MILITARY SEXUAL 

TRAUMA

Improvements Made, 

but VA Can Do More 

to Track and Improve 

the Consistency of 

Disability Claim 

Decisions

Report to Congressional Requesters

June 2014

GAO-14-477

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14- 477, a report to 

congressional requesters

June 2014

MILITARY SEXUAL TRAUMA

Improvements Made, but VA Can Do More to Track 

and Improve the Consistency of Disability Claim

Decisions

Why GAO Did This Study

In 2012, 1 in 5 female and 1 in 100 

male veterans told VA that they had 

experienced sexual abuse in the 

military. Referred to as military sexual 

trauma or MST, such abuse can result 

in disabling conditions like PTSD, 

which may entitle a veteran to VA

benefits. Yet, establishing that MST 

occurred—a prerequisite for approving 

these claims—can be difficult, given 

that servicemembers may be unwilling 

to file formal complaints. In 2002, VA 

broadened the scope of allowable 

evidence for MST-related claims to 

include indicators, such as behavioral 

changes. Beginning in 2011, VBA took 

additional steps to clarify the 2002 

changes. GAO was subsequently 

asked to review these actions.

This report examines: (1) steps VA 

took to improve MST-related decisions, 

(2) results of its actions, and (3) the 

extent it is evaluating the quality of 

claim decisions. GAO reviewed 

relevant federal laws, regulations, and 

guidance; analyzed VA data on MSTrelated claim decisions (fiscal years 

2010-2013); interviewed national VBA 

and VHA officials, key advocates, and 

stakeholders, VBA officials at 5 of 57 

regional offices (with varying workloads

and quality review scores), and VHA 

examiners associated with 3 of these 

offices; and reviewed a nongeneralizable sample of 18 claim files 

completed in 2013 for examples of how 

evidence was evaluated.

What GAO Recommends

GAO is recommending that VA 

improve training, conduct more 

outreach, and enhance its MST-related 

quality reviews and analyses. VA 

concurred with all of GAO’s 

recommendations.

What GAO Found

The Veterans Benefits Administration (VBA), within the Department of Veterans 

Affairs (VA), has taken several steps to improve decision-making on disability 

claims involving military sexual trauma (MST) and to rectify past errors. In 2011, 

VBA began assigning MST-related claims to adjudicators with expertise in 

complex cases and required them to receive MST-specific training, such as on 

the broadened scope of evidence allowed since 2002. In 2012, the Veterans 

Health Administration (VHA) also provided some optional training to medical 

examiners who provide key input into decisions for such claims. Noting that some 

MST-related claims may have been erroneously denied prior to the specialization 

and training of staff, VBA in April 2013 invited 2,667 veterans with denied claims 

for post-traumatic stress disorder (PTSD) to resubmit them.

According to VBA data, national approval rates for claims based on MST have 

markedly increased since fiscal year 2010, a change that agency officials 

attributed to the additional training and a better general understanding of MST

requirements. However, GAO found wide variation in approval rates among 

regional offices, which ranged from 14 to 88 percent in fiscal year 2013. Half of 

the offices had approval rates close to the average (between 40 and 60 percent), 

but the rest were higher or lower. While variation does not necessarily signify

inconsistency, staff GAO interviewed from four of five offices described ongoing 

difficulty applying the broadened standards, and GAO found several instances of 

widely varying interpretations. Both VBA and VHA staff also described variation 

in the thoroughness of VHA medical exams used by adjudicators to reach 

decisions. Some VHA medical examiners GAO spoke with required more 

evidence than others to establish that an MST incident occurred. VBA and VHA 

staff in almost every office GAO contacted said that further training would be 

useful, feedback that is consistent with good practices previously identified by 

GAO and others for reinforcing training. More recently, VHA has decided to make

upcoming training on MST-related exams required for all medical examiners who 

conduct them. With respect to reviewing previously denied claims, VBA was only 

able to contact veterans whose claims had been denied since September 2010, 

although those with older claims can also resubmit. VBA’s national outreach to 

other affected veterans was limited to two group meetings with veteran service 

organizations. 

While VBA has taken some steps to evaluate decisions for MST-related claims, 

its quality reviews and analyses of claim decisions have shortcomings. For 

example, a 2013 quality review focusing on consistency may under-estimate 

challenges associated with adjudicating MST claims. Also, due to varying 

methods and samples, quality reviews conducted to date are insufficient to 

measure improvement over time—a standard part of internal control. In addition, 

while VBA analyzes data on national approval rates to gauge the effect of 

process improvements, GAO’s analysis of approval rates by regional office and 

veteran gender found wide variation. VBA also does not systematically collect 

data on the number of exams received or why claims are denied—information

that could help VBA identify potentially problematic trends. VBA officials said the 

agency’s many competing priorities have precluded additional data collection and 

analysis to date, but added that they plan to review variations in approval rates in 

the near future.

View GAO-14-477. For more information, 

contact Daniel Bertoni at (202) 512-7215 or 

bertonid@gao.gov.
Page i GAO-14-477 Military Sexual Trauma 

Letter 1

Background 5

VA Has Taken Several Steps to Improve Processing of Claims 

Related to MST 10

Since Improvements, Approval Rates Have Increased Nationally 

yet Vary Widely by Region 13

VBA Has Not Optimized Opportunities to Evaluate or Collect 

Information about MST-Related Decisions 25

Conclusions 29

Recommendations for Executive Action 30

Agency Comments and Our Evaluation 31

Appendix I Objectives, Scope, and Methodology 34

Appendix II Text of Notification Letter Sent to Previously Denied 

Claimants 40

Appendix III Comments from the Department of Veterans Affairs 41

Appendix IV GAO Contact and Staff Acknowledgments 46

Figures

Figure 1: Disabilities Claimed in Relation to Military Sexual 

Trauma, Fiscal Year 2010 through Fiscal Year 2013 6

Figure 2: VBA’s Disability Compensation Claim Process for PTSD 

Claims Based on Military Sexual Trauma 8

Figure 3: Training for VBA Adjudicators and VHA Medical 

Examiners Regarding Claims Related to Military Sexual 

Trauma (MST) 12

Figure 4: Approval Rates for PTSD Claims Related to Military 

Sexual Trauma versus Other Stressors, Fiscal Year 2010 

through Fiscal Year 2013 14

Figure 5: Range of Regional Office Approval Rates for Claims 

Related to Military Sexual Trauma in Fiscal Year 2013 16

Contents
Page ii GAO-14-477 Military Sexual Trauma 

Figure 6: Number of Veterans Sent Notification Letters Regarding 

Previously Denied PTSD Claims Related to Military 

Sexual Trauma and Claims Resubmitted and Resolved 

between May 1, 2013 and March 26, 2014 20

Figure 7: Examples of Credible Supporting Evidence Needed to 

Substantiate that an In-Service Stressor Occurred by 

Type of PTSD Claim 23

Figure 8: Percentage of Claims Related to Military Sexual Trauma 

Approved for Males versus Females, Fiscal Year 2010 

through Fiscal Year 2013 28

Figure 9: The Number of Claims Related to Military Sexual 

Trauma Completed, Received, and Pending, Fiscal Year 

2010 through Fiscal Year 2013 39

Abbreviations 

DOD Department of Defense

MST military sexual trauma

PTSD post-traumatic stress disorder

STAR Systematic Technical Accuracy Review

VA Department of Veterans Affairs

VBA Veterans Benefits Administration

VHA Veterans Health Administration

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page 1 GAO-14-477 Military Sexual Trauma 

441 G St. N.W.

Washington, DC 20548

June 9, 2014

Congressional Requesters

Trauma resulting from sexual abuse while in military service—referred to 

as military sexual trauma (MST)—has recently gained attention as a 

pervasive and continuing problem among U.S. servicemembers. In fiscal 

year 2012, the Department of Defense (DOD) estimated that about 

26,000 servicemembers had experienced some form of unwanted sexual 

contact, an increase from about 19,000 in fiscal year 2010.1 At 

Department of Veterans Affairs (VA) health care facilities in 2012, about 1 

in 5 women and 1 in 100 men stated that they experienced sexual abuse 

in the military.2 The effects of MST can be severe and long-lasting, and 

can result in chronic medical conditions such as post-traumatic stress 

disorder (PTSD), depression, and anxiety disorders. Federal law 

generally entitles veterans with service-connected disabilities (i.e., injuries 

or diseases incurred or aggravated in active military service) to disability 

compensation benefits.3

 1 In the survey DOD used to generate these estimates, the agency defined the term 

“unwanted sexual contact” as sexual crimes between adults prohibited by military law, 

ranging from rape to abusive sexual contact. It involves intentional sexual contact that was 

against a person’s will or occurred when the person did not or could not consent. Unlike 

VA’s definition of military sexual trauma (see below), DOD’s definition of unwanted sexual 

contact does not specifically include verbal sexual harassment.

This includes disabilities resulting from MST. The 

Veterans Benefits Administration (VBA), within VA, is charged with 

processing these claims. From fiscal year 2008 through fiscal year 2013, 

veterans filed over 29,000 claims for disabilities related to MST. Yet, such 

claims can be difficult to substantiate, given that servicemembers may be 

unwilling to file formal complaints at the time of the precipitating incident 

2 Although rates of MST are higher among women, large numbers of men are also 

estimated to have experienced sexual abuse.

3 38 U.S.C. §§ 1110 and 1131. This does not include disabilities caused by a veteran’s 

own willful misconduct or abuse of alcohol or drugs.

