```

[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

   INVISIBLE WOUNDS: EXAMINING THE DISABILITY COMPENSATION BENEFITS 
             PROCESS FOR VICTIMS OF MILITARY SEXUAL TRAUMA

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

                                HEARING

                               before the

                 SUBCOMMITTEE ON DISABILITY ASSISTANCE
                          AND MEMORIAL AFFAIRS

                                 of the

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

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                        WEDNESDAY, JULY 18, 2012

                               __________

                           Serial No. 112-70

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

CLIFF STEARNS, Florida               BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado               CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida            SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee              MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana          LINDA T. SANCHEZ, California
BILL FLORES, Texas                   BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio                   JERRY McNERNEY, California
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey               TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan               JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York          RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York

            Helen W. Tolar, Staff Director and Chief Counsel

                                 ______

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                    JON RUNYAN, New Jersey, Chairman

DOUG LAMBORN, Colorado               JERRY McNERNEY, California, 
ANN MARIE BUERKLE, New York          Ranking
MARLIN A. STUTZMAN, Indiana          JOHN BARROW, Georgia
ROBERT L. TURNER, New York           MICHAEL H. MICHAUD, Maine
                                     TIMOTHY J. WALZ, Minnesota

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

                               __________

                             July 18, 2012

                                                                   Page

Invisible Wounds: Examining The Disability Compensation Benefits 
  Process For Victims of Military Sexual Trauma..................     1

                           OPENING STATEMENTS

Chairman Jon Runyan..............................................     1
    Prepared Statement of Chairman Runyan........................    48
Hon. Jerry McNerney, Ranking Democratic Member...................     3
    Prepared Statement of Hon. Jerry McNerney....................    49
Hon. Michael R. Turner, prepared statement only..................    50
Hon. Chellie Pingree, prepared statement only....................    51

                               WITNESSES

Anu Bhagwati, Executive Director, Service Women's Action Network.     4
    Prepared Statement of Ms. Bhagwati...........................    52
    Executive Summary of Ms. Bhagwati............................    54
Joy Ilem, Deputy National Legislative Director, Disabled American 
  Veterans.......................................................     6
    Prepared Statement of Ms. Ilem...............................    55
Lori Perkio, Assistant Director of Veterans Affairs and 
  Rehabilitation, The American Legion............................     8
    Prepared Statement of Ms. Perkio.............................    60
    Executive Summary of Ms. Perkio..............................    62
Dr. Barbara Van Dahlen, Executive Director, Give an Hour.........    21
    Prepared Statement of Dr. Dahlen.............................    62
    Executive Summary of Dr. Dahlen..............................    66
Margaret Middleton, Executive Director, Connecticut Veterans 
  Legal Center...................................................    23
    Prepared Statement of Ms. Middleton..........................    66
Ruth Moore, Constituent Witness..................................    30
    Prepared Statement of Ms. Moore..............................    68
    Accompanied by:

      Alfred ``Butch'' Moore, Jr., Husband to Ruth Moore
Col. Alan Metzler, Deputy Director, Sexual Assault Prevention and 
  Response Office, U.S. Department of Defense....................    35
    Prepared Statement of Mr. Metzler............................    69
    Accompanied by:

      Dr. Nate Galbreath, Senior Researcher and Training Advisor, 
          Sexual Assault Prevention and Response Office, U.S. 
          Department of Defense
Thomas Murphy, Director of Compensation and Pension Service, U.S. 
  Department of Veterans Affairs.................................    37
    Prepared Statement of Mr. Murphy.............................    75
    Accompanied by:

      Ms. Edna MacDonald, Director, Nashville Regional Office, 
          U.S. Department of Veterans Affairs

                        QUESTIONS FOR THE RECORD

Response From: DoD - To: Hon. Robert L. Turner, Subcommittee on 
  Disability Assistance and Memorial Affairs, Committee on 
  Veterans' Affairs..............................................    77

                   MATERIALS SUBMITTED FOR THE RECORD

Letter From: Anu Bhagwati, MPP, Executive Director, Service 
  Women's Action Network - To: The Hon. Eric K. Shinseki, 
  Secretary, U.S. Department of Veterans Affairs, Washington, 
  D.C............................................................    77
Additional Materials From: Anu Bhagwati, MPP, Executive Director, 
  Service Women's Action Network.................................    79

 
   INVISIBLE WOUNDS: EXAMINING THE DISABILITY COMPENSATION BENEFITS 
             PROCESS FOR VICTIMS OF MILITARY SEXUAL TRAUMA

                              ----------                              

                        Wednesday, July 18, 2012

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                      Subcommittee on Disability Assistance
                                      and Memorial Affairs,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to call, at 2:09 p.m., in 
Room 334, Cannon House Office Building, Hon. John Runyan 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Runyan, Turner, McNerney, and 
Michaud.
    Also Present: Representatives Pingree, Speier.

            OPENING STATEMENT OF CHAIRMAN JON RUNYAN

    Mr. Runyan. Good afternoon, and welcome to our hearing, 
Invisible Wounds: Examining the Disability Benefits 
Compensation Process for Victims of Military Sexual Trauma.
    First I ask unanimous consent to welcome a number of 
honorable colleagues who have asked to be allowed here to 
participate as guest members of the Subcommittee today. Hearing 
no objection, so ordered.
    As a Nation, we call on our armed servicemembers to 
sacrifice bravely on our behalf. They courageously put their 
lives at risk and face deadly enemies on the battlefield.
    When we think of these enemies, we think of those who 
oppose our freedom and our American way of life. We certainly 
do not think of soldiers needing to defend themselves from 
their fellow servicemembers. However, many of our 
servicemembers are required to do just that.
    Women are the fastest growing population among veterans, 
making up eight percent of the armed forces. However, the 
Department of Defense estimates that one in four women who join 
the armed services will be raped or assaulted, but that only 
about ten percent of such instances are ever reported.
    Even more alarming is that of those few who did report the 
incidence of military sexual trauma, over 75 percent stated 
that they would not have made the same decision about reporting 
the incident again due to the consequences it had on their 
military career.
    Despite the fact that many of these incidents go 
unreported, VA currently estimates that over half a million 
veterans have experienced military sexual trauma. This includes 
17 percent of veterans from recent conflicts in Iraq and 
Afghanistan.
    Although this is not the Committee's jurisdiction, there 
must be zero tolerance for this behavior in our military and 
the VA must recognize immediately the trauma inflicted on these 
men and women.
    Accordingly, the focus of today's hearing is how to assist 
these veterans in obtaining VA benefits for post-traumatic 
stress disorder or PTSD. This is often a difficult task given 
the sensitive nature of these claims and the lack of evidence 
documenting such incidents at the time that they occurred.
    Although VA has made great progress in adjudicating 
military sexual trauma claims by providing relaxed evidentiary 
standards and retraining employees on this issue, SWAN, one of 
the organizations testifying today, estimates that less than 
one-third of military sexual trauma PTSD claims are approved by 
the VA even though 53 percent of PTSD claims are granted 
overall.
    Although military sexual trauma is not a new issue, it is a 
serious matter which more light needs to be shed on. In recent 
years, as more and more of our brave servicemembers find the 
inner strength to overcome military cultural challenges and 
come forward to seek justice, help and healing, the more the 
Members of this Committee, DoD, and VA can understand the best 
means of assisting victims of military sexual trauma by 
obtaining the VA benefits that they need.
    One such veteran will be testifying before us today and I 
would like to personally thank Ms. Ruth Moore for coming to 
Washington and sharing her story with us today.
    Victims of military sexual trauma like Ms. Moore can carry 
scars in their hearts for the rest of their lives as a result 
of what they have endured. Such veterans are indeed deserving 
of VA benefits to help them enjoy the American way of life that 
their service has helped to secure.
    As the Department of Defense continues to address the 
issues arising from cultural resistence to reporting such 
abuse, the VA must continue to work to ensure that the proper 
benefits so needed by these victims are easily obtainable.
    So I will reiterate that the focus of the hearing today is 
precisely that. What benefits does the VA provide for victims 
of military sexual trauma, how are these claims adjudicated, 
and how can this process be improved?
    We welcome several witnesses to testify before us today 
ranging from representatives from veteran service organizations 
to experts on the effects and treatments of military sexual 
trauma to officials from the VA and the Department of Defense.
    I appreciate all of you taking the time to speak with us 
today about this issue of such importance to so many members of 
our American community.
    Because we have many distinguished guests with us today, I 
would like to reiterate my request that our witnesses abide by 
the decorum and rules of this hearing by summarizing your 
statements in five minutes or less during the oral testimony. 
Doing so will ensure that the Committee has the opportunity to 
hear from everyone.
    I would also like to remind all present that without any 
objection, your written testimony will be made part of the 
hearing record. Hearing none, so ordered.
    I now call on the distinguished Ranking Member from 
California, Mr. McNerney, for his opening statement.

    [The prepared statement of Chairman Jon Runyan appears in 
the Appendix]

           OPENING STATEMENT OF HON. JERRY MCNERNEY, 
                   RANKING DEMOCRATIC MEMBER

    Mr. McNerney. Thank you.
    Good afternoon. I would like to thank everyone for 
attending today's hearing which examines the VA's disability 
compensation process as it pertains to military sexual trauma 
or MST.
    I am happy to join DAMA Subcommittee Chairman Runyan and my 
colleagues today in holding this hearing. I am also pleased 
that two leading voices of the Congress on this issue, 
Representative Shellie Pingree of Maine and Representative 
Jackie Speier of California, are accompanying the Subcommittee 
on the panel today.
    I also welcome and thank Ms. Pingree's constituent, Ruth 
Moore, accompanied by her husband, for testifying about her MST 
experience with the VA.
    Servicemembers who experience military sexual trauma, who 
are brave enough to speak out about their experiences often do 
so at great risk to their reputation and their careers.
    The purpose of today's hearing is to evaluate ways in which 
the Veterans Benefits Administration and the Department of 
Defense can better address the needs of veterans affected by 
MST, to identify ways to prevent these horrible assaults and to 
treat and properly compensate the victims.
    MST refers to sexual harassment, sexual assault that occur 
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.
    Many MST victims state that when they do report an 
incident, their story is dismissed or they are encouraged to 
keep silent because of the need to preserve organizational 
cohesion.
    This is unfair to the victims. We must put protections in 
place to ensure a safe haven exists for women and men who 
experience military sexual trauma. Unfortunately, the 
consequences of MST are a pervasive problem within the veteran 
community.
    According to the Institute of Medicine, prevalence rates of 
MST range from 20 to 43 percent. Many veterans who are victims 
of MST express frustration with the VA's disability claims 
process, especially in trying to prove that the assault ever 
happened.
    For many women and men, their disability claims for post-
traumatic stress related to MST are denied. However, I am 
pleased that in July of 2010 in a response to action taken by 
this Committee, the VA relaxed its stressor evidentiary 
standards for post-traumatic stress which also includes MST.
    While representing a step in the right direction, there are 
still hurdles that men and women face in receiving the benefits 
they deserve.
    As SWAN will point out in its testimony, there are still 
disparities in compensation and confusion within the VBA on 
when service-connected compensation for MST is warranted.
    Training at the VA has improved slightly, but VBA claims 
decisions are still inconsistent and more must be done.
    As we build a VA for the 21st century, the VA and the DoD 
need to ensure that proper prevention, counseling, treatment, 
and benefits are available for MST victims.
    Veterans should also have access to VA personnel who are 
qualified to advise on often sensitive MST related issues. 
These veterans need to be treated with the dignity and respect 
they deserve.
    I look forward to hearing from the esteemed panel of 
witnesses. I thank you, and I yield back.

    [The prepared statement of Hon. Jerry McNerney appears in 
the Appendix]

    Mr. Runyan. I thank the gentleman.
    And at this time, I want to invite the first panel up to 
the witness table who are going to represent various veteran 
service organizations, and I welcome you to all come forward.
    Our first guest is, and bear with me----
    Ms. Bhagwati. Anu Bhagwati, sir.
    Mr. Runyan. Anu Bhagwati, thank you, who is the Executive 
Director of the Service Women's Action Network known as SWAN. 
Then we will welcome Ms. Joy Ilem, Deputy Legislative Director 
for Disabled American Veterans, and finally we will welcome Ms. 
Lori Perkio, the Assistant Director for Veterans Affairs and 
Rehabilitation for The American Legion.
    We appreciate all of our witnesses for taking the time to 
testify before us today.
    And, Ms. Bhagwati, you are now recognized for five minutes 
for your oral testimony.

STATEMENTS OF ANU BHAGWATI, EXECUTIVE DIRECTOR, SERVICE WOMEN'S 
ACTION NETWORK; JOY ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, 
DISABLED AMERICAN VETERANS; LORI PERKIO, ASSISTANT DIRECTOR OF 
    VETERANS AFFAIRS AND REHABILITATION, THE AMERICAN LEGION

                   STATEMENT OF ANU BHAGWATI

    Ms. Bhagwati. Thank you.
    Dear Mr. Chairman and Members of the Committee, thank you 
for holding this hearing on a critical issue facing our 
veterans' community and for the opportunity to present the 
views of the Service Women's Action Network or SWAN on the 
challenges confronting veterans who file PTSD claims related to 
military sexual assault or sexual harassment.
    According to VA, PTSD is the most common mental health 
condition associated with military sexual trauma or MST. For 
women veterans, MST is a greater predictor of PTSD than combat.
    Studies also indicate that sexual harassment causes the 
same rates of PTSD in women as combat does in men and 40 to 53 
percent of homeless women veterans have been sexually assaulted 
while in the military. Simply put, MST has devastated the 
veterans' community.
    I would also like to point out that many men suffer from 
the effects of military sexual violence. According to the 
Department of Defense, 12 percent of all unrestricted sexual 
assault reports are made by men. Additionally, according to VA, 
almost 46 percent of the veterans who screened positive for MST 
in 2010 were men.
    Veterans who suffer from the debilitating effects of MST 
face unique challenges in obtaining disability compensation 
from the VA.
    In 2011, SWAN and the American Civil Liberties Union, ACLU, 
filed a Freedom of Information Act request with the VA for data 
on MST claims. The data obtained through litigation showed that 
between fiscal year 2008 and 2010, only 32.3 percent of MST-
based PTSD claims were approved by VA compared to an approval 
rate of 54.2 percent for all other PTSD claims during this 
time.
    Also, veterans who had their MST PTSD claims approved by VA 
or among those veterans who had those claims approved, women 
were more likely to receive a 10 to 30 percent disability 
rating whereas men were more likely to receive a 70 to 100 
percent disability rating.
    To reiterate, veterans who file a PTSD claim based on MST 
only have a one in three chance of getting their claim 
approved. Also, data suggests a strong gender bias in PTSD 
disability ratings in favor of men.
    The MST claims process is broken at best. VA's PTSD policy 
discriminates in practice against veterans who are sexually 
assaulted or harassed while in uniform by holding them to an 
evidentiary standard which is not only higher than that of 
other groups of veterans suffering from PTSD but also 
completely unrealistic for the majority of survivors to meet.
    The language in the regulation that establishes the 
required evidence for what VA calls an in-service personal 
assault differs radically from the language used to describe 
the evidence required for all other PTSD claims.
    In fact, CFR 3.304, paragraph (f), the regulation, allows 
for lay testimony as acceptable evidence in all other PTSD 
cases except in cases of an in-service personal assault.
    VA policy fails veterans for a variety of reasons. First, 
sexual assault and sexual harassment in the military are 
notoriously under-reported. According to DoD, almost 87 percent 
of assaults go unreported meaning that official documentation 
of an assault rarely exists.
    Secondly, prior to the new evidence retention laws passed 
in the 2011 NDAA, the services routinely destroyed all evidence 
and investigation records in sexual assault cases after two to 
five years leaving gaping holes in MST claims filed prior to 
2012.
    Lastly, the allowance of so-called secondary evidence 
described in the regulation does not take into consideration 
the reality that many victims do not report the incidents to 
anyone including family members and for a variety of legitimate 
reasons including shame, stigma, embarrassment, or fear of 
retaliation.
    Although sexual assault increases the chance of adverse 
emotional responses and behaviors, it does not mean that all 
MST claimants will experience those symptoms. In fact, SWAN has 
spoken to survivors who demonstrate changes in behavior not 
included in the regulation such as improved job performance as 
a means of coping with the trauma.
    After a series of conversations, SWAN had with the Under 
Secretary of Benefits last year about VA's discriminatory 
practices, the under secretary issued a memo in June 2011 
providing further guidance to claims officers and instituting 
training requirements for processing MST claims.
    However, both the letter and the training simply reinforced 
the existing regulation which places a double standard on MST 
claimants.
    To fix MST claims policy, VBA must immediately revise the 
regulation to provide language that establishes the same 
evidentiary requirements for MST-based PTSD claims that it does 
for other claims.
    Furthermore, there should be no requirement that veterans 
filing MST claims go through an independent compensation and 
pension or C&P exam to verify that they have PTSD or any other 
conditions associated with MST. Veterans should not be forced 
to dig up their trauma for complete strangers who often lack 
the sensitivity or professional qualifications to speak to 
survivors of sexual trauma and who often unfairly reverse the 
PTSD diagnosis made by qualified VHA or other mental health 
providers.
    Additionally, claims reviewers should not have the 
authority to second guess evaluations by agency medical 
professionals or to discount VA treatment records in favor of 
these one-time C&P exam results.
    Thank you very much for your attention. I would be happy to 
answer any questions.

    [The prepared statement of Anu Bhagwati appears in the 
Appendix]

    Mr. Runyan. Thank you, Ms. Bhagwati.
    Next we will hear from Ms. Ilem.

                     STATEMENT OF JOY ILEM

    Ms. Ilem. Thank you, Mr. Chairman and Members of the 
Subcommittee. We appreciate DAV being invited to testify on the 
disability claims process for post-traumatic stress disorder 
based on military sexual trauma or MST.
    In preparing for this hearing, members of our National 
Service Officer Corps contacted a number of local VBA officials 
to determine what sources are being used by rating specialists 
in developing MST claims.
    A December 2011 VBA national training letter was identified 
as an important guide. It provides detailed and comprehensive 
guidance regarding these claims including pertinent 
regulations, definitions, court cases, specific markers to 
examine, timing for ordering PTSD examinations, and proper 
development actions to be taken all before a decision is made.
    Most notably we found a number of clear examples and 
statements to raters emphasizing that a special obligation 
exists on VA's part to assist claimants in gathering from 
sources other than military service records evidence 
corroborating a stressor and to help fully develop their 
claims, particularly in MST cases.
    The current regulation recognizes the difficulties inherent 
in establishing service-connection for conditions related to 
MST and provides a basis for a relaxed evidentiary standard.
    The most salient point made in the training letter is to 
emphasize that current regulations and court cases do not 
require actual documentation of a claimed stressor and that the 
opinion of a qualified mental health clinician can be 
considered credible supporting evidence that the claimed 
stressor occurred.
    Nevertheless, the letter notes that the final decision on 
service-connection remains with VBA raters.
    To DAV, the question at hand for this Subcommittee is 
whether VBA rating specialists are applying the unique 
provisions in the regulation and following the specific 
guidelines.
    In cases where veterans indicate that no official report of 
an assault exists, VA adjudicators must consider the stressor 
statement provided by the veteran to determine if other reports 
may document the event.
    Additionally, rating specialists should examine military 
personnel records for any sign of deterioration in work 
performance, requests for transfer to another duty station, 
disciplinary action, or unexplained social or behavioral 
changes in the claimant.
    Likewise, there are a number of medical complaints that may 
indicate a sexual assault took place such as a request for a 
pregnancy test or sexually transmitted diseases, repetitive 
trips to sick call with chronic, unresolved medical complaints 
can also be used collectively to help substantiate a stressor.
    It appears that these cases require special attention and 
efforts by raters, but it remains unclear whether these efforts 
are consistently and exhaustively being made in each case.
    Based on feedback from DAV national service officers, it 
appears that many of these claims are denied even when there 
appears to be sufficient documentation to support the claim 
under the liberal guidelines and lowered evidentiary standards.
    We also continue to hear reports from veterans who have had 
to pursue their cases for years and ultimately seek 
congressional intervention before their claims were approved.
    Additionally, a recent press report citing a Yale 
University legal services director documented a significantly 
lower percentage between VA's approval rates of claims for 
service-connection for MST related PTSD claims compared to 
service-connection of other PTSD claims as noted by Ms. 
Bhagwati.
    However, we have not seen this type of data provided or 
substantiated by VBA.
    In preparing for this hearing, we did, however, learn that 
VBA has an electronic capability to segregate and account for 
MST and personal assault cases from other types of PTSD claims. 
We believe open reporting of the status should be helpful to 
the Subcommittee in its oversight role and could help to 
determine if there is truly an inequity in establishing 
service-connection in these cases.
    Although VA has developed regulations and procedures that 
provide for a liberal approach to evidentiary development and 
adjudication of these claims, we urge VBA to conduct its own 
internal oversight and review of these cases to ensure that 
across the system its claims staff are properly trained and 
compliant with the procedures and policies set forth in the 
2011 training letter.
    In closing, we appreciate the Subcommittee's attention to 
this important issue and in the past decade, we note that 
progress has been made, but much more needs to be done to 
ensure that these disabled veterans are properly compensated 
for conditions related to MST on an equitable basis in 
comparison to veterans disabled by other causes.
    Many of these veterans endured long, unnecessary waits for 
their claims to be approved and many report they have been re-
traumatized by the process and bureaucracy that seems to 
surround these cases and ask only for a fair measure of justice 
given the indignities they have endured.
    That concludes my remarks and I am happy to answer any 
questions you may have.

    [The prepared statement of Joy Ilem appears in the 
Appendix]

    Mr. Runyan. Thank you, Ms. Ilem.
    Ms. Perkio, you are now recognized for five minutes.

                    STATEMENT OF LORI PERKIO

    Ms. Perkio. Mr. Chairman and Members of the Subcommittee, 
thank you for the opportunity to provide The American Legion's 
views on the invisible wounds, examining the disability and 
compensation benefits process for victims of military sexual 
trauma.
    Today's media provides a snapshot of the number of sexual 
assaults that are currently reported in the military. DoD 
estimates only 14 percent of all military sexual assaults are 
reported each year. It is estimated that a victim of military 
sexual trauma will wait an average of 12 years to report an 
incident.
    VA health care screens all veterans for military sexual 
trauma and provides free treatment and health care for those 
related conditions. It is often through this screening and 
treatment that veterans learn about filing a claim for VA 
disability benefits secondary to military sexual trauma.
    Filing a claim for PTSD due to military sexual trauma often 
causes extreme stress on behalf of the claimant as they have to 
repeat the events of the assault in support of their claim. It 
is highly recommended the veteran obtain an advocate familiar 
in the VA claims process to help them understand the 
requirements.
    VA reported 704 MST claims were granted from October 2011 
through February 2012. Seven hundred and twenty-six MST claims 
were denied in that same timeframe. I would like to provide you 
with some of the reasons that VA regional offices have denied 
claims for military sexual trauma.
    The Veterans Benefits Administration requires three 
elements to grant a claim for disability benefits. The first is 
a current diagnosis of a disability from a medical 
professional.
    The second is credible evidence that the claimed stressor 
occurred while the veteran served on active duty and proper 
recordkeeping by the military unit may be critical to this 
requirement.
    The third element is a nexus statement from a medical 
professional that the claimed condition is at least as likely 
if not due to the event which occurred while the veteran 
served. The requirements of the nexus statement are not clearly 
defined to the veteran.
    In order for a medical statement to be accepted as 
credible, the medical professional must also have reviewed 
service treatment records, all private and VHA behavioral 
health treatment records, and reviewed all pertinent 
information submitted in support of the claim. The nexus 
statement must list all the records reviewed.
    Rating veteran service representatives will not consider a 
medical statement as credible evidence if it is based solely on 
the verbal account of the veteran. VA may consider other 
evidence if there is no documentation within the military 
record such as a police report or medical examination specific 
to sexual assault.
    If documentation of behavioral changes are not mentioned 
within the service treatment records and were provided by a 
behavioral health department instead, these records need to be 
requested separately and by the veteran.
    The VA will obtain these records only if given the dates of 
treatment and the exact address of that treating facility. Most 
veterans do not realize this is not automatically included in 
their service treatment records.
    VA states it will consider documentation of pregnancy tests 
or tests for sexually transmitted diseases around the time of 
the incident or treatment for physical injuries around the time 
of the incident that were not claimed as due to trauma.
    While this information may be listed in the service 
treatment records, it may not state why the servicemember 
sought that type of treatment, especially if it is a result of 
sexual trauma they are not yet ready to discuss.
    If the service medical records have any type of notation 
that treatment was requested due to other than sexual assault, 
it may be considered as conflicting evidence and often used as 
a reason to deny the claim.
    Sudden requests for change in military occupation skill or 
requests for assignment changes without justification and 
changes in performance evaluation may be considered as credible 
evidence, especially if the documentation is within the 
military personnel file.
    Not all RVSRs request a personnel file when requesting 
medical records. Without the personnel file to corroborate the 
alternate evidence listed in 38 CFR 3.304, this evidence is 
often based solely on the word of the veteran, which at this 
time VA does not consider as credible evidence.
    The VA has the ability to use their own authority to reduce 
the number of denied claims for PTSD due to MST. In 2010, VA 
implemented the reduced criteria for post-traumatic stress 
disorder due to combat.
    Obtaining personnel records must be a mandatory requirement 
with all PTSD claims in the VA's duty to assist. In addition, 
provide clear explanation and clarification of credible 
evidence to support the claim as outlined in 38 CFR 3.304.
    I would like to thank you on behalf of The American Legion 
for providing testimony today.

    [The prepared statement of Lori Perkio appears in the 
Appendix]

    Mr. Runyan. I would like to thank you for your testimony.
    And with that, I will begin the questioning of the first 
panel starting in order of our Members' arrival.
    My first question is going to be to Ms. Ilem. You mentioned 
in your written testimony about collaborative efforts between 
the DoD and the VA in dealing with MST claims.
    Do you believe that collaboration is adequate and how do 
you think this process can be improved?
    Ms. Ilem. I think we have seen more collaboration with 
Secretary Hickey coming in, in terms of we looked at our last 
testimony that was before this Committee and specifically we 
had requested that VBA collaborate with SAPRO, the DoD's SAPRO 
office to make sure that the SAPRO information was included in 
their M21 manual.
    And we were pleased that following that hearing, it did 
take about a year, but eventually it did make its way into the 
M21 manual as an opportunity for raters to look at, you know, 
one other location for either one of the DoD forms, 2910 or 11. 
So I think we have seen an increase in the cooperation.
    However, we still have questions outstanding in our mind in 
terms of if VA requests that information, even with the 
permission of the veteran, due to the highly sensitive nature 
and DoD's wanting to protect the privacy of the veteran, if 
those will--will those records be forwarded because we had not 
seen that in SAPRO's documentation that VA is an exception of 
one of the people that can receive that documentation.
    So I look forward to the panels following this, to hearing 
from them if that has been clarified and that they, in fact, 
are collaborating together to make sure that evidence is 
available for veterans who want it to be made available to VA 
in support of their claims.
    Mr. Runyan. Thank you.
    I think this Committee recognizes that many veterans are 
having difficulty receiving benefits related to MST. And 
despite the relaxed evidentiary standard, many veterans still 
have difficulty providing the evidence required for the award 
of service-connection.
    In each of your opinions, can you touch upon, why that is 
happening?
    Ms. Bhagwati. I would not refer to them as relaxed 
evidentiary standards. I would refer to them as actually harder 
evidentiary standards.
    There is a two-tier system right now, one for PTSD 
generally and then one for MST PTSD, and for veterans who 
suffer from MST, 87 percent of these assaults were never 
reported for very good reasons including fear of retaliation 
within the military and a variety of other factors related to 
rape, assault, and the trauma that results.
    We have to think more strategically about what counts as a 
fair evidentiary standard. It is clear in all other cases of 
PTSD that the veteran's lay testimony is sufficient as long as 
that veteran has a diagnosis of Post-Traumatic Stress Disorder 
from a qualified medical provider as well as proof of time and 
service.
    There is language in that regulation for every other 
veteran suffering from PTSD with the exception of rape, 
assault, and harassment. It is completely unfair.
    Mr. Runyan. Thank you.
    Ms. Ilem.
    Ms. Ilem. I think probably we would like to see the data. 
For years, we have asked for data specific to MST related cases 
versus non-personal assaults. The first information that we had 
really seen was the FOIA information. And certainly we believe 
VA does have the capability to extract that information and 
perhaps has it, just briefly looking at their testimony, VA 
appears to have evaluated some of the raters' decisions.
    And I think we would definitely want to look at if these 
was there compliance with the rules and regulations and the 
policies that have been set forth so far. That is where I think 
probably the biggest, problem may lie because, there are 
oftentimes, a significant number of other opportunities to 
support those claims, but it appears perhaps they are not being 
consistent throughout the country because we continue to hear 
these complaints repeatedly from people that are saying I have, 
submitted a number of, everything that they have asked me and 
my claim was still denied.
    Mr. Runyan. Ms. Perkio?
    Ms. Perkio. Thank you.
    I have been a service officer for 16 years and I have been 
working VA claims. And that included military sexually trauma 
claims. And my experience as a service officer is that the 
evidence was not given the weight that it should have.
    I worked with one man. He had been raped and the next 
morning as he was walking around feeling very dejected and 
trying to figure out what he was going to do with the rest of 
his life, he chose to commit suicide by throwing himself under 
a truck.
