerning male and female servicemembers, both the VA and DoD have an 
opportunity to be leaders in sex-based differences research, improving 
health for women and men, military and civilian.
    As a record number of women join the military scene and an 
increasing number of women are achieving veteran status, the VA and DoD 
must also collaborate to recognize the unique medical problems women 
are facing, and the various treatment options. It is imperative that 
the VA increase the amount of sex-based research being conducted, in 
order to meet its goal of creating evidence-based practices that are 
beneficial for the health and health care of women. One crucial topic 
of research should be studying the effects that MST and PTSD have on a 
woman's life span and health.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 14, 2010

Helen Benedict
Professor of Journalism, Columbia University
2950 Broadway
New York, NY 10027

Dear Ms. Benedict:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittee on Disability Assistance and Memorial Affairs' 
and Subcommittee on Health's joint oversight hearing on, ``Healing the 
Wounds: Evaluating Military Sexual Trauma Issues,'' held on May 20, 
2010. We would greatly appreciate if you would provide answers to the 
enclosed follow-up hearing questions by Wednesday, July 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all full 
committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Jian Zapata by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

John J. Hall
Chairman
Subcommittee on Disability Assistance
and Memorial Affairs
                                                 Michael H. Michaud
                                                           Chairman
                                             Subcommittee on Health

                               __________

   Answers to Questions from the House Committee on Veterans' Affairs
 Subcommittees on Disability Assistance and Memorial Affairs and Health
    ``Healing the Wounds: Evaluating Military Sexual Trauma Issues''
                              May 20, 2010
                     From Professor Helen Benedict
    Question 1: Professor Benedict, you suggest that MST could be 
reduced by promoting women and taking other steps to increase respect 
for women amongst commanders and the troops overall. As a member of the 
Visitors Board at West Point, I've long supported women military 
leaders, what steps do you suggest be taken to better promote women 
servicemembers within the ranks?

    Response: I have heard many stories of individual officers and NCOs 
who so resent the presence of women in their units that they deny them 
deserved promotion, recognition and even medals. In one case in my 
book, for example, a female army specialist helped to save four 
soldiers in a mortar attack at great risk to herself. Her immediate 
superiors recommended her for a Bronze Star, but the commander of her 
platoon, who had a long history of antagonism toward all the women in 
his unit, blocked the reward. She was never recognized for her bravery.
    Officers should be taught not to overlook women in this way, of 
course. But there should also be some oversight from the command to 
check whether the promotions and rewards in any particular mixed-sex 
unit shows a conspicuous lack of women recipients.
    The adequate recognition of women is a problem in the civilian 
realm, too, a product of the age-old habit of not taking women 
seriously or recognizing their work. Within the military, this attitude 
is exacerbated by the Pentagon's ban against women in combat, which 
relegates them to second-class status in many eyes.
    Fixing this bias against women usually takes conscious and 
deliberate attention. I am not suggesting that the military use quotas 
for rewards and promotions, only that if no women are among those put 
up in any particular unit, a high-ranking commander or review board 
should sound the alarm and start an investigation.

    Question 2: You also recommend that the military screen and perhaps 
reject recruits with history of being sexual violent perpetrators and 
victims. What impact do you predict this type of scrutiny can have on 
reducing MST?

    Response: First, to make clear, I absolutely did NOT recommend 
rejecting victims of sexual violence from enlisting in the military. 
That is a misreading of my statement. If we did that, we would lose 
about one sixth of our male recruits and about half of our female 
recruits. And we would be further punishing the victims of a crime that 
is no fault of their own.
    No, what I said was that we should reject anyone who has a history 
of COMMITTING sexual or domestic violence. The reason is clear: rape is 
a serial crime. Most rapists rape again and again, and most men who are 
violent against women at home will continue that behavior in the 
military. Rejecting those men will screen out many potential assailants 
from the military.
    I also recommend child sexual and physical abuse counselors for all 
the military, because VA studies show that about half our troops come 
from violent homes. Such counselors may be able to prevent anger, 
sexual violence and suicidal behavior among servicemembers with 
troubled backgrounds.

    Question 3: Since a DoD survey reveals that men may make up more 
than one-third of military sexual harassment victims, what type of 
training do you recommend DoD and VA employ to prevent MST amongst both 
men and women?

    Response: It is essential that all sexual assault prevention 
training begin with a proper definition of sexual assault and rape. It 
needs to be made clear that assailants are not acting out of pent-up 
lust, or responding to seduction, but are predators taking advantage of 
their power or circumstances to force others into sexual contact.
    Sexual predators are more interested in dominating and degrading 
their victims than in satisfying sexual frustration.
    In short, it should be emphasized that the victim is never to 
blame. Even if he or she is drunk or flirtatious, or makes a careless 
or even serious mistake (such as leaving a weapon unattended), this is 
not the same thing as asking to be assaulted.
    The lack of blame and de-sexualization of rape and assault will 
help men and women feel safer to report and to seek treatment.
    For men, it needs to be emphasized that rape does not happen 
because either the victim or the perpetrator are homosexual. In fact, 
studies show that most rapists of men are heterosexual.
    For male victims, it is also essential that the Don't Ask, Don't 
Tell rule be repealed. While it exists, most male victims are too 
afraid to report an assault in case they are then labeled as homosexual 
and expelled from the military.

    Question 4: In your testimony, you mentioned that victims who did 
not report an assault while on active duty have often been denied 
treatment through VA. However, VA is responsible for treating all 
servicemembers who screen positive for MST, even if they do not have a 
service-connection. Can you elaborate on this point?

    Response: The contradiction here is about the gap between the rules 
and the practice. Even though troops are entitled to MST counseling, in 
practice many are told that their problems are a ``pre-existing 
personality disorder,'' and so are not covered by the military or the 
VA. Others are told that their problems are in their heads, that they 
are malingering, or otherwise lying. I say this because I have heard 
dozens of stories from soldiers themselves about this.
    Several news stories have come out about the way this diagnosis of 
pre-existing personality disorders is used by the VA to deny treatment 
and save money. It will take congressional oversight and condemnation 
to end this practice. The need is urgent, because the problem is 
widespread and devastating, and it affects not only MST victims, but 
even soldiers with physical wounds and traumatic brain injury.
    I know Congress has already held hearings on the problems soldiers 
face getting the counseling and treatment they need and deserve. 
National Public Radio and several other news outlets have been covering 
this problem for some time. The bottom line seems to be that the VA is 
instructing its psychologists and doctors to deliberately misdiagnose 
problems as pre-existing conditions in order to save money. This needs 
to be unearthed and stopped immediately.
    In short, the answer to this question is to better police the 
medical practices toward our troops both within the military and the 
VA.
    See http://veterans.house.gov/news/PRArticle.aspx?NewsID=111.

            Yours,

                                                     Helen Benedict
                                     Professor, Columbia University

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 14, 2010

Joy Ilem
Deputy National Legislative Director
Disabled American Veterans
807 Maine Avenue, SW
Washington, DC 20024

Dear Ms. Ilem:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittee on Disability Assistance and Memorial Affairs' 
and Subcommittee on Health's joint oversight hearing on, ``Healing the 
Wounds: Evaluating Military Sexual Trauma Issues,'' held on May 20, 
2010. We would greatly appreciate if you would provide answers to the 
enclosed follow-up hearing questions by Thursday, July 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all full 
committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Jian Zapata by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

John J. Hall
Chairman
Subcommittee on Disability Assistance
and Memorial Affairs
                                                 Michael H. Michaud
                                                           Chairman
                                             Subcommittee on Health

                               __________

        POST-HEARING QUESTION FOR JOY J. ILEM, DEPUTY NATIONAL 
         LEGISLATIVE DIRECTOR OF THE DISABLED AMERICAN VETERANS
          FROM THE SUBCOMMITTEES ON DISABILITY ASSISTANCE AND 
        MEMORIAL AFFAIRS AND HEALTH HEARING, Healing the Wounds:
   Evaluating Military Sexual Trauma Issues, COMMITTEE ON VETERANS' 
     AFFAIRS, UNITED STATES HOUSE OF REPRESENTATIVES, MAY 20, 2010
    Question 1: Ms. Ilem, you raise a good point, that military sexual 
trauma (MST) victims, both men and women, often do not report sexual 
trauma when it happens initially. As a result, these MST victims have 
difficulty in demonstrating the injuries caused by sexual trauma are 
``service-connected'' in the context of VA disability claims. Can you 
elaborate on the particular challenges faced by men in the military in 
reporting sexual trauma? What can DoD and VA do to increase prompt 
reporting of MST by victims, men and women alike?