 
Page 2 GAO-14-477 Military Sexual Trauma 

or incidents and, hence, lack official documentation to support their 

claim.4

In response to a court ruling,5 VA in 2002 revised its regulations for 

adjudicating PTSD claims related to in-service personal assault, including 

MST.6 The revised regulation provides that evidence outside a veteran’s 

service record may be used to corroborate his or her account of MST. As 

revised, the PTSD regulation acknowledges that VA may take into 

account, for example, records from civilian law enforcement authorities or 

rape crisis centers, statements from friends and family members, and 

evidence of behavioral changes, such as requests for transfer to another 

military duty assignment.7

Even after the 2002 regulatory changes, members of Congress and VBA 

continued to raise concerns that adjudicators were not accurately and 

consistently using the broader standard of evidence when adjudicating 

PTSD claims related to MST. These concerns were substantiated by the 

agency’s own quality assurance reviews, which revealed high error rates 

for these claims. As a result, VBA in 2011 undertook additional steps to 

improve decisions for all claims attributed to MST, especially those for 

PTSD.

You asked us to assess whether VA has adequately addressed concerns 

about how MST-related claims are adjudicated. This report examines:

 4 According to DOD, 2,949 servicemembers filed formal sexual abuse complaints in fiscal 

year 2012, which represents about 11 percent of the 26,000 servicemembers who were 

estimated to have experienced unwanted sexual contact during that fiscal year. In fiscal 

year 2013, DOD reported that 4,113 servicemembers filed formal reports. DOD does not 

plan to update its estimate of the overall prevalence of unwanted sexual contact until the 

end of fiscal year 2014.

5 Patton v. West, 12 Vet. App. 272 (1999).

6 Post-Traumatic Stress Disorder Claims Based on Personal Assault, 67 Fed. Reg. 10,330 

(Mar. 7, 2002). While MST-related claims were an impetus for these regulatory changes, 

those changes apply to in-service personal assaults generally and not just those that are 

sexual in nature. They are also specific to PSTD claims and do not impact the standard of 

evidence for other types of claims related to MST, such as depression or anxiety 

disorders. 

7 38 C.F.R. § 3.304(f)(5). The regulation also provides that VA will not deny a PTSD claim 

based on in-service personal assault without advising the veteran that evidence outside 

the service record or evidence of behavior changes may be considered and allowing the 

veteran to furnish it or advise VA of its existence.
Page 3 GAO-14-477 Military Sexual Trauma 

1. The steps VA has taken to improve decisions for claims related to 

military sexual trauma;

2. the results, to date, of VA’s actions to improve such decisions; and

3. the extent to which VBA is assessing the quality of its claim decisions 

related to military sexual trauma.

To identify steps VA has taken to improve MST-related claim decisions, 

we reviewed related federal laws and regulations as well as guidance, 

training materials, and planning documents for VBA’s improvement 

initiatives. In addition, we spoke with VBA and Veterans Health 

Administration (VHA) officials responsible for implementing the initiatives. 

To examine the results of VA’s actions, we analyzed VBA administrative 

data from fiscal year 2010 to fiscal year 2013 on the number of MSTrelated claims received, completed, and either approved or denied by 

disability claimed (e.g., PTSD, depression, or anxiety disorders), gender 

of the veteran, and VBA regional office.8 We also spoke with VBA and 

VHA officials responsible for implementing the improvement initiatives, 

and with relevant VBA staff in 5 of 57 regional offices to gain their 

perspective on these initiatives.9

 8 These data are collected through VBA’s RBA2000 database. When discussing data on 

MST-related “claims” for the purposes of this report, we are referring to the number of 

disability claims for medical conditions related to MST filed by veterans. A veteran may 

have filed multiple cases with the VBA, and these cases may contain multiple claims for 

physical or mental health conditions related to MST.

For the 3 offices that we visited in 

person, we also conducted telephone interviews with VHA medical 

examiners affiliated with those VBA offices to learn about exams 

associated with MST-related claims. In each of those offices, we also 

reviewed a non-generalizable sample of six claim files completed in 2013 

to provide illustrative examples of how VBA adjudicates MST-related 

claims. We selected claim files from among those recently closed at the 

time of our site visit and that included approved and denied claims and 

claims submitted by both men and women. To gain their perspective on 

9 We visited the Nashville, Portland, and San Diego VBA regional offices and conducted 

telephone interviews with Milwaukee and Pittsburgh staff. We selected these offices 

based on a range of criteria, including performance on VA accuracy and consistency 

reviews, claims processing time, the number of MST-related claims received, and 

geographic location, among other things. Staff we spoke with in each office included 

managers, adjudicators responsible for making MST-related claim decisions, quality 

review team members who review MST-related claims, and personnel who conduct 

veteran outreach related to MST.
Page 4 GAO-14-477 Military Sexual Trauma 

VA’s handling of MST-related claims, we interviewed representatives from 

national veteran advocacy organizations, including veteran service 

organizations, as well as those locally associated with the 3 VBA regional 

offices we visited.10 We also weighed VBA’s actions against its internal 

guidance, federal internal control standards, and good practices for 

implementing training. To assess the extent to which VBA is assessing 

the quality of its decisions for MST-related claims, we examined VA 

quality assurance efforts, including results of completed reviews and 

planning documents for future reviews. We also analyzed VBA 

administrative data for potential trends in MST-related claim decisions. 

We assessed the reliability of VBA administrative data used for all our 

analyses by (1) performing electronic testing for obvious errors in 

accuracy and completeness, (2) reviewing existing information about the 

data and the system that produced them, and (3) interviewing agency 

officials knowledgeable about the data. We determined that the data were 

sufficiently reliable for the purposes of providing information on trends in 

claim decisions starting in fiscal year 2010.11

We conducted this performance audit from April 2013 to June 2014 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

For additional details on our 

objectives, scope, and methodology, see Appendix I.

 10 Veteran service organization representatives assist many veterans with filing disability 

claims. As claimant representatives, veteran service organizations must be accredited by 

VA and are tasked with providing information on benefits and assistance in applying for 

them. For more information on VA’s accreditation program, see GAO, VA Benefits: 

Improvements Needed to Ensure Claimants Receive Appropriate Representation, 

GAO-13-643 (Washington, D.C.: Aug. 1, 2013). 

11 Although VBA has collected data on MST-related claims since fiscal year 2008, we 

used data since fiscal year 2010 because the codes in VBA’s data system used to flag 

MST-related claims were more accurate beginning at that time.
Page 5 GAO-14-477 Military Sexual Trauma 

While DOD is responsible for prevention, prosecution, and in-service 

treatment related to sexual abuse, VA is responsible for assisting 

veterans who experience health problems associated with MST after they 

leave the military. VA uses the following definition of MST: “psychological 

trauma, which in the judgment of a mental health professional employed 

by the Department, 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.”12

While MST is not, itself, grounds for a disability claim, VA provides 

compensation for physical or mental health disabilities caused or 

aggravated by it, such as PTSD or depression.

Perpetrators may be colleagues, superiors, or individuals not affiliated 

with the military, and MST can happen during working as well as 

nonworking hours.

13

 12 38 U.S.C. § 1720D requires that VA operate a program of counseling and other 

services for veterans needing them to overcome sexual trauma. VBA has indicated that 

the definition in this statute should be used for purposes of disability claims. See 

Department of Veterans Affairs, Adjudicating Posttraumatic Stress Disorder (PTSD) 

Claims Based on Military Sexual Trauma (MST), Training Letter 11-05 (Washington D.C.: 

June 17, 2013), Attachment. While we use the term “military sexual trauma,” which VA 

uses in some of its guidance, VA regulations generally refer to “in-service personal 

assault” or “personal assault.” 38 C.F.R. § 3.304(f)(5). In addition, the term MST is 

sometimes used to refer to the precipitating incident or incidents as well as any resulting 

trauma it causes.

From fiscal year 2010 

through fiscal year 2013, PTSD was the most common disability claimed 

as a result of an incident or incidents of MST, making up about 94 percent 

of all MST-related claims completed during that time (see fig. 1).

13 Through VHA, veterans may also receive medical treatment for conditions related to 

MST.

Background

VBA’s Disability 

Compensation Process for 

MST-Related Claims
Page 6 GAO-14-477 Military Sexual Trauma 

Figure 1: Disabilities Claimed in Relation to Military Sexual Trauma, Fiscal Year 

2010 through Fiscal Year 2013

As with all disability compensation claims, VBA evaluates MST-related 

claims through its 57 regional offices. The process starts when a veteran 

submits a claim and VBA adjudicators help him or her gather relevant 

evidence.14 To receive benefits for PTSD related to MST, a veteran must 

show: (1) a medical diagnosis of PTSD, (2) evidence of an incident or 

incidents of personal assault while in the military, and (3) a link between 

current symptoms and the incident or incidents.15

 14 VBA adjudicators include veterans service representatives who assist veterans during 

the initial data collection steps in the process and ratings veterans service representatives 

who work with veterans service representatives to evaluate the evidence and order 

medical exams, and ultimately decide whether to approve or deny a claim. 