    Not only did he have to live with the results of the 
medical injuries from that, the treatment that he received did 
not get used in support of his claim because he did not report 
that he had actually been sexually assaulted. The medical 
records and nobody in the VA would take into account the 
reasons why he may have tried to commit suicide when it was 
plain that there was definitely a change in his attitude, his 
personality, and his will to live.
    Those are the types of things that we would like to see the 
VA take more into account in supporting claims for military 
sexual trauma.
    In their own adjudication manual, it states behavioral 
changes will be considered. These are things that while the 
regulation is already there, the adjudication manual is there, 
more information needs to be provided to the raters on how to 
look at that information and apply it.
    Mr. Runyan. Thank you.
    And with that, I recognize the Ranking Member, Mr. 
McNerney.
    Mr. McNerney. Thank you, Mr. Chairman.
    Ms. Bhagwati, I believe that you mentioned that one of the 
problems that claimants have is that records have been purged 
after a certain number of years.
    Do you know if that is a policy or what regulates when 
records are purged and how can we change that so that there is 
more evidence that would be maintained?
    Ms. Bhagwati. There are some records that are still purged 
and some that are no longer purged thanks to the last National 
Defense Authorization Act. Perhaps Congresswoman Pingree can 
add to that.
    Unrestricted sexual assault reports are kept for 50 years 
and restricted reports for five years. What is still destroyed, 
however, is EO or sexual harassment investigations.
    So if you were sexually harassed and reported it, and this 
happened to me, I can tell you my firsthand experience, those 
EO reports are destroyed within two to five years. And it is 
done branch to branch. I served in the Marines, so the 
Department of the Navy is not tracking those or not keeping 
those copies forever.
    Mr. McNerney. So there is no policy with regard to keeping 
those?
    Ms. Bhagwati. Not for sexual harassment investigations.
    Mr. McNerney. Well, you concluded in your testimony that 
when you look at the VA's policies on paper, it is no surprise 
that veterans who suffer from MST related PTSD have only a one 
in three chance of having their claims approved.
    Could you please elaborate on that conclusion and how the 
VA regulations could be change to improve the outcomes of that?
    Ms. Bhagwati. It is an absolutely murderous process. We 
heard the example of one veteran who killed himself because of 
this process. But, you know, I went through it myself. It took 
four years.
    Frankly, VBA is inept at the regional office level. You can 
give them all the evidence you have. I had plenty of eyewitness 
statements, everything they asked for, all the sort of 
secondary evidence that is in the regulation, but it was flat 
out ignored.
    What happens when those claims get rejected is a lot of 
veterans fall into a downward spiral of worsening trauma, 
suicidal ideation, maybe attempted suicide, maybe completed 
suicide.
    We are really looking at a life and death situation here 
with this claims process. And we do not need----
    Mr. McNerney. So it is not----
    Ms. Bhagwati. It is not rocket science. We do not need to 
rewrite, you know. It is not an issue of allowing more 
evidence. It is requiring less evidence. It is a very simple 
fix. We should have one universal standard for PTSD claims.
    Right now lay testimony is not enough for sexual trauma 
survivors, but it should be in addition to the other 
requirements for all PTSD claims, a doctor's diagnosis or a 
mental health provider's diagnosis.
    Mr. McNerney. In your opinion, does it more have to do with 
the regulations or with the culture?
    Ms. Bhagwati. It is both. Unless there is a formal change 
in policy written in the regulation, you are counting on the 
individual regional officer, the claims person or claims 
provider to make a judgment about whether or not a VHA 
diagnosis or a mental health provider's diagnosis of PTSD is 
accurate or enough based on their years of experience doing 
rape crisis counseling work or sexual trauma counseling work.
    Essentially what happens is VBA gets to deny the expertise 
of its VHA experts or mental health professional experts. It is 
a completely backward system.
    And, unfortunately, you are right. There is bias within 
each individual claims officer who rejects these claims. And we 
cannot risk that bias. A fix to this regulation is very simple.
    Mr. McNerney. Okay. Well, that is a good segue into Ms. 
Pingree's bill, H.R. 930. Do you think the provisions in this 
bill would help the veterans affected by MST in facing the 
hurdles that they have, Ms. Bhagwati?
    Ms. Bhagwati. Yes, absolutely. I think H.R. 930 is a 
comprehensive solution that includes, not just post-traumatic 
stress but all the other mental health conditions associated 
with sexual trauma.
    Not everyone has PTSD from sexual assault, rape, or 
harassment. Other common conditions are other anxiety 
disorders, depression, and those are also life threatening.
    Mr. McNerney. Ms. Ilem, what in your opinion should be done 
to help the veterans that were denied claims prior to the 
recent improvements?
    Ms. Ilem. I think certainly having VBA, you know, do a 
review of cases is extremely important since it sounds like 
they have invested in doing some training with their people. If 
they are really committed to making sure that people are 
consistently following these rules, they have to do the 
oversight internally.
    I mean, it does take some work to develop these claims 
properly. And unless they go back and look, have those 
procedures been followed, and in those cases, I mean, they 
should, you know, think about reevaluating those claims. This 
has been a difficult process for so many people.
    Mr. McNerney. Do you think the VA should proactively do a 
system-wide review of the cases that have been denied?
    Ms. Ilem. Well, I think they should definitely look back 
from their previous training letter that was done, I believe in 
2005 prior to the update of the 2011 one, and would be a first 
good measure of looking at how well these standards have been 
applied in the regulation throughout those cases.
    They did indicate, I believe in their statement, that 
following a review, I think that they did, that they decided 
to, you know, make changes in their letter and make it very 
clear and concise about how they wanted their raters to 
approach these cases. But we are not seeing the evidence in 
terms of were there cases denied that should have been approved 
based on the evidence.
    Mr. McNerney. Thank you.
    Mr. Chairman, my time has expired.
    Mr. Runyan. I thank the gentleman.
    I now recognize the gentleman from Maine, Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman and Mr. 
Ranking Member, for having this very important hearing today 
and also for the Committee for allowing my colleague from 
Maine, Ms. Pingree, to serve here as well.
    And you do have the entire Maine delegation from the House 
here today, so it shows you the importance of this issue to 
have all of us here.
    But I also want to thank Ruth Moore and her family for 
coming today as well and taking the time to talk about your 
personal story which is extremely important.
    Unfortunately, Mr. Chairman, I will not be able to stay for 
the whole hearing as I have to meet with several employees from 
New Balance in Maine. They are currently negotiating the 
transpacific partnership agreement and depending on how that is 
negotiated would mean whether or not they will have to close 
the facilities or not. So I will not be able to stay for the 
whole hearing.
    But I do have a quick question for our panelists. When you 
talk about, you know, some of the soldiers and veterans not 
reporting when they have been sexually assaulted, have you 
heard anything from the experience with the MST survivors as 
how soldiers actually should start documenting their issues 
when they are in the military? Have they given you any advice 
of what they should do for that documentation for any of the 
panelists?
    Ms. Perkio. I know that DoD has implemented a new program 
where victims of military sexual trauma can go in and receive 
counseling and they get to choose whether their records will be 
held or destroyed.
    So if that servicemember says I just want treatment for 
this, I want you to help me through this program, but I do not 
want anything to follow me after this, and those records will 
stay destroyed.
    And so DoD actually is working on a new program. I could 
not tell you the particulars or who that person is, but I could 
get you the point of contact after the hearing.
    Mr. Michaud. That is what DoD is doing. But for those who 
have been sexually assaulted that you have talked to, have they 
given any additional suggestions on what DoD should do because 
clearly if they go in there, they are in the service, at that 
point in time, they might want to have everything destroyed, 
but when they start receiving help or what have you, they might 
decide to change their mind? So I am just looking for things 
that DoD can do differently that you might have heard from 
those who have been assaulted.
    Ms. Perkio. I have not been given any input from 
servicemembers, but I can tell you that working those claims, 
if all of the documentation was submitted and there was not a 
timeline to destroy behavioral health records and that they 
were, you know, integrated in with the service treatment 
records as well as their personnel records and file clerks were 
able to make sure that those records were complete, it would 
make a big difference on whatever action that servicemember 
chose to take at any point in their career either medically 
discharged or after they have been out filing a claim.
    Ms. Ilem. I would just add that, you know, that was one of 
the problems with regard to SAPRO that we had that we spoke 
about at the last hearing here in 2010, our concern over the 
destruction, not only the destruction of records, but the 
recordkeeping process.
    And as Ms. Bhagwati indicated, you know, that is still 
being sorted out. For the unrestricted, those records will be 
maintained for 50 years, but for the restricted ones, that is 
still in the works and they may be only maintained for up to 
five years.
    And as well as any of these other additional records, it 
has been up to each military service, as we understood, 
determining when those would be destroyed or how long they 
would be kept. And we are concerned about where are they being 
kept and can VA get them if the veteran requests or indicates 
that they did have counseling or, you know, outside help.
    So I think that is still a major issue on the DoD side and, 
again, look forward to the, you know, testimony by SAPRO if 
that has been worked out. We understand that, you know, 
Secretary Hickey and General Hertog have been talking about 
that, but to what extent, I do not know. We have not seen any 
formal agreements yet between the agencies.
    Mr. Michaud. Thank you.
    Ms. Bhagwati. Survivors will universally talk about the 
bias in the system within DoD and the bias specifically within 
the chain of command. One of the reasons we have such a high 
under-reporting rate is because of that bias, because of that 
fear of retaliation. It is not just fear of retaliation, but 
actual retaliation which very often happens.
    Here again, we are just talking about approximately the 13 
percent that actually report and whose evidence can then, if it 
is not destroyed, actually be used for a VA claim. But VA's 
responsibility now has to be to the entire percentage of 
survivors including the 87 percent who do not report for very 
good reasons, for fear of their lives many times.
    So in order to do that, there has got to be a change to the 
military judicial system so that there is no bias in that chain 
of command. And that is a longer conversation.
    Mr. Michaud. Great.
    Thank you very much, Mr. Chairman.
    Mr. Runyan. I thank the gentleman.
    And the gentleman from Minnesota, Mr. Walz, is now 
recognized.
    Mr. Walz. Thank you, Mr. Chairman, the Ranking Member, and 
thank you for once again holding important hearings on 
substantive matters and trying to make things right. I am very 
appreciative of that to both of you.
    And to our witnesses, thank you for helping educate us, 
helping bring it forward.
    As you do, I have such deep emotions on this as a retired 
military person. The anger and the disgust and the frustration 
all boil up on how do we end up in this point. It is just hard 
for me to fathom units that allow this to happen. And I 
recognize that it does.
    On the VA side, I think Ms. Bhagwati brought up a very good 
point here. That 100 percent of folks here have to be dealing 
with it. But we have to go back to the DoD side. We have got to 
figure out the prevention measures, too.
    And I know Ms. Pingree and Ms. Speier have worked heavily 
on this, that we have to continue to push that side of it.
    As we are dealing with this tragedy after the fact. I think 
many of you brought up really good points of how this situation 
arose.
    If you all three had the magic wand or were sitting over 
there at VA's position on this, what exactly would this look 
like? How we would deal with this? What exactly would happen 
from when the claim comes in and how we go forward? What would 
be your suggestion if you can help me as we are going to hear 
from them?
    And I certainly know that we are trying to train specific 
raters to deal with this so they know what is there. I am just 
trying to get a feel from all of you. Are they going about this 
the right way? Are we approaching it? Are we piecemealing 
together? What would you tell me?
    I know it is subjective here, but I think this is too 
important for us not to figure out something big to go about 
it. So if you would like to take a stab at that of what a claim 
should look like and how we should adjudicate these things that 
would be in the best interest of our servicemembers after the 
fact.
    So, please, go ahead.
    Ms. Bhagwati. I am beating a dead horse here. I think this 
is, the third time I have said it.
    Mr. Walz. Yes.
    Ms. Bhagwati. It is a very easy fix. If the evidence 
establishes a diagnosis of post-traumatic stress during service 
and the veteran's mental health provider connects that claimed 
stressor to the patient's service, then in the absence of clear 
and convincing evidence to the contrary and provided that the 
claimed stressor is consistent with the circumstances, 
conditions, or hardships of the veteran's service, the 
veteran's lay testimony should sufficiently establish the 
occurrence of the claimed in-service stressor.
    Mr. Walz. Ms. Bhagwati, are you convinced that that will 
bring those 87 percent forward?
    Ms. Bhagwati. Absolutely. You trust your mental health 
providers and you accept the lay testimony and the military 
record of the veteran period.
    Mr. Walz. What is the push-back of why we do not do that in 
your opinion?
    Ms. Bhagwati. It is rape mythology, sir. It is the sort of 
unspoken feeling that women make up that they were raped, 
assaulted, or harassed. And I say women specifically because I 
think there is a gender bias.
    Mr. Walz. That does go back to the bigger cultural issue 
both military and social----
    Ms. Bhagwati. Absolutely. It is a complete ignorance about 
the nature of rape, sexual assault, and sexual harassment.
    Mr. Walz. Don't you believe, and I have always believed 
this, the military has the potential to break those and set the 
precedence for a larger society, too?
    Ms. Bhagwati. Absolutely. The military can lead the way if 
it wants to.
    Mr. Walz. Okay. Well, I appreciate that.
    Ms. Ilem, I do not know if you have anything to add to 
that.
    Ms. Ilem. I think Ms. Bhagwati has brought up a couple of 
issues that there is really a differentiation between somebody 
who may have some alternative evidence that can be considered 
and the current regulations that exist today to rate these 
cases because there is that aspect of it and making sure there 
is consistency throughout the system across the board and then 
that there is oversight for them to really be reviewing it, 
and, yes, having claims raters that are familiar with these 
cases and really know how to dig in.
    It seems to me they really have to make a special effort to 
kind of piece together other things and really work with the 
veteran and the RO military sexual coordinator may have to be 
involved to try and assist the veteran along with the veteran 
service organizations to get the evidence that is needed under 
the current regulation.
    But the cases where somebody really keeps this a secret, 
does not tell anyone, there are not any indicators in the 
record to substantiate that.
    We have seen legislation in the Senate recently that DAV 
testified on where, you know, if you are being treated for a 
condition, you have been diagnosed, and you then, you know, 
have, even though that stressor is not reported that can 
support, you know, support your claim, I mean, I think that is 
the only change that could be, you know, available to people 
who have--there is absolutely no other evidence available to 
them.
    Mr. Walz. And I think all of you brought up a great point 
on this, too. I cannot imagine what a claim denial feels like 
because it is basically a denial that the incident happened.
    And, you know, I do not know if there is data that support 
the number of claims versus the number of denied claims. There 
definitely has to be a large number that were denied that the 
assault absolutely did happen. This is all a difficult process, 
from the psychological effects and treatment, to trying to get 
somebody well again, and that has to be taken into 
consideration. This process of claim adjudication on this is 
they are always important, that this is especially important.
    My time has expired, and I will yield back. But I thank you 
all.
    Mr. Runyan. I thank the gentleman.
    The chair now recognizes the gentleman from New York, Mr. 
Turner.
    Mr. Turner. Thank you, Mr. Chairman.
    And I would like to thank the panelists.
    I have one question for Ms. Perkio. You mentioned advocates 
to help negotiate or navigate people through this bureaucratic 
maze and through the legal system.
    Could you give us a little more on that, what you have in 
mind, how that might work? Where would you get these people?
    Ms. Perkio. The American Legion has 2,000 accredited 
American Legion service officers who are trained in assisting 
veterans in all types of claims. And we provide training twice 
a year for our service officers. There is no fee to work with 
an American Legion accredited service officer.
    I myself have been accredited and we are given training 
both from the VA and through The American Legion on how to, and 
through VHA, on how to handle claims. So just understanding the 
process and working with claims, working with senior veteran 
service officers.
    For instance, the process that I went through, you learn 
something new on every claim and every MST claim is going to 
have another element. And working with behavioral health has a 
big impact on how that claim is going to turn out so that that 
behavioral health provider understands what they need to do to 
support that veteran's claim as well.
    And that is where in my testimony, if the VBA would be more 
transparent in what they were really looking for in their 
information, for instance, on the letter from the medical 
professional that says that this is a nexus statement, that it 
is due to military sexual trauma, to know that the VBA wants to 
review all those documents in order to be an informed 
professional to write that letter and that they will not accept 
a statement just on the veteran's hearsay.
    And our service officers are well trained in that. All of 
our service organizations, actually the DAV, VFW, we all have 
service officers who will assist those veterans free of charge 
in filing claims. And so there is help available without going 
to an attorney.
    Mr. Turner. And how does the process start? Does the VA 
make the connection between a claimant and an advocacy group 
such as yours?
    Ms. Perkio. Typically a nurse case manager will be involved 
and they have a list of the service organizations that may be 
available right in the regional office next to them. And they 
will allow that servicemember to choose which service 
organization they may feel that they would like to work with.
    And so that referral process has worked very well in the 
past and that service officer will come in. And sometimes they 
will interview each department service officer with each 
organization to determine how well they fit with that.
    The credibility and the empathy and the understanding that 
goes with a claim regarding MST is going to go a long way in 
the trust that that person will put with you. They have to 
repeat that story not only to their medical care provider, but 
they repeat that story to that service officer and then the 
service officer will tell that veteran this is what we are 
going to do for you and this is what we are going to need. And 
that kind of helps that situation along.
    It is the servicemember who does not have an advocate that 
is really going to struggle and to meet a lot of road blocks. 
And being able to work with behavioral health makes a big 
difference.
    Mr. Turner. Is the VA obligated to provide an advocate or--
--
    Ms. Perkio. No, the VA does not provide an advocate. But in 
their letters, they will advise the veteran that there are 
advocates available and will give a list or a Web site that 
they can go and look to find an advocate for them.
    Mr. Turner. So all they do is dispense the advice on maybe 
how to best navigate this by contacting American Legion or----
    Ms. Perkio. Correct.
    Ms. Ilem. And it also depends on if you are talking about 
within VHA or VBA, but VHA does have military sexual trauma 
coordinators in each of its medical facilities. And oftentimes 
veterans do work directly with them to talk about how they can 
pursue their case, you know, for claims.
    And they may be referred to someone in a regional office. 
They also have that equivalent of a military sexual 
coordinator. So those people should also be able to provide 
that additional information if they want to have a veteran 
service organization assist them.
    Mr. Turner. All right. My time is up. Thank you.
    Mr. Runyan. I thank the gentleman.
    Mr. Turner. Yield back. Thank you.
    Mr. Runyan. The chair now recognizes the other half of the 
Maine delegation, Ms. Pingree.
    Ms. Pingree. Thank you very much. I really appreciate the 
opportunity to be here with your Committee and also to sit on 
my fellow delegation Member's Committee for a few minutes.
    But thank you very much, Chairman Runyan and to Ranking 
Member McNerney, both for holding this hearing and for everyone 
on this Committee's very thoughtful questions and being willing 
to take on what I think is an extremely important issue.
    I want to make just a couple of comments and then I have 
some questions as well.
    I think generally the VA is doing a good job providing 
counseling and treatment to victims of MST, but when it comes 
to awarding benefits, as we have heard so much already today, 
MST survivors face tremendous roadblocks and bureaucratic red 
tape.
    Since most attacks, as we have heard, go unreported, it is 
very hard for victims to provide the documentation during the 
claims and therein lies some of the source of our problem here.
    The current policy states that they will be very liberal in 
deciding MST cases and should accept secondary markers as the 
proof that the assault occurred, things like counseling reports 
for PTSD from MST, letters from family members citing 
behavioral changes, drug and alcohol abuse, but it has been our 
experience in my office that this policy is not being followed.
    The VBA remains vastly inconsistent when deciding on MST 
cases and what one regional office accepts, as we heard 
earlier, accepts as a secondary marker, another might deny and 
still not be violating VBA policy.
    I think we have to be sure that VBA gives MST survivors the 
benefit of the doubt, especially when so many of these 
survivors have lost faith in the system they swore to uphold.
    That is why I introduced the bill that you were asking 
about earlier and I appreciate the Chairman signing on to that 
bill. Basically it would provide service-connection for MST 
survivors if they provide a diagnose of PTSD and a medical link 
stating that the PTSD is caused by the assault similar to the 
policy now in place for combat related PTSD claims.
    I want to be clear about this. The bad guy in these stories 
are the perpetrators. They are the villains and the ones who 
should be held accountable. But by creating this policy that 
denies justice to the victim and forces them to spend years or 
even decades fighting for the benefits that they deserve, we 
are deepening the wounds for those veterans and making it much 
harder for them to get on with their lives.
    Ms. Bhagwati, thank you very much for your wonderful work 
and being here today.
    And thank you to everyone on the panel.
    A couple of questions. You have already talked a little bit 
about this very issue of the VBA and how it is working.
    Do you think it is enough to ease the PTSD evidentiary 
burden for MST claimants or do you think we also need to ease 
the burden for other common conditions associated with MST like 
depressive disorders and other anxiety disorders?
    Ms. Bhagwati. As I said in my testimony, according to the 
Veterans Affairs Department, PTSD is the most common mental 
health condition associated with MST, but depressive disorder 
and other anxiety disorders can be just as life threatening. 
And we certainly know that from the rest of the veterans' 
community.
    Many combat veterans are also suffering from depression 
rather than post-traumatic stress. So, no, it is not enough 
just to focus on PTSD. We have veterans committing suicide 
every day from major depressive disorder and other very, very 
serious conditions and very common conditions.
    Ms. Pingree. Either of the rest of you would like to answer 
that or talk about that?
    Ms. Ilem. I would agree. I mean, those are certainly other 
factors, mental health conditions that we see associated with 
MST related incidents.
    Ms. Perkio. In addition, all of the characteristics, 
anxiety, depression, those are all part of the PTSD criteria 
and so they should all be looked at because you never know when 
that claim may eventually be granted as a PTSD claim.
    Ms. Pingree. Thank you.
    Ms. Bhagwati, you also had mentioned that rape mythology 
when you talked about this earlier and the VA's fear of fraud. 
It is my impression that fraud is likely to be low in a 
situation like this. As you have reported and others have, very 
few people come forward to talk about a rape, a sexual assault, 
a sexual harassment because of the implications of doing that.
    But can you talk a little bit that since that is one of the 
reasons that we understand we do not have a better process 
here? Is there data to back it up or how can we sort of get rid 
of the mythology here?
    Ms. Bhagwati. The VA interestingly had the same concerns 
when it was debating whether or not to change the regulations 
related to combat and then the language ended up being about 
fear of hostile military or terrorist activity.
    But the VA had that discussion after the regulatory change 
and decided that there would not be any false allegations or 
false claims as a result of this regulatory change. And I think 
the same thing can apply to this MST change.
    We have looked through VA claims data. What often happens 
as a result of these mistakes, the first kind of rejection 
phase, is that the veteran, if they can tolerate it will 
appeal. Ultimately after a very, very lengthy appeals process 
or the very end of the phase, VA will reverse the decision and 
end up sort of siding with the veteran, but that can take years 
if not decades.
    Why not just get it right the first time and give the 
veteran the benefit of the doubt and just simplify the system?
    According to the FBI and numerous other agencies and 
studies, only two to eight percent, again, two at the low end, 
eight percent at the high end, of rape allegations are so-
called false allegations. That is a very low percentage.
    I would like to think that VA, is rooting for the 92 to 98 
percent of rape and assault survivors that are telling the 
truth and, who have investigations that can prove that they are 
telling the truth. That is all that that means. False reporting 
represents a very low percentage and is pretty much on par with 
other false allegations of crimes.
    Ms. Pingree. I have 30 seconds. Either of the other two of 
you like to say anything that was not covered about this?
    Ms. Ilem. I would just note DAV also, you know, has spoken 
to or consulted with clinicians that have had a long history of 
treating, especially in VA, for treating military sexual trauma 
issues.
    And we had the same sort of, you know, discussion that, you 
know, there may be a handful of cases in their career of 30 
years where they really feel that, you know, they cannot really 
come forward, to feel that, you know, that that was a truthful 
statement.
    But in the majority, the overwhelming majority of cases, 
they do. I mean, it takes a lot of commitment to come forward, 
to seek treatment, to have a diagnosis, and generally you have 
these long-term treatment records available, you know, that are 
consistent with an assault occurring.
    Ms. Pingree. Thank you. I am out of time, but thank you 
very much.
    Mr. Runyan. I thank the gentle lady.
    And on behalf of the Subcommittee, I want to thank each of 
you for your testimony and your service to our Nation's 
veterans. And with that, you are all now excused.
    And I want to invite the second panel to the table. Among 
our guests on the second panel today is Dr. Barbara Van----
    Ms. Van Dahlen. Dahlen.
    Mr. Runyan. --Dahlen, the president and founder of the Give 
an Hour organization which encourages doctors to volunteer 
their time to help victims of military sexual trauma. And we 
also welcome Ms. Margaret Middleton, the Executive Director of 
Connecticut's Veterans Legal Center, which works to seek 
justice and proper benefits on behalf of victims of military 
sexual trauma.
    Ms. Van Dahlen, you are now recognized for your oral 
testimony for five minutes.

 STATEMENTS OF BARBARA VAN DAHLEN, EXECUTIVE DIRECTOR, GIVE AN 
   HOUR; MARGARET MIDDLETON, EXECUTIVE DIRECTOR, CONNECTICUT 
                     VETERANS LEGAL CENTER

                STATEMENT OF BARBARA VAN DAHLEN

    Ms. Van Dahlen. Thank you for this opportunity to provide 
testimony regarding the issue of providing and improving access 
to care for veterans who have been sexually assaulted while 
serving in our military. It is an honor to appear before this 
Committee and I am proud to offer my assistance to those who 
serve our country.
    Over the past several months, we have seen an increase in 
the attention given to a very serious issue affecting our 
military community, military sexual assault.
    Understandably this type of attack and betrayal often leads 
to the development of severe mental health difficulties for the 
men and women who are victimized.
    And as we have heard, many of the female veterans treated 
by the Department of Veterans Affairs and other programs 
receive a diagnosis of military sexual trauma and this type of 
trauma is now the leading cause of post-traumatic stress 
disorder among female veterans, but it results in many other 
mental health issues as well, now surpassing combat trauma.
    In addition, the experience of military sexual assault 
increases the likelihood of other serious and devastating 
conditions and consequences such as substance abuse, 
homelessness, and suicide.
    While this issue is getting significant attention today, 
sexual assault has been affecting and often destroying the 
lives of those who serve for decades.
    As I began to prepare testimony for this hearing, I had 
occasion to speak with a colleague who devoted over 20 years of 
service to the military. He continues to serve as a civilian 
with the Department of Defense.
    I happened to mention to him that I was invited to testify 
before this Committee on this important topic. After stating 
that he was about to share something with me that he had never 
shared with anyone, not even his wife, he told me the following 
story.
    He enlisted in the military at the age of 17. It was the 
late 1970s. Within the first year of his service, he was 
sexually assaulted by two men with whom he served as part of an 
initiation process.
    He was humiliated and devastated. He told no one. He said 
there was no one to tell. Reporting would have made my life 
much worse. The stigma would have further damaged me and my 
career. I felt overwhelming guilt and shame.
    This veteran suffered the consequences of the attack 
psychologically and physically for years. At one point, he 
contemplated suicide and went so far as to put all his affairs 
in order and make arrangements for the care of his two-year-old 
daughter and young wife.
    His marriage fell apart and he and his wife separated. 
Fortunately, this veteran found help, repaired his marriage, 
and healed psychologically, though he continues to have 
significant physical problems that stem from the attack that 
shattered his life 30 years ago.
    He shared his story with me now because he wants the 
Members of this Committee to understand that servicemembers who 
are sexually assaulted are unlikely to report the assault to 
their command, to their peers, to anyone. And you cannot often 
tell from looking at them that they have been affected, not for 
years.
    We in the mental health profession know that it is critical 
for victims of sexual trauma to seek and receive assistance, 
support, and treatment as soon as possible. We also know that 
it is likely that many who suffer sexual attacks within the 
military will not seek care while they continue to serve.
    We must, therefore, ensure that all of those who seek 
services through the VA for sexual assault once they leave the 
service are treated as quickly and as supportively as possible 
by allowing trained mental health clinicians to determine the 
veracity of a veteran's claim of sexual assault.
    The signs and symptoms are well-known and VA mental health 
providers have already been given the appropriate 
responsibility for making this type of determination regarding 
reports of combat stress injuries.
    Moreover, given the humiliation survivors of sexual assault 
contend with, it is highly unlikely that many women or men will 
fabricate stories of military sexual trauma in order to receive 
VA benefits.
    In addition, the lives that are saved by adjusting the 
process by which victims of sexual assault can qualify for and 
receive services through the VA will far outweigh the very few 
cases that beat the system.
    In addition to changing the process for victims of sexual 
assault to apply for and receive services through the VA, we 
should continue to expand the network of providers available to 
meet the growing needs of the military community at large.
    The VA has made tremendous strides in recognizing that 
partnerships with community-based organizations are critical if 
we are to provide the mental health services that the men, 
women, and families who serve our country need when they come 
home to our communities.
    The VA recently signed an MOA with my organization, Give an 
Hour, which provides free mental health services to military 
personnel, veterans, and their loved ones. This MOA will 
facilitate appropriate referrals to our providers from the VA's 
veterans crisis line.
    It is easy to imagine how community-based efforts such as 
those provided by Give an Hour and other organizations can 
assist the VA in their efforts to provide swift and effective 
care to those who have given so much to our country.
    Thank you so much.

    [The prepared statement of Barbara Van Dahlen appears in 
the Appendix]

    Mr. Runyan. Thank you, Dr. Van Dahlen.