    Answer: It has been my experience in working with male veterans who 
report MST, that they too find it extremely difficult to come forward 
and report the incident to their superiors. They report feeling shame, 
humiliation, weakness, and a loss of trust among other military 
servicemembers along with many other typical responses to personal 
assaults. Some male victims have noted it is especially difficult to 
report these incidents given the ``warrior'' culture of the military, 
and the general (and mistaken) belief in our society that this type of 
assault is a crime against women. In fact, even in VA, it is most 
generally and incorrectly associated with women veterans--and is often 
considered ``a women veterans' issue.'' It is not. For a more detailed 
explanation, see my response below to Question no. 4.
    In our opinion, DoD and VA have many similar challenges before them 
to increase prompt reporting of MST incidents. The issue of stigma cuts 
across both agencies and likely only a concerted and lengthy campaign 
to reduce the stigma associated with MST would enable noticeable change 
to occur. Over the past several decades, this issue has been a catalyst 
for a number of high profile scandals in the military service branches, 
and has stimulated task force reports, policy changes, negative media 
coverage, as well as new research. A continuing focus on prevention of 
MST in the ranks, along with a no-tolerance policy and accountability 
of military leadership to address MST, would be critical and necessary 
steps to be made before victimized servicemembers will readily come 
forward to report these incidents. Until victims of MST feel assured 
that they will be believed, the incident will be properly investigated, 
the perpetrators appropriately punished and their military careers will 
not be negatively impacted because of their reporting MST incidents--it 
is unlikely that DoD will be able to increase prompt and routine 
reporting from within this population.
    Within VA health care programs, it is clear there is a much better 
chance that a veteran (male or female) will report MST in conjunction 
with seeking medical care or mental health services for conditions 
consequent to sexual trauma. However, male and female veterans still 
face a number of barriers in the Veterans Benefits Administration (VBA) 
related to verifying stressors and establishing service connection for 
conditions related to sexual assaults when those events were not 
reported during their military service. Many of these claims are 
denied, and veterans report that the VA's denial of their claim adds to 
the mental anguish resulting from the assaults.

    Question 2: From your testimony, it appears that the key 
differences between restricted and unrestricted reporting is that 
restricted reporting permits MST victims to secure examinations and 
treatment assisted by a Sexual Assault Response Coordinator (SARC) and 
Victim Advocate without notifying the victim's chain of command or law 
enforcement authorities. According to DoD, nearly 4,000 cases of sexual 
assault have been documented via a restricted reporting system, with 
just 15 percent of these cases ultimately being moved to the 
``unrestricted'' category, which I understand is necessary for 
prosecution under the Uniform Code of Military Justice (UCMJ). What are 
your thoughts on the two track reporting system? Do you have any 
concerns?

    Answer: Although somewhat controversial at first the ``two track'' 
reporting system does allow servicemembers, who in the past may have 
stayed silent, to come forward and receive necessary medical and mental 
health services for conditions related to sexual assaults--and most 
importantly the time to reflect (up to 1 year) and choose if they wish 
to pursue criminal actions against their perpetrators. DAV's biggest 
concern, highlighted in our testimony, is these same veterans' 
inability (and ultimately VA's) to access examination and treatment 
records that could be used to verify reports of sexual assault to 
establish service connection for MST-related conditions. For all 
essential purposes these critical records seem to be in permanent limbo 
or even worse, destroyed, due to an ineffective DoD administrative 
policy, and overabundance of caution concerning privacy, or simple 
bureaucratic red tape. We believe DoD needs to revamp its all-service 
branch policy dealing with standardizing the retention rules and making 
these records available to both the victims themselves, and to their 
official representatives, or VA benefits personnel, in appropriate 
circumstances, and with proper controls to protect privacy and 
confidentiality.

    Question 3: Your testimony cited several studies by VA on the 
number of veterans who reported having suffered a military sexual 
trauma while being screened. Do you think that the screening is 
capturing most of the veterans who suffered an MST, or is it likely 
that there is a significant number slipping through the cracks, due to 
stigma or otherwise?

    Answer: Research on this issue reflects that an effective screening 
program that promotes the detection of MST and access to evidence-based 
mental health care helps to reduce the burden of illness for those who 
have experienced MST. To that end, VHA's nationwide policy and 
universal screening program for MST represents one of the most 
comprehensive responses to sexual violence in any health care system in 
the United States. MST screening in VHA is part of all veterans' 
routine medical visit protocol that provides an opportunity for 
clinical staff to educate patients on mental and physical health 
conditions associated with a history of such trauma, inform them of 
specialized programs and treatment options to ultimately increase 
access to effective treatments. Performance monitoring indicates that 
in FY 2006, 86.7 percent of all VHA patients had been screened for MST, 
and prior research indicates that the remaining 13.3 percent who were 
not screened were atypical users of the system--those who used 
significantly fewer VHA services than screened patients.
    Even with this prospective approach to screening in VA, it is 
likely that some veterans are still falling through the cracks, but 
probably more so due to the general nature of stigma associated with 
sexual trauma and reporting. According to research findings, only 26 
percent of sexual assaults in the United States are ever reported. That 
said, most victims likely will never feel comfortable disclosing that a 
sexual assault occurred. However, VA's universal screening opens the 
door for the providers to counsel patients about mental and physical 
outcomes of a victim of sexual assault or other trauma who does not 
receive services. It is suggested that universal screening may be an 
effective and non-stigmatizing means of detection--especially for 
assessment of male patients for whom sexual trauma is rarely a focus of 
provider attention. VA researchers stated that although not all 
patients who screen positive for MST require mental health treatment, 
men and women with positive screens are approximately three times more 
likely than those with negative screens to be diagnosed with having a 
mental disorder. These research findings strongly suggest that VHA's 
screening program for MST has increased rates of mental health 
treatment among patients who screen positive for such trauma, and DAV 
believes that this finding represents very good progress.
    Additionally, research findings from female veterans of the 1991 
Persian Gulf War note that rates of sexual assault, physical sexual 
harassment and verbal sexual harassment were higher than those 
typically reported in a peace-time military sample, suggesting that 
exposure to these types of experiences may be more prevalent during 
times of combat. Researchers stated that given the longer deployments 
and increased stressors associated with the current wars in Iraq and 
Afghanistan relative to the Gulf War, recent war veterans eventually 
could report even higher rates of sexual assault and harassment.

    Question 4: You noted that the population of women being treated by 
VA for MST is nearly equal to the number of men receiving such 
treatment. Yet VA reports that, during FY 2009, 21 percent of women 
screened reported MST, compared to 1.1 percent of men. Is the 
discrepancy between the percent of each gender population screening 
positive for MST and the total number receiving treatment simply 
attributable to the fact that the population of men receiving treatment 
in VHA is far larger than the population of women? Or do some women who 
screen positive for MST not receive treatment? If so, why not?