If sexual assault is 

documented in the veteran’s service record and a recent PTSD diagnosis 

is present in the veteran’s claim file supporting all three of these 

requirements, VBA adjudicators may approve the claim without extensive 

research or consultation with medical examiners. However, in most cases 

related to MST, some or all of this information is not readily available and 

adjudicators must take additional steps to develop the claim. Specifically, 

since 2002, VBA’s regulations for PTSD claims have expressly allowed 

for a broad range of evidence to corroborate a veteran’s claim that the 

15 38 C.F.R. § 3.304(f). The regulation refers to an “in-service stressor,” and in the MST 

context, that in-service stressor would be the personal sexual assault.
Page 7 GAO-14-477 Military Sexual Trauma 

MST incident or incidents occurred.16 Adjudicators must consider a range 

of indicators, whether or not there is anything to support the claim in the 

veteran’s service record.17

• records from law enforcement authorities, rape crisis centers, mental 

health counseling centers, hospitals, or physicians;

Referred to by the agency as “markers,” such 

indicators include, but are not limited to:

• pregnancy tests or tests for sexually transmitted diseases;

• statements from family members, roommates, and fellow 

servicemembers; and

• evidence of behavioral changes, such as requests for transfer to 

another military duty assignment, deterioration in work performance, 

and substance abuse.

If the adjudicator does not find any formal reports or markers to suggest 

that an MST incident occurred, the PTSD claim is denied by the 

adjudicator without further review because the occurrence of the assault 

has not been corroborated. Conversely, VA officials stated that 

adjudicators should order a medical exam if a claim file contains both 

evidence of the MST incident—such as a marker—and evidence from lay 

statements or other sources suggesting the veteran has symptoms 

consistent with a diagnosis of PTSD.

These medical exams are conducted by medical examiners from VBA’s 

sister organization, the Veterans Health Administration (VHA), or by 

contractors retained by VBA and VHA.

18

 16 VA’s regulatory changes do not apply to claims other than PTSD, such as those for 

depression or anxiety disorders.

Depending on the information 

needed to decide the claim, the medical examiner is expected to provide 

the adjudicator with an assessment of one or more of the following: (1) 

whether the veteran has PTSD; (2) the likelihood that the claimed MST 

incident occurred (based on his or her interview with the veteran and a 

review of available markers); and (3) whether there is a link between the 

diagnosis and the MST incident.

17 38 C.F.R. § 3.304(f)(5).

18 A diagnosis of PTSD must be based on criteria contained in the American Psychiatric 

Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition.
Page 8 GAO-14-477 Military Sexual Trauma 

Using the results of the medical exam and other evidence in the veteran’s 

claim file, the VBA adjudicator determines whether the veteran is entitled 

to compensation and denies or approves the claim. If the claim is 

approved, the adjudicator also assigns a percentage rating based on the 

severity of the claimed disability. If the veteran disagrees with the final 

claim decision, he or she may submit an appeal.19

Figure 2: VBA’s Disability Compensation Claim Process for PTSD Claims Based on Military Sexual Trauma

See figure 2 for an 

overview of the process for adjudicating MST-related claims.

a A medical examiner may not need to assess one or more of these questions if sufficient evidence is present in the file.

 19 A veteran may appeal, in succession, to the Board of Veterans’ Appeals, the U.S. Court

of Appeals for Veterans Claims, the Court of Appeals for the Federal Circuit, and finally 

the Supreme Court of the United States. A veteran can also reopen a claim that was 

denied based on new and material evidence, file a claim for an increase in a serviceconnected disability, or file a claim for a new disability. A veteran can also file a claim 

alleging clear and unmistakable error in a prior final regional office or board decision.
Page 9 GAO-14-477 Military Sexual Trauma 

VBA has a number of quality assurance programs to help ensure that 

adjudicators accurately and consistently follow VA regulations and 

policies. Under the national Systematic Technical Accuracy Review 

(STAR) program, VBA selects a random sample of all completed claim 

files each month from each of its regional offices. Using a standard 

checklist, STAR staff review each claim file and assess whether 

adjudicators took correct actions during various parts of the process and 

ultimately made accurate decisions. In addition, in 2012 VBA established 

local quality review teams in each regional office that assess adjudicator 

performance using the same review checklist as the national STAR 

program. For each adjudicator, each month, these reviewers assess five 

randomly-chosen claims and assess them using a similar process.

Periodically, VBA also conducts targeted reviews to assess adjudicator 

accuracy or consistency in processing specific types of claims. In August 

2011, VBA conducted a special accuracy review in response to concerns 

that adjudicators were not making accurate decisions for PTSD claims 

related to MST. The review found errors in 98 of 385 randomly selected 

claims that had been denied (about 25 percent).20 In particular, 

adjudicators should have identified markers and ordered medical exams 

rather than denied the claim in 61 cases because the files contained 

markers. The reviewers made several recommendations for improving the 

adjudication process, such as to: (1) clarify VA policies on markers, (2) 

build expertise in adjudicating such claims, and (3) develop training.

 20 VBA officials described the sample as nationally representative, although they could not 

provide documentation that would allow us to verify the accuracy of this statement.

VBA’s Quality Assurance 

Programs
Page 10 GAO-14-477 Military Sexual Trauma 

To help improve adjudicator adherence to processing requirements for 

MST-related claims, in 2011 VBA began directing regional offices to 

designate MST specialists from among their adjudicators with experience 

processing complex claims.21

Also starting in 2011, VBA developed additional guidance and training for 

MST specialists (see fig 3). Specifically, in late 2011, the agency issued a 

guidance letter and rolled out 1.5-hour and 4-hour training sessions on 

how to process PTSD claims related to MST. VBA also rolled out a onehour training session on sensitivity in June 2011. All MST specialists were 

required to take each course once. The guidance letter and trainings on 

processing claims highlighted the breadth of evidence that may serve as 

a marker and support that the MST incident occurred. For example, the 4-

hour training session described actual cases in which VA’s 2011 quality 

reviewers had found that adjudicators missed markers—such as 

The purpose of specialization was to allow 

regional offices to identify staff with the appropriate skills and sensitivity 

and afford specialists the opportunity to hone their knowledge of the MST 

requirements over many claims. At one of the offices we visited, for 

example, an MST specialist and her backup served as the only points of 

contact for any communication with MST claimants. These specialists 

compiled evidence for MST-related claims and then passed the claims on 

to another MST specialist who identified markers, ordered medical 

exams, and made final decisions about whether to approve or deny the 

claims.

 21 VBA began to phase in specialization for MST-related claims in 2011, and it was later 

incorporated into VA’s larger claims restructuring initiative. This larger initiative directed 

regional offices to divide claims and adjudicators into three segmented lanes, based on 

the type and complexity of the claims. VA considers MST-related claims to be among the 

most complex, and processes them through the “special operations” lane. The first phase 

of regional offices implemented the new structure in early 2012, and all regional offices 

had implemented it by March 2013.

VA Has Taken 

Several Steps to 

Improve Processing 

of Claims Related to 

MST

VBA Added Specialization 

and Training for 

Adjudicators while VHA 

Provided Some Training to 

Its Examiners
Page 11 GAO-14-477 Military Sexual Trauma 

disciplinary problems and childbirth approximately nine months after the 

alleged MST incident—that should have qualified as markers and 

triggered a medical exam. The course material for the 1.5-hour session 

also noted the high degree of judgment required of adjudicators when 

evaluating whether a claimant’s claim file includes markers. Specifically, 

course materials and presenters stated that there is “no bright line” about 

what qualifies as a marker and that decisions must be made on a caseby-case basis.

With regard to medical examiners who conduct exams for MST-related 

claims, VHA has instituted comparatively limited training to date (see fig. 

3). The one-hour certification course, required of medical examiners who 

conduct any type of PTSD exam, devotes 2 of 54 slides to describing how 

examiners should use markers to assess the likelihood that an MST 

incident occurred.22

 22 Medical examiners specialize in conducting exams for certain types of conditions, such 

as PTSD, but do not further specialize by the type of traumatic event that may have 

caused the PTSD, such as MST or combat. 

In collaboration with VBA, VHA had also developed 

and held a 1.5-hour information session specific to conducting MSTrelated medical exams. This session was available for on-demand 

viewing between April 2012 and September 2012. However, because this 

training is not part of VHA’s formal training curriculum, it was optional for 

in-house medical examiners and not made available to contractors who 

conduct MST-related exams but are not directly employed by VHA. Over 

the course of our review, VHA officials said they began developing more 

formal training on conducting MST-related exams and will start providing 

it in September 2014. More recently, they also decided to require the 

training for both in-house examiners and contractors.
Page 12 GAO-14-477 Military Sexual Trauma 

Figure 3: Training for VBA Adjudicators and VHA Medical Examiners Regarding Claims Related to Military Sexual Trauma 

(MST)

VBA began allowing veterans to resubmit previously denied PTSD claims 

related to MST in April 2013. While veterans always had the option of 

resubmitting denied claims to VBA if, for example, they obtained new 

evidence, this initiative is unique in that it does not require veterans to 

provide any additional information. The initiative was designed to correct 

any development errors that had occurred before VBA undertook its 

specialization and training initiatives. VBA sent 2,667 notification letters to 

veterans whose PTSD claims related to MST were denied between 

September 2010 and April 2013. VBA officials also told us they provided 

the veterans’ information to the veteran service organizations that 

represented them during the original claim process. (For the content of 

the notification letter, see app. II). While veterans whose claims were 

denied prior to September 2010 were also eligible to resubmit, VBA 

officials said most of these veterans did not receive notification letters 

because the agency did not systematically track such claims as being 

related to MST.