    Next we will hear from Ms. Middleton.
    You are now recognized.

                STATEMENT OF MARGARET MIDDLETON

    Ms. Middleton. Chairman Runyan, Ranking Member McNerney, 
and Members of the Subcommittee, thank you very much for asking 
me to testify about the VA disability compensation process for 
victims of military sexual trauma.
    My name is Margaret Middleton. I am the Executive Director 
and Co-Founder of the Connecticut Veterans Legal Center. Our 
mission is to help veterans recovering from homelessness and 
mental illness overcome barriers to housing, health care, and 
income.
    I am also a visiting clinical lecturer at Yale Law School 
and I co-teach at the Veterans Legal Services Clinic there.
    In both of those capacities, I work with veterans seeking 
VA compensation for PTSD caused by sexual assault in the 
military.
    There are several experts at this hearing from the last 
panel who testified about the military culture, the extent of 
sexual assault in the military, and the scope of the VA's 
failure to assist those victims.
    Rather than repeat that testimony, I would like to share 
some personal experiences I have had helping veterans confront 
the evidentiary standard of 38 CFR 3.304(f)(5) which is the 
current standard.
    In my teaching capacity, I co-supervised a team of students 
who helped a female marine establish service-connection for 
PTSD stemming from a rape at Camp Lejeune in the early 1970s. 
At that time, she was 18 years old and extremely proud to be 
serving in the marines.
    She was out drinking at an NCO club where she was not 
supposed to be and the acquaintance who was walking her home 
pushed her through a window and raped her in an empty barracks 
room.
    This veteran felt tremendous shame and personal 
responsibility for having been out at night, for having been 
drinking, for having trusted the wrong person. She feared her 
romantic partner would leave her if she talked about the rape.
    And her assailant who bragged about his conquest caused the 
warrant officer she considered sort of a father figure to tell 
her that she was the reason why women should not be allowed in 
the military.
    This veteran was plagued for PTSD for decades following 
this assault and was diagnosed and is currently treated by a VA 
doctor for PTSD.
    Assisting this veteran get connected for service-connection 
was incredibly complicated. Her parents had died. Her marriage 
had failed. There were no surviving letters of hers, no 
journals, no court records. She had lost contact with anyone 
she had served with 30 years earlier. She had been too ashamed 
and afraid to seek medical help at the time. Mental health 
treatment then was even less common and more stigmatized than 
it is now.
    She was not demoted. She did not seek a transfer. She just 
continued to do her job and was honorably discharged from the 
marines.
    Under the current standard, it took hours of work by two 
incredibly talented Yale students and an unusually cooperative 
VA physician to build her case based on what meager 
contemporaneous evidence they could sort of scrape together.
    Almost no veteran has access to this kind of support and 
representation and they should not have to.
    Another option might have been an independent forensic 
psychiatric evaluation that would have cost several thousand 
dollars that my client did not have and VA does not pay for.
    This veteran's lack of documentary evidence is the rule and 
not the exception in these types of cases.
    I recently interviewed a female veteran who was raped by 
two sergeants in her barracks 30 years ago. They ordered 
everybody else out and they kept her behind.
    Decades later, similar to what the doctor just said, I was 
the first person that she had ever told. She did not tell 
anyone at the time because it would have meant the end of her 
career. And if you think her career was not important to her, 
she served in Iraq. She achieved the rank of master sergeant 
and she was retired honorably after 28 years serving in the 
military.
    This incredibly strong soldier held back tears when she 
told me the story and it was only one of the several episodes 
of MST that she described to me.
    This veteran's claim faces an almost impossible evidentiary 
burden because of this particular provision. She did not tell 
anyone what happened, so there are no medical records, no 
letters home, no actions taken against her assailants.
    In order to succeed in the army, this veteran felt forced 
to stay silent and now she will be punished for her silence 
because the VA will refuse to credit her story based on her 
testimony alone.
    As her advocate, it will take me and my team hours of phone 
calls to family members and old friends, combing through 
service personnel records, and begging doctors to provide a 
free forensic psychiatric evaluation to support her claim.
    This is surely not what the VA anticipated when it adopted 
Section (f)(5), but it is the reality of how this provision is 
working in practice. We know that this is grossly unfair. We 
know how to fix it.
    The VA can and should remedy this situation by amending the 
section to provide victims of military sexual trauma the same 
benefit of the doubt that other veterans are already afforded 
who seek compensation for PTSD.
    There is no excuse for permitting the current regulation to 
stand and I hope this Subcommittee exercises its responsibility 
to America's veterans by correcting this injustice. Holding 
this hearing is a really important step towards change.
    And I thank you again for the opportunity to testify and I 
would be happy to answer any questions.

    [The prepared statement of Margaret Middleton appears in 
the Appendix]

    Mr. Runyan. Thank you very much.
    And, again, both of you, thank you for coming today and 
sharing your testimony with us.
    Doctor, I have a question. It is actually two questions for 
you.
    In your written testimony, you stated that despite the 
cultural differences between military and civilian life, the 
symptoms of sexual trauma are consistent and easily 
identifiable by mental health professionals.
    Accordingly, you suggest VA should expand the network of 
qualified mental health specialists to assist the veterans who 
are victims of MST which in turn will assist VA claims 
processors review of the evidence in such claims. And now the 
two questions: how do organizations like yours become involved 
in this process?
    Ms. Van Dahlen. Mm-hmm.
    Mr. Runyan. And do you believe that having such access to 
an expanded network of mental health providers will encourage 
more victims of MST to come forward and report what has 
happened to them?
    Ms. Van Dahlen. Absolutely, to the second question. I think 
we have already seen through, and our network now has provided 
57,000 hours of free mental health care to servicemembers, 
veterans, and their families. It is an option outside the VA, 
outside DoD, that many desperately need and want for a variety 
of reasons. So expanding the opportunity for victims of 
military sexual trauma to seek a provider in their community 
who would then be able to provide that confirmation of the 
military sexual attack would, I think, bring many more victims 
to be able to receive services and benefits. It is an issue in 
discussion right now, and has been for quite some time, 
regarding Post-Traumatic Stress in general. That currently only 
VA clinicians are allowed to provide that assessment. But there 
are many who believe that opening that door and allowing 
community-based mental health providers to provide expertise in 
areas that they are fully capable of making that diagnosis and 
assessment would assist in providing care, would assist in 
moving the process along more quickly in terms of benefits, 
services, etcetera.
    Mr. Runyan. I remember, and I know many of the other 
Members who are here do also, when Secretary Shinseki sat in 
that exact same seat a couple of months ago saying our capacity 
to deal with the mental health issues we have in the VA, we are 
behind the ball on it. And it was a challenge that day to say, 
well, what is the number? How serious is the issue? And this is 
another unfortunately prime example of it. We do have the get a 
grasp on it. And if organizations like yours are an avenue to 
do something like that, I would hope that the VA would be open 
to something like that. Because it is a problem that we do not 
really know the magnitude of and what the sheer numbers of it 
are going to end up being.
    Ms. Van Dahlen. I think that is absolutely right. And I 
would say that there has been tremendous progress. And I am 
very optimistic. Because up until a few months ago we were 
really working separately. Even though we had been there for 
several years now, since I began this organization seven years 
offering services. And they were happening. But it was only 
until very, very recently that we have now formed the first 
little step in an official relationship. And we are very 
optimistic. Because the numbers are very clear that this is, 
many refer to it as, you know, a tidal wave, a tsunami. There 
will be more and more of those who come home who are in need of 
assessment, treatment, support. Not just for themselves, but 
their families. So I agree completely. And I believe we are 
moving in the right direction. But as this issue gets more 
attention then more, which is a good thing, of those who have 
been assaulted will step forward. Which will create more 
backlogs within the VA. So again, I totally agree we need to 
move in that direction and hopefully we will.
    Mr. Runyan. Thank you. Ms. Middleton, can you elaborate a 
little on some of the frustrations you have experienced dealing 
with the VA as an advocate on behalf of the victims?
    Ms. Middleton. Sure. Absolutely. I think the, our 
experience at the Connecticut Veterans Legal Center is that the 
way the regulations look on paper and the way they get used is 
very different. And that is why I really hope that the 
leadership here will use their bully pulpit to push the VA to 
change this regulation. Because it is not enough to say just 
bring in some extra documentation, what is the big deal? There 
is no reason why these veterans should be required to produce 
documents that other veterans do not have to. There is no, I 
cannot understand any reasonable explanation for that. And so 
it actually seems like kind of an easy fix from my point of 
view.
    Mr. Runyan. Thank you. And with that I will recognize the 
Ranking Member, Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman. I want to thank both 
of the panelists here for their volunteer efforts in this 
issue. And not only you panelists but the organizations that 
you represent. It is a lot of work and it is not easy work. So 
thank you very much.
    Dr. Van Dahlen, what is your view of how well the military 
sexual trauma coordinators are doing? Is this an effective 
program?
    Ms. Van Dahlen. Well I think that what we have seen over 
time, and again this is the good news, there is more and more 
that is happening that is working well. But the problem is so 
large and the VA system is so vast that it is as, it is the 
case with many issues. Not only military sexual trauma but 
other situations, combat trauma that result in Post-Traumatic 
Stress. It depends very much on the leadership in that 
particular region. It depends on that particular person. So we 
hear very mixed reviews. That in some areas it is working very 
well and in others not so much. And I think again it is about 
coordination of services. It is about leadership. It is about 
coordinating with organizations like ours so that we have more 
conversations that are happening. So I think the answer is good 
news that in fact they now exist, but we are not there yet.
    Mr. McNerney. Well what in your opinion would be the 
biggest barriers to determining appropriate VA services to MST 
victims?
    Ms. Van Dahlen. Well I think the biggest barrier right now 
is what we have been talking about today. That there is not any 
reason to require--and here is another issue that we sort of 
talked about but I want to make very, very clear. For a large 
number, especially this is a way that military victims are in 
some ways perhaps different than civilians, the men and women 
who serve, they are so dedicated to their service. They want to 
stay in the service. They want to maintain their focus on 
mission. We may not be able to find evidence of behavior 
change, even if we have the best detectives on the planet going 
back and looking at, well, what else was happening to them at 
that period? Can we find it in their employment records? Can we 
ask other members of their community did you see a change to 
verify, to validate? You will not be able to find that. And so 
requiring them to provide some kind of evidence is contrary to 
the reality of who these men and women are. And that is a huge 
barrier.
    Mr. McNerney. Ms. Middleton, one of the things that 
interested me about your testimony was that you are advocating 
regulatory change as opposed to legislative change. Why does 
that make more sense to you?
    Ms. Middleton. I would love to see victims of MST get the 
compensation they deserve. And whether that requires an act of 
Congress or it requires the VA to change their own rule is not 
really of importance to me. I mean, however, however these 
folks receive justice is going to be great.
    Mr. McNerney. But I mean, in your opinion it could be done 
purely regulatory?
    Ms. Middleton. I mean, my understanding is that the VA 
promulgated this regulation in the first place. So they could 
change it. But I do not see why given the opportunity Congress 
would not fix this problem.
    Mr. McNerney. Well it was clear from your description of 
the case in Camp Lejeune that the soldier had few options if 
she wanted to remain in the military. She faced big obstacles, 
monumental obstacles really. Would you, how would you compare 
that experience to what somebody in the service would 
experience today? Is there any improvement?
    Ms. Middleton. I mean, the two veterans who I spoke about, 
one of them, I mean both of those instances I described were 
quite old. One of these veterans was discharged not that long 
ago, because she had such a long career in the military. And 
she described a later episode of MST that was very similar to 
the extent that she was completely unable to talk about it 
without jeopardizing her career. And I think that Dr. Van 
Dahlen summed it up very well. There is no incentive for these 
people to talk about this in the context of their work 
environment. And there is no reason that we should expect to 
see some kind of reflection of this in their personnel file. 
Which really makes, it really reflects the fact that this 
regulation reflects a misunderstanding about the way military 
sexual trauma actually works.
    Mr. McNerney. Okay. So we have quite a bit of work to do 
yet then. Thank you. I yield back.
    Mr. Runyan. I thank the gentleman. The chair now recognizes 
Ms. Pingree.
    Ms. Pingree of Maine. Thank you very much, Mr. Chairman. 
Thank you both for your testimony. And I concur with my 
colleagues here, I really very much appreciate the work that 
you are doing and the assistance that you and your 
organizations give to so many people who need our assistance 
who frankly should not have to be in the position where they 
require such complex assistance. And I hope we can fix that.
    I will ask this question of both of you. We see many 
denials where the VA states that the veteran could not be 
service-connected because they were sexually assaulted prior to 
their military service. VA examiners tell them their condition 
is related to the earlier assault, not the one that occurred in 
the military. I think that for these veterans a service assault 
would at least aggravate a preexisting condition but it seems 
like an inappropriate way to look at it. Do you see these types 
of denials in your work? And do you have comments about them?
    Ms. Van Dahlen. Yes. And unfortunately one of the things 
that happens with victims of sexual assault is they, if that 
sexual assault is untreated they are more likely to be victims 
again. And so to say that because a man or woman was sexually 
assaulted before they entered the military, somehow then the 
psychological damage that we are seeing is not related to the 
additional assault, makes no sense psychologically. It makes no 
sense. It is like it is almost the, in fact it is, the opposite 
logic that we use for combat stress. Combat stress, we 
understand, we know this, the more deployments, the more 
exposure to trauma, the more significant the psychological 
damage. We have kind of gotten that right, finally. But here we 
are saying the opposite. It makes no sense psychologically in 
any way. And in fact we know that victims are more likely if 
gone, if they are untreated, to become victims in the future.
    Ms. Middleton. I would say I have almost never spoken to a 
veteran who reported to me an incident of military sexual 
trauma who did not also experience some kind of trauma prior to 
entering the military. It is very, very common in my 
experience. And it is just one more reason why we should not 
hold the veterans to this unnecessary evidentiary standard. 
Because we do not need to muddy the water for the VA RO folks 
who already apply the rule pretty haphazardly.
    Ms. Pingree of Maine. Any other specific patterns of 
denials that you see, besides some of what we have discussed 
today? Obviously you are looking at a lot of different 
situations.
    Ms. Van Dahlen. Well, I would like to just go back to the 
question that was asked about how prior generations, how much 
different is it today? I would say not that different, not in 
terms of the reports that we hear. And one thing again that has 
changed, which is good news, there are many, many in the 
Department of Defense who are outraged and coming forward. Men 
and women both who tell me that they have witnessed in their 
own units, these are leaders who will say that they see now 
signs. And sometimes that they feel like they are, that the 
system has not caught up quite with the change that is 
happening in the culture. So men and women are still faced 
with, and it is, combat stress, the impact of combat stress is 
slightly different. I think that curve we are kind of getting a 
little bit closer to more acceptance and support. But this one 
is even further behind the curve. But at least there are men 
and women in the Department of Defense, many, many clinicians 
in the VA, who would say, you know, we know, we know what we 
are seeing, we know what we are looking at, we can diagnose 
this. That is the good news. But in terms of the obstacles for 
reporting, and the way that women and men are often treated 
when they do report, very similar stories for this generation 
as well.
    Ms. Pingree of Maine. That is very discouraging when you 
think about how we feel our culture has moved forward. Yet that 
somebody who experienced this 30 years ago might have the, 
someone else might have a similar experience today. Did you 
have a comment, Ms. Middleton?
    Ms. Middleton. Only that we see veterans applying for 
compensation who are denied in all kinds of areas. It just 
happens to be that for claimants who are applying for PTSD 
connected to military sexual trauma there is an extra burden 
that as advocates we are really disheartened by. Because it 
creates a tremendous amount of unnecessary work and time away 
from other veterans we could be helping.
    Ms. Pingree of Maine. Great. Thank you very much. Thank 
you, Mr. Chair.
    Mr. Runyan. On behalf of the Subcommittee I would like to 
thank you both for your testimony and all that you do to 
support our veterans. And with that you are dismissed.
    Ms. Van Dahlen. Thank you.
    Ms. Middleton. Thank you.
    Mr. Runyan. I would now like to welcome our third panel to 
the table, Ms. Ruth Moore, who is an extremely brave woman here 
today to tell her story about the military sexual trauma she 
experienced and her fight to obtain VA benefits. Ms. Moore is 
accompanied by her husband, Mr. Alfred ``Butch'' Moore, Jr. Ms. 
Moore has been working with Representative Pingree and I now 
turn to my honorable colleague for any remarks she might wish 
to make.
    Ms. Pingree of Maine. Well, thank you very much Mr. Chair. 
Let me just give another brief introduction and thank Ruth 
Moore and her family, her husband and her daughter, for joining 
us today. She is a MST survivor who fought the VBA system, as 
we are about to hear, for many years before she was finally 
service-connected. They made the long trip down from Maine. And 
I want to correct the record here, I share, I share Ruth Moore 
with Congressman Michaud. She actually lives in his district. 
But we were able to speak with her soon after we introduced the 
piece of legislation and have been happy to be in contact with 
her really appreciated her telling her story.
    For 25 years Ruth has had to battle with the Navy, the VA, 
and frankly her own memories. I do not think many of us can 
truly appreciate all of what she and her family have been 
through. And I totally appreciate how brave she is to come with 
us today and tell her story. It is not an easy thing to do. But 
I think Ruth would say she knows if she keeps silent, and if 
all of the survivors of MST are silent, the problem will never 
go away. I appreciate your courage in coming here today. And I 
want to add one last thing.
    Our local newspaper wrote a story about Ruth last week. And 
when the reporter asked her her biggest fear about testifying 
she said that they will hear my words but will not understand 
the depth of it. Well I want you to know you are in good hands. 
This is a Committee that cares deeply about this issue. I 
appreciate your holding the hearing today, and I appreciate you 
inviting Congressman Michaud's and my constituent to join us 
today. Thank you very much, Ruth.
    Mr. Runyan. I thank the gentle lady. And with that we will 
recognize Ms. Moore for her testimony. You are now recognized.

 STATEMENT OF MS. RUTH MOORE, CONSTITUENT WITNESS; ACCOMPANIED 
     BY ALFRED ``BUTCH'' MOORE, JR., HUSBAND TO RUTH MOORE

                    STATEMENT OF RUTH MOORE

    Ms. Moore. Thank you. Good afternoon, ladies and gentlemen. 
My name is Ruth Moore and it is an honor to be among you today. 
As you know, I am a military sexual trauma survivor who lives 
with PTSD and depression. I am here today to share my 23-year 
struggle to get help from the Veterans Health Administration 
and disability compensation from the Veterans Benefits 
Administration.
    In 1987 I was a bright, vivacious 18-year-old serving in 
the United States Navy. After my training school my first 
assignment was to an overseas duty station in Europe. Two and a 
half months after I arrived, I was raped by my supervisor 
outside of the local club, not once but twice. I sought help 
from the chaplain but did not receive any. I tried to move 
beyond this nightmare but had contracted an STD.
    At this point my life spiraled downward and I attempted 
suicide. Shortly thereafter I was MedEvac'd to Bethesda Naval 
Hospital and ultimately discharged from the Navy. No 
prosecution was ever made against my perpetrator. In hindsight 
it was easier for the military to get rid of me than to admit 
to the rape.
    My problems began at the point of separation as the 
psychiatrist diagnosed me with a borderline personality 
disorder. I did not have a borderline personality disorder. 
This was the standard diagnosis that was given to all MST 
survivors at that time to separate them from active duty and to 
protect the military from any and all liability. This travesty 
continued and I was counseled by outprocessing to waive all 
claims to the VA as I would get health care through my former 
spouse, who was on active duty.
    From 1987 to 1993, I struggled with interpersonal 
relationships, could not trust male supervisors, and could not 
maintain employment. I filed my first VA claim in Jacksonville, 
which was denied despite having several markers for PTSD and 
gynecological issues. My life continued to spiral downward and 
I was not able to maintain my marriage. In 1997 I fled from my 
house and lived out of my van for two weeks before I was able 
to start rebuilding my life with my present spouse. Things were 
very difficult and I developed additional markers of PTSD, 
including night terrors, panic attacks, severe migraines, and 
insomnia.
    In 2003 I filed for disability and was denied again. 
However, I enlisted the aid of the Disabled American Veterans. 
With their help I was awarded 30 percent compensation for 
depression. I was denied PTSD and was told that I did not 
submit enough evidence to prove that I was raped, despite 
having submitted a letter from my former spouse who remembered 
the rape and the chlamydia. Given this eyewitness testimony, 
the VA still denied this as credible proof. There was no record 
of my medical treatment for STD from that duty station as my 
medical records had been expunged. Additionally, I was coded by 
Togas VA as having a traumatic brain injury or brain syndrome.
    In 2009, I entered into my first comprehensive treatment at 
the VA hospital in White River Junction, Vermont. I met an MST 
coordinator who truly listened to me. She began a systemic 
review of my records and determined that they had been 
expunged, by noting the glaring inconsistencies between my lab 
work notes and service record. My psychiatrist and counselor 
determined that I did not have borderline personality disorder, 
nor traumatic brain syndrome. My MST coordinator and I refiled 
for an increase in disability and my clinicians wrote 
supportive records for the VBA to make an accurate 
determination. They readjudicated my claim to 70 percent but 
denied my status as individually unemployable, citing that I 
did not complete the necessary paperwork.
    At this point I was very frustrated and suicidal with the 
stresses of the VBA system and claims process. In my final 
effort, I called the Honorable Bernie Sanders and his staff 
agreed to investigate why the VA was taking so long and denying 
my claim. I took Mr. Sanders copies of all the paperwork I had 
filed, including the VBA time and date stamped missing 
information. Within two weeks my claim was finally adjudicated 
to 70 percent with IU and it was total and permanent. My rating 
should have been 100 percent by the VBA criteria, but I was so 
grateful for a favorable determination that I have not pursued 
it.
    Ladies and gentlemen, this process took me 23 years to 
resolve. And I am one of the fortunate ones. It should not be 
this way. If I had been treated promptly and received benefits 
in a timely manner back at the time of my discharge, my life 
would have been much different. I would not have had to endure 
homelessness and increased symptomology to the point where I 
was suicidal. I would not have miscarried nine children. And I 
firmly believe that I would have been able to develop better 
coping and social skills. Instead my quality of life has been 
degraded to the point where I am considering the possibility of 
getting a service animal to relieve the stress that my husband 
endures as my unpaid caretaker. I am asking you, no I am 
pleading with you, to please favorably consider the legislation 
that would prevent this from happening to others.
    Congresswoman Pingree's legislation is one way to change 
the burden of proof that is required to enable MST survivors to 
receive proper adjudication for MST and PTSD. Please do what is 
right. Support this legislation. It is urgently needed. And 
thank you for your time and audience today.

    [The prepared statement of Ruth Moore appears in the 
Appendix]

    Mr. Runyan. Thank you very much, Ms. Moore. And we truly do 
appreciate you being here. Once you volunteered to serve our 
Nation through the armed services, but you being here today and 
continuing to share your story, you are continuing to serve by 
shining a light on this. Sharing your experience to us is only 
going to help us make sure that this does not happen to anyone 
else. And I know you have endured some horrific challenges, as 
you just discussed in your time in the military and in your 
personal life after that. And, I am kind of choked up. I just 
really again would thank you for being here today. I know 
working with Ms. Pingree on this piece of legislation is one of 
many steps we discovered here today, that we will look into.
    If there is anything I or my colleagues can do, and this 
goes out to any veteran, do not ever hesitate to call us. 
Because that is truly what we are here for, is to serve you 
because of your service to this great Nation. I again thank you 
for being here. I know it is not easy to sit here and talk 
about something like this. And I am going to refrain from any 
questions that I might have. And thank you again for our 
testimony. And I yield to the Ranking Member, if he would have 
anything to say.
    Mr. McNerney. Well thank you, Mr. Chairman. Ms. Moore, Mr. 
Moore, thank you for serving our country. Thank you for taking 
that service enough to be here in front of us today. It is 
important to hear your testimony and your testimonial. And it 
will have an effect. We will do what is necessary. We cannot 
promise immediate change. But certainly, you know, having that 
in front of us and reminding us of how difficult life can be as 
a result of this sort of experience will remotivate us to work 
as hard as we can on this issue. So I am not going to ask any 
questions. But I want to thank you for coming, and bringing 
your husband and your daughter.
    Ms. Moore. Thank you.
    Mr. Runyan. Ms. Pingree?
    Ms. Pingree of Maine. Well thank you very much. And Ruth, I 
will thank you again, and to your family for being here with 
you today. It really does mean a lot and I really appreciate 
the chair and the Ranking Member for their sentiment. And I 
appreciate the Ranking Member for saying what I think is 
important to say. That you are serving your country twice 
today, coming forward and speaking here and providing us with 
another firsthand story about how difficult this situation is.
    I will not torture you much. But I will let you just have 
the opportunity if you would like to speak a little more about 
the many markers. We have talked a lot today about the burden 
of proof and how we just put it back and back and back. And the 
number of times that you have gone through the process in 
attempting to resolve your own situation, which took an 
enormous amount of strength and determination and resolve to 
continue to go back and try to find the assistance that you 
needed. Can you talk a little bit to the extent that you would 
like to about the markers that you provided and how they were 
rejected?
    Ms. Moore. I would be happy to. The markers that I have. As 
it was addressed here, there are many markers for PTSD. Some of 
them are recognized, some of them are not recognized, and it 
all depends upon the clinician who is making the diagnosis. I 
am happy to say that over time the process has improved in the 
VA and we now have more capable and competent providers who are 
able to recognize these markers and make appropriate diagnoses. 
I am also happy to say that the general perception of the 
military is improving with respect to MST survivors. At the 
time that I was in it was an embarrassment to the command to 
have an MST case. The commanding officer did not want this to 
be a record on their, or a mark on their record for poor 
administration or poor leadership.
    I think what it really boils down to is we need to have 
capable, competent providers who are trained to understand 
these things. I think the burden of proof that I submitted was 
credible proof. Having an eyewitness testimony being shot down 
and told that that was not credible proof to the VA was 
certainly very disturbing. It was documented and received in 
2004, and it was mysteriously lost from my records. And then in 
2009, Mr. Sanders brought it forward again because I had a copy 
of it. I was one of the few people that made copies of 
everything and kept them. Many people do not. Many people are 
told just move on with this. If you want to have a career you 
need to just forget this and move on. I was not so intelligent 
back then and I did not forget it, and I did not move on with a 
career. It was very hard for me. So I think that the markers 
that we have now are much better. And I think the legislation 
that you are proposing would make it much better for many 
veterans. Because, you know, we need to be believed and heard.
    I would also encourage the panel to consider the fact that 
VA systems are different from region to region. I live in Maine 
now. I lived in Maine at the time. And I was denied in Maine. I 
was denied in Florida. It was not until I reached the White 
River Junction VA Center that I actually found what an MST 
coordinator was. And I actually found out that what happened to 
me happened to other people. She was so sympathetic and she was 
so helpful. And the first thing she did was look at my record 
and she says, ``Well this is missing, and this is missing, and 
this is missing.'' These are classic things that happen with 
MST cases. Their files are expunged. And to clarify for the 
panel, I will say that in a medical record the left side of the 
record is your lab notes, the right side of the record is your 
treatment record. And my record had been expunged so badly that 
things were missing out of one side but not the other. So it 
was like a great big puzzle without the pieces. And you could 
see part of the picture but not all of the picture. And then by 
the VBA standards that basically meant that nobody wanted to 
take the time to look, so I was denied.
    Ms. Pingree of Maine. Well thank you for providing that 
information. And I do want to add that while we are looking at 
the problems with the system today and the things that need to 
be changed, and many of the challenges that people faced, I do 
want to acknowledge that when you did encounter a competent and 
thoughtful and well trained MST coordinator who was able to be 
in the position to help solve your problem it was very useful. 
And, you know, we have many hardworking people at the VA who 
are struggling under a system that is in the process of change 
and often with a huge workload. So I do want to acknowledge 
there are times when you meet those people who really do offer 
you assistance in your life. And certainly Senator Sanders as 
well.
    Just in closing, again, thanking you very much for your 
testimony here today. And I know you have talked a lot about 
the challenges that you have gone through. But I want to 
acknowledge your daughter Samantha who is in the room today. 
Who as I understand is getting a Girl Scout Medal of Honor this 
year, only the 21st person in America to receive one for many 
of her heroic acts. So you two are clearly wonderful parents 
and have done many great things in your life, and we are proud 
to have you in Maine.
    Ms. Moore. Thank you.
    Mr. Runyan. With that, on behalf of the Committee I would 
like to thank you for your testimony, and thank you for your 
service to this country, and your continued service to our 
country. And with that, you are now dismissed. And I will 
invite the fourth panel to the witness table.
    Today we welcome Colonel Alan Metzler, Deputy Director of 
the U.S. Department of Defense's Sexual Assault Prevention and 
Response Office; and we also welcome Mr. Tom Murphy, Director 
of Compensation and Pension Service for U.S. Department of 
Veterans Affairs. Mr. Murphy is accompanied by Ms. Edna 
MacDonald, Director of the Nashville Regional Office at the 
U.S. Department of Veterans Affairs. And Colonel Metzler, you 
are now recognized for five minutes for your testimony.