    Answer: There is no discrepancy in the information provided to the 
Subcommittees. In my testimony I noted that, ``. . . the size of each 
VA clinical population (men to women) who reported MST within VA 
treatment programs is almost equal: 53,295 women and 46,800 men 
respectively.'' To be clear this reference refers to how many veterans 
seen in VHA have reported or screened positive for MST, not the number 
of veterans who were treated. According to VA's FY 2009, Military 
Sexual Trauma Screening Report, 21.9 percent (or 53,295) of female 
veterans screened positive for MST, compared to male veterans at 1.1 
percent (or 46,800). In the same report, VA also stated that every VA 
facility provided MST-related care to both men and women in FY 2008 
with specifically:

      474,966 MST-related [treatment] encounters, comprising 
314,128 encounters with female veterans (80.2 percent of these were 
mental health care) and 160,838 encounters with male veterans (78.0 
percent of these were mental health care)

    The VHA has over 6 million unique users of its health care system. 
Approximately 95 percent of those users are men and approximately 5 
percent are women. Of the 95 percent of male users or 5.5 million 
patients, 1.1 percent or (46,800) screened positively (meaning, they 
reported MST). Of the 5 percent of women (approximately 500,000) using 
the system, 21.9 percent or (53,295) screened positively (meaning, they 
reported MST). VHA testified that 1 in 5 women and 1 in 100 men seen in 
VHA respond ``yes'' when screened for MST. Although rates of MST are 
higher among women than men, the disproportionate ratio of men-to-women 
serving in the military, results in only slightly fewer men being seen 
in VHA with MST than women. In other words, the actual number of men-
to-women who were screened and reported MST is nearly equivalent.
    VA researchers concluded that the high numbers of MST reported 
among its entire patient population underscore the contention that 
military sexual trauma represents a significant problem with particular 
relevance to VHA. Of particular note is the opportunity for VHA to 
focus on early detection and treatment of MST to prevent chronic long-
term health consequences associated with MST such as chronic post-
traumatic stress disorder, anxiety, depression and substance-use 
disorders--especially in the most recent generation of veterans coming 
to VHA for care.
    For further information and data related to my responses to 
questions no. 3 and 4, please see Evaluation of Universal Screening for 
Military-Related Sexual Trauma, ps.psychiatryonline.org, June 2008, 
Vol. 59, No. 6. [a VA Research and Development-funded study published 
in the journal of the American Psychiatric Association].

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 14, 2010

Kaye Whitley, Ed.D.
Director, Sexual Assault Prevention and Response Office
Office of the Under Secretary of Defense for Personnel and Readiness
U.S. Department of Defense
1400 Defense Pentagon
Washington, DC 20301

Dear Ms. Whitley:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittee on Disability Assistance and Memorial Affairs' 
and Subcommittee on Health's joint oversight hearing on, ``Healing the 
Wounds: Evaluating Military Sexual Trauma Issues,'' held on May 20, 
2010. We would greatly appreciate if you would provide answers to the 
enclosed follow-up hearing questions by Wednesday, July 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all full 
committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Jian Zapata by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

John J. Hall
Chairman
Subcommittee on Disability Assistance
and Memorial Affairs
                                                       Doug Lamborn
                                                     Ranking Member
                                         Subcommittee on Disability
                                    Assistance and Memorial Affairs

Michael H. Michaud
Chairman
Subcommittee on Health
                                                Henry E. Brown, Jr.
                                                     Ranking Member
                                             Subcommittee on Health

                               __________

                       Hearing Date: May 20, 2010
     Committee: HVAC, Member: Congressman Hall, Congressman Brown, 
     Congressman Michaud, Congressman Lamborn, Witness: Dr. Whitley
      Date of Sexual Harassment and Sexual Assault in the Military
    Question 1: According to DoD's study issued over 15 years ago, in 
1995, before the current conflicts in Iraq and Afghanistan, it was 
estimated that 78 percent of women and 38 percent of men had been 
victims of sexual harassment. What is the rate of sexual harassment and 
sexual assault in the military today? And what training is in place for 
commanders (both at the officer and non-commissioned officer level) to 
ensure that military sexual trauma is treated as it is--a crime?

    Answer: In order to generate an estimate of the incidence of sexual 
assault in the military, the Department of Defense (DoD) relies on the 
information collected through its quadrennial Gender Relations Survey 
(GRS). The most recent GRS from 2006 found that 6.8 percent of women 
and 1.8 percent of men on active duty experienced some form of unwanted 
sexual contact (e.g., a sexual assault) during the previous year. In 
the same study, 34 percent of women and 6 percent of men experienced 
some form of sexual harassment. The 2010 GRS is currently underway and 
this data will be available in FY 2011.
    Regarding the issue of training, the DoD Instruction 6495.02, 
Sexual Assault Prevention and Response Program Procedures, specifies 
sexual assault program training requirements for both commanders and 
senior enlisted leadership. This training occurs at numerous stages 
throughout their military careers and addresses their responsibility in 
appropriate prevention and response to the crime of sexual assault.
    Impact of Screening Military Recruits for Prior Sexual Violence
    Question 2: Military Sexual Trauma (MST) experts have suggested MST 
could be curbed by DoD screening its recruits for history of sexual 
violence. What is the potential impact of this type of scrutiny to 
DoD's mission? Also, if such screening was implemented, would you 
prefer barring sexual assault perpetrators and victims from military 
service or rather providing them with extra training and counseling if 
needed?

    Answer: The Department already screens and denies entry for 
recruits with a history of sexual assault perpetration. Paragraph 4.7 
of Department of Defense (DoD) Directive 6495.01, Sexual Assault 
Prevention and Response (SAPR), makes it DoD Policy to ``Prohibit the 
enlistment or commissioning of personnel in the active duty Armed 
Forces, National Guard or Reserve components when the person has a 
qualifying conviction for a crime of sexual assault.''
    Screening out victims of sexual violence would not realistically 
contribute to reducing the incidence of sexual assault in the military. 
Such a disqualifier would only serve to punish a victim for having 
reported a crime that occurred prior to service. Servicemembers who 
have been victims of sexual violence prior to accession into the 
military may currently report that abuse to SAPR personnel and receive 
assistance, to include counseling and treatment in a military treatment 
facility.
        Retention and Disposition Policy of DoD for MST Records
    Question 3: What is the retention and disposition policy of DoD for 
MST records, restricted and unrestricted, and is that policy different 
across military service branches?

    Answer: The Department has two primary forms used in for 
documentation of sexual assaults, DD Form 2910, Victim Reporting 
Preference Statement, and DD Form 2911, Forensic Medical Report: Sexual 
Assault Forensic Examination.

      Currently, signed and dated copies of DD Form 2910, 
Victim Reporting Preference Statement, are kept indefinitely by the 
Military Services by the Sexual Assault Response Coordinator (SARC) to 
whom the sexual assault was reported. In the Air Force and Army, the 
forms are kept at the installation where the sexual assault was 
reported. In the Navy, the forms are entered into its Case Management 
System--an electronic database. In the Marine Corps, the SARC maintains 
the form for 3 years and after that time period, the SARC forwards the 
forms to be maintained at HQ Marine Corps. The Department of Defense is 
currently formulating additional guidance to standardize the retention, 
storage and retrievability of both documents in the long term.
      When the DD Form 2911, Forensic Medical Report: Sexual 
Assault Forensic Examination, is completed by a Department of Defense 
medical care provider, the form is to be included as part of the 
victim's military medical record if the report is unrestricted.