VBA Has Notified Some 

Veterans of the 

Opportunity to Resubmit 

Previously Denied Claims
Page 13 GAO-14-477 Military Sexual Trauma 

Our review of VBA data shows that national approval rates for all types of 

claims related to MST have increased since fiscal year 2010, almost 

doubling during that time period. In addition, the approval rates for PTSD 

claims related to MST have also become more comparable to PTSD 

claims related to other stressors, such as combat (see fig. 4).23

 23 VA regulations outline evidentiary requirements for PTSD claims and special 

evidentiary rules for PTSD claims based on: 1) PTSD diagnosed in-service, 2) combat, 3) 

fear of hostile military or terrorist activity, 4) status as prisoner of war, and 5) in-service 

personal assault, which would include MST. 38 C.F.R. § 3.304(f).

Since Improvements, 

Approval Rates Have 

Increased Nationally 

yet Vary Widely by 

Region

Approval Rates for MSTRelated Claims Increased 

Nationwide
Page 14 GAO-14-477 Military Sexual Trauma 

Figure 4: Approval Rates for PTSD Claims Related to Military Sexual Trauma versus 

Other Stressors, Fiscal Year 2010 through Fiscal Year 2013

While these trends do not necessarily attest to the accuracy of claim

decisions or establish whether any specific initiatives caused the change, 

VBA officials said they believe the trends indicate that the initiatives are 

working. Specifically, the new guidance and training on MST-related 

requirements highlighted the many sources that could be used as 

markers and lead to medical exams, and officials thought this led to the 

increased approval rates. They also viewed the increased comparability 

with other types of PTSD claims as a sign that veterans are having less 

difficulty establishing that an MST incident occurred than in the past.

Almost all VBA regional office staff we spoke with said that the 

specialization and training helped reinforce or clarify MST-related 

requirements. For example, adjudicators in three of five offices we spoke 

with specifically noted that it was useful to collaborate with other MST 

specialists about whether evidence qualified as a marker. At the same 

time, a few regional staff members and veteran service organization

representatives expressed concern that MST specialists are being held to 

the same performance standards for timeliness as other adjudicators and, 
Page 15 GAO-14-477 Military Sexual Trauma 

as such, may prioritize speed over quality. In terms of training and 

guidance, adjudicators or managers in three of the five offices we spoke 

with cited the written guidance on MST-related claims as particularly 

helpful for making decisions about markers and other requirements. We 

also found that VA followed a number of good practices in developing and 

implementing its training.24

While national approval rates have risen, our analysis of VBA data shows 

wide variation in approval rates among regional offices. Regional office 

approval rates for MST-related claims varied from about 14 to 88 percent 

in fiscal year 2013, and although about half of the offices had approval 

rates close to the average (between 40 and 60 percent), the rest were 

higher or lower (see fig. 5).

For example, the agency developed training 

content based on its research on errors commonly made with MSTrelated claims, and the Under Secretary for Benefits publicized the 

importance of the training.

25

 24 GAO, Human Capital: A Guide for Assessing Strategic Training and Development 

Efforts in the Federal Government, GAO-04-546G (Washington, D.C.: Mar. 1, 2004). GAO 

developed this guide through consultations with government officials and experts in the 

private sector, academia, and nonprofit organizations; examinations of laws and 

regulations related to training and development in the federal government; and reviewing 

the sizeable body of literature on training and development issues, including previous 

GAO products on a range of human capital topics.

25 The results are not specific to PTSD claims, although nationally, 94 percent of MSTrelated claims are for PTSD. These results reflect all 57 regional offices. When we 

excluded offices with fewer than 20 MST-related claims, we found that the range of 

approval rates remained the same. 

Approval Rates Varied by 

Region and Some 

Adjudicators and Medical 

Examiners Have 

Interpreted Processing 

Requirements Differently
Page 16 GAO-14-477 Military Sexual Trauma 

Figure 5: Range of Regional Office Approval Rates for Claims Related to Military 

Sexual Trauma in Fiscal Year 2013

Some variation in approval rates may be expected given that, for 

example, offices may receive claims with differing characteristics or 

strengths of evidence. As such, high denial rates or high approval rates 

do not necessarily equate to inappropriate denials or approvals. However, 

the extent of the variation raises the question of whether the data reflect 

real differences in evidence or differences in how the requirements are 

interpreted and applied. VBA officials we asked said that such variation 

could result at least in part from inconsistent implementation of MST 

specialization across regions, varied understanding of how to identify 

markers, and less experienced adjudicators in some locations.

Our interviews and observations suggest that VBA adjudicators 

sometimes differ in how they interpret MST-related requirements and 

make approval decisions. Adjudicators or quality review staff in four of 

five offices we spoke with said that—even with better guidance and 

training—identifying markers remains a difficult task. We also learned of 

cases where adjudicators varied widely in their interpretation of what 

qualified as a marker, particularly with regard to elapsed time. 

Specifically:
Page 17 GAO-14-477 Military Sexual Trauma 

• An MST adjudicator in one regional office told us she only counts 

evidence as a marker if it occurred within 2 months of the stated MST 

incident. However, VBA guidance does not provide a specific time 

frame for markers.

• In one 2013 claim file we reviewed, the adjudicator had not 

considered as a marker an HIV test taken 2 months before the 

veteran claimed that the MST incident occurred. Two supervisors 

reviewing the file with us said that a different adjudicator may well 

have considered the test to be a marker, given its proximity to the 

claimed date and the possibility that the veteran forgot the precise 

date of the MST incident.

• An MST adjudicator in another regional office told us that she once 

counted as a marker a pregnancy test that occurred 2 years after the 

cited MST incident. She said that she had initially determined that the 

test was not a marker, but received an error report for this from 

national quality review staff, perhaps because veterans with PTSD 

may not remember the exact date of the MST incident. She said she 

disagreed with this error, but reversed her decision. Since that error 

report, the adjudicator and quality review staff in the regional office 

said adjudicators’ definition of what qualifies as a marker has been 

very expansive.

• In one of the offices we interviewed, quality review staff said that 

“vague” complaints of pain or anxiety around the time of the MST 

incident would, in their view, qualify as markers. However, they 

described claim files from other offices in which the adjudicator did not 

consider such complaints to be markers.

• A key VBA official involved in developing agency policy on MSTrelated claims said that medical records documenting PTSD 

diagnoses related to MST should be interpreted as markers, even if 

they occurred many years after the claimed MST incident. However, 

at least 2 of the 15 claims made in 2013 that we reviewed included 

medical treatment records of this type that were not treated as 

markers.

The high degree of judgment required for identifying and weighing 

markers, as acknowledged in training and by officials with whom we 

spoke, could account for some variation in decision-making. For example, 

supervisors in one regional office told us that, hypothetically, two 

adjudicators could come to opposite conclusions about whether a piece of 

evidence qualified as a marker, and both decisions might comply with the 
Page 18 GAO-14-477 Military Sexual Trauma 

VA requirements. Nonetheless, the importance of consistent decisionmaking has been underscored by VBA’s quality assurance plan, our 

former evaluation of VBA disability claim processing, and the Institute for 

Defense Analyses.26 Adjudicators and regional office quality review staff 

in almost every office we interviewed cited actions that could further 

clarify their understanding, given the relative complexity of MST-related 

cases and the grey areas involved in identifying markers. They 

suggested, for example, refresher courses and the opportunity to see 

examples of the errors found during quality assurance reviews as a way 

to reinforce training. This is consistent with Office of Personnel 

Management guidance and our past work, which state that training and 

guidance should be reinforced or adjusted in circumstances where staff 

members remain confused about their responsibilities or when there is a 

gap between desired and actual practice.27

We also heard concerns that VHA medical examiners vary in the 

thoroughness of their reviews. VBA adjudicators generally rely on 

examiners’ assessments when deciding whether to approve a claim, and 

staff from four of five offices expressed concern about the quality of some 

medical examiners’ opinions. For example, quality review staff in one 

office noted that medical examiners vary in how thoroughly they sift 

through the claim files to identify markers. Seven of the nine medical 

examiners we spoke with also noted that their colleagues vary in their 

level of thoroughness in reviewing claims related to MST. For example, 

one medical examiner cited examples of examiners who complete exams 

in 15 minutes whereas she said it should take multiple hours, if done 

correctly. The medical examiner noted that less thorough reviews might 

lead to less informed assessments.

Moreover, medical examiners we spoke with cited different evidentiary 

thresholds for providing a positive opinion about the occurrence of the 

MST incident. Five of the nine medical examiners we spoke with said if 

they do not find specific evidence of a marker in a veteran’s claim file, 

 26 See GAO, Veterans’ Disability Benefits: VA Has Improved Its Programs for Measuring 

Accuracy and Consistency, but Challenges Remain, GAO-10-530T (Washington, D.C,: 

Mar. 24, 2010) and Institute for Defense Analyses, Independent Assessment of the 

Quality Assurance Program in the Department of Veterans Affairs, IDA Paper P-4744 

(Washington, D.C.: July 2011).

27 Office of Personnel Management, Training Evaluation Field Guide: Demonstrating the 

Value of Training at Every Level (Washington, D.C.: January 2011) and GAO-04-546G. 
Page 19 GAO-14-477 Military Sexual Trauma 

they will not provide a positive opinion about the occurrence of the MST 

incident. For example, two of these examiners said that they do not 

always agree with markers identified by the adjudicator and, in those 

cases, may spend hours sifting through the files to identify their own 

markers. If they do not find any markers after this search, they told us 

they would not provide a positive opinion about the occurrence of the 

MST incident. Alternatively, three other examiners said that they may still 

provide a positive opinion that the MST incident occurred if they believe 

the veteran but cannot find evidence in the file.28

Despite variation in examiner training and practices, VBA does not collect 

information that would help determine the extent to which MST-related 

claims are handled appropriately or consistently by VHA examiners. For 

example, VBA does not track the number of exams that adjudicators 

return to the medical examiner because the examiner’s opinion was 

deemed confusing or incomplete. At the same time, such information 

might provide a low estimate of less thorough exams because some 

examiners said that exams are only returned if they have very 

pronounced errors or omissions.