   STATEMENTS OF COL. ALAN METZLER, DEPUTY DIRECTOR, SEXUAL 
  ASSAULT PREVENTION AND RESPONSE OFFICE, U.S. DEPARTMENT OF 
 DEFENSE; ACCOMPANIED BY DR. NATE GALBREATH, SENIOR RESEARCHER 
 AND TRAINING ADVISOR, SEXUAL ASSAULT PREVENTION AND RESPONSE 
   OFFICE, U.S. DEPARTMENT OF DEFENSE AND MR. THOMAS MURPHY, 
 DIRECTOR OF COMPENSATION AND PENSION SERVICE, U.S. DEPARTMENT 
    OF VETERANS AFFAIRS; ACCOMPANIED BY MS. EDNA MACDONALD, 
    DIRECTOR, NASHVILLE REGIONAL OFFICE, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

                 STATEMENT OF COL. ALAN METZLER

    Colonel Metzler. Chairman Runyan, Ranking Member McNerney, 
and Members of the Subcommittee, thank you for inviting us to 
appear today. I am the Deputy Director of the Department's 
Sexual Assault Prevention and Response Office and my colleague 
is Dr. Nate Galbreath, the Senior Executive Advisor for 
Research and Training.
    Let me begin by restating Secretary Panetta's bottom line 
on this serious issue. Sexual assault has no place in the 
Department of Defense. Secretary Panetta has put great emphasis 
on dealing with the crimes of sexual assault. It is an affront 
to the basic American values we defend and it is a stain on the 
good honor of our armed forces. Since our policy was instituted 
in 2005 we have remained committed to our vision, a culture 
free from sexual assault.
    Our uniformed leadership is committed to driving this 
change. In May, the Joint Chiefs of Staff issued an 
unprecedented strategic direction signed by eight four-star 
leaders, including the Chairman and Vice Chairman of the Joint 
Chiefs, and the Chiefs of Staff of each of the military 
services, and the National Guard. This direction calls on the 
entire force to focus on four areas. Enhancing awareness; 
encouraging open communication and timely reporting; holding 
offenders accountable; and providing responsive victim 
services. Our goal is to create a culture that will not 
tolerate sexual assault.
    While we are absolutely committed to combating and 
eliminating sexual assault from the armed forces, we remain 
acutely aware of the brutal facts that point to the challenges 
we face. Although the department received 3,100 sexual assault 
reports in 2011, offenses ranging from wrongful sexual contact 
to rape, our anonymous survey data suggests that in 2010 as 
many as 19,000 servicemembers were victims of some form of 
sexual assault. It remains unacceptable to us that we would 
have even one of these crimes occurring in our armed forces.
    We have undertaken many enhancements to support victims, 
encourage reporting, increase the availability of documents for 
veterans. And I would like to talk briefly about some of those 
efforts. In February, 2011 we launched the DoD Safe Helpline, a 
worldwide 24/7 crisis support service for members who are 
sexual assault victims. To date, more than 47,000 unique users 
have visited that Web site, and more than 4,000 individuals 
have received live services. We are professionalizing our key 
positions that support victims by designing a Sexual Assault 
Response Coordinator (SARC) and victim advocate certification 
program that will consist of credentialing that aligns with the 
National Advocate Credentialing Program.
    In December the Secretary of Defense mandated increased 
retention for sexual assault documentation. For unrestricted 
reports, documents will be kept for 50 years, and this was 
specifically designed to allow transitioning servicemembers and 
our veterans who may desire to make a claim at a later date.
    Also in December the Secretary created a new protection for 
victims. They now have the option to request a permanent or 
temporary transfer from their command or base, or to a 
different location within their command or base. Victims make 
the request to their commander, and they must receive an answer 
in 72 hours. If denied for some reason the victim may appeal to 
the first general officer in the chain of command.
    I would also like to mention, Mr. Chairman, several new 
initiatives that will enhance prevention and accountability. In 
December the President signed an Executive Order that added a 
new privilege that protects communications between a victim and 
victim advocate, enhancing victim trust in the department's 
response system. Our sexual assault incident database has now 
gained initial operational capability. This tool will 
standardize reporting for oversight and accountability and it 
will help us manage victim care. For victims making an 
unrestricted report, the reporting form will be maintained in 
this database and it will be maintained for 50 years, a 
capability we designed into the system specifically for 
transitioning servicemembers.
    To advance accountability, Secretary Panetta directed the 
initial decision on cases of rape, sexual assault, forcible 
sodomy, and attempts, they will be elevated to a commander who 
is at least a colonel or a Navy captain who holds special court 
martial convening authority. And this mandate became effective 
on June 28th and it ensures an experienced commander will make 
these important decisions.
    In April, Secretary Panetta also directed several other new 
policies. Establishing special victim unit capabilities; 
requiring sexual assault policies be explained to all 
servicemembers within 14 days of their entrance on active duty; 
allowing Reserve and Guard members who have been sexually 
assaulted to remain in their active duty status to obtain 
treatment and support; and the requirement for annual 
organizational climate assessments.
    Finally at the Secretary's discretion in May, we conducted 
a review of existing precommand and senior enlisted training in 
the Marine Corps, the Navy, and the Air Force, and we have 
reviewed the Army's new program as well. We completed our 
report last month. We have made recommendations to the 
Secretary and there are other additional oversight assessments 
ongoing, to include a review of our sexual assault response 
coordinator training and joint base assessments.
    We also want the Committee to be aware of the work we have 
done to collaborate directly with the Department of Veterans 
Affairs. During the last two years our office has visited 20 VA 
facilities to provide education on our program. These sessions 
have been well attended by administrators, providers, and even 
patients. We have also provided educational briefings to the 
VA's military sexual trauma coordinators, training hundreds on 
the specific elements of our program. Just last month we 
augmented our DoD Safe Helpline for transitioning 
servicemembers. This tool recognizes the special needs of 
victims of sexual assault and helps smooth the transition to 
the Department of Veterans Affairs. And while the hearing was 
going on, we did research and look into our Web site and I can 
confirm to you that we have links to the veterans service 
organizations that can help our members transition and we are 
open to adding many more.
    Finally in its June, 2011 Veterans Benefits Manual, the 
Department of Veterans Affairs has added our Department of 
Defense reporting forms to help document a sexual assault.
    Mr. Chairman, Members of the Committee, despite these many 
efforts we have much more to do. Secretary Panetta and our 
uniformed leaders are committed to creating a climate of mutual 
trust, respect, and dignity. We are committed to creating a 
climate in which victims feel confident that they will be 
believed, that their reports will be taken seriously, and that 
there will be no fear of retaliation. We are committed to 
creating a climate in which bystanders act to intervene. We are 
committed to providing the full range of services to all 
victims of sexual assault. We are committed to continue our 
work with the Department of Veterans Affairs to further improve 
victims' transition from active duty to veteran status. And 
most important, we are committed to ensuring that the 
discretion over how to report and decisions regarding treatment 
and support services rest entirely with the victim.
    Through this approach we aim to create a culture that is 
intolerant of sexual assault, one that cares for our victims, 
one that inspires trust and confidence, one that encourages 
reporting, and one that enables our military justice system to 
hold offenders accountable.
    We appreciate the Subcommittee's attention to this 
important issue and we look forward to your questions.

    [The prepared statement of Alan Metzler appears in the 
Appendix]

    Mr. Runyan. Thank you, Colonel Metzler. I next recognize 
Mr. Murphy for his testimony.

                   STATEMENT OF THOMAS MURPHY

    Mr. Murphy. Good afternoon, Chairman Runyan, Ranking Member 
McNerney, and Members of the Subcommittee. I am accompanied 
today by Ms. Edna MacDonald, Director of the Nashville Regional 
Office and former Deputy Director for Policy and Procedures in 
Compensation Service. Thank you for inviting me today to speak 
about the VA disability benefit for PTSD based on MST and 
sexual harassment.
    Over the last several decades women have entered the 
military in increasing numbers and now comprise a significant 
percentage of the veteran population. Associated with this 
growth, VA has seen an increase in the filings of PTSD claim 
based on MST. However, VA recognizes that both men and women 
can be victims.
    Because of the personal and sensitive nature of MST 
stressors, victims find it difficult to report or document 
these events. Due to this fact, it is often difficult to 
establish the occurrence of the stressor. In order to address 
this, VA developed regulations and procedures that allow more 
liberal evidentiary development and adjudication procedures for 
this type of claim. Under VA regulations service-connection for 
PTSD requires three things. First, medical diagnosis of the 
condition; second, a medical opinion connecting current 
symptoms and an in-service stressor; and third, credible 
supporting evidence that the claimed in-service sterssor 
occurred.
    As with all PTSD claims, VA initially reviews the veteran's 
military service record for evidence of MST. Such evidence may 
include a DD form 2910, the victim reporting performance 
statement, and the DD form 2911, sexual assault forensics 
examination report. VA's personal assault regulation also 
provides that evidence from sources other than a veteran's 
service records may corroborate the veteran's account of the 
stressor. This includes, but is not limited to, law enforcement 
authorities, rape crisis centers, pregnancy tests, tests for 
sexually transmitted diseases, and statements from family 
members, roommates, clergies, etcetera. Evidence of behavior 
change called markers is also used. Examples are request for a 
transfer, deterioration or hyper work performance, substance 
abuse, and so on.
    When this type of evidence is obtained VA schedules the 
veteran for a C&P examination and requests an opinion as to 
whether the claimed in-service MST stressor occurred. This 
opinion serves to establish the occurrence of the stressor.
    VA has recently taken numerous other steps to assist 
veterans with timely, equitable, and consistent resolution of 
these claims. In August 2011, VBA reviewed a statistically 
valid sample of approximately 400 MST related PTSD claims. The 
goal was to assess the current process and procedures and 
formulate methods for improvement. This led to development of 
an enhanced training curriculum with emphasis on standardized 
evidentiary development practices. VBA issued Training Letter 
11-05, Adjudicating Post-Traumatic Stress Disorder Claims Based 
on Military Sexual Trauma, in December of 2011. This was 
followed by a nationwide Microsoft Live Meeting broadcast 
focused on describing the range of potential markers that could 
indicate occurrence of an MST stressor.
    We recently created dedicated, specialized MST claims 
processing teams within each VA regional office for exclusive 
handling of MST related PTSD claims. VHA has developed and 
implemented specific training for clinicians conducting PTSD/
C&P examinations for MST related claims in November of 2011. 
VBA and VHA further collaborated to provide a training 
broadcast targeted to VHA clinicians and VBA raters on this 
very important topic which aired initially in April, 2012, and 
has been rebroadcast numerous times.
    The results of these efforts are substantial. The grant 
rate for PTSD based on MST when we started this effort in 
October of 2012 was 41.7 percent. Following the completion of 
the process changes and training outlined just a moment ago, we 
are seeing a steady grant rate of 53.9 percent for the period 
of January through June, 2012. Due to the significant change in 
the outcome for these veterans, we are sending each veteran 
that was denied prior to receiving a VA examination a letter 
notifying them of the opportunity to have their claim 
reexamined. VA will make every effort to ensure that the 
claimants receive the benefits they deserve and secure the 
maximum rating and effective date to which they are entitled.
    In summary, VA recognizes the sensitive nature of MST 
related PTSD and the difficulty of obtaining evidence of an in-
service sterssor. Currently PTSD regulations provide multiple 
means to establish an occurrence and VA initiated initial 
training efforts and specialized handling procedures to ensure 
thorough, accurate, and timely processing of these claims.
    This concludes my testimony. I would be happy to address 
any questions from the Members of the Subcommittee.

    [The prepared statement of Thomas Murphy appears in the 
Appendix]

    Mr. Runyan. Thank you, Mr. Murphy. I have a group of 
questions and I am not sure if I am going to put them out there 
in the right order. But two years ago when VA amended 38 CFR 
3.04(f) making certain claims for noncombat PTSD easier to 
verify, during the notice and comment period, several 
commenters asked that the amended regulation apply to MST. In 
response, VA stated that they did not feel this was necessary 
because the relaxed evidentiary standard already provided to 
the regulation specific for MST was adequate. We have had 
testimony earlier and having been briefed by the VA on this, I 
can imagine your stance. You feel that it is easier. But I 
think the users that are doing it do not have the same feeling, 
or the same experience. Is there any way you can clear this up? 
Because it is, in the statement and the comments, it 
specifically said it was outside the scope of the rule when VA 
made the comment back to the commenter about the issue. Do you 
have any idea how we can clarify this? And maybe we have to 
change the regulation to actually make it work for those who we 
are trying to help?
    Mr. Murphy. Mr. Chairman, I am going to ask Ms. MacDonald 
to address this concern. She has significantly more depth and 
expertise in this area.
    Ms. MacDonald. Thank you, Tom. Chairman, when we looked at 
the regulation based on Fear, there is this misunderstanding 
that we have heard so far in testimony today that, specifically 
a veteran's lay statement is accepted for all other forms of 
PTSD except MST. It is a slight misunderstanding. In other 
forms of PTSD we do require what we call objective 
documentation. Not just the fact that a veteran served in the 
military. But for combat veterans, before we can accept their 
lay statement, we have to have a military documentation that 
they were actually in a combat zone. For Fear, for that 
regulation, it also requires documentation that they were in an 
environment where there was hostile military or terrorist 
activity before you ever get to the lay statement. Why we 
believe that the MST regulation is a lower evidentiary 
threshold is that, because we know so many do not get reported, 
there is no requirement for any military objective 
documentation of occurrence of the stressor. That is why the 
regulation was written, to allow us to look for markers and 
other sources that are what we would call in the regular world, 
circumstantial evidence. That is not concrete proof. And what 
we have heard today is what you were just talking about. Is it 
adequately being applied, that liberal threshold? And that is 
what Mr. Murphy was alluding to in his testimony that we do 
believe we have made significant strides to make sure that we 
dedicated resources and we trained VA employees properly in the 
way we want this and the way we expect it to be applied.
    Mr. Runyan. Is amending the regulation necessary? I think 
Congressman Walz and Ms. Pingree both agree that, the chances 
of a false claim are very minimal in cases like this. Do we 
need to change the regulation to make sure this works for MST 
victims?
    Mr. Murphy. No, sir. I do not believe we need to do that. 
And I think when you look at the performance numbers of the 
grant rate of PTSD today versus the grant rate for all other 
types of PTSD that are not MST related, you see that the 
numbers track very closely. Now, I am not sitting here saying 
by any means that we have got this thing completely nailed down 
and its is perfect. There is no process on earth that is that 
way. So this is a process that we are going to continue to look 
at, and we are going to focus on, and continue to ensure that 
MST tracks at the same rate. In addition, we have heard many 
testimony on different ideas, different processes, different 
thoughts. And we will continue to gather those and look for 
ways to make the process even better and more consistent than 
it is today, so that no veteran is wrongly denied. But I do not 
believe we need to go back and do a regulation change in order 
to put that down and make it solid. I think the performance 
over the last six months is proving that we have consistency in 
process.
    Mr. Runyan. And if you could, I am sure you do not have it 
on hand, but throughout, I know there has been reference to 
when the policy was changed and when VA revisited the 
regulations, which was in 2010. Because we have sat up here all 
day, we have heard that sexual assaults are underreported. And 
actually the execution of adjudicating the MST claim, we are 
not seeing the whole picture all the time. And I think this is 
the big frustration we have with the VA a lot of time. You are 
telling us what sounds good when you are sitting at that table, 
but we are not seeing the whole picture. Because I think most 
people, and the people who have been here and testified today, 
would agree that there is room for more improvement. And I 
think we all agree on that. The issue at hand is what are the 
improvements that we take in this Congress to do that? I think 
we all agree, and I think the Ranking Member agrees, we are not 
going to fix it today. But we have to get the ones that we can 
tackle the most with. And I would appreciate the statistics 
that say it was this way, and when we did the change in `10 we 
got better results. Maybe it is time to address that again 
because I think we all agree and we need different results. And 
I would appreciate it if you could submit that to the 
Committee.
    Mr. Murphy. Yes, sir. We will do that. We will take it back 
before the release in 2010 and we will point out the 
significant changes that happened in that data as the results 
of different actions that were taken from then to now.
    Mr. Runyan. I appreciate that. And with that I recognize 
the Ranking Member Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman. Colonel Metzler, 
thank you for serving our country and wearing that uniform, and 
taking on this difficult issue. One of the things we are 
hearing today over and over is the reluctance of servicemembers 
to come forward because of the cohesion of the unit that they 
are in. And that is important. I mean, you want a military unit 
that can go into a difficult situation and trust each other, 
and that is a characteristic that is hard to nuture. So what 
happens to a unit when this sort of an issue comes up? Does it 
disrupt the unit? I mean, does the leader get disposed? Is 
there training that takes place in the unit? I mean, this is, 
if there is a unit where people are preying on each other, then 
you are not going to have unit cohesion anyway. So it does not 
hurt to go in and actually do some stuff to that unit. What 
happens when this kind of a charge comes forward and is 
verified?
    Colonel Metzler. Good order and discipline, unit cohesion, 
a climate of trust and a climate of respect all come from the 
command and the leadership. And the effectiveness of a unit 
derives from the effectiveness of that commander and those 
senior leaders who set the appropriate climate, who set those 
standards, and communicate those standards, and enforce those 
standards. And when those standards are failed to be followed, 
the unit, cohesion breaks down, the mission is placed in 
jeopardy, and lives are placed in jeopardy, both in a combat 
environment and in a peacetime environment. And what we need to 
do is ensure that we teach every single member of our armed 
forces that if there is violence being committed against them, 
sexual violence being committed against them, that we will take 
those reports seriously, that we will investigate them fully, 
and that we will hold the offenders appropriately accountable.
    Mr. McNerney. So I take it there is an anonymous, a Web 
site a member can go to anonymously and make a report?
    Colonel Metzler. There is a couple of tools available. 
There is the DoD Safe Helpline. It has been in operation since 
February of 2011. It is 24/7, worldwide capable. You can call, 
click, or text into that capability. And there are crisis----
    Mr. McNerney. Is the unit leader advised when there is a 
report from someone within their unit?
    Colonel Metzler. The installation commander is advised of 
all unrestricted and restricted reports and the unit commander 
is notified for unrestricted reports. And then the commander is 
required by policy to report that to a military criminal 
investigative organization for investigation.
    Mr. McNerney. Okay. Are servicemembers routinely screened 
for MST?
    Colonel Metzler. Sir, military sexual trauma and the 
screening and the diagnosis for that is outside the scope of 
our office's oversight. What we do know are the specifics in 
terms diagnosing military sexual trauma (MST). And so what we 
have done is built a structure to ensure that we have the 
records, to make sure that they are available, that our 
counselors know how to retrieve them. We have this 24/7 
worldwide hotline that can access crisis intervention 
counselors who can advise them of all the processes associated 
with MST. And as I mentioned in my opening statement, we have 
been doing a lot of partnership with the VA to train their 
military sexual trauma coordinators, and to train our 
coordinators that work with wounded warriors.
    Mr. McNerney. Well it sounds good. I would like to have 
confidence that it was being effective. Mr. Murphy, what do you 
feel about HR 930? Do you think that is going to make things 
better? Do you think that is going to make it so that people 
that are suffering and going through the experiences that Ms. 
Moore experienced, is it going to make it easier for them? Or 
do you think it is going to make it harder? Or do you think it 
is going to make a difference at all within the VA?
    Mr. Murphy. Mr. McNerney, that is a bill that we have not 
completed formal views on from the VA perspective, so I am not 
prepared to comment on that today.
    Mr. McNerney. So now, and my limited understanding is that 
H.R. 930 will result in reduced evidentiary standards. Is that 
what your understanding is of H.R. 930?
    Mr. Murphy. Yes. That is my understanding of the bill.
    Mr. McNerney. Is there a need to reduce evidentiary 
standards?
    Mr. Murphy. As I told Mr. Runyan a few moments ago, I think 
that we adequately cover it with the existing regulations that 
we have today. But that is not a comment on the nature of the 
bill. And the reason I say it is not a comment on the nature of 
the bill that we hit the main topic in it. As with most bills, 
they come through, there are many fine points and details in 
there that need to be considered by a general counsel in VA 
before we can pull an official position on it.
    Mr. McNerney. If that bill were to be signed into law, how 
difficult would it be to enforce its requirements?
    Mr. Murphy. Assuming the bill was signed into law, then it 
would just take us the time that it would take to put, to 
modify existing regulations to be in compliance with the 
requirements of the law, to put some training in place for the 
existing dedicated teams that we have inside of VA and in VHA, 
and start adjudicating claims under the new law.
    Mr. McNerney. All right. I yield back.
    Mr. Runyan. The chair now recognizes Ms. Pingree.
    Ms. Pingree of Maine. Thank you, Mr. Chair. Thank you to 
the panel for testifying. I do appreciate the tremendous change 
in attitude and awareness that has gone on, both at the DoD and 
VA. I, you know, say in view of the testimony, and what many of 
us here in our offices, we still have a long way to go in 
changing the culture of the military and in dealing with 
victims of MST. But I do appreciate both of your testimony 
today and the work that is being done to move us in the right 
direction.
    I want to just talk for a minute about the exam threshold. 
So the exam threshold in the MST claims process, we have been 
told by the VBA, and this is for Mr. Murphy, that a veteran's 
statement alone is not sufficient to trigger a compensation and 
pension exam. However, in the background information you 
provided my office, and presumably sent out to regional 
offices, it clearly states that the veteran's lay statement is 
sufficient to prove the assault occurred. So my question is, 
how does this work? Is the veteran's testimony enough to prove 
the assault happened? And how can it not be enough to get an 
exam?
    Mr. Murphy. Again, I am going to ask Ms. MacDonald to 
answer that.
    Ms. Pingree of Maine. Fine. Fine.
    Mr. Murphy. Again, she is the expert on this area.
    Ms. MacDonald. Thank you, Congresswoman Pingree. It, by 
itself, in the absence of any other supporting marker would not 
be enough to request an exam.
    Ms. Pingree of Maine. Okay. So thank you for clarifying 
that. And I think that reinforces why we hear in our helpful 
conversations with the VBA, or the VA, that you know, we are 
moving forward on setting a different standard. But on almost a 
weekly basis, I hear from a veteran who was sexually assaulted 
while serving in the military. And when they go to the VA with 
that claim, they are denied because they could not produce a 
court filing, or a report, or some other kind of proof that the 
attack occurred. So even though we are often told that the 
proof is not required, that is not what seems to be happening 
in your offices. And I do appreciate the increased training, 
the difficult in changing even the culture of the system. But I 
guess I have two views and I want to ask your comments on it. I 
mean, A, I think we have further to go before the 
implementation of what we are hoping will happen, happens. And 
while I am not here to promote a piece of legislation, but that 
is why I submitted the bill that, in a sense, does have reduced 
evidentiary standards. It would provide a service-connection 
for MST survivors if they provide a diagnosis of PTSD and a 
medical link stating that the PTSD is caused by the assault. I 
believe that is similar to what happens with combat related 
PTSD claims. And I am of the belief that until we get there, 
possibly with legislation, possibly with a change in 
regulation, we are not going to be there. So if you want to 
talk a little more about that, I just think we see it 
differently. And I guess my concerns are the testimony we have 
heard today, the difficulty that people are having getting the 
assistance that they need.
    Mr. Murphy. I do have a couple of comments. First of all, 
as you stated, we are a long way from having this down pat and 
making sure every veteran is taken care of and getting what 
they are due. Second, that we have made the improvements in the 
process today that you are seeing because of the consistency of 
training, the focusing of only a select few individuals that 
received a much higher level of training than what the general 
population gets. And specifically focused and targeted around 
identifying the very subtle markers. This is something that is 
not public knowledge. It is not generally reported. But some 
minor, barely noticeable behavior on the part of the veteran is 
all it takes to say, ``Yes, there is something here, plus the 
veteran's statement, let us move forward with this claim.'' In 
fact, I just learned one earlier listening to a previous 
statement talking about the absence of evidence in a file is 
also a marker. And I am not saying that, that we are not doing 
that. I am saying that that was beyond my level of expertise in 
this area, which is why Ms. MacDonald is sitting next to me 
today. So again, we have a long way to go. We have made 
significant progress. But we are not done yet.
    Ms. Pingree of Maine. Well again, thank you for the work 
that you are doing. I think we are all here today because we 
hear with deep concern the number of people who serve this 
country and then find themselves victim of military sexual 
trauma. And we started out with some very stark figures in the 
beginning here about the difficulty of people being able to get 
assistance, the difficulty of crimes being prosecuted, the 
difficulty even for a veteran to come forward. And I think we 
have to remember over and over that these are very special 
circumstances. That people who served their country want to 
continue to serve. We have enormous work to do to change the 
culture. But I think on the other side we have a lot of work to 
do to make sure we help those people who need our help. Thank 
you very much.
    Mr. Runyan. I thank the gentle lady. The chair now 
recognizes Ms. Speier.
    Ms. Speier. Mr. Chairman, thank you for allowing me to sit 
in on this hearing and to participate in it. I want to thank 
all the panelists for participating in the hearing today, and 
for your service. I was, the first bit of good news I heard 
this morning was from General Hickey at a Committee down at 
Oversight and Government Reform Committee where we were looking 
at the delays in VA, the handling of VA cases. And she actually 
on her own volition went back and looked at the MST cases 
versus the other PTSD cases and saw that there was a 
discrimination in the cases as it related to MST/PTSD and that, 
and you reflected that, I think Mr. Murphy, in your comments. 
And that now you are sending letters out to those that were 
declined or denied their claims and asking them to reapply.
    Which really makes the case over and over again about what 
the military has done consistently, which is sweep this issue 
under the rug. We have done a horrible job. It has gone on now 
for a quarter of a century. We keep messing around the edges. 
We create SAPR, we do hearings, we create reports, and then 
nothing changes. And now we have an absolute scandal at 
Lackland Air Force Base, where we have 12 trainers implicated, 
and 31 victims. Only one victim, however, has come forward on 
her own to file a complaint. Which makes the case over and over 
again, people, both men and women, are not filing complaints 
because they know what happens. They find a way to slap them 
with a disability of personality disorder and then discharge 
them involuntarily from the military.
    So to Congresswoman Pingree's point, if we know that 19,000 
occur a year, only 3,000 actually report, of those 3,000 only 
200 actually get convictions. There is no motivation for anyone 
who wants to make a career in the military to report.
    So if we know it is 19,000 a year, I think the figures are 
thrown out as something like 500,000 victims of MST in this 
country right now. And to think that we are still going to 
require, knowing that we have done such a lousy job in dealing 
with these cases and somehow finding the victim at fault, why 
would we not take the position that we have taken with Agent 
Orange? Which is basically if you come down with one of these 
cancers, or one of these conditions, the presumption is that 
you got it in the military, you got it when you were serving in 
Vietnam, and there is a presumption made. Why do we not just 
create a presumption? If someone comes forward and says they 
are a victim of military sexual assault or trauma, that we 
believe them because we have done such a lousy job in terms of 
handling these cases? Colonel, can you respond to that?
    Colonel Metzler. I have some comments on some of the issues 
that you raised. I think one of the most important that I would 
like to address is that the department does take this 
seriously.
    Ms. Speier. Well you know----
    Colonel Metzler. We are absolutely committed to solving 
this problem.
    Ms. Speier. I am so tired of hearing persons in your 
position and higher say there is zero tolerance for MST and yet 
there is another scandal underway right now, and a court 
martial taking place at Lackland Air Force Base. We are not 
doing a good enough job. Until we take it out of the chain of 
command, these problems will continue to exist because we are 
not dealing with the conflict of interest that is inherent in 
that situation. And why would we have unit commanders who have 
no legal training, have not gone to law school, have no 
judicial experience, making decisions as to someone's relevance 
in terms of having an investigation or prosecution move 
forward?
    Colonel Metzler. Ma'am, it is the position of the 
department that commanders will lead this change. Commanders 
set the tone in their units. Commanders set standards of 
discipline. Commanders set the climate of their units. What 
commanders pay attention to is what gets done and what gets 
fixed. That is why we are assessing commanders----
    Ms. Speier. Excuse me, Colonel, but I am about to run out 
of time, so let me just ask a number of questions and see if 
you can answer them. How many permanent or temporary transfers 
have been granted since this new ruling went into effect? How 
many have been declined? How many special victims units have 
been created? And have you considered at all the relevance of 
having an MST/PTSD therapy program that is different from the 
PTSD program that exists for the general military veterans 
population? And maybe that is a question to you, Mr. Murphy.
    Colonel Metzler. Under the transfer authority that the 
Secretary ordered, there are transfers that are happening. I do 
not have the specific data. We have met with all of the 
services in the last week, talked to them about it. Ma'am, we 
are happy to get that information and we will provide it to 
you.
    Ms. Speier. And actually to the Committee as well. I think 
that would be----
    Colonel Metzler. Absolutely. And that will also be part of 
our annual report, and it will be part of our official record. 
So we will make that available to the Committee. With regard to 
special victims units, that is a process that is underway. The 
Secretary has asked us to create that in April. We have had 
meetings with folks to work on the concept. The Army is already 
working----
    Ms. Speier. So there is not one?
    Colonel Metzler. The special victims unit capability is 
being created. It was guidance from the Secretary to create 
that capability. The Army has a very good program that we are 
modeling that we have met with. I think it is Mr. Strand who 
has worked on that.
    Ms. Speier. Russell Strand?
    Colonel Metzler. You are familiar with his work. And we are 
working with the U.S. Army Military Police School because of 
the special training that they are already providing to some 
attorneys and to investigators. And it is a concept and a 
capability that we intend to----
    Ms. Speier. So the Army has it, but they had it even before 
the guidance by the Secretary. So when do you anticipate the 
other services will have these SVUs?
    Colonel Metzler. Ma'am, I do not have a specific date. But 
we will make sure we get that to you.
    Ms. Speier. And then to you, Mr. Murphy. The question of 
having a separate kind of therapy program for MST PTSD 
survivors?