    In a restricted report, the DD Form 2911 remains with the Sexual 
Assault Forensic Examination kits that is maintained by a designated 
custodian and then is destroyed at the 1-year mark.
    Each Service has its own forms and retention policies for sexual 
harassment complaints:

      In the Army, a formal sexual harassment complaint is 
filed using a DA Form 7279, Equal Opportunity Complaint Form. After a 
complainant's case is closed, the complaint packet (with DA Form 7279) 
will be filed by the first Equal Opportunity Advisor (EOA) in the 
complainant's chain of command. The EOA retains the file for 2 years 
from the date of the final decision on the case.
      The Navy uses the Navy Equal Opportunity Formal Complaint 
Form (NAVPERS 5354/2) for recording formal harassment complaints. Per 
the Navy policy, a command must maintain completed complaints and 
investigations for 36 months.
      The Marine Corps uses the Equal Opportunity Contact Sheet 
to record reports of sexual harassment. Closed complaints are 
maintained by the receiving command for 2 years.
      The Air Force uses two forms for documenting allegations 
of sexual harassment: AF Form 1587, Equal Opportunity Formal Complaint 
Summary, and AF Form 1587-1, Equal Opportunity Informal Complaint 
Summary. Hardcopy forms must be kept for a period of 2 years after 
complaint closure at the installation EO office where the sexual 
harassment complaint was filed. Additionally, all complaint information 
is entered in the Air Force Complaint Management System, Equal 
Opportunity Network (EONet).
                  Unrestricted Sexual Assault Records
    Question 4: If a record of a sexual assault is made unrestricted by 
the victim, this means a DoD criminal investigation is triggered. It 
also usually means that the victim has agreed that details of the 
attack, and his or her identity, can be used in prosecuting a suspect 
for a sexual assault. What is the reason for maintaining the record 
associated with the investigation of the unrestricted case (as well as 
the forensic examination record) in a different place than that of the 
individual's military personnel record when the victim has given 
consent that this information can be made available to others? Is there 
a basis at some point, after the case is disposed of, and perhaps after 
the victim leaves the military, for the MST record to be filed in the 
official military personnel record?

    Answer: According to the 2006 Defense Manpower Data Center (DMDC) 
Gender Relations Study, one of the primary reasons victims choose not 
to report a sexual assault is because they are afraid that doing so 
negatively impacts their career. Given that, including a copy of the DD 
Form 2910, Victim Reporting Preference Statement, in a Servicemember's 
official personnel record could discourage reporting of sexual assault 
by victims, as they could perceive it could disparage their record and 
halt their career advancement. Victims also fear losing control of 
private information. Requiring the DD Form 2910 in official personnel 
records would further erode a victim's control and privacy, which is 
already partially destroyed by a sexual assault.
    Copies of DD Form 2910, Victim Reporting Preference Statement, are 
kept indefinitely by the Military Services. For unrestricted reports, 
the completed DD Form 2911, Forensic Medical Report: Sexual Assault 
Forensic Examination is part of the Servicemember's military medical 
record. For restricted reports, DD Form 2911 remains with the Sexual 
Assault Forensic Examination (SAFE) Kit that is maintained by the 
designated custodian, and then is destroyed at the 1-year mark.
                   Restricted Sexual Assault Records
    Question 5: In a case of MST where a restricted record is created, 
does the victim who wants no investigation or prosecution of the 
perpetrator receive a copy of that completed record for his or her 
personal information? If not, can you explain why not?

    Answer: Yes. The victim receives a signed and dated copy of the 
completed DD Form 2910, Victim Reporting Preference Statement, for his 
or her personal information. Below is text from that form encouraging 
victims to keep a copy for their records:
    ``NOTICE: DOCUMENTATION FOR RECORD KEEPING PURPOSES. Victims are 
advised to maintain a signed and dated copy of this form for their 
records. This form may be used by the victim in other matters before 
other agencies (e.g., Department of Veterans Affairs) or for any other 
lawful purpose.''
              Centrally Archiving MST Records within SAPRO
    Question 6: Has consideration been given to centrally archiving MST 
records within SAPRO itself so that Veterans Business Administration 
and Veterans Service Officer National Service Officers with power of 
attorney would have one unified DoD source for searching such records? 
What are the negative implications for SAPRO's collecting all such 
reports in a central archive?

    Answer: Yes, consideration has been given to centrally archiving 
MST records. The Department will have a central archive of sexual 
assault reports when the Defense Sexual Assault Incident Database 
(DSAID) managed by SAPRO comes online. In order to prevent negative 
implications such as the unapproved release of personally identifying 
information (PII), DSAID will not record PII of victims who make 
restricted reports. Inquiries from the Department of Veterans Affairs 
about supporting documentation on restricted and unrestricted Reports 
of sexual assault should be answered by the Military Service that 
provided assistance, care, and investigative support to that victim.
                 Percentage of Reported Sexual Assaults
    Question 7: Your testimony noted that DoD has found that about 8 of 
10 sexual assaults in the military go unreported. Does this number 
represent an improvement from the percentage that went unreported prior 
to the implementation of the ``restricted reporting'' disclosure 
option?

    Answer: The number of victims opting to make a restricted report 
has increased 18 percent since FY 2007, and has been rising since the 
inception of the restricted reporting option in 2005. The Department 
believes these victims would not have come forward had there not been 
the option for restricted reporting. In addition, given the rise in 
restricted reporting, the Department believes that the percentage of 
sexual assaults going unreported is decreasing.
    Since 2005, 3,486 victims have made restricted reports. The 
Department's baseline data started in 2005 when the Sexual Assault 
Prevention and Response (SAPR) program was put in place.
             VA Services for DoD Victims of Sexual Assault
    Question 8: Please discuss in greater detail how DoD and VA work 
together to ensure that transitioning servicemembers who have suffered 
a military sexual trauma are referred to or informed of the appropriate 
VA services.

    Answer: The Department of Defense (DoD) has been working with the 
Department of Veterans Affairs (VA) since the inception of the Sexual 
Assault Prevention and Response (SAPR) program in 2005. One of the key 
areas of collaboration has been related to documentation. Victims of 
sexual assault are provided with a signed, dated copy of DD Form 2910, 
Victim Reporting Preference Statement, that they may present during a 
disability evaluation should they so choose. The Department provided a 
blank copy of this form and education about its use to the Veterans 
Benefits Administration (VBA) in 2007. The VBA agreed to accept the 
document as evidence of having made a report of sexual assault.
    Additional areas of coordination include:

      A representative from VA sits on the Sexual Assault 
Advisory Council, which is the main oversight body for the Sexual 
Assault Prevention and Response program in the Department.
      DoD's Sexual Assault Prevention and Response (SAPR) staff 
team with members of VA's Military Sexual Trauma Support Team brief on 
their respective programs at national conferences.
      Members of the Department of Defense's SAPR staff have 
attended Veterans Health Administration's annual training conference 
for Military Sexual Trauma Coordinators and briefed on the DoD Sexual 
Assault Prevention and Response Program for the past 3 years.
      DoD participates in VA seminars to educate VA providers 
about sexual assault and the DoD and VA programs.
      DoD and VA are working on a joint brochure for 
distribution to Servicemembers leaving active duty to remind them of 
the sexual assault support services available within each Department.

    To ensure the Department of Defense does not overlook any potential 
area of connection, the DoD SAPR staff meet with a variety of veterans 
groups to identify any gaps there might be related to the issue of 
sexual assault as Servicemembers transition from active duty to veteran 
status. Meeting with non-governmental groups, such as Iraq and 
Afghanistan Veterans of America and the National Organization for 
Women, has provided a fuller understanding of the challenges that 
veterans might be experiencing.
           Disciplinary Actions Taken against Servicemembers 
                      Convicted of Sexual Assault
    Question 9: Please describe in detail the disciplinary actions 
taken against servicemembers convicted of a sexual assault. Please 
describe the range of severity of the punishments available, and how 
the specific disciplinary action taken is determined in each case.

    Answer: Disciplinary actions taken against Servicemembers convicted 
of a sexual assault follow the Uniform Code of Military Justice (UCMJ). 
Convictions for sexual assault may result in confinement, reductions in 
rank, forfeiture of pay and allowances, and/or punitive discharge from 
Service, or any combination. Under Article 120 of the UCMJ, the maximum 
punishment for the crime of rape is ``Death or such other provided 
punishment as a court martial may direct.''
    Commanders have discretion under the UCMJ to dispose of offenses by 
members of their command. Disposition of offenses range from 
administrative action to courts-martial, depending on the severity of 
the offense and the evidentiary considerations.
               Educating Servicemembers on Reporting MST
    Question 10: What steps has DoD taken to educate servicemembers on 
how to go about reporting MST and how to do so anonymously, if they 
feel that is necessary?