Given these variations, 

veterans may have differing chances of getting positive opinions that the 

MST incident occurred, depending on a given examiner’s approach. 

Almost all of the examiners we spoke with said that more training on 

identifying markers would be useful. While all examiners conducting 

PTSD exams receive required training that includes high level information 

about MST-related exams, VHA’s more detailed information session on 

the topic was optional for VHA medical examiners and not offered to 

contractors at the time of our review.

Few veterans to whom VBA sent notification letters had resubmitted their 

previously denied claims as of March 26, 2014 (see fig. 6). According to 

VBA analysis, 587 of the 2,667 veterans to whom VBA sent notification 

letters resubmitted their claims between May 1, 2013 and March 26, 

2014. VBA made decisions on resubmissions from 429 of these veterans 

 28 We did not explicitly ask the other two examiners about their threshold for providing a 

positive opinion about whether the MST incident occurred.

Veterans May Be Unaware 

of the Opportunity to 

Resubmit Previously 

Denied Claims
Page 20 GAO-14-477 Military Sexual Trauma 

and overturned original denials for 150 of them. Resubmissions from the 

remaining 158 veterans were pending.29

Figure 6: Number of Veterans Sent Notification Letters Regarding Previously 

Denied PTSD Claims Related to Military Sexual Trauma and Claims Resubmitted 

and Resolved between May 1, 2013 and March 26, 2014

Some veterans who received notification letters may not resubmit their 

claims because the letters were confusing or the process was too 

emotionally taxing to revisit, according to staff from five veteran advocacy 

organizations and three VBA regional offices. For example, one regional 

staff member characterized the notification letters as impersonal and 

expressed concern that they did not provide a direct phone number to

VBA staff with experience assisting MST claimants. Staff from another 

regional office noted that reopening a claim would require the veteran to 

revisit very painful memories. Given this, veterans may be unwilling to risk 

having their claim denied a second time.

Furthermore, an undetermined number of eligible veterans did not receive 

notification letters and may be unaware of the opportunity to resubmit 

their claims. Veterans with claims denied before September 2010 did not 

 29 VBA officials said that veterans resubmitting claims may experience some delays 

because adjudicators are currently prioritizing claims that have been pending for a year or 

more.
Page 21 GAO-14-477 Military Sexual Trauma 

receive letters because prior to that time, VA data systems did not 

systematically flag claims as MST-related. Between May 1 and December 

2, 2013, VBA made decisions on 174 resubmitted claims from veterans 

who were not sent notification letters, such as those with claims denied 

before September 2010. However, it is unclear what proportion of older 

denied MST-related claims this number represents, given the limitations 

with VBA’s data tracking. It is also unknown whether these claims were 

resubmitted in response to the initiative or because they were already 

eligible for resubmission due to new evidence. Moreover, even veterans 

with newer claims may not have received notification letters if they moved 

since submitting their original claims to VBA and providing a mailing 

address.

VBA’s national efforts to inform veterans who did not receive notification 

letters were limited to two meetings with national veteran service 

organization representatives in June 2013. VBA did not require that 

regional offices publicize the initiative and we did not see any examples of 

targeted outreach related to this initiative at the five offices we visited. 

Local veteran service organization representatives we spoke with said 

that few to no veterans had approached them about the resubmission 

initiative. Although these local organizations play a key role in informing 

veterans about benefits and assisting them with claims, for one VBA 

regional office, only 1 of the 10 representatives we spoke with had heard 

about the initiative. At the national level, most veteran service 

organizations we spoke with also said they knew little about the initiative. 

An official from one of the organizations said they heard about the 

initiative by chance and subsequently publicized it on the organization’s 

Facebook page. Keeping stakeholders—such as veterans and veteran 

service organizations—informed about initiatives is a key component of 

internal control and important for ensuring that eligible veterans know 

about available opportunities.30

 30 GAO, Standards for Internal Control in the Federal Government, 

Representatives from two veteran 

advocacy organizations and adjudicators from one regional office we 

spoke with said that VBA should conduct more outreach regarding this 

initiative, including posting flyers in VHA medical centers, where 

veterans—including those with denied MST-related claims—may visit to 

receive counseling or other services.

GAO/AIMD-00-21.3.1 

(Washington, D.C.: Nov. 1, 1999).
Page 22 GAO-14-477 Military Sexual Trauma 

In our interviews outside and within VBA, we found continuing, albeit 

differing, concerns about the fairness of the evidentiary requirements for 

MST-related claims. First, stakeholders outside and within the agency 

disagreed on whether the requirements for PTSD claims attributed to 

MST were too stringent, particularly when compared to those for PTSD 

claims attributed to other stressors. On the other hand, staff within VBA 

expressed concern that MST-related evidentiary requirements for mental 

health disabilities other than PTSD were more stringent than those for 

PTSD because markers cannot be used for other mental health 

disabilities.

Concerns Regarding the Evidentiary Requirements for PTSD Claims

Stakeholders we interviewed expressed divergent views about the 

fairness of the requirements for PTSD claims related to MST and the 

implications for expanding them. Outside of the agency, representatives 

from four of five veteran advocacy organizations we interviewed 

expressed concern that the requirement to substantiate an MST incident 

is still difficult to meet for many with valid claims.31 Some of these 

representatives said that even markers can be difficult to find or may not 

exist, since veterans may have initially tried to hide their experience due 

to fear of reprisal or feelings of shame or embarrassment, among other 

reasons. These representatives contrasted the requirements for other 

PTSD claims with those for PTSD claims related to MST. For example, 

they noted that for PTSD claims related to fear of hostile military or 

terrorist activity, a veteran’s own testimony alone generally may establish 

the claimed incident (i.e., in-service stressor),32

 31 The fifth organization did not have a position on this issue.

and took the position that 

this constitutes a far lower burden of proof than for PTSD claims related 

to MST. However, in contrast to these perspectives, VBA officials pointed 

out that in such cases, a veteran’s own testimony alone may establish the 

claimed in-service stressor only if that stressor is consistent with the 

places, types, and circumstances of the veteran’s service. For example, 

officials said that the veteran’s testimony could be sufficient if the military 

record established that the veteran was located in an area where the 

claimed stressful military event could have occurred (see fig. 7). VBA 

officials noted that the 2002 allowance for MST markers was the agency’s 

way of broadening the range of permissible evidence while still requiring 

32 38 C.F.R. § 3.304(f)(3).

VBA’s Evidentiary 

Requirements Evoke 

Differing Concerns outside 

and within the Agency
Page 23 GAO-14-477 Military Sexual Trauma 

some level of proof beyond the veteran’s own testimony. They said that to 

eliminate or further ease these requirements would eliminate the agency’s 

ability to verify the claim, as is required for all other types of claims.33

Figure 7: Examples of Credible Supporting Evidence Needed to Substantiate that an In-Service Stressor Occurred by Type of 

PTSD Claima

a To receive benefits for all types of PTSD claims, a veteran must also show a diagnosis of PTSD and 

a causal association between the diagnosis and the stressful event.

b Such an exam would include interviewing the veteran about the MST incident.

Concerns Regarding the Evidentiary Requirements for Other Mental 

Health Claims

VBA staff we interviewed in all five regional offices expressed concern 

that the MST-related evidentiary requirements for mental health 

disabilities other than PTSD are more stringent than those for PTSD. 

Because VA’s 2002 regulatory changes allowing for markers only apply to 

 33 Legislation pending in Congress would address the evidentiary requirements for PTSD 

claims related to MST. On June 4, 2013, the House of Representatives passed H.R. 671, 

the Ruth Moore Act of 2013, which includes a statement of the sense of the Congress that 

the VA should update and improve its regulations related to MST. In the Senate, S. 294, 

also entitled the Ruth Moore Act of 2013, would amend current law to provide, for 

example, that under certain conditions a veteran’s lay testimony alone may establish the 

occurrence of MST. S. 294 was introduced and referred to the Committee on Veterans’

Affairs on February 13, 2013.
Page 24 GAO-14-477 Military Sexual Trauma 

PTSD claims, staff said that MST-related claims for other mental health 

disabilities, such as depression or anxiety disorders, are more difficult to 

substantiate. They explained that, unlike PTSD, a claimant diagnosed 

with depression or an anxiety disorder must have evidence other than 

markers to connect his or her disability to military service, such as 

medical records related to treatment received while the veteran was in the 

military. For example, if a veteran has no in-service treatment history, is 

diagnosed with depression years after leaving service, and says that the 

depression is a result of MST, he or she would need to have 

documentation such as a formal complaint of sexual assault in his or her 

military records to substantiate that the event occurred in military service

and evidence linking the assault to the depression. In one file we 

reviewed, a veteran’s PTSD claim related to MST was denied when the 

medical examiner diagnosed the veteran with depression instead of 

PTSD. The letter sent to the veteran regarding the decision noted that the 

markers would have served as evidence to support the occurrence of 

MST if the diagnosis had been PTSD. However, the letter said the 

markers could not be used because the veteran was subsequently 

diagnosed by the medical examiner with depression. No formal complaint 

of sexual assault was present in the file. Regional staff in four offices 

expressed concern that it is difficult for them to substantiate claims for 

other mental health disabilities that are related to MST, given that 

veterans infrequently file formal complaints of sexual assault while in 

service.34

VBA plans to reevaluate its evidentiary requirements for non-PTSD 

mental health claims related to MST, according to officials. They said the 

2002 regulatory changes allowing for MST markers were aligned with 

broader evidentiary requirements for all PTSD claims—which include

other types of in-service events, such as combat, and are also specific to 

PTSD—and the agency did not intentionally exclude other types of mental 

health claims. One official noted that any changes would involve 

reviewing relevant diagnostic criteria and considering any implications for 

mental health claims that are unrelated to MST.