    Mr. Murphy. The separate kind of therapy program falls 
under the Veterans Health Administration. I do not have any of 
the VHA folks with me here today. However, I can talk a little 
bit about that they have dedicated counseling and professionals 
that we work closely with DoD to ensure that we are getting the 
handoff of what little evidence does exist. So I cannot answer 
that for you in detail today.
    Ms. Speier. Mr. Chairman, can I ask one more question?
    Mr. Runyan. You may.
    Ms. Speier. I think the issue that was raised earlier is a 
relevant one, and you raised it, Mr. Chairman. And I was 
wondering if it would be helpful to the Committee, and to 
Members who are concerned about this issue, if the VA would on 
a quarterly basis provide information to you as Chair of the 
Committee about how many of these cases are being handled. How 
many are actually being, claims that are being filed, and how 
many are actually being granted, and what the percentage of the 
disability is being granted as a result. To just track to see 
if the change is permanent and to what extent it is 
comprehensive.
    Mr. Runyan. That is very possibly something we can put in 
Ms. Pingree's piece of legislation.
    Ms. Speier. Thank you.
    Mr. Runyan. All right. Well with that----
    Colonel Metzler. Mr. Chairman, with your permission there 
was one other issue that was raised that I did not get a chance 
to respond to. And it is an important fact that we would like 
to point out. Since 2006 to 2010, we do have very good data 
that tells us that the incidents of sexual assault, of all 
ranges of sexual assault are down. And that the reporting 
trends are up, the reporting trends have doubled. Now it has 
been said many times that the trend right now is about 14 
percent of victims report. We are not satisfied with that. The 
data is moving in the right direction. But we are focused on 
solving this problem. And Congresswoman, we will work this 
problem, I can assure you.
    Mr. Runyan. Well I thank you all for your testimony. And 
ladies, gentle ladies, thank you for coming and being guests 
here today.
    I am not going to make a big closing statement. But I would 
say this, specifically dealing with this Committee, and I have 
said it directly to Secretary Shinseki sitting right there at 
that exact same table. One of the biggest metrics we miss in 
the VA is customer service. We measure everything else, but was 
the job we are there to do, which is service the veteran, done 
right? And were they satisfied with the result? Because if the 
VA were a private entity, a company, you would not be in 
business very long because you would not have very many happy 
customers. That is the metric we miss every single day. It is 
three or four or five down the list sometimes. And that is 
really something that I continue to press and, I hope every 
other Member of this Committee, and every other Member of this 
Congress, would agree with that. Because that is truly, what 
these men and women do for us by putting their lives on the 
line to sacrifice for our freedoms, the least we can do is give 
them what, give them by the laws we have created what they are 
due. Just to that. And most of us would agree we owe them more 
than that. It is how do we get there?
    But with that, on behalf of this Committee I thank all of 
our distinguished witnesses for their testimony today. I 
appreciate your service to our Nation's veterans. And you are 
all now excused. And I ask unanimous consent that all Members 
have five legislative days to revise and extend their remarks 
and include extraneous material. Hearing no objections, so 
ordered. I thank the Members for their attendance today and 
urge that all of you be vigilant participants in the 
Committee's efforts to ensure that victims of military sexual 
trauma have access to the benefits they need to live happy and 
health lives. And this hearing is now adjourned.

    [Whereupon, at 4:38 p.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

            Prepared Statement of Hon. Jon Runyan, Chairman
                                Remarks:
    Good afternoon. Welcome to our hearing, ``Invisible Wounds: 
Examining the Disability Benefits Compensation Process for Victims of 
Military Sexual Trauma.''
    First, I ask unanimous consent to welcome a number of our honorable 
colleagues who have asked to be allowed to participate as guest Members 
of the Subcommittee today. Hearing no objection, so ordered.
    As a Nation, we call on our armed servicemembers to sacrifice 
bravely on our behalf. They courageously put their lives at risk and 
face deadly enemies on the battlefield.
    When we think of these enemies, we think of those who oppose our 
freedom or are American way of life. We certainly do not think of 
soldiers needing to defend themselves from their fellow servicemembers. 
However, many of our servicemembers are required to do just that.
    Women are the fastest growing population among veterans, making up 
8% of the armed forces. However, the Department of Defense estimates 
that one in four women who join the armed services will be raped or 
assaulted, but that only about 10% of such incidents are ever reported.
    Even more alarming is that of those few who did report incidents of 
military sexual trauma, over 75% stated that they would not make the 
same decision about reporting the incident again, due to the 
consequences it had on their military career.
    Despite the fact that many of these incidents go unreported, VA 
currently estimates that over half a million veterans have experienced 
military sexual trauma. This includes 17% of veterans from the recent 
conflicts in Iraq and Afghanistan.
    Although this is not the Committee's jurisdiction, there must be 
zero-tolerance for this behavior in the military, and VA must recognize 
immediately the trauma inflicted on these men and women.
    Accordingly, the focus of today's hearing is how to assist these 
veterans with obtaining VA benefits for post-traumatic stress disorder, 
or PTSD. This is often a difficult task given the sensitive nature of 
these claims and the lack of evidence of documenting such incidents at 
the time that they occurred.
    Although VA has made great progress in adjudicating military sexual 
trauma claims by providing relaxed evidentiary standards and re-
training employees on this issue, SWAN, one of the organizations 
testifying today, estimates that less than one-third of military sexual 
trauma PTSD claims are approved by VA, even though 53% of PTSD claims 
are granted overall.
    Although military sexual trauma is not a new issue, it is a serious 
matter on which more light has been shed in recent years.
    As more and more of our brave servicemembers find the inner 
strength to overcome military cultural challenges, and come forward to 
seek justice, help and healing, the more the Members of this Committee, 
DoD, and VA can understand the best means of assisting victims of 
military sexual trauma with obtaining the VA benefits that they need.
    One such veteran will be testifying before us today, and I would 
like to personally thank Ms. Ruth Moore for coming to Washington and 
sharing her story with us today.
    Victims of military sexual trauma like Ms. Moore carry scars in 
their hearts for the rest of their lives as a result of what they have 
endured. Such veterans are indeed deserving of VA benefits to help them 
enjoy the American way of life that their service has helped to secure.
    As the Department of Defense continues to address issues arising 
from the cultural resistance to reporting such abuse, the VA must 
continue to work on ensuring that the proper benefits, so needed by 
these victims, are easily obtainable.
    So, I will reiterate - the focus of our hearing today is precisely 
that--what benefits does VA provide for victims of military sexual 
trauma, how are these claims adjudicated, and how can this process be 
improved?
    We welcome several witnesses to testify before us today, ranging 
from representatives of veterans service organizations, to experts on 
the effects and treatments of military sexual trauma, to officials from 
VA and the Department of Defense.
    I appreciate all of you taking the time to speak with us today 
about this issue of such importance to so many members of our American 
community.
    Because we have many distinguished guests today, I would like to 
reiterate my request that our witnesses abide by the decorum and rules 
of this hearing by summarizing your statements to five minutes or less 
during oral testimony. Doing so will ensure that the Committee has the 
opportunity to hear from everyone.
    I also remind all present that without any objection, your written 
testimony will be made part of the hearing record.
    I now call on the distinguished Ranking Member for his opening 
statement.

                                 
              Prepared Statement of Hon. Jerry McNerney, 
                       Ranking Democratic Member
    Good afternoon. I would like to thank everyone for attending 
today's hearing focused on examining the VA disability compensation 
process as it pertains to military sexual trauma or MST.
    I am happy to join DAMA Subcommittee Chairman Runyan and my 
colleagues in holding this hearing.
    I am also pleased that two of the leading voices in Congress on 
this issue, Representative Chellie Pingree of Maine, and Representative 
Jackie Speier of California are accompanying the Subcommittee Members 
on the dais today. I also welcome and thank Ms. Pingree's constituent, 
Ruth Moore, accompanied by her husband, for testifying about her MST 
experience with VA.
    Servicemembers who experience military sexual trauma and are brave 
enough to speak out about their experiences often do so at great risk 
to their careers and reputation.
    The purpose of this hearing today is to evaluate ways in which the 
Veterans Benefits Administration (VBA) and the Department of Defense 
(DoD) can better address the needs of veterans affected by MST and 
identify ways to prevent these horrible assaults, treat and properly 
compensate the victims.
    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.
    Many MST victims state that when they do report an incident, their 
story is dismissed or they are encouraged to keep silent because of the 
need to preserve organizational cohesion.
    This is unfair to the victims. We must put protections in place to 
ensure a safe haven exists for the women and men who experience 
military sexual trauma.
    Unfortunately, the consequences of MST are a pervasive problem 
within the Veteran community. According to the Institute of Medicine, 
prevalence rates of MST range from 20-43%. Many veterans who are 
victims of MST express frustration with the VA's disability claims 
process, especially in trying to prove to that the assault ever 
happened.
    For many women and men, when their disability claims for post-
traumatic stress related to MST are denied.
    However, I am pleased that in July 2010, in response to action 
taken by this Committee, the VA relaxed its stressor evidentiary 
standards for post-traumatic stress, which also includes MST.
    While this represented a step in the right direction, there are 
still hurdles that women and men face in receiving the benefits they 
deserve.
    As SWAN points out in its testimony, there are still disparities in 
compensation and confusion within VBA on when service-connection 
compensation for MST is warranted.
    Training at VA has improved slightly, but VBA claims decisions are 
still inconsistent and more must be done.
    As we build a VA for the 21st century, VA and DoD need to ensure 
that the proper prevention, counseling, treatment and benefits are 
available for MST victims.
    Veterans should be able to have access to VA personnel who are 
qualified to advise on the often-sensitive 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.
    Thank you, I now yield back.

                                 
              Prepared Statement of Hon. Michael R. Turner
    Thank you, Chairman Runyan, for holding this important hearing. I 
would also like to recognize your advocacy on this issue within the 
House Armed Services Committee. Special thanks, as well, to all the 
panelists for their advocacy of victim's rights and determination to 
address the military culture and climate. I have worked with Anu and 
SWAN for several years now and their contribution to this issue has 
been instrumental in achieving many legal and policy changes.
    Before I start my remarks, I would like to point out that the great 
majority of the Servicemembers are patriotic citizens that serve their 
country honorably and selflessly. And while today's hearing may focus 
on the criminal behavior of a relative few, their behavior should not 
be used to broadly tarnish the reputation of the many Servicemembers 
who have honorably sacrificed for their country.
    I became involved in this issue in 2008 following the tragic murder 
of Lance Corporal Maria Lauterbach. Maria reported being sexually 
assaulted and was later murdered by a fellow Marine while she was 
stationed at Camp LeJeune, North Carolina. During the course of the 
investigation a Marine Corps representative told me that ``we lost two 
good Marines today.'' When, in fact, we had only lost one good Marine, 
Maria Lauterbach, and another Marine who was a rapist and murder that 
tarnished the reputation of the Corps. Later, during the course of 
Congressional hearings on the subject, a Lieutenant General stated that 
Maria ``never alleged any violence or threat of violence in either 
sexual encounter.''
    These and several other incidents demonstrated a fundamental lack 
of understanding of the problem and how to deal with it. In addressing 
the issue of military sexual assault it is necessary to address some 
fundamental areas, namely: Command, Culture and Accountability. I think 
the hearing today strikes at the heart of the cultural element. Culture 
within the Department of Defense and the Department of Veterans 
Affairs.
    In working on sexual assault issues on the House Armed Services 
Committee and the Military Sexual Assault Prevention Caucus, which I 
co-chair with Niki Tsongas, we have sculpted legislation that aims to 
facilitate a culture that encourages victims to come forward and 
punishes the criminal actors that degrade our military. The personal 
nature of sexual assault makes it difficult for victims to come forward 
and discuss the details of their experience. This is compounded by 
policies that require victims to repeatedly relive the experience and 
re-victimize the victims. These additional stresses decrease the 
likelihood of victims coming forward and permit the retention of 
criminals. As Anu pointed out in her testimony, the DoD Sexual Assault 
Prevention and Response Office (SAPRO) report indicated that 86.5% of 
sexual assaults go unreported. The end result is that some of these 
criminal later draw DoD and VA benefits, while their victims are left 
to fight to substantiate their PTSD claims.
    Addressing the issue before the Committee today is a step towards 
creating a more victim-centric system that improves our military by 
rewarding victims for coming forward and punishing the bad actors. In 
addressing this issue, Niki Tsongas and I included a provision in the 
Defense STRONG Act last year requiring the DoD to retain records 
prepared in connection with sexual assaults involving members of the 
Armed Forces or dependents of members. That provision was later 
included in the FY12 NDAA. This provision requires the Department of 
Defense to permanently retain records of sexual assault in the 
military, and ensures that a servicemember who is a victim of sexual 
assault has access to these records. Servicemembers find it difficult 
to obtain documentation proving their sexual assault once they have 
left the services because DoD destroys many of these documents after 
only a few years. It is our hope that improving this process will 
contribute to removing the negative stigma that surrounds the process 
and, thereby, improves military culture and climate.
Question:
    Col. Metzler and Mr. Murphy. What is the status of implementation 
of this new policy (HR1540 Sec 586)?

                                 
          Prepared Statement of Congresswoman Chellie Pingree
    Thank you Chairman Runyan and Ranking Member McNerney for allowing 
me to participate in today's hearing. I also want to thank you for 
holding this hearing--the topics covered today are extremely important, 
as the welfare of our veterans' mental health and the disability and 
mental health system that cares for them should be one of Congress's 
highest priorities.
    Military sexual trauma continues to be a pervasive problem in our 
Armed Forces. DoD data shows that roughly 19,000 reported assaults 
occur each year, and that approximately 85% of these assaults go 
unreported. It happens to both men and women at increasingly high 
rates.
    These attacks on our service men and women are occurring in the 
active duty ranks and even at the military academies--it is a disgrace 
that needs to stop now. I commend Defense Secretary Panetta for the 
changes he is making to DoD policy to prevent MST and prosecute these 
attackers, but more needs to be done.
    Data shows that survivors of MST are very likely to suffer from 
Post Traumatic Stress Disorder and other mental health conditions, 
leading many of these veterans to file claims with the VBA. I commend 
the Veterans Health Administration, which has an ``open door'' policy, 
where MST survivors can get free treatment and counseling based on self 
reported MST.
    While the VHA's MST policy does what it can for MST victims, there 
is another side of the VA that in far too many cases fails MST 
survivors by producing roadblocks and bureaucratic red tape. Countless 
MST survivors are so affected by the personal assault they experienced 
that they file PTSD claims with VBA, only to be denied service 
connection because they cannot prove the assault occurred.
    Since most attacks go unreported, leaving no military documentation 
for victims to produce during the claims process with VBA. VBA's 
current policy states that they will be very liberal in deciding MST 
cases, and should accept ``secondary markers'' as proof the assault 
occurred--things like counseling reports for PTSD from MST, letters 
from family members citing behavioral changes, drug and alcohol abuse, 
etc . . .
    On the surface it appears VBA's policy gives veterans the benefit 
of the doubt and that VA understands current DOD shortcomings around 
MST, and common sense prevails when adjudicating these sensitive cases. 
I would like to commend VBA under Secretary Allison Hickey for her 
commitment to MST survivors and the increased emphasis she has put on 
these types of claims while serving as VBA undersecretary.
    Unfortunately, however, I am of the opinion that the VA is just too 
big an agency for anything short of a regulation change to fix this 
problem. No amount of training can ensure raters take the larger 
picture into account when reviewing these cases. VBA remains vastly 
inconsistent when deciding MST cases, and what one Regional Office 
accepts as a secondary marker, another might deny and still not be 
violating VBA policy. For instance, I have seen veterans denied service 
connection for lack of sufficient proof, even after they provided 
medical reports from in patient counseling for MST-related mental 
health conditions--at VA Medical Centers.
    We have to be sure that VBA gives MST survivors the benefit of the 
doubt, especially when so many of these survivors have lost faith in 
the system they swore to uphold. That is why I introduced a bill that 
would provide service connection for MST survivors if they provide a 
diagnosis of PTSD and a medical nexus stating the PTSD is caused by the 
assault.
    This language in this bill is very similar to the July 2010 change 
VBA implemented for veterans suffering from PTSD related to fear of 
hostile enemy action or terrorist activity. These veterans need only 
show a diagnosis of PTSD, a medical link and the claimed stressor must 
be consistent with the types of events consistent with military 
service. Unfortunately, the data continues to show that sexual assault 
in the military is so pervasive that it is consistent with the types of 
events consistent with military service. I want to thank Chairman 
Runyan for his support of the bill, as I know it would go along way to 
addressing the issues we continue to hear about from veterans and their 
families.
    Let's be clear. The bad guys in these stories are the perpetrators. 
They are the villains and the ones who should be held accountable. But 
by creating a policy that denies justice to the victims and forces them 
to spend years or even decades fighting for the benefits they deserve, 
we are deepening the wounds for these veterans and making it all that 
much harder for them to get on with their lives.

                                 
                   Prepared Statement of Anu Bhagwati
    Dear Mr. Chairman and Members of the Committee:
    Thank you for holding this hearing on a critical issue facing our 
veterans' community, and thank you for the opportunity to present the 
views of the Service Women's Action Network (SWAN) on the challenges 
confronting veterans who file claims for PTSD suffered as a result of 
sexual assault and sexual harassment in the military.
    SWAN has been advocating for changes to the VA claims process for 
several years. We actively supported the VA's change to the claims 
process for combat related PTSD-claims and have provided testimony many 
times to both House and Senate committees on issues and challenges 
facing women veterans at both the VHA and VBA, and the unique 
challenges faced by veterans filing Military Sexual Trauma (MST) 
claims.
    According to VA, PTSD is the most common mental health condition 
associated with MST. For women veterans, MST is a greater predictor of 
PTSD than combat. \1\ Studies also indicate that sexual harassment 
causes the same rates of PTSD in women as combat does in men. \2\ And 
40 to 53% of homeless women veterans have been sexually assaulted in 
the military. \3\ Simply put, MST has devastated the veterans' 
community.
---------------------------------------------------------------------------
    \1\ Maureen Murdoch, et al., ``Gender Differences in Service 
Connection for PTSD,'' Medical Care 41, no. 8 (2003), 950-961.
    \2\ Maureen Murdoch, et al., ``The Association between In-Service 
Sexual Harassment and Posttraumatic Stress Disorder among Compensation-
Seeking Veterans,'' Military Medicine 171, no. 2 (2006), 166-173.
    \3\ Erik Eckholm, ``Surge Seen in Number of Homeless Veterans,'' 
The New York Times, November 8, 2007; b. Donna L. Washington, et al., 
``Risk Factors for Homelessness among Women Veterans,'' Journal of 
Health Care for the Poor and Underserved 21 (2010): 81-91.
---------------------------------------------------------------------------
    The MST claims process is broken at best. VA's PTSD policy 
discriminates against veterans who were sexually assaulted or harassed 
while in uniform by holding them to a standard which is not only higher 
than that of other groups of veterans suffering from PTSD, but also 
completely unrealistic for the majority of survivors to meet. As we 
discovered by analyzing VA claims data (see below), the process fails 
the majority of survivors. The process also serves to betray and re-
traumatize these veterans, often directly contributing to worsening 
symptoms and increasing rates of suicide.
    First, it should be noted that the MST PTSD claims process 
adversely affects all veterans, not just women. Many men suffer from 
the effects of sexual violence experienced while serving in the 
military. According to the Department of Defense, 12% of all 
unrestricted sexual assault reports are made by men. \4\ Additionally, 
according to VA, 45.7% of the veterans who screened positive for MST in 
2010 were men, and 39% of veterans receiving treatment for MST were 
men. \5\
---------------------------------------------------------------------------
    \4\ Department of Defense, SAPRO. 2012. ``Fiscal Year 2011 Annual 
Report on Sexual Assault in the Military''.
    \5\ Department of Veterans Affairs, Office of Mental Health 
Services. 2011. ``Summary of Military Sexual Trauma-related Outpatient 
Care Report, FY 2010.'' Washington, D.C.: Department of Veterans 
Affairs, Office of Mental Health Services.
---------------------------------------------------------------------------
    Veterans who suffer from the debilitating effects of Military 
Sexual Trauma face unique challenges in obtaining disability 
compensation from the VA. In 2011, SWAN and the American Civil 
Liberties Union (ACLU) filed a Freedom of Information Request with the 
VA for data on MST claims. The data obtained through litigation showed 
that during FY 2008, 2009 and 2010, only 32.3% of MST-based PTSD claims 
were approved by VBA compared to an approval rate of 54.2% of all other 
PTSD claims during that time. \6\ As a point of comparison, data 
obtained by Veterans for Common Sense indicates that 53% of Iraq and 
Afghanistan deployment related PTSD claims through October 2011 were 
approved. \7\
---------------------------------------------------------------------------
    \6\ In conjunction with the ACLU, SWAN filed a Freedom of 
Information Act (FOIA) request to obtain data concerning approval/
rejection rates of MST-based PTSD disability claims. Based on data 
analyzed for fiscal years 2008-2010, 32.3% of MST- based PTSD claims 
were approved vs. 54.2% of all other PTSD claims over the same period. 
!
    \7\ Veterans for Common Sense. 2012. ``Iraq and Afghanistan Impact 
Report''. Washington D.C.: Available at http://
veteransforcommonsense.org/wp-content/uploads/2012/01/VCS--IAIR--JAN--
2012.pdf.
---------------------------------------------------------------------------
    Looking more deeply at the MST data, SWAN discovered that among 
veterans who had their MST-PTSD claims approved by VA, women were more 
likely to receive a 10% to 30% disability rating, whereas men were more 
likely to receive a 70% to 100% disability rating. \8\
---------------------------------------------------------------------------
    \8\ In conjunction with the ACLU, SWAN filed a Freedom of 
Information Act (FOIA) request to obtain data concerning gender 
differences in compensation awarded for MST-related PTSD claims. The 
data showed men are more likely than women to receive 70% to 100% 
ratings for MST-related PTSD claims, and women were more likely to 
receive 10% to 30% ratings (p/ecfr.gpoaccess.gov/cgi/t/text/text- 
idx?c=ecfr&tpl=/ecfrbrowse/Title38/38tab--02.tpl
---------------------------------------------------------------------------
    If 2 out of 3 MST claimants still cannot meet this PTSD evidentiary 
burden, the policy can hardly be called generous. VA policy fails 
veterans for a variety of reasons. First, sexual assault and sexual 
harassment in the military are notoriously under-reported. According to 
the Pentagon's Sexual Assault Prevention and Response Office (SAPRO), 
86.5% of sexual assaults go unreported, \10\ meaning that official 
documentation of an assault rarely exists. Secondly, prior to the new 
evidence retention laws passed in the 2011 National Defense 
Authorization Act, the services routinely destroyed all evidence and 
investigation records in sexual assault cases after 2 to 5 years, 
leaving gaping holes in MST claims filed prior to 2012. Lastly, the 
evidentiary standard described in the regulation does not take into 
consideration the reality that many victims do not report the 
incident(s) to anyone, including family members, for a variety of 
legitimate reasons, including shame, stigma, embarrassment, or 
disorientation associated with sexual trauma. Although sexual assault 
increases the chance of adverse emotional responses and behaviors, \11\ 
it does not mean that all MST claimants will experience these symptoms. 
In fact, SWAN has spoken to many assault survivors who demonstrate 
changes in behavior that are not included in the regulation, such as 
improved job performance as a means of coping with the trauma.
---------------------------------------------------------------------------
    \10\ Department of Defense. SAPRO, 2012.
    \11\ Dean G. Kilpatrick, Ph.D. 2000. ``The Mental Health Impact of 
Rape''. National Violence Against Women Prevention Research Center, 
Medical University of South Carolina. Available at: http://
www.musc.edu/vawprevention/research/mentalimpact.shtml.
---------------------------------------------------------------------------
    In the MST community, the failures of the VA claims process are 
notorious. SWAN has spoken with veterans who suffer PTSD related to 
both MST and combat--what veterans cynically call the ``double 
whammy''. These veterans chose to abandon their MST claims and submit a 
claim only for combat related PTSD, as they felt their combat claim was 
more likely to be approved, and that the uphill battle to file an MST 
claim wasn't worth the agony.
    SWAN has presented our data to VA Secretary General Eric Shinseki 
and to General Allison Hickey, the Under Secretary for Benefits at VBA, 
to demand change to VA policy on MST claims. After a series of 
conversations SWAN had with VBA about its discriminatory practices, the 
Under Secretary issued a memo in June 2011 providing further guidance 
to claims officers and instituting training requirements for processing 
MST claims. However, examination of both the letter and the training 
revealed it simply reinforced the existing regulation which our data 
shows is not working. Rather than resolve the problem by easing the 
double standard placed on MST claimants, the VBA has done nothing but 
reinforce failure.
    To fix MST claims policy, VBA must immediately revise the 
regulation (38 CFR 3.304, Chapter 1, Part 3, Subpart A) to provide 
language that establishes the same evidentiary requirements for MST-
based PTSD claims that it does for other claims. Specifically, if the 
evidence establishes a diagnosis of PTSD during service and the 
veterans' mental health provider connects that claimed stressor to the 
patient's service, then in the absence of clear and convincing evidence 
to the contrary, and provided that the claimed stressor is consistent 
with the circumstances, conditions, or hardships of the veteran's 
service, the veteran's lay testimony alone should sufficiently 
establish the occurrence of the claimed in-service stressor.
    Furthermore, there should be absolutely no requirement that 
veterans filing MST claims go through an independent Compensation and 
Pension exam to verify that they have PTSD. We know from talking to 
countless veterans that these exams often unfairly reverse the 
diagnosis that was made by qualified VA MST counselors or other mental 
health providers. C & P exams are terrifying for veterans who have been 
assaulted or harassed as it forces them to talk about traumatic and 
devastating experiences with complete strangers. These experiences 
often taken years or even decades for veterans to come to grips with, 
or to talk comfortably about, and veterans should not be forced to 
repeat them to complete strangers who often lack the sensitivity or 
professional qualifications to speak to survivors of sexual trauma. The 
trust that is built between a MST counselor or mental health provider 
and his/her patient is one that cannot be replaced by strangers. VBA 
must trust the expertise of VHA or other sexual trauma experts who have 
worked intimately with their patients.
    Additionally, to sensitize claim reviewers to the needs of assault 
and harassment victims, the VA should implement the recommendations of 
the Institute of Medicine Committee on Veterans' Compensation to 
collect gender-specific data on MST claim decisions, develop additional 
MST-related reference materials for raters, and incorporate training 
and testing on MST claims into its rater certification program. \12\ 
The agency should also establish a presumption of soundness for the 
diagnoses of its own treating physicians and counselors; claim 
reviewers should not have the authority to second-guess evaluations by 
agency medical professionals or to discount VA treatment records in 
favor of one-time Compensation and Pension (C&P) exam results.
---------------------------------------------------------------------------
    \12\ Committee on Veterans' Compensation for Posttraumatic Stress 
Disorder, Institute of Medicine and National Research Council of the 
National Academies, PTSD Compensation and Military Service (Washington 
DC: The National Academies Press, 2007).
---------------------------------------------------------------------------
    Finally, SWAN proposes revising the current VA work credit system, 
which paradoxically prolongs the adjudication process by privileging 
speed over accuracy in initial claim determinations. By measuring 
employee productivity strictly by number of cases processed, the VA 
offers reviewers an incentive to take any shortcut necessary to clear 
their desks of pending claims. The resulting combination of too much 
work and too little time ultimately gives rise to premature--and 
inaccurate--determinations, setting in motion years of appeals. In 
order to encourage accurate determinations at the Regional Office level 
and remove the incentive to recycle claims, the agency should award 
work credit only after the final stage of review.
    Thank you very much for your attention. I would be happy to answer 
any questions.
Executive Summary
    The Service Women's Action Network (SWAN) has worked on the issue 
of Military Sexual Trauma (MST)- related Post Traumatic Stress Disorder 
(PTSD) claims for a number of years now with the VA, VBA and Congress. 
SWAN has advocated for a relaxation in the evidentiary standards for 
MST-based PTSD claims to allow lay testimony of the veteran to be used 
to reflect the standards of evidence used in other PTSD claims. In 
2011, SWAN and the ACLU filed Freedom of Information Act requests with 
the VA to ascertain the scope of MST-based PTSD claims, and to 
specifically examine approval rates and disability ratings of those 
claims.
    Examination of the documents produced by the VA clearly shows that 
the current system in use by the VBA that employs a higher standard of 
evidence for sexual assault claims results in only 1 in 3 (32.3%) MST- 
based PSTD claims being approved. This is much lower than the 1 in 2 
(54.2%) acceptance rate of all other PTSD claims. Additionally, an 
examination of disability ratings revealed a strong bias, as women were 
more likely to receive a 10 to 30 percent rating and men were more 
likely to receive a 70 to 100 percent disability rating.
    This data reinforces what SWAN and many other veterans' advocates 
already know: the possibility of getting an MST-based PTSD claim 
approved by the VBA under the current regulations continues to be an 
arduous and overwhelmingly difficult process for the veteran, and is a 
process that more often than not results in a ruling unfavorable to the 
veteran.
    To improve MST claims policy, VBA must immediately revise the 
regulation (38 CFR 3.304, Chapter 1, Part 3, Subpart A) to provide 
language that establishes the same evidentiary requirements for MST-
based PTSD claims that it does for other claims. Specifically, if the 
evidence establishes a diagnosis of PTSD during service and the 
veterans' mental health provider connects that claimed stressor to the 
patient's service, then in the absence of clear and convincing evidence 
to the contrary, and provided that the claimed stressor is consistent 
with the circumstances, conditions, or hardships of the veteran's 
service, the veteran's lay testimony alone should sufficiently 
establish the occurrence of the claimed in-service stressor.