    Answer: The DoD Instruction 6495.02, Sexual Assault Prevention and 
Response Program Procedures, requires that every Servicemember receive 
training on the restricted and unrestricted reporting options for 
sexual assault, and how to report an incident. As a result, the 
Military Services have incorporated training about sexual assault 
reporting and prevention into a wide variety of settings, including:

      Accession Training
      Annual Training
      Professional Military Education
      Leadership Development Training
      Pre-Command Training
      Flag and General Officers/Senior Executive Service 
Training
      Training for civilians who supervise Servicemembers
      Pre-Deployment Training
      Post-Deployment Reintegration Training

    This training is supported by a numerous reminders of how to 
prevent and respond to sexual assault, including posters, brochures, 
Web sites, and public service announcements.
    The assessment of the lasting awareness of these outreach and 
training efforts is key to ensuring these messages are being retained 
as desired. To that end, as part of the strategic plan for the Office 
of the Under Secretary of Defense for Personnel and Readiness, the 
Department will be measuring awareness levels and adjusting outreach 
and training as appropriate.
                      Deployed vs. Home Reporting
    Question 11: Where do most reporting events occur? How easy is it 
for someone to report an event in a combat theater of operations vs. 
being on home base.

    Answer: According to the 2006 Gender Relations Survey of the Active 
Duty by the Defense Manpower Data Center, of the 6.8 percent of women 
and 1.8 percent of men who indicated they had experienced an incident 
of unwanted sexual contact in the 12 months prior to the survey, three-
quarters of respondents indicated that it occurred at a military 
installation. Also, about two-thirds of respondents indicated the 
incident occurred at their current permanent duty station which could 
also be a military installation. Additionally, 28 percent of women and 
44 percent of men indicated that the incident occurred while deployed.
    Sexual assault may be reported anywhere. The Department has sexual 
assault response coordinators, victim advocates, and other personnel 
who may receive a restricted or unrestricted report are stationed in 
garrison and deployed around the world. Annual refresher training and 
pre-deployment training is designed to remind Servicemembers of their 
sexual assault reporting options and how to make a report no matter 
their location.
    Given the nature of war, certain areas in the combat theater of 
operations may pose unique challenges to Servicemembers' immediately 
accessing sexual assault response personnel. Sexual assault response 
personnel receive specialized training on how to receive reports at 
home base and in combat theater of operations.
                  Access to DoD Restricted MST Reports
    Question 12: Some other witnesses testified about the need for 
gaining access to DoD's restricted MST reports in order to provide 
documentation for service connection. What do you think of that 
suggestion? Do you have any concerns regarding privacy or other issues 
when outsiders are given access to these confidential documents?

    Answer: The greater the number of individuals given access to 
confidential documents, the less confidential those records become. 
Even with strict safeguards, the situation that many victims fear is 
losing control of their private information. Department surveys show 
that victims of sexual assault do not report the assault to an 
authority because they feel uncomfortable making a report, think they 
will be labeled a troublemaker, and do not want anyone to know about 
the incident. Victims who make restricted reports do so because they 
fear the negative repercussions of being a victim of sexual assault.
    Victims should certainly have access to their records. For example, 
they can access their records under the Privacy Act. That access should 
be provided in a way that best guards their confidentiality. Others who 
seek documentation to determine service connection should inquire with 
the Military Service that provided assistance, care, and investigative 
support, and obtain consent from the victim to access the victim's 
records.
Sexual Assault Prevention and Response efforts with National Guard and 
                             Reserve Forces
    Question 13: Can you comment on sexual assault prevention and 
response efforts with National Guard and Reserve forces? Is data from 
Guard and Reserve components studied and included in your reports? If 
not, why not and how can we correct this oversight?

    Answer: The Department's Sexual Assault Prevention and Response 
(SAPR) policy applies to activated National Guard and Reserve members 
who are sexually assaulted when performing active service and inactive 
duty training. The Service Secretaries are responsible for establishing 
comprehensive SAPR policies, procedures, and programs and ensure 
implementation, monitoring, and evaluation at all levels of military 
command, including those levels at the National Guard and Reserve 
components, and training for members of their Military Departments.
    The Department has also incorporated the National Guard and Reserve 
components into its oversight framework and works with closely with the 
respective SAPR program managers to ensure program accountability. Data 
from the Guard and Reserve components are studied and included in the 
Department of Defense Annual Report on Sexual Assault in the Military. 
The National Guard Bureau is currently working with the Department in 
the development of the Defense Sexual Assault Incident Database to 
record and manage all reports of sexual assault involving members of 
the National Guard into the system.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                      June 14, 2010

Susan McCutcheon, R.N. Ed.D.
Director, Family Services, Women's Mental Health and Military Sexual 
    Trauma
Office of Mental Health Services, Veterans Health Administration
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20240

Dear Ms. McCutcheon:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittee on Disability Assistance and Memorial Affairs' 
and Subcommittee on Health's joint oversight hearing on, ``Healing the 
Wounds: Evaluating Military Sexual Trauma Issues,'' held on May 20, 
2010. We would greatly appreciate if you would provide answers to the 
enclosed follow-up hearing questions by Wednesday, July 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all full 
committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Jian Zapata by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

John J. Hall
Chairman
Subcommittee on Disability Assistance
and Memorial Affairs
                                                       Doug Lamborn
                                                     Ranking Member
                                         Subcommittee on Disability
                                    Assistance and Memorial Affairs

Michael H. Michaud
Chairman
Subcommittee on Health
                                                Henry E. Brown, Jr.
                                                     Ranking Member
                                             Subcommittee on Health

                               __________

                        Questions for the Record
    The Honorable John Hall, Chairman, The Honorable Doug Lamborn, 
    Ranking Member, Subcommittee on Disability and Memorial Affairs
   and The Honorable Michael Michaud, Chairman, The Honorable Henry 
  Brown, Jr., Ranking Member, Subcommittee on Health, House Committee
  on Veterans Affairs, Healing the Wounds: Evaluating Military Sexual 
                      Trauma Issues, May 20, 2010
    Question 1: In addition to PTSD, experts point out that Military 
Sexual Trauma (MST) can also lead to women's cancer and sexual 
transmitted diseases amongst men and women. To combat these diseases, 
stakeholders recommend that DoD and VHA dedicate greater funding on 
research and screening that is gender specific. What is VHA's position 
and plans on this viewpoint?