 34 While our analysis of VBA data suggests similar approval rates for PTSD and nonPTSD mental health claims attributed to MST, VBA data do not allow for comparisons of 

approval rates by whether non-PTSD mental health conditions were diagnosed in or postservice.
Page 25 GAO-14-477 Military Sexual Trauma 

Since conducting the 2011 quality review that triggered its improvement 

initiatives, VBA has conducted two more quality reviews of MST-related 

claims, but both have limitations. VBA conducted the first of these reviews 

in October 2012, which examined whether adjudicators took appropriate 

actions with respect to claims that received a medical exam and were 

subsequently denied. While it provided some information on errors made 

by adjudicators, for example, in interpreting medical examiner opinions, it 

did not provide any information about the quality of the adjudication 

process for approved claims or claims that were denied without a medical 

exam. However, adjudicators in at least one of the regional offices we 

visited raised concerns about the potential for inappropriate approvals, in 

addition to inappropriate denials. VBA officials said this review of denied 

claims was conducted at the request of Congress, which was particularly 

interested in claims denied following a medical exam.

VBA conducted its second review in December 2013, which assessed the 

consistency of adjudicators’ knowledge of how to process MST-related 

claims. Adjudicators present on the day the review was administered 

were given a case scenario involving a PTSD claim related to MST and a 

related questionnaire that probed errors found in prior reviews. They were 

asked to identify relevant markers from a multiple-choice list, and to 

determine whether a medical exam should be ordered and whether the 

case should be approved, denied, or deferred for additional information. 

VBA found that 85 percent of 755 adjudicators correctly approved the 

case, 14 percent incorrectly deferred their decision to approve or deny the 

VBA Has Not 

Optimized 

Opportunities to 

Evaluate or Collect 

Information about 

MST-Related 

Decisions

VBA Has Conducted Few 

Quality Reviews of MSTRelated Claims
Page 26 GAO-14-477 Military Sexual Trauma 

claim, and 1 percent incorrectly denied it.35

In addition to these limitations, VBA’s reviews of MST-related claims have 

not allowed it to monitor the quality of its processes over time, a standard 

part of internal control and best practice for ensuring that associated 

training is relevant and sufficient.

VBA is requiring that all 

adjudicators who provided incorrect answers to the questionnaires 

receive more training by the end of April 2014. While this review provided 

some information on common errors made by adjudicators, the results 

may underestimate the challenge of adjudicating MST-related claims, 

given that responding to multiple choice questions about a hypothetical 

case may be less difficult than sifting through a real claim file to identify 

markers, order an exam, and make a decision. In addition, because the 

review was administered as a one-time test and was not mandatory, the 

results may not include adjudicators who were absent on the day of the 

review or did not participate for other reasons.

36 The results of the MST-specific quality 

reviews discussed above are not comparable because they measured 

quality in different ways. Similarly, neither can be compared with the 2011 

quality review completed prior to VA’s improvement initiatives because (1) 

the quality reviews of denied claims were selected from overlapping time 

periods and (2) the consistency study used a different measure of 

quality.37 Furthermore, while VBA does conduct longitudinal reviews of 

the accuracy and consistency of all claim files through its national STAR 

and local quality reviews,38

 35 The review included one questionnaire for adjudicators who gather evidence (veterans 

service representatives and related quality review staff) and one questionnaire for 

adjudicators who determine whether to approve the claim (ratings veterans service 

representatives and related quality review staff.) The 755 adjudicators who answered the 

question were from 53 of 57 regional offices. 

only a limited number of MST-related claims 

are reviewed each month, if at all, and VBA does not specifically track the 

inclusion or results of MST-related claims within these reviews.

36 GAO/AIMD-00-21.3.1 and Office of Personnel Management, Training Evaluation Field 

Guide: Demonstrating the Value of Training at Every Level.

37 Specifically, the 2011 and 2012 reviews of denied claims both focused on different 

types of denied claims—all denied claims versus those that were denied after receiving an 

exam—that were completed between 2008 and the time that each review was conducted, 

and thus cannot show change in quality over time.

38 Results from national STAR and local quality reviews are used to track performance 

trends within and/or among all regional offices.
Page 27 GAO-14-477 Military Sexual Trauma 

At the time of our review, VBA officials were planning to conduct two 

additional reviews of MST-related claims to identify training needs. 

Specifically, after calculating regional office approval rates at our request, 

VBA officials decided to assess the quality of claim decisions among 

offices with relatively high or rising denial rates. The agency planned to 

review approximately 500 claims from 20 offices, starting in April 2014. 

Further, officials said VBA will conduct an additional quality review in 

September or October 2014. They said this review will focus on randomly 

selected PTSD claims related to MST and include both those approved 

and denied. However, as with past reviews, these planned reviews will 

focus on different subsets of claims, and therefore, it is unclear how the 

agency will use them to monitor trends over time.

In response to congressional requests, VBA has examined trends in 

approval rates for PTSD claims related to MST as well as those related to 

combat and other stressors. Both VBA’s and our analyses show that 

approval rates for PTSD claims related to MST have increased, and are 

becoming more comparable to those for other types of PTSD claims. VBA 

officials said the increased approval rates show the effects of VBA’s 

specialization and training initiatives.

Nevertheless, VBA has not analyzed other available data that could help 

it identify potential problem areas to target training needs, such as 

approval rates by regional office and veteran gender for all MST-related 

claims. As noted earlier, our analysis of existing VBA data found wide 

variances in approval rates across regional offices, ranging from 14 to 88 

percent. In addition, we found that approval rates for MST-related claims 

from female veterans remained consistently higher than those from males 

between fiscal years 2010 and 2013 (see fig. 8).39

 39 Between fiscal years 2010 and 2013, about 63 percent of MST-related claims 

completed were filed by females, 36 percent were filed by males, and 1 percent was filed 

by veterans who did not specify their gender.

VBA Has Studied Its 

Approval Rates for PTSD 

Claims Nationally, but Has 

Not Analyzed Available 

Data by Regional Office or 

Veteran Gender
Page 28 GAO-14-477 Military Sexual Trauma 

Figure 8: Percentage of Claims Related to Military Sexual Trauma Approved for 

Males versus Females, Fiscal Year 2010 through Fiscal Year 2013

As discussed earlier, variations in approval rates do not necessarily mean 

that decisions were inaccurate, as they could be attributed to actual 

differences among claims and their levels of evidence. However, they do 

pose reasonable questions as to the level of consistency among 

adjudicators. VBA officials said the agency’s many competing priorities 

have precluded their following up with more data collection and analysis 

to date, although they do plan to review variations in approval rates in the 

near future.

Finally, VBA does not electronically collect information about the number 

of MST-related claimants who receive medical exams, how often such 

exams are considered insufficient, and why claims are denied.40

 40 VBA does collect some high-level data on reasons for claim denials, but VBA officials 

said it provides very limited information on actual reasons for each claim. Current codes to 

capture reasons for denials in VBA’s data system include, for example, “not in the line of 

duty,” “not aggravated by service,” “no diagnosis,” and “not incurred/caused by service.”

As noted 

above, we found instances where VBA adjudicators may vary in how they 

interpret requirements for identifying markers and ordering an exam, and 

where VHA medical examiners may vary in how they conduct such 

exams. Without systematically collecting information about exams and 

why claims were ultimately denied, VBA cannot identify national or 
Page 29 GAO-14-477 Military Sexual Trauma 

regional trends in these areas. Officials acknowledged that MST has 

become a more prominent topic in recent years, particularly within 

Congress, and that VBA will collect and analyze more data as needed.41

In adjudicating claims related to sexual assault, VA faces the difficult task 

of assessing events for which there is often no concrete evidence. The 

difficulty of the task reveals the pernicious nature of MST: 

servicemembers may fear the repercussions of reporting an experience 

that was, itself, traumatic. This fear can be confounded if the perpetrator 

was a colleague or someone in a position of power, and this betrayal of 

trust can inflict profound confusion and pain.

VA has taken a number of important steps to redress the dearth of 

evidence in a veteran’s service record, both going forward with 

adjudicating new claims and acknowledging the potential for error in prior 

MST-related claim decisions. However, its decision to broaden the scope 

of allowable evidence—and thereby reduce inappropriate denials—brings 

its own challenges. Evaluating such a range of evidence requires 

expertise and a substantial degree of judgment by adjudicators and 

examiners, and some variation in determinations may be expected by 

virtue of the different circumstances surrounding each case. However, a 

level of inconsistency may occur that is not acceptable, especially if a 

veteran’s chance of getting a claim approved is contingent on the 

particular adjudicator or medical examiner responsible for the review. Yet, 

to completely avoid such inconsistencies could require either a highly 

prescriptive set of rules for weighing the available evidence of sexual 

abuse, or, conversely, removing altogether the requirement for evidence 

of the assault—actions that carry their own risks and would require 

careful decision making.