    Furthermore, there should be absolutely no requirement that 
veterans filing MST claims go through an independent Compensation and 
Pension (C &P) exam to verify that they have PTSD. We know from talking 
to countless veterans that these exams serve no purpose and in fact 
often unfairly reverse the diagnosis that was made by qualified VA MST 
counselors or other mental health providers. C & P exams are terrifying 
for veterans who have been assaulted or harassed as it forces them to 
talk about traumatic and devastating experiences with complete 
strangers. These experiences often take years or even decades for 
veterans to come to grips with, or to talk comfortably about, and 
veterans should not be forced to repeat them to complete strangers who 
often lack the sensitivity or professional qualifications to speak to 
survivors of sexual trauma. The trust that is built between a MST 
counselor or mental health provider and his/her patient is one that 
cannot be replaced by strangers. VBA must trust the expertise of VHA 
mental health experts who have worked intimately with their patients.
    Additionally, to sensitize claim reviewers to the needs of assault 
and harassment victims, the VA should implement the recommendations of 
the Institute of Medicine Committee on Veterans' Compensation to 
collect gender-specific data on MST claim decisions, develop additional 
MST-related reference materials for raters, and incorporate training 
and testing on MST claims into its rater certification program. The 
agency should also establish a presumption of soundness for the 
diagnoses of its own treating physicians and counselors; claim 
reviewers should not have the authority to second-guess evaluations by 
agency medical professionals or to discount VA treatment records in 
favor of one-time C&P exam results.
    Finally, SWAN proposes revising the current VA work credit system, 
which paradoxically prolongs the adjudication process by privileging 
speed over accuracy in initial claim determinations. By measuring 
employee productivity strictly by number of cases processed, the VA 
offers reviewers an incentive to take any shortcut necessary to clear 
their desks of pending claims. The resulting combination of too much 
work and too little time ultimately gives rise to premature--and 
inaccurate--determinations, setting in motion years of appeals. In 
order to encourage accurate determinations at the Regional Office level 
and remove the incentive to recycle claims, the agency should award 
work credit only after the final stage of review.

                                 
                   Prepared Statement of Joy J. Ilem
    Messrs. Chairman and Members of the Subcommittee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
testify at this oversight hearing focused on the process and procedure 
involved in veterans' obtaining disability compensation benefits for 
post-traumatic stress disorder (PTSD) associated with military sexual 
trauma (MST), specifically on the types of evidence that may be 
submitted to substantiate a claim related to MST, and an exploration of 
ideas that may improve the evaluations of these claims.
    For a number of years, DAV has advocated greater collaboration 
between offices of the Department of Veterans Affairs (VA) and the 
Department of Defense (DoD) to address conditions related to MST and to 
identify better ways to treat and properly compensate veterans for 
those conditions. We also continue to express a fervent hope that DoD 
is effectively addressing methods to prevent the incidence of sexual 
assaults and harassment within all branches of the military services.
    This topic is obviously extremely sensitive to many service 
members, veterans and the respective Departments that are responsible 
for the safety and well-being of service members and veterans. When a 
service member is wounded by enemy rifle fire or mortar shrapnel in 
engagement with an enemy, as a society we recognize the sacrifice and 
loss of our wounded military personnel, but when a military service 
member is wounded by personal or sexual violence, often perpetrated by 
a fellow service member, military authorities and society in general 
respond in a very different way.
    The continued prevalence of sexual assault in the military is 
alarming and has been the object of numerous military reports, 
Congressional hearings, documentaries and media coverage. 
Unfortunately, recent media reports do not lend confidence that DoD is 
succeeding in its goal of reducing and eliminating this scourge; 
however, it appears from recent developments that the Secretary of 
Defense has determined to address MST in a new and enlightened manner 
compared to the past. He announced the establishment of independent 
special victims units to investigate incidents of MST in the military 
ranks. He also indicated DoD will address some of its historic problems 
in archiving records associated with the incidence of MST.
    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 of the 
military service's programs complies with DoD policy. SAPRO serves as 
the 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 prevention through training and education programs, 
ensure treatment and support of victims, and enhance system 
accountability.
    According to SAPRO, in 2011 reports of sexual assault were filed by 
3,192 service members across all military service branches, a 1% 
increase over 2010 and a 1.1% decrease from 2009. \1\ However, DoD 
recognizes that these types of crimes are remarkably under-reported. 
For last year, DoD projected a more accurate number, likely closer to 
19,000 assaults, based on its bi-annual Workplace and Gender Relations 
Survey of Active Duty Members (WGRA).
---------------------------------------------------------------------------
    \1\ Department of Defense Sexual Assault Prevention and Response, 
Annual Report on Sexual Assault in the Military, Fiscal Year 2011; 
April 2012. http://www.sapr.mil/media/pdf/reports/Department--of--
Defense--Fiscal--Year--2011--Annual--Report--on--Sexual--Assault--in--
the--Military.pdf.
---------------------------------------------------------------------------
    VA data bears out the significant reports of MST. According to VA, 
during fiscal year 2009, 21.9 percent of women and 1.1 percent of men 
screened by the Veterans Health Administration (VHA) reported that they 
had experienced an in service stressful MST event. Another VA study 
found that of 125,000 enrolled veterans screened, about 15 percent of 
women veterans from Operations Iraqi and Enduring Freedom reported 
experiencing sexual assaults or harassment during 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. Women with MST had a 59 percent higher 
risk for mental health problems; the risk among men was slightly lower, 
at 40 percent. \3\ The most common conditions linked to MST were 
depression, PTSD, anxiety, adjustment disorder, and substance-use 
disorder.
---------------------------------------------------------------------------
    \2\ US Dept of Veterans Affairs, VA Research Currents. November-
December 2008. http://www.research.va.gov/resources/pubs/docs/va--
research--currents--nov-dec--08.pdf.
    \3\ Ibid.
---------------------------------------------------------------------------
    The complaints we hear from veterans regarding MST are primarily 
focused on the VBA disability claims process. Many survivors indicate 
that they are frustrated with the process particularly in cases when 
the sexual assault was not officially reported. They express a feeling 
of being ``re-traumatized'' in their efforts to get help from VBA even 
when they have provided significant evidence; statements from 
witnesses, friends or family; a detailed account of the incident; along 
with a diagnosis and extensive treatment records from a VA or non-VA 
mental health provider--only to have the claim for service-connection 
denied.
    Unfortunately, many service members who experience these types of 
traumas do not disclose them to anyone until many years after the fact 
but frequently experience lingering physical, emotional or 
psychological symptoms following these incidents. When a service member 
experiences sexual assault during military service there are a number 
of complicating factors that often prevent or discourage survivors from 
coming forward and reporting the incident to their superiors. Fear of 
retribution within the military unit structure; the perpetrator is 
their superior or a friend of the superior to whom they must report; 
and negative impact on military career are just a few reported barriers 
to coming forward and reporting such incidents. Traditional military 
culture and the military's closed system for reporting, investigating 
and prosecuting these types of crimes also constitute barriers against 
reporting such incidents. Despite DoD's ``zero-tolerance'' policy, 
reports continue to document these incidents. Not only is there stigma, 
shame, guilt, and feelings of isolation associated with sexual assault 
in general, to add insult to injury, in some cases, these incidents are 
not being properly addressed as mandated by policy through the chain of 
command. Perpetrators often are not punished.
    On their discharge from military service many survivors of MST end 
up seeking health care and mental health counseling services for MST 
from the VA health care system. Under a current Veterans Health 
Administration (VHA) policy, all patients are screened for MST and 
receive medically necessary treatment and counseling without charge for 
MST-related conditions at VA health care facilities and in VA Vet 
Centers. Service connection or disability compensation is not required 
for eligibility to gain access to this treatment.
    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.
    According to current VBA policy, 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 or mental health 
counseling centers, hospitals, or physicians; pregnancy tests or tests 
for sexually transmitted diseases; and statements from family members, 
roommates, fellow service members, 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 C.F.R. Sec.  3.304(f)(5).)
    Also noteworthy, VBA's policy prohibits the denial of claims for 
service connection for PTSD based on in-service personal assault 
without a rater's first advising the veteran claimant that information 
from sources other than the veterans' 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. Finally, the 
regulation 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.
    Unfortunately, even with the liberalization of the regulations, if 
an assault is not officially reported during military service, 
establishing service connection later for conditions related to MST can 
be very challenging. According to an Institute of Medicine (IOM) 
National Research Council report on PTSD compensation in 2007, 
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 and noted that available 
information suggests that women veterans are less likely to receive 
service connection for PTSD and that this gap is related to their being 
unable to substantiate non-combat traumatic stressors such as MST. The 
committee stated that VA guidance for rating these cases at that time 
addressed MST specifically, but that little attention was being paid to 
the unique challenges of documenting an in-service stressor or 
approaches for solving this problem. DAV is pleased to report that the 
Veterans Benefits Administration has made numerous improvements in 
adjudication policies on MST since that report was filed.
---------------------------------------------------------------------------
    \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. Washington 
DC, 2007.
---------------------------------------------------------------------------
    In May 2010, VBA officials testified that all rating specialists in 
VA regional offices were provided with detailed information on proper 
claims processing methods in a 2005 training letter, in an effort to 
ensure that veterans who filed claims associated with MST received fair 
and thorough consideration of those claims. \5\ Following the joint 
hearing on May 20, 2010, VBA responded to DAV's request to include 
SAPRO information in its M-21-1MR, Part IV, Subpart ii, Chapter 1, 
Section D for these types of claims. In December 2011, VBA amended its 
guidance to VA rating specialists, expanding requirements for raters 
examining personal trauma cases based on MST, including using SAPRO as 
a source for possible documentation.
---------------------------------------------------------------------------
    \5\ Bradley G. Mayes & Susan McCutcheon, RN, EdD; Joint Statement 
before the House Veterans Affairs Committee, Subcommittee on Disability 
Assistance and Memorial Affairs, ``Healing the Wounds: Evaluating 
Military Sexual Trauma Issues,'' May 20, 2010. http://
democrats.veterans.house.gov/hearings/
Testimony.aspx?TID=72876&Newsid=577&Name=%20Bradley%20G.%20Mayes.
---------------------------------------------------------------------------
    We appreciate these specific changes made by VBA, including the 
information about SAPRO, but DAV remains concerned about how many 
claims may have been denied prior to that information being included in 
the manual or on faulty application of the existing regulations.
    In preparing for this hearing we contacted VBA officials, through 
our National Service Officer (NSO) Corps, to see what references are 
currently being used by rating specialists/adjudicators in developing 
PTSD claims based on MST. A document associated with a December 2011 
``Fast Letter'' provides very detailed and comprehensive guidance 
regarding these claims to include: pertinent regulations; statutory 
definition of MST; related court decisions; specific ``markers'' to 
examine in veterans' records; timing for ordering a PTSD examination; 
and proper development actions to be taken prior to a decision being 
rendered in the case.
    Most notably in the document we found a number of clear examples 
and statements to raters emphasizing the fact that a special obligation 
exists on VA's part to assist claimants in gathering, from sources 
other than in-service records, evidence corroborating an in-service 
stressor and to help fully develop their claims particularly in MST 
cases given the unique problems of documenting personal-assault claims. 
The instructions are concise--that evidentiary development must proceed 
under the special requirements of title 38, C.F.R., Sec.  3.304(f)(5) 
and that a veteran's complete military record should be obtained if 
necessary, and reasonable efforts expended to obtain any other evidence 
a veteran may identify as a potential source to support the claim. The 
document goes on to explain the purpose of the liberalizing categories 
in the regulation is to recognize the difficulties inherent in 
establishing service-connection for PTSD claims based on MST and other 
personal assaults and to provide the basis for a relaxed evidentiary 
standard and a liberal approach to evaluation of these claims.
    The most salient feature made in the Fast Letter's attachment is to 
emphasize that current regulations and court cases do not require 
actual documentation of the claimed stressor, and that the opinion of a 
qualified mental health clinician is considered credible supporting 
evidence of the claimed MST stressor. Nevertheless, the letter notes 
that the final decision on service connection remains with VBA raters.
    To DAV, the question at hand for this Subcommittee is whether VBA 
adjudicators and rating specialists who are responsible for developing 
and rating MST claims are using all the amended provisions in M21-1 and 
following those prescribed VBA-wide guidelines in the Code of Federal 
Regulations to assist veterans in uncovering potential evidence that 
may be available to support their claims, even if unreported. In cases 
where veterans indicated that no official report of assaults were 
filed, VA adjudicators should be asking veterans detailed questions or 
considering stressor statements provided by veterans to determine if 
other reports could have documented these events (such as calls or 
visits to rape crisis centers or mental health counseling centers; 
requests for pregnancy tests or tests for sexually transmitted 
diseases; statements in personal diaries or letters to clergy or family 
members immediately following personal assaults).
    In our view, if a veteran indicates an assault took place on a 
specific date(s), he or she should be asked about subsequent treatment 
for any health or mental health problems following the sexual assault, 
i.e., complaints of stomach pain; nausea; vomiting; headaches; anxiety; 
panic attacks; depression; or suicidal ideation, etc. Rating 
specialists should be examining military personnel records for requests 
for transfer filed by individuals following assault to another duty 
assignment; a deterioration in work performance noted; or documentation 
of a sudden onset of substance abuse or other unexplained social or 
behavioral changes. The M21-1 guidance lists additional options to 
assist VBA claims developers but it unclear whether these efforts are 
consistently and exhaustively being made. DAV asks this Subcommittee to 
require VBA to examine compliance with this guidance system-wide and 
submit a report of its findings to aid the Subcommittee in its 
oversight role.
    We bring one more issue to the Subcommittee's attention on this 
topic. Under DoD's confidentiality policy, military 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 the assault to 
specified individuals and receive medical treatment and counseling, 
without triggering any official criminal or civil investigative 
process. Despite the progress on the VA's part to include SAPRO 
information in its M21-1 manual, to maintain confidentiality in the 
case of restricted reporting, DoD policy prevents release of MST-
related records with limited exceptions. However, 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. One of DAV's primary concerns is 
that VA be able to access restricted DoD records (with the veterans' 
permission) documenting reports of MST for an indeterminate period. To 
establish service connection for PTSD there must be credible evidence 
to support a veteran's assertion that the stressful event actually 
occurred. Restricted records are highly credible resources but it is 
questionable if they are readily available, even with the consent of 
the veteran. With the veteran's authorization, we believe DoD should 
provide VA adjudicators access to all MST records, whether restricted 
or unrestricted, to aid VBA in adjudicating these cases.
    We also have questions with respect to where and how physical 
assessment records that are completed following assaults and subsequent 
mental health treatment records related to the restricted MST reports 
are kept and for how long. We are concerned that these records are 
being maintained separately from victimized service members' medical 
treatment and personnel records and whether each service maintains MST 
records in a consistent manner. According to DoD policy physical 
evidence associated with a restricted report of an MST event is 
destroyed after one year if the service member or veteran does not wish 
to pursue civil or criminal sanctions against the perpetrator. 
Legislation is pending in the Senate that would extend this period of 
records retention for restricted MST records to five years. DAV 
supports an extension of this period to 50 years, matching the current 
DoD policy on retention of unrestricted records of sexual assaults.
    DAV NSOs continue to assist MST victims with their claims for 
disability compensation. In this work, however, our NSOs are frustrated 
at the routine occurrence that MST claims are denied by VA for lack of 
evidentiary documentation. This suggests that, in some cases, VBA 
rating specialists are not following current policy as detailed in this 
statement. 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 survivors of MST, as well as 
preventing the problem at its source, should work in concert to lower 
the burden of this claims process and ensure service members and 
veterans are fully assisted by the government and their advocates in 
securing the benefits they deserve and have earned. In recent days we 
are advised that more collaboration is now occurring between leaders of 
VBA and SAPRO, but we await the results of these efforts, especially in 
relation to records keeping, archiving and accessing MST documentation.
    Additionally, we urge VBA to identify and map claims related to 
personal trauma with a focus on MST to determine the number of claims 
submitted annually, their award rates, denial rates, and the conditions 
most frequently associated with these claims. We believe this type of 
reporting would be helpful to the Subcommittee in its oversight role. 
Therefore, DAV renews our request that VBA develop this important data-
set and make it public. Finally, VBA is responsible for ensuring that 
its claims staffs are properly trained and compliant with the 
procedures and policies outlined in this testimony to assist veterans 
in producing fully developed claims; therefore, VBA should conduct its 
own oversight to review these claims to ensure the directives that have 
been issued are in fact being followed.
    Mr. Chairman, again DAV thanks you for the opportunity to share our 
views at this important hearing focused on MST related disability 
claims. We strongly believe that survivors of sexual assault during 
military service deserve recognition, assistance in developing their 
claims and compensation for any residual conditions found related to 
the assault. DAV believes these cases need and deserve special 
attention. Because of the circumstances of these injuries, victimized 
individuals who have come forward are courageous, and their courage 
needs to be recognized by the government.
    In the past decade, progress has been made on this issue; however, 
more needs to be done to ensure that these disabled veterans are 
properly compensated for conditions related to MST on an equitable 
basis in comparison to veterans disabled by other causes. We continue 
to hope hearings of this nature can not only help heal these deep 
wounds that are often invisible but have profoundly changed the lives 
of those affected, but also stimulate both Departments to improve their 
efforts to address them and the underlying causative factors.
    Establishing service connection for a condition related to MST is 
important on a number of levels. Specifically, veterans with service 
connection gain improved access to VA health care. Disability 
compensation can also make a significant difference in a disabled 
veteran's financial stability and overall health and well-being. 
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.
    We appreciate the attention to these issues and hope the 
Subcommittee will consider the issues of concern and recommendations 
DAV has made today. I would be pleased to address your questions, or 
those of other Subcommittee members.

                                 
                   Prepared Statement of Lori Perkio
    Mr. Chairman and Members of the Subcommittee:
    Thank you for the opportunity to provide testimony on behalf of The 
American Legion regarding the obstacles faced by veterans applying for 
compensation benefits related to military sexual trauma. Disability 
compensation is, in its most basic sense, based on the residual effects 
of injury or disease incurred in service. There are many potential 
residual effects resulting from sexual trauma incurred in the military, 
ranging from disorders of the genitourinary system to sexually 
transmitted diseases to Posttraumatic Stress Disorder (PTSD). As with 
any service connected disability, in order to establish service 
connection, a veteran must prove three points of fact in conjunction 
with the disorder. A veteran must prove there is a current condition. A 
veteran must establish evidence showing the occurrence of the event or 
disease during their period of service. Finally a medical opinion from 
a doctor is required, providing a nexus between the event in service 
and the present condition.
    For victims of Military Sexual Trauma (MST) the most difficult 
point to prove is usually the occurrence of the event in service. There 
are a variety of reasons for this difficulty. Some of these reasons are 
institutional or even societal. Some of these reasons revolve around 
the circumstances and culture often associated with the triggering 
incidences.
    The VA is clearly aware of the difficulties the victims of MST face 
in conjunction with the claims process. In 2004 a document produced by 
the Veterans Health Initiative (VHI) on MST recognized some of the 
challenges and offered advice to VA health care providers regarding 
patients of theirs who might be seeking service connection and 
compensation for residual effects of MST incurred in service.
    The guide recognizes some of the ``downsides'' veterans might face 
filing a claim. Veterans will be forced to undergo detailed 
descriptions of the horrifying events which have resulted in their 
present PTSD symptoms. Many veterans attach symbolic value to receiving 
service connection and could be further traumatized by repeated 
rejections and denials. Citing a 1995 Armed Forces Sexual Harassment 
Survey which stated ``59 percent of women filing rape charges while 
they were in service said they were not taken seriously.'' The guide 
worries that ``For sexually traumatized veterans whose attempts for 
redress in the military were disbelieved, minimized or even punished, 
denial of service-connection [sic] may represent a re-enactment of 
earlier `betrayals'''
    Further complicating the process is that in many cases there may be 
no records which could verify a veteran's claim of assault or sexual 
trauma in service. As mentioned above, some long standing patterns 
which are now changing slowly in the military created a negative 
environment for victims to file charges of rape or assault in the 
service. When such a culture existed, many chose not to even file due 
to the arduous task ahead where the victim was as much on trial as the 
attacker, if not more so.
    Even new military programs developed to help victims deal with 
sexual trauma in the military are often based on anonymity, to assuage 
concerns of victims who feel their reporting of the incident may 
adversely impact their career. While this may actually be increasing 
the number of victims who receive needed help, and is important, it can 
be disastrous in a long term sense for veterans who file claims for 
disability related to these assaults, as there are no records to link 
specifically to them in service.
    The lack of available data is noted in 38 CFR Sec.  3.304(f)(5) 
which clearly recognizes the frequent absence of concrete information 
in the military record to indicate the occurrence of such traumatic 
events and notes in the adjudication of posttraumatic stress disorder 
claims that alternate sources of information can be used to indicate 
the presence of such an event. Recognizing the importance of types of 
evidence such as behavior changes, deterioration in work performance, 
substance abuse, episodes of depression, unexplained economic or social 
behavior changes and the like, the regulations show the difficulty 
inherent in proving the existence of the event in question. 
Paradoxically, often these events must be theorized as existing in the 
holes left by gaps in what records are actually present.
    Despite the regulatory requirement to pay special attention to 
these types of information, American Legion service officers frequently 
report that this is not how these claims are actually adjudicated in 
the field. Oftentimes, the special attention required is only evident 
once the claim reaches the Board of Veterans Appeals after many years 
of an arduous appeals process. Some veterans do not even see the proper 
deference towards these types of evidence until their claim appears 
before the Court of Appeals for Veterans Claims. Simply put, despite 
regulations which require VA to pay ``special attention'' to alternate 
sources of information, all too often veterans are told the additional 
information is not compelling enough to make a difference. All too 
often it seems, there is no special attention granted to this 
information.
    In a statement released on July 11th of this year, VA delineated an 
express lane process for veterans' claims including ``Special 
Operations'' treatment for PTSD claims associated with MST. Presumably, 
under this ``Special Operations'' treatment these MST PTSD claims will 
finally receive the proper deference due alternative forms of evidence, 
although it is entirely too early to see what impact, if any, the 
special treatment will have on MST PTSD claims.
    Interestingly, the VA has recently tackled the difficult issue of 
adjudicating claims for PTSD in cases where there was a known lack of 
records to corroborate a veteran's claim. In 2010, in recognition of 
the frequent absence of concrete records to documented occurrences in 
combat zones, VA changed their regulations relating to the adjudication 
of PTSD claims related to combat type stressors that occurred in combat 
zones. The decision to change these procedures came about after careful 
consideration, and involved a procedure which mandated a VA doctor's 
opinion diagnosing PTSD related to a stressor consistent with the 
rigors and experiences of a combat zone.
    Subsequent to this regulatory change, VA has seen accuracy results 
in PTSD claims greatly improve. This change has improved the process 
for adjudicating combat PTSD claims, and the veterans who served with 
those invisible wounds have been able to receive some measure of 
justice.
    At the time of the regulatory change, the issue of MST claims for 
PTSD was raised in conjunction with the proposed changes for combat 
related PTSD. VA's response at the time, noted in the July 13, 2010 
Federal Register, was to cite the existence of the special rules for 
adjudicating these types of claims noted in 38 CFR Sec.  3.304(f)(5) 
and seemed to indicate the mere presence of this special rule obviated 
the need for any further liberalization of regulations related to PTSD 
adjudication in MST cases.
    The American Legion believes VA's response in that instance needs 
to be revisited. There are clear parallels to the struggles of veterans 
fighting to be recognized with service connection for PTSD in combat 
situations and in situations of sexual trauma. In both cases, the 
trauma contributes to lasting effects which can reach into every aspect 
of the veteran's life. In both cases, the reliving of the event as a 
necessary part of the process of service connection can be devastating 
and contribute to further trauma. In both cases, there is a long 
established understanding of the lack of available records to help 
validate the claim.
    The recent change to the PTSD claims model for combat veterans has 
shown there is a remedy to the failing of the claims process where 
there is an absence of records. The American Legion believes this is 
the directions we must look to in order to solve the problems faced by 
victims of MST in the claims process as they seek service connection 
for PTSD related to their trauma. Whether this is accomplished through 
internal regulatory change by VA along the lines of the initiative 
displayed in improving the process for combat veterans, or by change of 
law, the important message is that the system needs to change to help 
these veterans.
    If a victim of sexual trauma in the military is currently 
experiencing symptoms of PTSD related to that trauma, a doctor is fully 
qualified to make that assessment according to the Diagnostic and 
Statistical Manual of Mental Disorders (DSM) whether the currently 
utilized DSM-IV or the upcoming DSM-V the important factor is ensuring 
a diagnosis conforms to careful medical understanding. With a doctor's 
detailed evaluation, and relating the PTSD to an event in service, the 
evidentiary requirement for MST victims could be treated in the same 
manner in which we treat combat veterans. If the described incident is 
consistent with the nature of sexual trauma and conforms to the 
diagnosis, the existence of the in service stressor should be conceded 
by VA.
    The veterans in question have already been terribly victimized. 
Unlike combat veterans, they are unlikely to be hailed as heroes, 
although the courage to come forward and seek treatment is no less 
admirable. As a nation we must be reaching out to these veterans and 
telling them it is not only okay to come forward, but we have to 
reestablish trust with them.
    It is easy to miss this critical consideration when addressing the 
issue of MST. These are veterans who came forward to serve their 
country, and their trust has been shattered. In many cases their trust 
in the system is nil. It is not enough to be a cold, dispassionate 
system to adjudicate their benefits. We owe them an attempt to restore 
faith and trust in the system. We owe them an attempt to show their 
country does not think less of them.
    The system needs fixing, but it is not a complicated fix. The 
lessons of combat PTSD have shown us VA can make these changes on their 
own initiative, and The American Legion urges them to act now to do so 
for victims of MST.
    The American Legion thanks this subcommittee for the opportunity to 
come before you today to express our views on this critical issue, and 
furthermore thanks to this subcommittee for ensuring that the victims 
of Military Sexual Trauma are not forgotten or allowed to fall by the 
wayside.
Executive Summary
    The American Legion recognizes the obstacles faced by victims of 
Military Sexual Trauma (MST) when filing for service connection in the 
disability benefits system. The lack of data in the military records 
system is a great obstacle to veterans trying to prove service 
connection. In this way, victims of MST filing for PTSD face very 
similar obstacles to combat veterans filing for PTSD, in both cases the 
lack of records is one of the biggest obstacles to obtaining service 
connection.
    In 2010 VA voluntarily fixed their regulations to make it easier 
for veterans who had served in combat zones to obtain service 
connection for PTSD related to combat and combat conditions, by 
relaxing evidentiary requirements for veterans with a diagnosis of PTSD 
related to combat.
    The American Legion believes VA must use its authority to change 
their regulations in a similar fashion for MST victims seeking service 
connection for PTSD. Despite the existence of regulations for MST 
victims that require VA to pay special attention to alternate sources 
of information which could confirm the occurrence of an event in 
service, VA adjudicators are inconsistent in applying that special 
consideration. Therefore, a more substantial regulatory change, on the 
level of what was done in 2010 for combat victims, is in order to 
provide justice for MST victims seeking service connection for PTSD.

                                 
              Prepared Statement of Dr. Barbara Van Dahlen
    Thank you for this opportunity to provide testimony regarding the 
issue of improving the access to care through the Department of 
Veterans Affairs for veterans who have been sexually assaulted while 
serving in our military. It is an honor to appear before this 
Committee, and I am proud to offer my assistance to those who serve our 
country.
Background on Military Sexual Trauma
    Over the past several months we have seen an increase in the 
attention given to a very serious issue affecting our military 
community: military sexual assault. One reason for the increase in 
interest has been the release of a documentary film called The 
Invisible War. The film--which debuted at the Sundance Film Festival 
and opened in theaters in June--presents the stories of several women 
and men who were sexually assaulted while serving in the military. The 
service members who stepped forward to share these stories chose to 
serve our country by joining the armed forces--and were devastated by 
the assault they experienced and the lack of support they received from 
the institution they had devoted themselves to.
    The film has received critical acclaim and has stimulated 
conversations in both the civilian and military communities regarding a 
brutal reality that affects far too many men and women who serve. In 
2011 alone, 3,192 men and women reported that they were sexually 
assaulted while serving. By telling the painful stories of several 
victims of sexual assault, the film provides an important framework to 
understand the impact of this type of attack on those who serve and 
their families. It sets the stage for discussions and actions that must 
be taken if we are to protect those who defend our country from attacks 
that can occur from within. And it confirms that we must ensure 
services are available for those who have already been harmed.
    Understandably, this type of attack and betrayal often leads to the 
development of severe mental health difficulties for the men and women 
who are victimized. Indeed, today many of the female veterans treated 
by the Department of Veterans Affairs and other programs receive a 
diagnosis of Military Sexual Trauma (MST), and this type of trauma is 
now the leading cause of post-traumatic stress disorder among female 
veterans, surpassing combat trauma. In addition, the experience of 
military sexual assault increases the likelihood of other serious and 
devastating conditions and consequences such as substance abuse, 
homelessness, and suicide.
    This hearing focuses on a set of very important questions related 
to assisting the victims of military sexual trauma who seek care 
through the Department of Veterans Affairs (VA). Specifically, this 
committee seeks to explore the process and procedures involved in 
obtaining VA disability compensation benefits for post-traumatic stress 
disorder based on military sexual trauma. And it aims to determine how 
to improve the evaluation process for veterans who have been sexually 
assaulted so that those in need are quickly identified and treated.