    Response: VA fully supports research on the critically important 
impact of military sexual trauma (MST) on the health of Veterans--both 
women and men. VA research has clearly indicated that MST is associated 
with wide range of diverse physical and mental health outcomes, 
including sexually transmitted diseases (STDs) and Post-Traumatic 
Stress Disorder (PTSD). MST research will continue to be a high 
priority for VA, as our understanding of its health consequences 
(including possible links to cancer) leads to better screening, 
treatment, and improvements in care and health.
    VA research has recognized the need for gender specific approaches 
and for better understanding of gender differences related to MST. 
Currently, VA has a number of research studies that are examining 
gender differences related to MST. One of these studies is examining 
the impact of gender, combat and sexual trauma, and other factors on 
medical and psychiatric outcomes and stress associated condition. A 
second study is examining the stigma and gender differences in barriers 
to health care use, including those related to sexual assault.
    The first comprehensive evaluation of VA's mandated MST screening 
and treatment program included both female and male Veterans, and 
suggested that the comprehensive VA policies surrounding MST are of 
significant clinical benefit for patients. An ongoing study is further 
analyzing VA's MST screening assessment tools including differences in 
interpretation and responses to the screening questions by gender.
    In addition to focusing on gender-specific issues, several studies 
addressing the health consequences of sexual assault, MST, and other 
military traumas include a focus on STDs and women's cancer. VA 
research has found that MST is associated with a number of chronic 
medical conditions, as well as obesity or weight loss among women. 
Several VA studies are now analyzing the relationships between sexual 
violence and women Veterans' gynecological health, including 
associations between sexual assault and sexual risk behaviors, barriers 
to obtaining gynecological examinations and cervical cancer screening, 
and the incidence and prevalence of abnormal cervical cytology (which 
could lead to cervical cancer if untreated).
    A longitudinal study of both male and female Marines is also 
examining MST effects on health behavior, including the association 
between MST and cancer and STDs, as well as actual health outcomes 
related to cancer and STDs. A new VA study of Vietnam women Veterans 
will provide another opportunity to assess the relationships between 
stressful and traumatic experiences and mental and physical health 
outcomes, including cancers.
    VA plans to continue the important focus on research related to the 
health consequences of MST. Expanded research informatics (for example, 
linking screening and clinical reminders) and research infrastructure 
capabilities, like the Women Veterans' Practice-based Research Network 
(PBRN) will support this research and gender-specific approaches to 
improve screening, access to care and treatments that best meet the 
needs of Veterans who have experienced MST. The PBRN involves 
development of infrastructure and building of research capacity in 
order to examine new treatments, quality performance and improvements, 
models of care (e.g., integrated mental health and primary care), and 
provider education and training innovations. The PBRN will facilitate 
VA research-clinical partnerships to enhance the implementation and 
dissemination of innovations and best practices. It also seeks to build 
capacity in VA women's health research, facilitate meeting Federal 
requirements to recruit and include women in relevant VA research 
locally and across sites, and to facilitate testing and disseminating 
VA-based women's health-related interventions.

    Question 2: We also understand that many MST treatment programs and 
residential facilities don't offer separate settings for men and women 
victims. MST victims complain that Veterans Health Administration (VHA) 
treatment programs lack the privacy needed for them to open up 
concerning their injuries. More alarming are reports that MST victims 
in mixed-gender settings are being sexually harassed by other patients 
and even health providers. Can you point out any downside of 
segregating patients by gender, and if you favor gender specific 
treatment facilities for MST victims, what resources are needed to make 
this a reality?

    Response: The recently issued Uniform Mental Health Services 
Handbook codifies the longstanding VA practice of promoting treatment 
in environments that are sensitive to gender-related issues. For 
example, all inpatient and residential programs must provide separate 
and secured sleeping accommodations for women. Mixed gender units must 
ensure safe and secure sleeping and bathroom arrangements, including, 
but not limited to, door locks and proximity to staff.
    For a subset of Veterans, there are advantages to models of care in 
which treatment occurs in an environment where all Veterans are of one 
gender. Both male and female survivors of MST may have concerns about 
their safety, ability to disclose and engage fully in treatment, and 
address gender-specific concerns in mixed gender environments.
    Among VA's residential programs that provide specialized MST-
related care, approximately half treat only women, and one treats only 
men. Veterans who feel a strong need for a same gender treatment 
environment would be able to receive MST-related mental health care 
from these programs with a single gender environment.
    There are also advantages to mixed gender programs that provide 
specialized MST-related care to include: helping survivors to challenge 
assumptions and confront fears about the opposite sex; fostering 
respect for appropriate boundaries in relationships; and promoting an 
emotionally corrective experience. Also, mixed-gender treatment 
programs can help improve accessibility to care and maximize efficient 
use of resources. This is particularly true for programs operating on 
``cohort'' models in which a program runs a specified number of weeks 
with a group of patients beginning and ending the program together.
    Given there are advantages associated with each approach, VA does 
not promote one model as universally appropriate for all treatment 
settings. Rather, we encourage careful consideration of the needs of 
specific Veterans and use of single-gender programs when they are 
clinically appropriate.
    Sexual harassment from VA employees is unacceptable and is subject 
to disciplinary action. Sexual harassment by another Veteran resident 
is also unacceptable and subject to disciplinary action. With respect 
to sexual harassment from other Veterans, each resident is provided 
sexual harassment prevention training as part of his/her orientation to 
the program. Annual safety and security reviews of mental health 
residential programs carefully monitor compliance with this 
requirement. Should sexual harassment occur, victims are provided 
support and more extensive clinical intervention and psychotherapeutic 
support as clinically indicated. The treatment team also addresses the 
sexual harassment clinically with the perpetrator to ensure that it 
does not re-occur. During this clinical interaction, staffs work with 
the perpetrator to assess the factors leading up to the event and 
provide counseling to the Veteran and any needed adjustments to the 
treatment plan. As one potential result of such an event, disciplinary 
action by the treatment team can include counseling, restrictions and/
or discharge from the program. Staffs treat reports of possible 
criminal activity with the highest priority, including notifying the 
appropriate law enforcement agency, which could include VA Police in 
accordance with VA policy and regulations. More generally, the VA's MST 
Support Team, a national education and monitoring team established by 
VA Office of Mental Health Services, fosters discussion among providers 
and program directors about the potential impact of additional sexual 
harassment for survivors of previous sexual trauma.

    Question 3: If a Veteran is uncomfortable with the gender of an MST 
coordinator at a given VA facility, is there a protocol to match them 
with somebody else able to perform a similar role?

    Response: The facility MST Coordinator focuses on ensuring that the 
facility meets mandates related to screening, treatment, education/
training, and outreach. MST Coordinators in many cases serve as the 
initial point of contact for MST survivors entering the system before 
they are assigned to a clinical provider who will work with them on an 
ongoing basis. If a Veteran does not feel comfortable having even this 
initial contact with an individual of a certain gender, facilities will 
make arrangements as needed to assist the Veteran in engaging in care 
without necessitating a meeting with the MST Coordinator. With regard 
to treatment, national outreach materials specifically state that 
``Veterans should feel free to ask to meet with a provider of the same 
or opposite sex if it would make them feel more comfortable.'' 
Furthermore, the Uniform Mental Health Services handbook strongly 
encourages facilities to give Veterans the option of being assigned a 
same-sex mental health provider or an opposite-sex provider if the 
trauma involved a same-sex perpetrator.
    Ensuring the capacity of facilities to be able to meet this request 
for a preferred provider gender is a priority for the Office of Mental 
Health Services. To determine this capacity the VA's MST Support Team 
is preparing an in depth study of providers of MST-related mental 
health care. This study will elucidate several important factors about 
providers of MST-related care, and will: a) determine the number of 
unique providers at each facility who deliver MST-related mental health 
care and describe the characteristics of those providers, and b) assess 
the relationship of provider gender to patient gender to determine 
whether patients are able to express preferences for same gender 
providers, as is VHA policy. These study deliverables will provide 
important information in helping to ensure sufficient capacity for 
specialized MST-related mental health services at each VHA facility.

    Question 4: Please elaborate on VA's separate-gender treatment 
programs. How many women-only programs does VA have for treatment of 
MST and PTSD?

    Response: Many facilities have specialized outpatient mental health 
services focusing on women and/or sexual trauma. For Veterans who need 
more intense treatment and support, there are also 8 programs that 
provide specialized women's mental health care in residential or 
inpatient settings. One additional VA program provides specialized care 
for women in a residential setting in conjunction with a local non-VA 
non-profit program for homeless and at-risk Veterans. These programs 
are considered regional and/or national resources, not just a resource 
for the local facility. Some of these specialized women's programs 
focus on MST only, while others focus on specialized women's care in 
general (including MST). These programs are a subset of the larger 
number of programs able to provide specialized care in a VA residential 
or inpatient setting for mental health conditions related to MST.