Even without sweeping changes to policy, there is substantial opportunity 

to make process changes that could better ensure benefits are 

appropriately awarded to veterans with valid MST-related claims. In 

contrast to VA’s actions to date, which largely have been taken in 

response to external requests, a more proactive and systematic approach 

could further dispel confusion among adjudicators and examiners, identify 

errors, and inform veterans of opportunities to resubmit denied claims. 

 41 Both House and Senate versions of pending legislation, the Ruth Moore Act of 2013 

(H.R. 671 and S. 294), would require VA to report data on MST-related claims as well as 

information on employee training related to MST.

Conclusions
Page 30 GAO-14-477 Military Sexual Trauma 

Specifically, without more thorough and continuous training, some 

adjudicators and medical examiners are likely to remain confused about 

what qualifies as evidence. In addition, designing quality reviews to track 

trends over time, more fully analyzing data on MST-related claim 

decisions, and exploring options for collecting additional data could help 

VA flag potential areas of inconsistency for more careful review. 

Meanwhile, the limited outreach to veterans denied benefits for an MSTrelated claim could leave many unaware of new opportunities to have 

their claims reassessed under the broadened evidentiary requirements.

The Acting Secretary of Veterans Affairs should direct the Under 

Secretary for Benefits to

• expand existing training and guidance to adjudicators responsible for 

MST-related claims by, for example, providing mandatory refresher 

courses or regularly distributing examples of relevant errors identified 

from quality assurance reviews.

• develop a plan for conducting more comprehensive quality reviews of 

MST-related claims that allows the agency to identify problem areas, 

target improvement efforts, and track performance over time.

• further analyze existing data on MST-related claim decisions by, for 

example, determining approval rates by regional office and veteran 

gender.

• explore ways to systematically collect additional data on MST-related 

claims that might allow the agency to better track consistency. Such 

data could include reasons for denials, whether claim evaluations 

included a medical exam, and how often related medical exam reports 

are returned to VHA for clarification or deemed insufficient.

• expand outreach to veterans who are eligible to resubmit their 

previously denied PTSD claims related to MST. The agency should 

conduct this outreach in partnership with the Veterans Health 

Administration or external organizations, such as veteran service 

organizations.

The Acting Secretary of Veterans Affairs should further direct the Under 

Secretary for Health to ensure that planned training on conducting MSTrelated exams is provided to all medical examiners who perform them, 

including contractors.

Recommendations for 

Executive Action
Page 31 GAO-14-477 Military Sexual Trauma 

We provided a draft of this report to VA for review and comment, and its 

written comments are reproduced as appendix III in this report. VA 

generally agreed with our conclusions and concurred with all of our 

recommendations. The agency outlined how it plans to address our 

recommendations as follows:

• Regarding our recommendation to expand existing training and 

guidance to adjudicators, VA said that VBA is in the process of 

developing refresher training and anticipated that it will be 

available to staff by August 15, 2014. As VBA finalizes this 

training, it should consider making the training mandatory to all 

staff processing MST-related claims or to those whose claim

decisions have been found to be in error.

• Regarding our recommendation to develop a plan for conducting 

more comprehensive quality reviews, VA said that VBA plans to 

conduct special MST-related reviews twice each year and 

systematically analyze the results of each review within 4 months

of completion. VA said that its current plans were sufficient to 

implement the recommendation. However, we would need 

additional information about the planned reviews—such as 

whether they will employ comparable methodologies and samples 

of claim files to allow VBA to track performance over time—before 

considering this recommendation implemented.

• Regarding our recommendation to further analyze existing data on 

MST-related claim decisions, VA said VBA will review and analyze 

such data by October 2014 and conduct follow-up analyses every 

6 months thereafter. 

• Regarding our recommendation to explore ways to systematically 

collect additional data on MST-related claims, VA said VBA has 

begun developing such an approach, particularly in terms of 

tracking reasons why claims are denied. VBA plans to conduct its 

first analysis in October 2014 with follow-up analyses every 6 

months thereafter. VBA and VHA plan to use the information to 

identify areas where variations in approval rates may result from 

different interpretations of how to adjudicate claims or conduct 

medical exams. 

• Regarding our recommendation to expand outreach to veterans 

about the option to resubmit previously denied claims, VA said 

Agency Comments

and Our Evaluation
Page 32 GAO-14-477 Military Sexual Trauma 

VBA will conduct additional outreach by September 30, 2014, 

working closely with VHA, veteran service organizations, and 

others.

• Regarding our recommendation that planned training on 

conducting MST-related exams be provided to all relevant medical 

examiners, VA outlined plans for ensuring that examiners 

participate in the training. Specifically, by April 30, 2015, all VHA 

medical examiners and contractors will be required to take the 

training and VA medical centers and vendors who employ 

contractors will be required to certify that examiners completed the 

training.

VA also provided technical comments, which we incorporated into our 

report as appropriate.

We are sending copies of this report to the appropriate congressional 

committees and the Acting Secretary of Veterans Affairs. In addition, the 

report is available at no charge on the GAO website at 

http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7215 or bertonid@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix IV.

Daniel Bertoni

Director, Education, Workforce, and Income Security Issues
Page 33 GAO-14-477 Military Sexual Trauma 

List of Requesters

The Honorable Patty Murray

Chairman

Committee on the Budget 

United States Senate

The Honorable Bernard Sanders

Chairman

Committee on Veterans’ Affairs

United States Senate

The Honorable Jon Runyan

Chairman

Subcommittee on Disability Assistance and Memorial Affairs

Committee on Veterans’ Affairs

House of Representatives

The Honorable Mark Begich

United States Senate

The Honorable Richard Blumenthal

United States Senate

The Honorable Jon Tester

United States Senate

The Honorable Chellie Pingree

House of Representatives
Appendix I: Objectives, Scope, and 

Methodology

Page 34 GAO-14-477 Military Sexual Trauma 

The objectives of this report were to examine (1) the steps the 

Department of Veterans Affairs (VA) has taken to improve decisions for 

claims related to military sexual trauma (MST), (2) the results, to date, of 

VA’s actions to improve such decisions, and (3) the extent to which the 

Veterans Benefits Administration (VBA) within VA is assessing the quality 

of its claim decisions related to MST. To address these objectives, we 

reviewed related federal laws and regulations as well as guidance, 

training materials, and planning documents for VA’s improvement 

initiatives. We also reviewed GAO criteria on internal controls, program 

management, and good practices for implementing training. Further, for 

all three objectives, we interviewed VBA and Veterans Health 

Administration (VHA) officials, VBA and VHA regional staff, and national 

and local advocates. (See below for more information about our 

interviews). We also reviewed a small sample of completed claim files to 

obtain examples of the evidence available for establishing the occurrence 

of MST incidents and VBA and VHA processes to evaluate such 

evidence. (See below for more information about this claim file review.) 

To examine the results of the initiatives to date and the extent to which 

VBA is assessing the quality of claim decisions, we analyzed VBA 

administrative data on MST-related claim approval rates and spoke with 

relevant VBA staff. (See below for more information about our review of 

these data and our efforts to ensure their reliability.) We also reviewed 

VBA reports about their quality assurance reviews and the resubmission 

initiative for previously denied claimants. We assessed the reliability of 

these reports by reviewing related documentation and interviewing 

agency officials knowledgeable about how they were produced. We 

determined that the results presented in this report were sufficiently 

reliable for our purposes.

To obtain information relevant to all three objectives, we interviewed VBA 

officials responsible for developing and disseminating policy, training, and 

guidance on MST-related claims and quality assurance staff including 

officials responsible for the Systematic Technical Accuracy Review 

(STAR) and Quality Review and Consistency Programs. We also spoke 

with VHA officials responsible for overseeing medical examiners who 

conduct exams related to VBA disability claim decisions and VHA staff 

and officials responsible for developing and disseminating medical 

examiner training on MST-related exams.

In addition, we interviewed managers and staff at the regional level to 

better understand how MST-related policies and initiatives were 

implemented. We selected 5 of VBA’s 57 regional offices for review. The 

Appendix I: Objectives, Scope, and 

Methodology

Interviews
Appendix I: Objectives, Scope, and 

Methodology

Page 35 GAO-14-477 Military Sexual Trauma 

offices were selected to reflect a variety of characteristics related to (1) 

performance on VA accuracy and consistency reviews,1 (2) efficiency of 

claim processing,2 (3) number of MST-related claims received,3 (4) time 

elapsed since certain VA initiatives were adopted,4 and (5) geographical 

region.5

For all 5 regional offices, we spoke with managers, adjudicators who 

specialize in MST-related claims, quality review team members who 

review MST-related claims, and personnel who conduct veteran outreach 

related to MST. For the 3 offices that we visited in person, we interviewed 

one or more VHA psychologists who conduct medical exams for MSTrelated claims or provide clarification to VBA adjudicators regarding MSTrelated exams completed by others. We also spoke with local veteran 

service organization representatives in each of these 3 offices who had 

previously worked on MST-related claims.

We visited 3 of the selected offices in person (Nashville, 

Portland, and San Diego) and conducted interviews with the remaining 2 

over the phone (Milwaukee and Pittsburgh). The information obtained 

during these interviews is not generalizable to all VBA regional offices.