    While this issue is getting significant attention today, sexual 
assault has been affecting--and often destroying--the lives of those 
who serve for decades. As I began to prepare testimony for this 
hearing, I had occasion to speak with a colleague who devoted over 20 
years of service to the military. He continues to serve as a civilian 
in a high level position with the Department of Defense. I happened to 
mention to him that I was invited to testify before this committee on 
this important topic. After stating that he was about to share 
something with me that he had never shared with anyone, not even his 
wife, he told me the following story.
    He enlisted in the military at the age of 17. It was the late 
1970s. Within the first year of his service, he was sexually assaulted 
by two men with whom he served, as part of an initiation process. He 
was humiliated and devastated. He told no one. He said, ``There was no 
one to tell--reporting would have made my life much worse. The stigma 
would have further damaged me and my career. I felt overwhelming guilt 
and shame.'' This veteran suffered the consequences of the attack, 
psychologically and physically, for years. At one point he contemplated 
suicide and went so far as to put all his affairs in order and make 
arrangements for the care of his two-year-old daughter and young wife. 
His marriage eventually fell apart and he and his wife separated. 
Fortunately, this veteran found help, repaired his marriage, and has 
healed psychologically--though he continues to have significant 
physical problems that stem from the attack that shattered his life 30 
years ago.
    He shared his story now because he wants the members of this 
committee to understand that service members who are sexually assaulted 
are unlikely to report the assault to their command, to their peers, to 
anybody. Data from the Department of Defense substantiate his claim. 
Reports indicate that an estimated 86% of service members do not report 
an assault when it occurs. There are many reasons for this, one being 
that for 25% of military sexual assault survivors, the person they 
would report the assault to is the perpetrator.
    We in the mental health profession know that it is absolutely 
critical for victims of sexual trauma to seek and receive assistance, 
support, and treatment as soon as possible. We also know, however, that 
many who suffer sexual attacks within the military will not seek care 
while they continue to serve. We must, therefore, ensure that all of 
those who seek services through the Department of Veterans Affairs for 
sexual assault once they leave the service are treated as quickly and 
as supportively as possible.
    Trained mental health clinicians are quite capable of determining 
the veracity of a veteran's claim of sexual assault. The signs and 
symptoms are well known, and VA mental health providers have already 
been given the appropriate responsibility for making this type of 
determination regarding reports of combat stress injuries. It would be 
appropriate and consistent, therefore, to allow trained mental health 
professionals to determine--as they currently do within the VA for 
combat-related trauma--that the claimed stressor of military sexual 
trauma is adequate to support a diagnosis of post-traumatic stress 
disorder and that the veterans symptoms are related to the claimed 
stressor for the purposes of seeking and receiving appropriate care and 
services through the VA.
    Moreover, given the humiliation survivors of sexual assault contend 
with, it is highly unlikely that many women or men will fabricate 
stories of military sexual trauma in order to receive VA benefits. In 
addition the lives that are saved by adjusting the process by which 
victims of sexual assault can qualify for and receive services through 
the VA will far out weigh the very few cases that ``beat the system.''
    In addition to changing the process for victims of sexual assault 
to apply for and receive services through the VA, we should continue to 
expand the network of providers available to meet the growing needs of 
the military community at large. The VA has made tremendous strides in 
recognizing that partnerships with community-based organizations are 
critical if we are to provide the mental health services that the men, 
women, and families who serve our country need when they come home to 
our communities. For example, the Department of Veterans Affairs 
recently signed an MOA with my organization, Give an Hour, which 
provides free mental health services to military personnel, veterans, 
and their loved ones. This MOA will facilitate appropriate referrals to 
GAH providers from the VA's Veterans Crisis Line. It is easy to imagine 
how community-based efforts such as those provided by Give an Hour and 
other organizations can assist the VA in their efforts to provide swift 
and effective care to those who have given so much to our country.
Scope and History of the Problem
    The issue of military sexual trauma has indeed received increased 
attention over the past few years. Looking at the number of reports 
filed with DoD in recent years confirms the magnitude of the problem. 
In 2010 there were 3,158 total reports of sexual assault in the 
military. The Department of Defense estimates that this number 
represents only 13.5% of total assaults in 2010. If this estimate is 
accurate then the total number of military sexual assaults would have 
been upwards of 20,000. Of the 3,158 reports that were made in FY2010, 
only 529 ever went to trial.
    Of the 3,192 military sexual assaults reported in 2011, service 
members were the victims in 2,723 of those assaults. Eighty-four 
percent of the incidents reported occurred in FY11, 14% were related to 
incidents occurring from FY08 to FY10, and 2% concerned incidents 
occurring in FY07 and prior. Of the 3,192 reports filed in 2011, only 
791 individuals received some form of disciplinary action, and of that 
group 489 individuals had courts martial charges initiated against 
them.
    On February 15, 2011, fifteen female and two male military veterans 
filed a class action lawsuit against former Defense Secretaries Donald 
Rumsfeld and Robert Gates. The case was ultimately dismissed but an 
appeal is being considered. The film The Invisible War profiles several 
of the victims involved in this class action suit.
    But this is not the first time that the issue of military sexual 
assault has received this type of public attention. Americans became 
aware of the issue during the Tailhook scandal in 1991. Tailhook refers 
to a series of incidents in which more than 100 U.S. Navy and Marine 
Corps aviation officers were alleged to have sexually assaulted or 
otherwise engaged in ``improper and indecent'' conduct with at least 87 
women at the Las Vegas Hilton.
    In July 1992, a series of hearings on women veterans' issues 
conducted by the Senate Committee on Veterans Affairs brought the 
problem of military sexual assault to policy makers' attention. 
Congress responded to these hearings by passing a public law that, 
among other things, authorized health care and counseling for women 
veterans who were experiencing mental health consequences resulting 
from sexual assault or sexual harassment during their military service. 
Signed into law in November 1992, this public law was later expanded to 
include male veterans. Following the passage of these laws, a series of 
Department of Veterans Affairs directives mandated universal screening 
of all veterans for a history of military sexual trauma and mandated 
that each facility identify a Military Sexual Trauma Coordinator to 
oversee the screening and treatment referral process.
    Although careers ended and policies changed following the Tailhook 
scandal, far too many men and women serving in our armed forces 
continue to be sexually assaulted at home and abroad. Most of these 
(often young) men and women were unable to protect themselves from an 
attack from one of their ``battle buddies.'' But why would they think 
that they would ever need to protect themselves from this type of 
assault? They joined the military to serve their country. They were 
taught that those with whom they serve share their dedication and 
commitment, are there to protect them, are closer than family. It is no 
surprise that military sexual assault often leads to a shattering of 
trust and a sense of despair. Many have likened military sexual assault 
to incest in the sense that many victims of military sexual assault are 
devastated by the betrayal and brutality they experience at the hands 
of one of their own.
    Fortunately, additional measures are now under way within the 
military to protect those who serve and to prosecute those who prey on 
them. Secretary of Defense Panetta has proposed new steps the military 
will take to address the problem of sexual assaults. One recommended 
policy change is the requirement that a higher authority within the 
military review the most serious cases, a step to ensure that cases 
remain within the chain of command and leaders are held responsible. 
Secretary Panetta also announced the creation of a special victims unit 
within each of the services and an explanation of sexual assault 
policies to all service members within 14 days of their entry into the 
military. In addition, the secretary has proposed intensified 
investigations, heightened training, and more resources. These are all 
excellent recommendations that may begin to stem the tide of 
victimization. We must also increase access to care for those who have 
already been affected.
Impact of Military Sexual Assault/Trauma
    Military sexual assault has been associated with an increased risk 
of depression, post-traumatic stress disorder, and substance abuse. 
Women who have been sexually assaulted in the military are more than 
four times more likely to have post-traumatic stress disorder than 
peers who have not been sexually assaulted. They are also more likely 
to suffer from multiple mental health concerns. In FY2011 19.4% of the 
OEF/OIF/OND female veterans reported a history of military sexual 
assault. In addition, one in five women veterans who present to the VA 
for health care screen positive for Military Sexual Trauma. Not 
surprisingly, women who enter the military at younger ages and those of 
enlisted rank appear to be at an increased risk for MST.
    Women and men in the military must face unique challenges 
associated with the experience of sexual assault. They must decide if 
they are willing to report the incident--and face whatever personal or 
professional reprisals that follow. But there are symptoms that all 
victims of sexual assault share, whether the attack occurs within the 
military or civilian community. Indeed, in addition to the physical and 
psychological pain of the attack itself, women and men who are sexually 
assaulted often experience years of emotional distress, damaged 
relationships, and overall dysfunction.
    Post-traumatic stress disorder refers to a collection of symptoms 
that occur for a prolonged period of time following a severe trauma. As 
we know, many victims of sexual assault develop post-traumatic stress. 
These symptoms can be grouped into three main categories:

    --  Re-Experiencing: This is a repeated reliving of the event that 
interferes with daily functioning. This cluster of symptoms includes 
flashbacks, frightening thoughts, recurrent memories or dreams, and 
physical reactions to situations that remind a person of the event.
    --  Avoidance: These symptoms stem from the desire of a person to 
change his or her routine to escape similar situations to the trauma. 
Victims might avoid places, events, or objects that remind them of the 
experience. Emotions related to avoidance are numbness, guilt, and 
depression. Some individuals have a decreased ability to feel certain 
emotions like happiness. They might also be unable to remember major 
parts of the trauma and feel that their future offers fewer 
possibilities than other people have.
    --  Hyper-arousal: Hyper-arousal symptoms are primarily 
physiological. They include difficulty concentrating or falling asleep; 
being easily startled; feeling tense and ``on edge''; and being prone 
to angry outbursts.

    It is easy to see how the presence of one or more of these symptoms 
can dramatically interfere with one's ability to pursue a career, 
engage in meaningful relationships, or live one's life.
    In addition, victims of sexual assault often turn to alcohol or 
other substances in an attempt to relieve their emotional suffering. 
Victims of sexual assault report higher levels of psychological 
distress and higher levels of alcohol consumption than non-victims. And 
when compared to non-victims, sexual assault survivors are 3.4 times 
more likely to use marijuana, 6 times more likely to use cocaine, and 
10 times more likely to use other major drugs. Many of the women 
veterans who are now living among the homeless population in the United 
States have what is referred to as a ``dual diagnosis''--a consequence 
of the sexual trauma they endured. They have a mental health condition 
such as post-traumatic stress disorder, depression, or severe anxiety 
and they have a substance abuse problem, making it even more difficult 
for them to receive or benefit from treatment for the assault that 
injured them.
    Furthermore, it is common for victims of sexual assault to engage 
in behaviors that result in physical and/or psychological harm to 
themselves. Deliberate ``self-harm'' or ``self-injury'' refers to 
incidents when a person inflicts physical harm on him or herself, 
usually in secret. Some victims of sexual assault may use self-harm to 
cope with the difficult or painful feelings associated with their 
experience of sexual trauma. Self-harm can cause permanent damage to 
the body, as well as additional psychological problems that hinder the 
healing process, such as guilt, depression, low self-esteem or self-
hatred, along with a tendency toward isolation. Some common methods of 
self-harm include cutting, burning, pulling out hair, scratching, and 
eating disorders.
    For sexual assault victims specifically, self-injury may

    --  provide a way to express difficult or hidden feelings
    --  provide a way of communicating to others that support is needed
    --  provide a distraction from emotional pain
    --  provide self-punishment for what they believe they deserve
    --  provide a feeling of control--it is not uncommon to feel that 
self-harm is the only way to have a sense of control over life, 
feelings, and body, especially if other things in life seem out of 
control

    Finally, one of the most concerning consequences of sexual assault 
is associated with the depression that so many experience following an 
attack. Depression that goes untreated can continue for years following 
the attack. And untreated depression results in an increased risk of 
suicide. Indeed, of the group of men and women who have experienced 
sexual assault many experience suicidal thoughts, and many attempt or 
complete suicide.
Access to Care
    We know that early intervention following the experience of trauma 
promotes healing and decreases the likelihood that the trauma will 
result in chronic and disabling mental health conditions. And we know 
that it is extremely difficult for victims to overcome the common 
feelings of fear, guilt, and shame they feel following an assault. As a 
result, many are reluctant to come forward to report an assault or seek 
treatment. And we know that if veterans are further victimized by the 
reporting and investigative process itself, they are likely to suffer 
additional psychological damage that worsens their condition. We must, 
therefore, assure that those who seek care for military sexual assault 
are treated with respect and given the attention and treatment they 
need and deserve.
    We have the systems and programs in place--through the Department 
of Veterans Affairs, through state and local governmental agencies, and 
through community-based programs like Give an Hour--to provide the 
education, support, and treatment that service members who have been 
sexually assaulted and their families need and deserve. We have 
treatment strategies that can relieve suffering and heal relationships. 
We have trained clinicians working within the VA and in surrounding 
communities who have the requisite skills to accurately assess those 
who present with symptoms related to sexual trauma. We must allow our 
trained clinicians to make these determinations so that the veterans 
who have suffered these acts of betrayal and violation are able to 
reclaim and rebuild their lives.
Executive Summary
    Over the past several months we have seen an increase in the 
attention given to a very serious issue affecting our military 
community: military sexual assault. The brutal reality is that in 2011 
alone, 3,192 men and women reported that they were sexually assaulted 
while serving. Meanwhile, reports indicate that an estimated 86% of 
service members do not report an assault when it occurs. There are many 
reasons for this, one being that for 25% of military sexual assault 
survivors, the person they would report the assault to is the 
perpetrator.
    Understandably, this type of attack and betrayal often leads to the 
development of severe mental health difficulties for the men and women 
who are victimized. Indeed, today many of the female veterans treated 
by the Department of Veterans Affairs and other programs receive a 
diagnosis of Military Sexual Trauma (MST), and this type of trauma is 
now the leading cause of post-traumatic stress disorder among female 
veterans, surpassing combat trauma. In addition, the experience of 
military sexual assault increases the likelihood of other serious and 
devastating conditions and consequences such as substance abuse, 
homelessness, and suicide.
    We in the mental health profession know that it is absolutely 
critical for victims of sexual trauma to seek and receive assistance, 
support, and treatment as soon as possible. We also know, however, that 
it is likely that many who suffer sexual attacks within the military 
will not seek care while they continue to serve. We must, therefore, 
ensure that all of those who seek services through the Department of 
Veterans Affairs for sexual assault once they leave the service are 
treated as quickly and as supportively as possible by allowing trained 
mental health clinicians to determine the veracity of a veteran's claim 
of sexual assault. The signs and symptoms are well known, and VA mental 
health providers have already been given the appropriate responsibility 
for making this type of determination regarding reports of combat 
stress injuries.
    In addition to changing the process for victims of sexual assault 
to apply for and receive services through the VA, we should continue to 
expand the network of providers available to meet the growing needs of 
the military community at large. The VA has made tremendous strides in 
recognizing that partnerships with community-based organizations are 
critical if we are to provide the mental health services that the men, 
women, and families who serve our country need when they come home to 
our communities.

                                 
              Prepared Statement of Margaret M. Middleton
    Chairman Runyan, Ranking Member McNerney and Members of the 
Subcommittee, thank you very much for the opportunity to appear before 
you today and offer my testimony on the highly important issue of 
military sexual trauma and the VA's disability compensation benefits 
process. My name is Margaret Middleton. I am the Executive Director and 
co-founder of the Connecticut Veterans Legal Center. Our mission is to 
help veterans recovering from homelessness and mental illness overcome 
barriers to housing, healthcare, and income. I am also a visiting 
clinical lecturer co-teaching the Veterans Legal Services Clinic at 
Yale Law School. In both of these capacities I work with veterans 
seeking VA compensation for PTSD caused by sexual assault in the 
military.
    There are several experts at this hearing who have eloquently 
testified as to the appalling extent of sexual assault in the military 
and the scope of the VA's failure to assist those victims. Rather than 
repeat those statistics I'd like to share some personal experiences I 
have had in representing veterans to illuminate how the evidentiary 
standard set forth in Title 38 of the Code of Federal Regulations 
section 3.304 prevents worthy claimants from receiving compensation 
they deserve.
    As written, 38 CFR 3.304(f) requires that a veteran seeking 
disability compensation for PTSD caused by MST must provide VA with 
``credible supporting evidence that the claimed in-service stressor 
occurred.'' Part Five of this section includes a long list of potential 
evidence including police records and medical reports that could be 
used to corroborate the personal assault. On paper, this requirement 
seems reasonable. Don't we all like to believe we would seek justice or 
medical treatment if we were attacked? Working with victims of MST 
taught me how misinformed that view is. What I have learned from these 
men and women is that the response to assault in the military is very 
particular to the military culture and military justice system and 
should not be thought of as analogous to sexual assault in civilian 
society. Current Department of Defense practices disincentivize victims 
from coming forward and seeking justice. Reporting an offender could 
jeopardize a servicemember's career, destroy his working relationships, 
or subject her to further harassment or even official punishment. The 
current regulation demonstrates a fundamental misunderstanding of the 
nature of sexual assault in the military and it is past time to correct 
it.
    I would like to share with you two examples of veterans I have 
assisted in applying for VA compensation for PTSD caused by rape in the 
military and the difficulty of using 38 CFR 3.304(f)(5) in these real 
world cases. In my teaching capacity, I co-supervised a team of 
students who helped a female veteran establish service connection for 
PTSD stemming from a rape at Camp Lejeune in the early 1970's. This 
veteran had been out drinking at an NCO club. She was 18. The 
acquaintance walking her home pushed her through a window and raped her 
in a barren room. This veteran felt tremendous shame and personal 
responsibility for having been out at night, for having been drinking, 
and for having trusted the wrong person. She feared that her romantic 
partner would leave her if she told him she had been raped. What's 
worse, her assailant bragged about his conquest and her warrant officer 
told her that ``she was the reason why women should not be allowed in 
the military.'' She was plagued by PTSD for decades following this 
assault and was diagnosed and is treated for it by a VA doctor.
    Section 3.304 places a heavy burden on a traumatized veteran like 
this client. The culture and atmosphere of the military discouraged her 
from reporting this rape, but winning a PTSD claim like hers requires 
the kind of documentation that can only come from speaking about the 
event. As time passes producing this type of documentation becomes 
increasingly difficult. For veterans like our client, whose rape 
occurred in the 1970s, this is a monumental obstacle to overcome.
    As her advocates, assisting this veteran was incredibly involved. 
Her parents had died, her marriage failed, there were no surviving 
letters of hers from that time, and no journals or court records. She 
had lost contact with anyone she had served with thirty years earlier. 
She had been too ashamed and afraid to seek medical help. Mental health 
treatment was even less common and more stigmatized then than it is 
now. She didn't seek a transfer and she wasn't demoted - she just did 
her job and suffered silently. What documentary evidence is she 
supposed to provide to corroborate her experience? In a civil case, a 
judge or jury would be able to weigh the credibility of her testimony 
and the testimony of a doctor treating her; why does the VA demand 
more?
    Under the current standard, it took hours of work by two incredibly 
talented Yale law students and an unusually cooperative VA psychiatrist 
to build her case based on the meager contemporaneous evidence of 
weight loss and missed duty assignments available in her service 
records. Most veterans do not have the benefit of a team of law 
students tirelessly scrutinizing their records, or a VA psychiatrist 
willing to draft and redraft letters with law students to include the 
type of language the VA requires. Another option might have been an 
independent forensic psychiatric evaluation that would have cost 
several thousand dollars my client did not have and for which the VA 
would not pay.
    The lack of documentary evidence is the rule, not the exception. I 
recently met with a female veteran being treated at the VA for PTSD 
caused by MST. While in boot camp, two sergeants had sent everyone out 
and kept her behind; they raped her in the barracks. Decades later I 
was the first person she ever told. She didn't tell anyone at the time 
because it would have meant the end of a career. This veteran, who 
served in Iraq, achieved the rank of Master Sergeant and retired after 
28 years in the military fought back tears as she related this 
experience. This was only one of the episodes of MST she described.
    This veteran's claim also faces an almost impossible evidentiary 
burden because of 38 CFR 3.304(f)(5). She did not tell anyone what had 
happened so there are no medical records, no letters home, and no 
action taken against her assailants. In order to succeed in the Army 
this veteran felt forced to stay silent and now she will be punished 
for her silence because the VA will refuse to credit her story based on 
her testimony alone. As her advocate, it will take me and my team hours 
of phone calls to family members and old friends, combing through 
service personnel records, and begging doctors to provide free 
psychiatric evaluations to prove her claim. This is surely not what the 
VA anticipated when it adopted 38 CFR 3.304(f)(5), but it is the 
reality of how it is working in practice.
    We create the conditions that compel traumatized people like these 
two women to remain silent, and then we punish them for that silence by 
refusing to accept their story when they come forward to tell it. We 
know that this is grossly unfair, and we know how to fix it. The VA can 
and should remedy this situation by amending 38 CFR 3.304(f)(5) to 
provide victims of military sexual trauma the same benefit of the doubt 
that combat veterans are afforded under 38 CFR 3.304(f)(2). There is no 
excuse for permitting the current regulation to stand. I hope this 
subcommittee exercises its responsibility to America's veterans to 
correct this injustice. Holding this hearing is an important step 
towards change and I thank you again for the opportunity to testify.

                                 
                    Prepared Statement of Ruth Moore
    Good Afternoon Ladies and Gentlemen of the House. My name is Ruth 
Moore and it is an honor to be among you today. As you know, I am a 
Military Sexual Trauma survivor who lives with PTSD and Depression. I 
am here today to share my 23-year struggle to get help from the 
Veterans Health Administration and disability compensation from the 
Veterans Benefits Administration.
    In 1987, I was a bright, vivacious 18-year-old, serving in the 
United States Navy. After my training school, my first assignment was 
to an overseas duty station in Europe. 2\1/2\ months after I arrived, I 
was raped by my supervisor outside of the local club. Not once, but 
twice. I sought help from the Chaplain, but did not receive any. I 
tried to move beyond this nightmare, but had contracted a STD. At this 
point, my life spiraled downward and I attempted suicide. Shortly 
thereafter, I was medivac'd to Bethesda Naval Hospital, and ultimately 
discharged from the Navy. No prosecution was ever made against the 
perpetrator. In hindsight, it was easier for the military to get rid of 
me, than admit to a rape.
    My problems began at the point of separation, as the psychiatrist 
diagnosed me with a Borderline Personality Disorder. I did not have a 
personality disorder; this was the standard diagnosis that was given to 
all victims of MST at that time, to separate them from active duty and 
protect the military from any and all liability. This travesty 
continued when I was counseled by ``Outprocessing'' to waive all claims 
to the VA, as I ``would get healthcare'' through my former spouse who 
was on active duty.
    From 1987 to 1993, I struggled with interpersonal relationships, 
could not trust male supervisors, and could not maintain employment. I 
filed my first VA claim in Jacksonville which was denied, despite 
having several markers for PTSD and gynecological problems. My life 
continued to spiral downward, and I was not able to maintain my 
marriage. In 1997, I fled from my house and lived out of my van for two 
weeks before I was able to start rebuilding my life with my present 
spouse. Things were very difficult, and I developed additional markers 
of PTSD including night terrors, panic attacks, severe migraine 
headaches, and insomnia.
    In 2003, I refiled for disability and was denied again; however, I 
enlisted the aid of the Disabled American Veterans. With their help, I 
was awarded 30% compensation for depression. I was denied PTSD and was 
told that I did not submit enough evidence to prove that I was raped, 
despite having submitted a letter from my former spouse who remembered 
the rape and when I was treated for Chlamydia. Given this eyewitness 
testimony, the VA still denied this as credible proof. There was no 
record of my medical treatment for STD from that duty station as my 
medical records had been partially expunged. Additionally, I was coded 
by the Togus VA as having a Traumatic Brain Injury or Brain Syndrome.
    In 2009, I entered into my first comprehensive treatment at the VA 
hospital in White River Junction, Vermont. I met a MST Coordinator who 
truly listened to me. She began a systemic review of all my records, 
and determined that they had been expunged by noting the glaring 
inconsistencies between my lab work, treatment notes, and service 
record. My psychiatrist and counselor determined that I did not have 
Borderline Personality Disorder, and the later diagnosis of Traumatic 
Brain Syndrome was inaccurate. My MST coordinator and I refiled for an 
increase in disability, and my clinicians wrote supportive records for 
the VBA to make an accurate determination. They readjudicated my claim 
to 70% but denied my status as individually unemployable, citing that I 
did not complete the necessary paperwork.
    At this point, I was very frustrated and suicidal with the stresses 
of the VBA system and claims process. In my final effort, I called the 
Honorable Bernie Sanders and his staff agreed to investigate why the VA 
was taking so long and denying part of my claim. I took Mr. Sanders 
copies of all the paperwork I had filed, including the VBA time and 
date stamped ``missing information'' to prove that they had originally 
received it. Within two weeks, my claim was finally adjudicated to 70% 
with IU and it was a total and permanent decision. My rating should 
have been 100% by the VBA criteria, but I was so grateful for a 
favorable determination that I have not pursued it further.
    Ladies and Gentleman, this process took me 23 years to resolve, and 
I am one of the fortunate ones. It should not be this way. If I had 
been treated promptly and received benefits in a timely manner, back at 
the time of my discharge, my life would have been much different. I do 
not believe that I would have been totally and permanently disabled in 
my 40's. I would not have had to endure homelessness and increased 
symptomology to the point where I was suicidal, I would not have 
miscarried 9 children, and I firmly believe that I would have been able 
to develop better coping and social skills. Instead, my quality of life 
has been degraded to the point where I am considering the possibility 
of getting a service animal to relieve the stress that my husband 
endures, as my unpaid caretaker.
    I am asking you, no - pleading with you, to please consider 
favorably the legislation that would prevent this from happening to 
others. Congresswoman Pingree's legislation is one way to change the 
burden of proof that is required to enable MST survivors to receive 
proper adjudication for MST and PTSD.
    Please, do what is right. Support this legislation, as it is 
urgently needed. Thank you for your time and audience today.

                                 
             Prepared Statement of Colonel Alan R. Metzler
    Chairman Runyan, Ranking Member McNerney, and members of the 
subcommittee, thank you for inviting me today to provide you with an 
update on the progress the Department of Defense has made in caring for 
victims of sexual assault. I am here as the Deputy Director of the 
Sexual Assault Prevention and Response Office (SAPRO).
    When we last briefed you in 2010, we told you of our efforts to 
standardize professionalize and institutionalize our Sexual Assault 
Prevention and Response - or SAPR - program. Since that time, we have 
pushed forward to expand and improve our support of victims of sexual 
assault and hold offenders appropriately accountable. Secretary Panetta 
has put great emphasis on dealing with the problem of sexual assault in 
the military. He has emphasized that sexual assault is an affront to 
the basic American values we defend, and it is a stain on the good 
honor of the great majority of our troops and families.
    Before beginning my testimony today, we think is important to start 
with a baseline of understanding on several important issues:

      Congress has authorized the Department of Veterans 
Affairs (VA) to provide counseling and appropriate care and services to 
overcome the psychological trauma that results from a physical assault 
of a sexual nature, battery of a sexual nature, or sexual harassment 
which occurred while a veteran served on active duty or active duty for 
training.
      In the Department of Defense (DoD), the office that I 
represent is tasked with policy and oversight relating to the 
prevention and response of sexual assault only. Sexual harassment is 
addressed by the Equal Opportunity Program. Reported incidents of 
sexual harassment are not included in our statistics.
      Finally, we 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 have focused on incidents 
post-2005, so that we can modify our current policy.

    Since our Sexual Assault Prevention and Response policy was 
instituted in 2005, we have remained committed to our vision: A culture 
free from sexual assault. One sexual assault is too many. Given the 
recent changes to the program, we are optimistic that we have set the 
right initiatives in motion to achieve that vision. The horror of 
sexual assault demands an immediate response to those persons and 
behaviors that violate our shared military values of trust, honor and 
integrity. However, the solution requires more than just an immediate 
response to the crime. The solution comes from working this problem at 
every level of military - and civilian - society. From policies that 
improve the capabilities of institutions, down to the prevention skills 
and knowledge that empower our individual Service members, these 
initiatives must be supported and then be allowed to work. I can tell 
you that the Department will not ignore, tolerate or condone sexual 
assault. This is our problem. We own it. We must fix it.
Overcoming Barriers to Reporting and Care-Seeking
    In 2010, we told you that a chief challenge facing DoD and VA is 
the fact that sexual assault is one of the most underreported crimes in 
both civilian and military society. As you know, sexual assault has 
severe effects on civilian and military victims - but there are other 
factors that complicate a victim's experience in the military and act 
as barriers to reporting:

      First, sexual assault often occurs where a victim works 
and lives. Until recently, a victim was unable to escape painful 
reminders that keep him or her from moving on from the incident. 
Victims are also concerned that making a report will cause them to lose 
their privacy, subject them to unwanted scrutiny, and potentially mark 
them as weak. They worry that their career advancement will be 
disrupted.
      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. The bond of trust is broken, and when the 
perpetrator is in a position of authority, victims feel isolated, 
exploited, and powerless.
      Third, research has found that a history of any kind of 
assault doubles the risk of posttraumatic stress symptoms when the 
victim is exposed to combat. \1\ We also know that military sexual 
assault victims are also at greater risk for depression, anxiety 
disorders, and substance abuse. \2\ These psychological problems - 
these ``invisible wounds'' - have insidious effects that disrupt lives, 
families, and military units. Long-term physical effects can include 
disabilities that impact a person's ability to work, gastrointestinal 
health, and pain disorders. \3\
---------------------------------------------------------------------------
    \1\ Smith, et al., (2008). Prior Assault and Posttraumatic Stress 
Disorder After Combat Deployment, Epidemiology, 19, 505-512.