    Question 5: Dr. McCutcheon, we understand that VHA is treating 
almost 75,000 Veterans for sexual trauma related injuries. Your 
testimony suggests that Veterans who are denied VBA disability benefits 
based upon the finding that their sexual trauma-related injuries are 
not service-connected, may still be entitled to treatment by the VHA if 
your therapists conclude that the injuries suffered by Veterans are 
service-connected. Should VBA provide greater weight to the medical 
findings of trained VHA therapists and health professionals re: 
service-connection injuries from MST?

    Response: As stated in testimony, Veterans are entitled to free VHA 
counseling and care and services to overcome psychological trauma, 
which in the judgment of a VA mental health professional, resulted 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 or active duty for training whether or not their 
disabilities are service-connected.
    Service-connection and disability ratings are determined by the 
Veterans Benefit Administration (VBA) based on all the evidence of 
record. VBA considers the findings of VHA's trained therapists with 
respect to diagnosis, service connection, and extent of a Veteran's 
disability. VBA adjudicators assign weight to the evidence according to 
its credibility and other factors. In some cases, VBA asks VHA 
professionals to review a Veteran's records to see if there are markers 
that can be found denoting reduced level of functioning.

    Question 6: In your estimation, of the Veterans treated by VHA for 
sexual trauma injuries, what percentage of such Veterans has service-
connected conditions?

    Response: Of the 37,132 female MST positive Veterans who received 
MST-related outpatient care from VHA in fiscal year (FY) 2009, 68.1 
percent had service connection as indicated on their VHA medical 
record. Of the 24,826 male MST positive Veterans who received MST-
related outpatient care from VHA in FY 2009, 54.9 percent had service 
connection as indicated on their VHA medical record. Based on the 
available data we are unable to determine if their service connection 
was for injuries or conditions related to their MST.

    Question 7: Disabled American Veterans (DAV) cited in its testimony 
the effectiveness of prolonged exposure therapy and advocated for its 
universal expansion to VA Medical Centers for treating MST. Does VA 
have plans to expand the use of such therapy? If so, please elaborate.

    Response: As part of its commitment to making the best treatments 
available to Veterans, VA has provided national training to disseminate 
and implement both Prolonged Exposure Therapy (PE) and Cognitive 
Processing Therapy (CPT), and continues to provide such training to 
additional staff. These two evidence-based psychotherapies for PTSD are 
recommended in the VA/Department of Defense Clinical Practice 
Guidelines for PTSD at the highest level, indicating ``a strong 
recommendation that the intervention is always indicated and 
acceptable.'' Both PE and CPT have been examined in a number of 
randomized controlled trials and shown to be effective, in similar 
degree, for PTSD related to multiple types of trauma, including sexual 
trauma and combat-related trauma. In addition, they are recognized in 
the 2008 Institute of Medicine report, ``Treatment of Post-Traumatic 
Stress Disorder'', as the only therapies with proven effectiveness for 
treatment of PTSD. PE and CPT are used throughout VHA to treat Veterans 
with PTSD related to military sexual trauma (as well as to other types 
of trauma), and VHA Handbook 1160.01, Uniform Mental Health Services in 
VA Medical Centers and Clinics, now requires that all Veterans with 
PTSD have access to PE or CPT.
    As part of VA's efforts to make PE and CPT widely available to 
Veterans, VA's national-level programs have trained more than 2,700 VA 
mental health staff in PE and/or CPT. In addition, more than 400 VA 
mental health staff are being trained in the use of Cognitive 
Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT) for 
depression, the second most common mental health diagnosis for women 
Veterans clinically judged to be a consequence of MST. The training for 
all of these psychotherapies includes specific information relevant for 
adapting the clinical approach for Veterans whose mental health 
problems are a result of MST. The MST Support Team has worked with each 
of these national initiatives to include materials relevant to MST 
survivors and to promote attendance by clinicians working with MST 
survivors.
    Initial program evaluation data show significant gains in therapist 
competency following the training, as well as significant clinical 
improvements among Veterans receiving these treatments. Plans are 
underway to provide additional, intensive staff training in PE, CPT, 
CBT, and ACT in FY 2011, with a focus on sites that have fewer trained 
staff in these therapies. Plans are also underway to establish 
decentralized training capacity within all Veterans Integrated Service 
Networks (VISNs), further broadening dissemination and promoting 
sustainability over time.

    Question 8: VA's efforts to screen all Veterans accessing VHA for 
MST are to be commended. However, this screening does not capture 
Veterans who are not seeking care through VHA. What is VA doing to 
reach out to Veterans who are victims of MST but who have not accessed 
VHA?

    Response: VA recognizes the importance of engaging in outreach to 
ensure that Veterans are aware VA has MST-related services available. 
VA conducts outreach in accordance with existing statutory authority 
and VHA policy. To this end, the VA's MST Support Team has developed 
MST-related educational handouts, posters and brochures to educate 
Veterans about VA services, describe symptoms associated with sexual 
trauma, and highlight the availability of effective treatments. These 
materials are distributed to MST Coordinators who display them in VHA 
facilities and distribute them to local communities. This includes 
reaching out to local military bases and/or attending demobilization 
events when appropriate. MST Coordinators often receive invitations to 
present at local events and will take this opportunity to speak about 
VA's services and general commitment to this issue.

    Question 9: The American Legion's statement for the record 
discusses the work of their services officers in helping women Veterans 
receive treatment and compensation for conditions that result from 
military sexual trauma. Does VA collaborate with American Legions 
service officers and those of other VSOs?

    Response: Yes, VA has coordinated nationally with the American 
Legion to distribute outreach materials. Also, at the local level many 
MST Coordinators and facilities work collaboratively with partner 
organizations to engage in outreach and other activities.

    Question 10: In her testimony, Dr. Whitley stated that reports of 
sexual assault have increased about 10 percent annually over the past 3 
years, due to outreach and education. As DoD has persuaded more victims 
of MST to come forward, has VA experienced an increase in the number of 
Veterans seeking treatment for MST? If not, do you anticipate an 
increase, or were many of the Servicemembers now coming forward while 
in service already willing to seek treatment through VA?

    Response: Surveillance reports from the VA's MST Support Team 
indicate that in the past 3 years, the proportions of VHA patients who 
report MST have remained relatively constant, ranging from 21.9-22.2 
percent among women, and 1.1-1.3 percent among men. However, as the 
total numbers of Veterans seeking VHA care increases, there has been a 
corresponding increase in absolute numbers of MST patients. The 
proportions of these patients who receive MST-related care each year is 
also increasing, with the highest increases being among Veterans 
recently returned from Iraq and Afghanistan.
    However, it is important to note that there are several 
complications to comparing DoD figures and VHA MST surveillance data. 
First, pursuant to 38 U.S.C. 1720D, VA is authorized to treat both 
sexual assault and sexual harassment under a single construct, Military 
Sexual Trauma. DoD's Sexual Assault Prevention and Response Office 
(SAPRO) figures reflect only sexual assault. Also, because only a 
portion of Veterans ever seek VA care after separation from military 
service, estimates of the prevalence of MST in VA health care are not 
reliable indicators of overall increases in the prevalence of sexual 
assault or sexual harassment in the general Veteran population. Shifts 
in DoD rates of reported sexual assault may or may not correspond with 
an increased rate of Veterans seeking care from VHA. Finally, Veterans 
need not have reported MST during military service to receive MST-
related care from VHA after separating from military service. Veterans 
captured in VA figures may or may not be the Veterans captured by SAPRO 
figures.

    Question 11: Does VA offer any other intensive inpatient MST 
programs besides the National Women's Trauma Recovery Program in 
California?