Outside of VA, we spoke with representatives from national veteran 

service organizations and other advocacy groups. These included 

representatives from the Disabled American Veterans, Iraq and 

Afghanistan Veterans of America, National Veterans Legal Services 

 1 We used data from VBA’s ASPIRE Dashboard to rank regional office performance on 

VA’s national accuracy and consistency reviews of disability and compensation claim 

decisions for May 2013, the most recent data at the time of our selection.

2 We used data from VBA’s ASPIRE Dashboard to rank regional office performance on 

the efficiency of claim processing in May 2013. Regional offices were ranked based on the 

percentage of backlogged claims, average days of processing time for claims, and 

average days pending for claims.

3 We used data requested from VBA’s Office of Field Operations to rank regional offices 

on the number of MST-related claims received in fiscal year 2012, the most recent data at 

the time of our selection. For this criterion, we focused on selecting regional offices with a 

higher number of MST-related claims received, since these types of claims are the focus 

of our study.

4 We used data requested from the Office of Field Operations to rank regional offices 

based on the date of adoption of the special operations lanes initiative, which uses 

specialized staff to adjudicate MST-related claims. 

5 We used VBA’s regional office structure, which categorizes regional offices into eastern, 

western, southern, and central regions.
Appendix I: Objectives, Scope, and 

Methodology

Page 36 GAO-14-477 Military Sexual Trauma 

Program, Service Women’s’ Action Network, and Veterans of Foreign 

Wars. We selected interviewees based on the size of the organization 

and recommendations from other stakeholders.

For each of the 3 VBA regional offices we visited in person, we reviewed 

a non-generalizable sample of 6 claim files that were completed in 2013 

(18 total) to provide illustrative examples of how VBA adjudicates MSTrelated claims. These claim files included the evidence collected by 

adjudicators, correspondence with the veteran on the status of their claim, 

and the decision made on the claim. We selected claim files from among 

those recently completed at the time of our visit to each regional office. 

We chose files that provided variation in terms of the claimed disability, 

decision made on the claim (approval or denial), and veteran gender. Our 

sample also included two PTSD claims related to other stressors for 

comparison purposes. For each claim file, we documented the disability, 

evidence provided to support the claim, key findings from the medical 

exam, nature and frequency of correspondence with the veteran, and 

decision on whether to approve or deny the claim.

We obtained and analyzed data from VBA’s RBA2000 database for the 

following types of disability claim decisions:

• MST-related claims. We obtained data on the number of all MSTrelated claims that were received, completed, and approved or denied 

for each fiscal year from 2008—the earliest year for which VBA has 

data—through 2013. We also obtained breakouts for these data by 

disability claimed, veteran gender, and regional office.

• PTSD claims related to other non-MST stressors. Similar to the data 

for MST-related claims, we obtained data on the number PTSD claims 

related to other stressors that were received, completed, and 

approved or denied for each fiscal year from 2008 through 2013 for 

comparison purposes. We also obtained breakouts for these data by 

veteran gender and regional office.

In requesting data from VBA, we chose to exclude data on decisions 

made regarding re-evaluation requests for a higher disability rating 

percentage because such decisions are based largely on the diagnoses, 

not on whether the claim is MST-related. We chose to report approval 

rates by MST-related disability or “claim” rather than unique case or 

unique veteran. Each unique case can include claims for multiple 

Claim File Review

Analysis of VBA Data on 

Claim Decisions
Appendix I: Objectives, Scope, and 

Methodology

Page 37 GAO-14-477 Military Sexual Trauma 

disabilities, and each unique veteran may have multiple cases with claims 

for multiple disabilities. Therefore, we determined that analysis at the 

level of individual disabilities provided the most accurate and nuanced 

information about MST-related decision making.

We assessed the reliability of the data obtained by (1) performing 

electronic testing for obvious errors in accuracy and completeness, (2) 

reviewing existing information about the data and the system that 

produced them, and (3) interviewing agency officials knowledgeable 

about the data. We determined that the data were sufficiently reliable for 

purposes of providing information on trends in claim decisions. However, 

there were several limitations to the data obtained:

• The data obtained may under-represent the number of MST-related 

claims completed because VBA does not have procedures in place to 

verify whether adjudicators appropriately flag MST-related claims in 

the system.

• We chose to report on claim decisions made since fiscal year 2010 

due to data reliability concerns about older decisions. Although VBA 

databases have allowed the agency to track MST-related claims since 

fiscal year 2008, its tracking system became more accurate in fiscal 

year 2010. Prior to that time, the codes used to identify MST-related 

claims only referred to PTSD, and officials expressed concern that 

adjudicators applied the codes inconsistently. In fiscal year 2010, VBA 

developed more detailed codes for identifying MST-related claims, 

including codes that identified claims for both PTSD and other 

disabilities. The agency also provided more guidance to adjudicators 

about appropriately applying the codes.

We analyzed VBA data to determine the most common disabilities 

associated with MST-related claims and examined trends in approval 

rates. We calculated approval rates by dividing the number of claims 

approved by the number completed for each type of claim. We examined 

trends in approval rates nationally as well as by veteran gender and 

regional office. We chose to include all 57 regional offices in our 

analyses. To assess whether any individual decision could unduly impact 

the approval rates in offices with fewer claims, we also conducted an 

analysis that excluded offices with 20 or fewer claims in fiscal year 2013. 

We ultimately decided to include the results from these offices after 

determining that both analyses resulted in the same range of approval 

rates.
Appendix I: Objectives, Scope, and 

Methodology

Page 38 GAO-14-477 Military Sexual Trauma 

We were unable to determine the causes for variation among regional 

office rates due to the absence of data on factors that could impact claim 

decisions—such as the reasons for denial—and the limited number of 

MST-related claims in each regional office. Trends in approval rates do 

not necessarily attest to the accuracy of claim decisions, and could be 

attributed to actual differences among claims and their levels of evidence.

Our analyses focused on completed claims by fiscal year. Since claims 

may take awhile to complete, sometimes more than a year, in any given 

year, a large number of cases may be pending and therefore not captured 

in our analyses for one or more years. Given limitations with the 

administrative data, we could not analyze whether completed claims 

differed significantly from pending claims and whether including pending 

claims would alter the results of our analysis of potential trends in MSTrelated claim decisions. Figure 9 provides the number of MST-related 

claims completed, received, and pending in each fiscal year from 2010 

through 2013. Information on pending claims was obtained from VBA’s 

MAP-D database, which tracks information on claims still in process. VBA 

officials said the number of pending MST-related claims may be underrepresented. They explained that an adjudicator may not know a claim is 

related to MST until later on in the process and thus, would not flag it as 

an MST-related claim in MAP-D.6

 6 They stated that adjudicators are more likely to have accurate information about a 

claim’s relationship to MST by the time the claim is completed and documented in the 

RBA2000 database.
Appendix I: Objectives, Scope, and 

Methodology

Page 39 GAO-14-477 Military Sexual Trauma 

Figure 9: The Number of Claims Related to Military Sexual Trauma Completed, 

Received, and Pending, Fiscal Year 2010 through Fiscal Year 2013
Appendix II: Text of Notification Letter Sent to 

Previously Denied Claimants

Page 40 GAO-14-477 Military Sexual Trauma 

Veteran XXX,

The Department of Veterans Affairs (VA) records show that you 

previously filed a disability claim for posttraumatic stress disorder (PTSD) 

and stated that the stressor was related to sexual trauma experienced in 

the military.

Although your claim was denied, in VA’s continued efforts to assist 

Veterans, claims for PTSD based on military sexual trauma (MST) are 

being reviewed. A new review will determine if any evidence was 

overlooked. Participation in a VA examination may be required.

Please contact your local VA regional office if you would like your PTSD 

claim reviewed to determine entitlement to service connection.

For convenience, submit the enclosed VA Form 21-4138 (Statement in 

Support of Claim) and indicate that you would like to have your PTSD 

claim based on MST reviewed.

If you have any additional evidence to support your claim, including 

statements from family members or fellow service members, please 

advise the regional office.

Sincerely,

Thomas J. Murphy

Director, Compensation Service

Appendix II: Text of Notification Letter Sent to 

Previously Denied Claimants
Appendix III: Comments from the Department 

of Veterans Affairs

Page 41 GAO-14-477 Military Sexual Trauma 

Appendix III: Comments from the 

Department of Veterans Affairs
Appendix III: Comments from the Department 

of Veterans Affairs

Page 42 GAO-14-477 Military Sexual Trauma 
Appendix III: Comments from the Department 

of Veterans Affairs

Page 43 GAO-14-477 Military Sexual Trauma 
Appendix III: Comments from the Department 

of Veterans Affairs

Page 44 GAO-14-477 Military Sexual Trauma 
Appendix III: Comments from the Department 

of Veterans Affairs

Page 45 GAO-14-477 Military Sexual Trauma 
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 46 GAO-14-477 Military Sexual Trauma 

Daniel Bertoni, (202) 512-7215, or bertonid@gao.gov

In addition to the contact named above, Michele Grgich (Assistant 

Director), Carl Barden, James Bennett, Susan Bernstein, Bianca Capone, 

William Colvin, Helen Desaulniers, Joel Green, Jonathan McMurray, Jean 

McSween, Nhi Nguyen, Almeta Spencer, Barbara Steel-Lowney, Walter 

Vance, Kathleen Van Gelder, and Craig Winslow made contributions to 

this report.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact 

Staff 

Acknowledgments

(131248)
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