    Response: Veterans with experiences of MST can receive treatment 
through most of VA's residential/inpatient treatment programs. There 
are 14 programs able to provide specialized care in a VA residential or 
inpatient setting for mental health conditions related to MST. One 
additional program provides specialized care in a residential setting 
in conjunction with a local non-profit program for homeless and at-risk 
Veterans. These programs are considered regional and/or national 
resources, not just a resource for the local facility. Eight of these 
residential/inpatient programs are MST/sexual trauma treatment 
programs. Six of these residential/inpatient program are more general 
treatment programs that have multiple staff with expertise in MST/
sexual trauma. Although these programs do not necessarily have an 
explicit focus on MST/sexual trauma, staff can often work individually 
with Veterans who need MST-specific care as an adjunct to the care they 
receive through the more general program. Veterans also may be able to 
receive specialized MST-related group or individual therapy through the 
outpatient clinic at the facility that offers the specialized 
residential or inpatient program.

    Question 12: Once a Veteran screens positive for having suffered an 
MST, what steps does VA take? What happens to those Veterans who 
decline treatment? Does VA take special steps to help this subset of 
Veterans?

    Response: All Veterans seen in VHA are screened for MST. Those 
Veterans who screen positive are offered a referral for free MST-
related care. If a Veteran refuses this referral, clinicians respect 
this decision, recognizing that there are many good reasons why a 
Veteran may decline a referral for care at the time of screening 
positive. Some Veterans may not feel ready to enter treatment; others 
may have engaged in treatment in the past and/or feel that their 
experiences of MST are not currently impacting their lives in a way 
that warrants current treatment. Veterans who screened positive but who 
decline a referral are informed that if they change their mind, they 
may request services at any time in the future. Clinicians also make 
outreach and informational materials on MST and the local MST 
Coordinator's name and contact information available to Veterans who 
screen positive.

    Question 13: What is the extent of the coordination between VA and 
DoD to prevent incidents of MST?

    Response: As a health care system working primarily with Veterans 
and other individuals already discharged from the military, VA's 
prevention efforts mainly address secondary and tertiary prevention 
issues--that is, prevention of developing or worsening of aftereffects 
related to MST. VA is not in a position to address primary prevention--
that is, prevention of experiences of MST to begin with--but has 
developed a strong collaborative working relationship with the DoD's 
SAPRO in order to facilitate coordination of responses across the 
Departments. In an effort to ensure that all providers and staff are 
aware of each Department's services, VA's national MST Support Team and 
DoD's SAPRO have presented at each others' national MST/sexual assault 
trainings. The two entities also communicate as needed to help connect 
individual Veterans to services that match their treatment needs.

    Question 14: Ms. Bhagwati's testimony stated that MST survivors 
describe the horror of using VA Medical Centers nationwide. She also 
asserts that Veterans are often ignored, isolated, or misunderstood at 
VA facilities because their PTSD is not combat-related and that women 
who do attend the residential treatment programs have experienced 
sexual harassment by staff or fellow patients. Please respond to this 
testimony.

    Response: We regret that Ms. Bhagwati has this perspective of VA 
care, and would be happy to work with her to hear more about her 
concerns and share more about what we have done and continue to do to 
ensure accessible, quality care for MST survivors. Please also note the 
earlier response to Question 2. VA's commitment to such care is 
established in longstanding VA policies and most recently reinforced in 
VHA Handbook 1160.01, ``Uniform Mental Health Services in VA Medical 
Centers and Clinics.'' The Handbook contains key provisions addressing 
the treatment of conditions related to MST. For example, all Veterans 
seeking VA care must be screened for MST and all Veterans who screen 
positive for MST are entitled to free VHA counseling and care and 
services to overcome psychological trauma as described in 38 U.S.C. 
1720D(a)(1). Every facility must have a designated MST Coordinator who 
serves as the point of contact for MST-related issues, including staff 
education and training and monitoring of MST-related screening and 
treatment. MST is an experience that is associated with a number of 
health conditions, necessitating both widespread working knowledge of 
issues related to MST among VA staff in general as well as the 
availability of providers with specialized expertise in this area who 
can provide targeted evidence-based care.
    Further reflecting its commitment to ensuring that Veterans receive 
the support they need and deserve, in FY 2007, the OMHS established a 
national-level VA Military Sexual Trauma (MST) Support Team to conduct 
monitoring of MST screening and treatment, to oversee MST-related 
education and training, and promote best practices in care for Veterans 
who experienced MST. As noted earlier, OMHS has funded national 
training initiatives to promote evidence-based practices for PTSD, 
depression, and anxiety. Because these conditions are commonly 
associated with MST, these national initiatives have been an important 
means of expanding MST survivors' access to cutting-edge treatments. 
Several of these treatments were developed and originally tested 
primarily with rape victims and child sexual abuse survivors. As such, 
the MST Support Team has worked with each of these national initiatives 
to include materials relevant to MST survivors and to promote 
attendance by clinicians working with MST survivors.
    Additionally, the MST Support Team is completing a study of patient 
perceptions of the quality of VHA health care among Veterans who are 
MST survivors. Results revealed that patient perceptions of overall 
quality ratings were fairly high for both men (78.5 percent) and women 
(72.3 percent), and did not significantly differ among patients who did 
and did not report MST. These results suggest that MST patients' 
perceptions of overall quality of care are commensurate to those of 
other VHA outpatients.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      June 23, 2010

Bradley G. Mayes
Director, Compensation and Pension Service
Veterans Benefits Administration
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20402

Dear Mr. Mayes:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittee on Disability Assistance and Memorial Affairs' 
and Subcommittee on Health's joint oversight hearing on, ``Healing the 
Wounds: Evaluating Military Sexual Trauma Issues,'' held on May 20, 
2010. I would greatly appreciate if you would provide answers to the 
enclosed follow-up hearing questions by Thursday, July 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all full 
committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your responses 
to Cecelia Thomas by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

    Sincerely,

                                                       John J. Hall
                                                           Chairman

                               __________

                        Questions for the Record
   House Committee on Veterans' Affairs, The Honorable John J. Hall, 
 Chairman, Subcommittee on Disability Assistance and Memorial Affairs,
    ``Healing the Wounds: Evaluating Military Sexual Trauma Issues''
                              May 20, 2010
    Question 1. One witness today urged DoD to enter into a MOU to 
share with VA records and other information related to MST claims. Does 
VBA believe that it has the access to DoD files, particularly 
restricted records, needed to properly adjudicate MST claims?

    Response: An MOU between VA and DoD outlining each agency's role 
will be explored. VBA released Fast Letter 10-25 on July 15, 2010, 
outlining the roles and responsibilities of each agency, and a process 
will be put in place to ensure that these procedures are clear and 
available to all. The Fast Letter also updated procedures that require 
regional offices to request and accept DoD Form 2910, Victim Reporting 
Preference Statement and Form 2911, Forensic Medical Report: Sexual 
Assault Examination, along with other similar forms, as corroborating 
evidence of a report of MST.

    Question 2. I appreciate that VBA has provided its claims personnel 
a training letter describing special processing methods involving MST 
related claims and that all regional offices have a Women's Veteran 
Coordinator, who is well-versed in MST issues. Yet, given the 
complexity of MST and the often hidden wounds, many stakeholders 
suggest that VBA provide more training and other resources to its staff 
to address MST related claims. How does VBA respond to this 
recommendation? What more do you plan to do or should be done?

    Response: VBA agrees with this recommendation and has already 
increased the number of conference calls with WVCs from quarterly to 
monthly. These conference calls routinely address the sensitivity of 
handling MST claims and feature guest speakers who specialize in the 
needs of women Veterans and personal trauma issues. At the 2009 WVC 
Training Conference, a VHA staff psychologist spoke on the care that VA 
provides for MST and how MST affects the men and women who experience 
this trauma (physiologically, emotionally and cognitively). VBA will 
continue to provide this specialized training in future conferences. 
Meanwhile, VBA hosts information regarding Women Veterans on our WVC 
SharePoint site. VBA continues to strengthen the training programs for 
all staff engaged in claims development and rating of MST cases.

                                 
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