    \2\ Kimerling, et al., (2007) American Journal of Public Health, 
vol. 97, issue 12.
    \3\ Consequences of Sexual Violence, retrieved from http://
www.cdc.gov/ViolencePrevention/sexualviolence/consequences.html.
---------------------------------------------------------------------------
    Research shows that making a report is the primary means whereby 
victims access medical care and other support. \4\ In 2005, the 
Department launched a policy to encourage victims to report the crime. 
The Department offers two reporting options: Restricted and 
Unrestricted Reporting. The addition of Restricted Reporting as an 
option was critical first step in our program. Restricted Reporting 
allows victims to confidentially access medical care and advocacy 
services to heal their wounds and maintain their privacy by not having 
to report their victimization to their commander or law enforcement. 
Restricted Reporting is having the desired effect. By the end of FY11, 
the Department had received 5,245 Restricted Reports since the option 
was made available in 2005. We believe that number represents 5,245 
victims who would have not 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 an 
Unrestricted Report, allowing us the potential to hold those offenders 
appropriately accountable.
---------------------------------------------------------------------------
    \4\ Department of Justice. (2002). Rape and Sexual Assault: 
Reporting to Police and Medical Attention, 1992-2000. Washington, DC: 
Rennison, Callie Marie.
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New Enhancements and Expansion of the DoD Sexual Assault Prevention and 
        Response Program
    In recent months we have expanded or implemented several new 
initiatives that will further support our victims and encourage 
prevention.
Military Rule of Evidence 514
    Recently the Uniform Code of Military Justice was amended to 
further institutionalize victim privacy. In December 2011, the 
President signed an Executive Order that added Military Rule of 
Evidence (MRE) 514 into military law. \5\ MRE 514 is a privilege that 
took effect on January 12 of this year to protect the communications 
between a victim and a victim advocate when a case is handled by a 
military court. This rule allows victims to trust that what is shared 
with these helping professionals will remain protected. The privilege 
fills an important gap that once allowed DoD victim advocates and 
sexual assault response coordinators to be compelled to testify about 
their communications with victims. We believe MRE 514 is an invaluable 
contribution to the climate of confidence we are building.
---------------------------------------------------------------------------
    \5\ Executive Order 13593, effective on January 12, 2012.
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DoD Safe Helpline
    The Department is also reaching out to victims with a new 
initiative that was launched last year. In April 2011, the Department 
launched DoD Safe Helpline as a crisis support service for adult 
Service members of the DoD community who are victims of sexual assault. 
Available 24/7 worldwide, users can ``click, call or text'' for 
anonymous and confidential support. The Safe Helpline is owned by the 
Department and operated by the non-profit Rape, Abuse and Incest 
National Network (RAINN), the nation's largest anti-sexual violence 
organization, through a contractual agreement with DoD SAPRO. Safe 
Helpline has a robust database with a wide-range of military and 
civilian services available for referral. The database also contains 
SARC contact information for each Military Service, the National Guard, 
and the Coast Guard as well as referral information for legal 
resources, chaplain support, healthcare services, the Departments of 
Labor and VA, including VA's Veterans Crisis Line, Military OneSource, 
and 1,100 civilian rape crisis affiliates. In its first year of 
operation, from April 2011 to April 2012, the Safe Helpline had more 
than 36,000 unique visitors to its website. Additionally, the DoD Safe 
Helpline assisted more than 2,700 individuals through its online and 
telephone hotline sessions and texting referral services. Please note 
that website visitors and the people helped are not filing reports of 
sexual assault. Rather, they are confidentially accessing information 
and finding out about services available to them.
    While we designed this service as a crisis hotline, we are finding 
that many of our service users are talking to us not only about events 
that just occurred, but also about incidents that occurred several 
months or even years ago. Given this opportunity for additional 
assistance, Safe Helpline has expanded its services through the launch 
of a mobile site and an app that can be downloaded for the iPhone, 
iPad, and devices with Android operating systems. The mobile site 
offers all the functionality of the standard website, but packages the 
content into a format that is easily displayed on a smart phone. The 
Safe Helpline app gives members of the DoD community affected by sexual 
assault access to resources and tools to help manage the short-and 
long-term effects of sexual assault. The app helps users create a plan 
that is right for them, from exercises that aid in reducing stress to 
tools to help them transition to civilian life. They can even customize 
plans and exercises so they can refer back to them at any time. The app 
is available in the Apple App Store or the Android Market.
DoD Safe Helpline Services for Transitioning Service Members
    In order to help our transitioning Service members, we are working 
to provide a continuum of care with VA for our Service members who have 
experienced sexual assault. We launched the Safe Helpline Transitioning 
Service Members (TSM) enhancements on 1 June 2012.
    TSMs seeking assistance following a sexual assault may be either 
unaware of or overwhelmed by the options and resources available to 
them upon leaving the military. TSMs seeking benefits related to an 
assault often are dealing with much more than paperwork. They may face 
concerns over confidentiality, privacy, and stigma. Safe Helpline 
offers an anonymous, confidential service that provides a safe space to 
discuss what options are best suited to their needs.
    SAPRO collaborated with VA and Department of Labor to streamline 
pertinent information for military sexual assault victims via the SHL. 
Through leveraging Safe Helpline's existing infrastructure, the 
Department is able to present clear and easily accessible information 
on counseling, benefits determinations, transitions, and employment, 
which may enable them to reach out for long-term support upon leaving 
the military. By bridging the gap from DoD to VA for sexual assault 
victims, we provide a continuum of care from active duty to veteran. 
TSM resources are easily accessible through the Safe Helpline via 
telephone, text, safehelpline.org, and through the Safe Helpline app.
DoD-wide Victim Assistance Standards
    As we improve our assistance to victims of sexual assault, we are 
sharing these important lessons with other programs within the 
Department. Last year, DoD SAPRO worked with the Military Services and 
other DoD offices to improve the effectiveness and standardization of 
response to victims of all crimes. The DoD Working Group on Victim 
Assistance, led by DoD SAPRO, and comprised of victim assistance-
related offices at the Office of the Secretary of Defense (OSD) level 
and Military Service representatives, was established in January 2011, 
to explore opportunities for achieving efficiencies, improvements, and 
standardization in victim assistance.
    The DoD Working Group determined that standards for victim 
assistance were needed across the Department. The DoD Working Group 
drafted standards that establish a foundational level of assistance for 
victims of crime and harassment across the military community, 
regardless of DoD program or physical location. These standards are 
intended to be consistent with those established by national victim 
assistance organizations and also incorporate the unique needs of the 
military community. In addition, the DoD Working Group drafted a 
charter for a senior-level Victim Assistance Leadership Council to 
promote efficiencies, coordinate victim assistance-related policies, 
and assess the implementation of victim assistance standards across the 
Department's victim assistance-related programs. We are now working to 
codify these victim assistance standards into Department policy.
    It is also important that victims get the best medical care 
possible. Sexual assault victims receiving assistance from DoD have 
always had an option to receive a general medical examination or a 
Sexual Assault Forensic Examination, or ``SAFE,'' that recovers 
evidence of sexual assault for later use in legal proceedings. However, 
recent improvements in laboratory capabilities and examination 
procedures required we update the Department's SAFE kit. For this 
reason, the Department called together civilian and military experts to 
improve the Sexual Assault Forensic Examination kit, the kit's 
instructions, and the DD Form 2911 - the SAFE Report. These updates 
were deployed to the field last year and better align the Department's 
procedures with national standards recommended by the Department of 
Justice.
SARC and Victims Advocates Certification Program
    Encouraging victim reporting is just one way that the Department is 
building a climate of confidence - a climate where victims know they 
will be supported and treated fairly with dignity and respect. 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. At the heart of our sexual 
response system are the Sexual Assault Response Coordinator (SARC) and 
Victim Advocates. Service members worldwide have access to a 24 /7 
response. Because the SARC and Victim Advocate play such an important 
role in the SAPR program, we have recently moved to professionalize 
these positions by designing a certification process. Once finalized, 
the proposed certification program will consist of credentialing that 
meets national standards, a competencies framework, and training 
oversight that will help us standardize the assistance provided to 
sexual assault victims. This certification process will also 
professionalize roles within the SAPR program and ensure all victims 
receive assistance from a certified SARC or SAPR Victim Advocate.
Expanded Document Retention
    SARCs and Victim Advocates work with victims to help them decide 
whether to make a Restricted or Unrestricted Report. To ensure that 
victims make an educated decision in which they are fully informed of 
their choices, we developed the Victim Reporting Preference Statement 
(the DD Form 2910) to explain their reporting options. The completed DD 
Form 2910 is an important record by which the Department documents the 
victim's report of sexual assault and which of the reporting options he 
or she selected. In each case, the SARC or Victim Advocate emphasizes 
that the victim should keep a copy of the DD 2910 in their personal 
files. This recommendation, to keep the completed DD 2910, is also 
noted on the bottom of the form.
    However, we know that not every individual can keep track of this 
important document over the course of a military career. We want to 
ensure victims of sexual assault have access to this and other 
documents that may be helpful to them. For example, such documents may 
be needed to establish a Service-connected disability should they 
suffer lasting effects from the crime. Consequently, the Department 
issued a Directive Type Memorandum in December 2011 that mandates 
increased retention time for this and other sexual assault records. For 
records that pertain to Unrestricted Reports, including investigative 
documentation, the SAFE report, and the victim's Reporting Preference 
Statement, documents will be kept for 50 years.
    For Restricted Reports, we also expanded retention times. We 
expanded retention time for the SAFE kit and associated documentation 
from one year to five years. As I noted before, a victim making a 
Restricted Report of sexual assault may convert to an Unrestricted 
Report at any time. However, at the one-year point following a 
Restricted Report, the SARC will contact the victim and inform him or 
her that the SAFE kit and documentation will be available for an 
additional four years should he or she wish to convert the report. 
SARCs will also keep a hard copy of the DD Form 2910 - the Reporting 
Preference Statement - in Restricted Reports for five years.
Expedited Transfer Option
    Victims of sexual assault are also informed by the SARC that they 
now have the option to request a permanent or temporary transfer from 
their assigned command or base, or to a different location within their 
assigned command or base. Victims making an Unrestricted Report may 
make such a request to their commanding officer and must receive an 
answer within 72 hours. If the victim's commanding officer denies the 
request for transfer, the victim may appeal this decision to the first 
general or flag officer in their chain of command, who again has 72 
hours to provide a response. Procedures for this new expedited transfer 
option were issued to the Services in a Directive Type Memorandum in 
December 2011. The Services were also directed in this memorandum to 
make every reasonable effort to minimize disruption to the normal 
career progression of a Service member who reports that he or she is a 
victim of sexual assault, and to protect victims from reprisal or 
threat of reprisal for filing a report.
Defense Sexual Assault Incident Database
    The Department believes that comprehensive data collection and 
analysis is vital to policy analysis and program implementation. The 
Defense Sexual Assault Incident Database (DSAID) received its operating 
authority in March 2012. The Air Force and National Guard Bureau 
received training earlier this year and are now actively entering cases 
into the system. The Marine Corps began using the system on July 1. The 
Navy SARCs are currently being trained on DSAID and will begin using 
the system August 1, 2012. We are currently working to interface with 
the Army's existing data systems and expect DSAID to be fully 
implemented by the end of August - which is on the schedule that we 
have been reporting to Congress since January 2010. DSAID has two 
primary functions: standardization of reporting of sexual assault and 
managing victim care. Once we have full implementation, we expect that 
our ability to analyze sexual assault data will be greatly enhanced. In 
addition, the Victim Reporting Preference Statement (the DD Form 2910) 
for Unrestricted Reports will be uploaded to DSAID, so they can be 
maintained for 50 years.
Pre-command Training for Officers and Senior Enlisted Leaders
    Changing our culture to achieve our goals involves prevention as 
well as accountability. One of the methods we are employing is 
oversight assessments. In January, the Secretary of Defense directed 
that we conduct a review of pre-command and senior enlisted leader 
Sexual Assault Prevention and Response (SAPR) training to identify 
strengths and areas for improvement. DoD SAPRO visited pre-command and 
senior enlisted leader training conducted by the Marine Corps, Navy, 
and Air Force and reviewed Army's newly developed Sexual Harassment / 
Assault Response and Prevention (SHARP) Program training support 
package for senior enlisted leaders that will be deployed in Summer 
2012. DoD SAPRO training experts, subject matter experts, and Service 
representatives evaluated both the method of delivery of SAPR training, 
as well as the content of the training, to identify strengths and areas 
for improvement. SAPRO identified a number of practices the Military 
Services should continue in their SAPR training for commanders. SAPRO 
has developed a number of recommendations that are designed to build on 
the successful practices the Military Services have already put into 
place, will drive improvements in SAPR training for commanders, and 
will support the strategic goals of the Department's SAPR program. 
These recommendations are currently before the Secretary of Defense for 
his consideration.
Sexual Assault Offense Withhold Policy
    To advance accountability, one of the most recent changes in 
Department policy was directed by the Secretary of Defense in April of 
this year. Effective on June 28, 2012, the initial disposition of cases 
of rape, sexual assault, forcible sodomy, and attempts to commit these 
crimes will be withheld from any officer who is below the O-6 level and 
who does not hold special court-martial convening authority. This 
means, commanders at the company or squadron level no longer have 
authority to decide the initial disposition of cases of rape, sexual 
assault, forcible sodomy, or associated attempts. In the past, victims 
have stated that they do not want to report because they believed the 
offender was more popular or more important to their commander than 
they were. The presumption was that unit commanders may be less likely 
to believe the victim and more likely to believe the offender. Now, 
disposition decisions for these very serious reports of sexual assault 
will be decided by someone above the level of the unit commander, a 
commander with greater experience, and senior officers more neutral in 
perception and in fact will make a reasoned decision.
    In April, Secretary Panetta also directed a number of other new 
policies that we are now working to implement or standardize across the 
Services:

      Establishing ``Special Victims Unit'' capabilities within 
each of the Services, to ensure that specially trained investigators, 
prosecutors, sexual assault nurse examiners, SARCS, and victim-witness 
assistance personnel are available to assist with sexual assault cases;
      Requiring sexual assault policies be explained to all 
Service members within 14 days of their entrance on active duty;
      Allowing reserve and National Guard members who have been 
sexually assaulted while on active duty to remain in their active-duty 
status to obtain the treatment and support afforded to active-duty 
members;
      Requiring annual organizational climate assessments; and
      Mandating wider public dissemination of DoD resources, 
including information about the DoD Safe Helpline.
Challenges in Caring for Military Victims of Sexual Assault
    We need your assistance in removing at least one barrier to victim 
care; that is state mandatory reporting laws.
    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, Service members 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. Section 11160 of California's Penal Code requires healthcare 
practitioners to make a report to law enforcement when a victim 
presents to them with an injury suspected to be from a criminal act. 
That report must include the victim's name, whereabouts and a 
description of the person's injury. There is no discretion allowed by 
the law on the part of a healthcare provider. Once the healthcare 
provider notifies civilian law enforcement, we cannot guarantee 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 more 
available in California. Despite our efforts, no action has been taken 
to remove this important barrier to reporting. This is a legislative 
challenge we need help in resolving.
Conclusion
    The Department of Defense has made significant progress since 2005 
in assisting victims of sexual assault. However, much work remains. Our 
policy has changed substantially in the last two years since we last 
appeared before this committee and we are pleased that we have the 
personal attention of the Secretary of Defense, who has played an 
invaluable role in helping us push the Sexual Assault Prevention and 
Response program forward.
    Thank you for your time and for the opportunity to testify today. I 
would be happy to answer your questions.

                                 
                 Prepared Statement of Thomas J. Murphy
    Good afternoon, Chairman Runyan, Ranking Member McNerney, and 
Members of the Subcommittee. I am accompanied today by Ms. Edna 
MacDonald, Director of the Nashville Regional Office and former Deputy 
Director for Policy and Procedures in Compensation Service.
    Thank you for inviting me to speak today on the timely and 
important topic of VA disability benefits for posttraumatic stress 
disorder (PTSD) based on military sexual trauma (MST) and sexual 
harassment.. The Department of Veterans Affairs (VA) is committed to 
serving our Nation's Veterans by accurately adjudicating MST claims in 
a thoughtful and caring manner, while fully recognizing the unique 
evidentiary considerations involved in such an event. Under Secretary 
for Benefits Allison Hickey has spearheaded the efforts of the Veterans 
Benefits Administration (VBA) to ensure that these claims are 
adjudicated compassionately and fairly, with sensitivity to the unique 
circumstances presented by each individual claim.
Increase in MST Related PTSD Claims
    Over the last several decades, women have entered the military in 
increasing numbers and now comprise a significant percentage of the 
Veteran population. Associated with this growth, VA has seen an 
increase in the filings of PTSD claims based on MST. However, VA 
recognizes that both men and women can be victims. According to the 
Veterans Health Administration (VHA), of the population of Veterans 
screened at its health care facilities, about one in five women and one 
in one hundred men state that they have experienced such an in-service 
event.
    VA is aware that, because of the personal and sensitive nature of 
the MST stressors in these cases, it is often difficult for the victim 
to report or document the event when it occurs. Reasons for this may 
include fear of reprisal, feelings of shame or guilt, or the perception 
of an unresponsive military chain of command. As a result, if the MST 
event subsequently leads to post-service PTSD symptoms and a claim is 
filed, the available evidence is often insufficient to establish 
occurrence of the stressor. To remedy this, VA developed regulations 
and procedures that appropriately allow more liberal evidentiary 
development and adjudication procedures for these claims.
PTSD Regulations
    Under VA regulations at 38 C.F.R. Sec.  3.304(f), service 
connection for PTSD requires:

      Medical evidence diagnosing the condition;
      A link, established by medical evidence, between current 
symptoms and an in-service stressor; and
      Credible supporting evidence that the claimed in-service 
stressor occurred.

    VA recognizes that certain in-service stressful events may be 
difficult to document. As a result, there are five categories of PTSD 
with particularized rules for establishing occurrence of the in-service 
stressor. These include stressors related to:

      In-service diagnosis of PTSD;
      Combat;
      Fear of hostile military or terrorist activity;
      Former prisoner-of-war status; and
      In-service personal assault.
MST Claims Processing
    As with other PTSD claims, VA will initially review the Veteran's 
military service records for evidence of MST. Such evidence may 
include:

      DD Form 2910, Victim Reporting Preference Statement; and
      DD Form 2911, Sexual Assault Forensic Examination Report.

    VA's regulation pertaining to in-service personal assault also 
provides that evidence from sources other than a Veteran's service 
records may corroborate the Veteran's account of the stressor incident, 
such as:

      Law enforcement authorities;
      Rape crisis centers;
      Mental health counseling centers;
      Hospitals;
      Physicians;
      Pregnancy tests;
      Tests for sexually transmitted diseases; and
      Statements from:

     I  Family members;
     I  Roommates;
     I  Fellow Servicemembers;
     I  Clergy members; and
     I  Sexual assault response coordinators and victim advocates.

    Evidence of behavior changes is another type of relevant evidence 
that may establish occurrence of an assault, such as:

      Requests for transfer to another military duty 
assignment;
      Deterioration in work performance;
      Substance abuse;
      Episodes of depression, panic attacks, or anxiety without 
an identifiable cause; and
      Unexplained economic or social behavior changes.

    Veterans are provided notification regarding the types of evidence 
that may establish occurrence of an in-service personal assault and are 
requested to submit or identify any such evidence. When this type of 
evidence is obtained, VA will schedule the Veteran for an examination 
with a mental health professional and request an opinion as to whether 
the claimed in-service MST stressor occurred. This opinion can serve to 
establish occurrence of the stressor, one element necessary for 
establishing service connection for PTSD.
VA Efforts to Assist MST Claimants
    VA has recently taken numerous other steps to assist Veterans with 
a timely, equitable, and consistent resolution of these claims.
    VBA has placed a primary emphasis on informing VA regional office 
personnel of the issues related to MST and providing training in proper 
claims development and adjudication. During August 2011, VBA reviewed a 
statistically valid sample of approximately 400 MST related PTSD 
claims. The goal was to assess current processing procedures and 
formulate methods for improvement. This led to development of an 
enhanced training curriculum with emphasis on standardizing evidentiary 
development practices. The VBA ``Challenge Training Program,'' which 
all newly hired claims processors are required to attend, now includes 
a module on MST within the course on PTSD claims processing. MST topics 
are also included in the standard ``PTSD and Other Psychological 
Conditions'' training course that all claims adjudicators are required 
to complete. Additionally, the VA electronic Learning Management System 
includes learning topics on MST.
    To further reinforce the importance of proper MST claims 
processing, VBA developed and issued Training Letter 11-05, 
Adjudicating Posttraumatic Stress Disorder Claims Based on Military 
Sexual Trauma, in December 2011. This was followed by a nationwide 
Microsoft Live Meeting broadcast on MST claims adjudication. The 
broadcast focused on describing the range of potential markers that 
could indicate occurrence of an MST stressor and the importance of a 
thorough and open-minded approach to seeking such markers in the 
evidentiary record.
    In addition to these general training efforts, VBA provided its 
designated Women Veterans Coordinators with updated specialized 
training. These employees are located in every VA regional office and 
are available to assist both female and male Veterans with their claims 
resulting from MST. They also serve as a liaison with the Women 
Veterans Program Managers at the local VHA health care facility to 
coordinate any required health care. As a further means to promote 
adjudication of these claims consistent with VA's regulation, VBA has 
recently created dedicated specialized MST claims processing teams 
within each VA regional office for exclusive handling of MST-related 
PTSD claims. Additionally, because the medical examination process is 
often an integral part of determining the outcome of these claims, VBA 
has worked closely with the VHA Office of Disability and Medical 
Assessment to ensure that specific training was developed for 
clinicians conducting PTSD compensation examinations for MST-related 
claims. This training was provided at a conference attended by VHA 
clinicians during November 2011. VBA and VHA further collaborated to 
provide a training broadcast targeted to VHA clinicians and VBA raters 
on this very important topic which aired initially in April 2012 and 
has been rebroadcast numerous times. VA is committed to applying the 
PTSD regulations related to MST in a manner most favorable to our 
Nation's Veterans and providing those who suffer from PTSD as a result 
of an in-service personal assault with disability compensation.
Conclusion
    In summary, VA has recognized the sensitive nature of MST-related 
PTSD claims and the difficulty inherent in obtaining evidence of an in-
service MST event. Current PTSD regulations provide multiple means to 
establish an occurrence, and VA has initiated additional training 
efforts and specialized handling procedures to ensure thorough, 
accurate, and timely processing of these claims.
    This concludes my testimony. I would be happy to address any 
questions from Members of the Subcommittee.

                                 
                        Question For The Record

Response From: DoD - To: Hon. Robert L. Turner
    Question: What is the status of implementation of this new policy 
(HR1540 Sec 586)?
    Answer: The Department of Defense issued Directive-Type Memorandum 
(DTM) 11-062 to direct the retention of DD Forms 2910 (Victim Reporting 
Preference Form) and 2911 (Report of Sexual Assault Forensic Exam) for 
five (5) years in Restricted cases and fifty (50) years in Unrestricted 
cases. These provisions will be incorporated into Department of Defense 
Sexual Assault Prevention and Response Program Procedures (Department 
of Defense Instruction (DoDI) 6495.02) when it is reissued. The 
document retention provisions relating to archived investigative 
records will be incorporated into the new Inspector General 
``Investigation of Sexual Assault in the Department of Defense'' 
(Department of Defense Instruction (DoDI) 5505.mm) when issued.

                                 
                   Materials Submitted For The Record

    Service Women's Action Network (SWAN)

    July 12, 2011

    The Honorable Eric K. Shinseki
    Secretary, U.S. Department of Veterans Affairs
    810 Vermont Avenue, NW
    Washington, DC 20420

    Dear Secretary Shinseki:

    My name is Anu Bhagwati. I am a former Marine Corps Captain and now 
serve as Executive Director of Service Women's Action Network (SWAN), a 
national advocacy organization founded by women veterans. It is our 
goal to transform military culture so that all uniformed personnel have 
equal opportunity and the freedom to serve in uniform without threat of 
harassment, discrimination, intimidation, or assault, and to transform 
the VA so that all veterans, including women, receive the health care 
and benefits they deserve. Our National Peer Support Helpline receives 
hundreds of calls each year from veterans and servicemembers. The vast 
majority of our clients were sexually assaulted or harassed in service, 
and many report having negative encounters with the VA. Their 
experiences directly inform our policy work.
    I am writing to request a meeting with you and your staff to 
discuss the need for specific VA reforms with respect to both health 
care and benefits for Military Sexual Trauma (MST) survivors. We have 
testified before Congress on the issue of MST reform five times in the 
last three years. I have no doubt that if you fully understood the 
obstacles survivors of sexual trauma face both in VHA and VBA, you 
would implement immediate common sense reforms to help our veterans get 
the services and benefits they so desperately need.
    I am writing to you today not only as the Executive Director of 
SWAN, but also as a veteran who is intimately familiar with VA's 
services for MST patients, and for women veterans generally. Since 
leaving the Marine Corps in 2004, my experiences with VA have been 
enormously painful and dangerously re-traumatizing due to the poor 
quality of care I have received on numerous occasions and the 
inordinate amount of effort it has required to survive and navigate the 
VHA and VBA bureaucracy.
    VBA denied my initial claim for depression and Post-Traumatic 
Stress Disorder (PTSD) based on sexual harassment despite overwhelming 
in-service evidence, statements from witnesses, my own detailed 
testimony, and several diagnoses from both non-VA and VA mental health 
providers, including a MST counselor whom I have been seeing for four 
years. VBA's rejection was devastating. It is only through the support 
of close family and friends that I continued to fight through my own 
betrayal, disappointment, and trauma to get what I earned for my 
service.
    Just last month (four years, six lawyers, two Representatives and 
one Senator later), VBA finally approved my claim.
    Had I not finally enlisted the intervention of government 
officials, I have no doubt my claim would have languished in VBA's 
bureaucratic labyrinth for several more years. Despite years of trauma 
reinforced by VBA's ineptitude, I consider myself incredibly lucky. My 
clients, peers and colleagues continue to suffer because VBA has failed 
them. Many have been lost to substance abuse or the streets after 
rejection by VBA, while others have attempted or completed suicide. MST 
survivors often suffer alone, re-living the shame, hatred and betrayal 
of a psychological or physical attack by their own peers. When VBA 
rejects a veteran's MST claim, the department re- triggers the 
veteran's emotional anguish and psychological turmoil. This heart-
wrenching rejection is often a reminder of every betrayal that was 
first experienced when the veteran was raped, assaulted or harassed in 
uniform. It causes the veteran to re-live the worst moments of his or 
her life. VBA's denial of a veteran's trauma is an experience from 
which many veterans simply do not recover.
    As you may know, SWAN sued the VA and the Department of Defense 
last fall for FOIA documentation related to domestic violence, military 
rape, sexual assault, and sexual harassment. We have received and 
analyzed the data your department provided, and the results are 
astonishing. VBA approves only 32% of MST-related PTSD claims. This 
acceptance rate is far less than the acceptance rate of PTSD claims 
overall. In fact, 53% of total PTSD claims are granted. The evidence 
suggests enormous bias against veterans whose PTSD originated from MST. 
There is no doubt that VBA's system for handling MST-related claims 
needs immediate repair.
    It is time now for the VA to treat all veterans with respect, and 
to provide the same level of care and benefits to our wounded warriors, 
regardless of the source of their wounds. In 2010, the VA finally 
adjusted its compensation policy for combat veterans suffering from 
PTSD, but denied justice to tens of thousands of MST survivors by not 
doing the same for them. As the policy stands now, VA has set up a 
cruel double standard that is directly contributing to the re- 
traumatization and further betrayal of our veterans who suffer from the 
effects of military rape, sexual assault, and sexual harassment.
    The VA's failure to recognize the sacrifices of all wounded 
warriors is no longer knowledge exclusive to survivors. SWAN helped 
Representative Chellie Pingree (D-ME) introduce H.R. 930, a common 
sense bill that would bring parity to the VBA claims process and 
justice for survivors of military rape, sexual assault, and sexual 
harassment who suffer from PTSD and other mental health conditions by 
providing the same standard of evidence as combat PTSD survivors. In 
addition to creating a single standard for applicants, it would also 
acknowledge that the wounds of MST survivors are as legitimate as those 
of combat survivors. It is a bill overwhelmingly supported not only by 
SWAN but by the veterans' community at large, including Veterans of 
Foreign Wars, Vietnam Veterans of America, and Iraq and Afghanistan 
Veterans of America. Additionally, Wounded Warrior Project and Disabled 
American Veterans have written to the VA to express their support for 
the proposed evidentiary standard reform for MST survivors.
    SWAN has read the VA's recent letter dated June 27, 2011 written by 
Undersecretary Allison Hickey regarding the processing of MST claims, 
and finds that it is an insufficient and unsuitable remedy to a 
systemic institutional problem. The guidance issued in that memo is not 
based on fact, but rather, on the misplaced hope that regional claims 
officers will put aside their biases and instead simply trust the 
evidence presented to them. I and tens of thousands of others over the 
years have put our faith in the system, and the system betrayed us, 
once again. MST survivors have put their lives in the hands of far too 
many individual claims officers for far too long. I urge you therefore 
to make this evidentiary change a permanent policy for the VA as you 
have done in the past, without forcing Congress to intervene.
    I will be attending the VA's National Training Summit on Women 
Veterans this weekend in Washington DC, and would be delighted to meet 
with you before or after your scheduled address to the community. We 
look forward to hearing from you.
    With great respect for your service to our nation,

    Anu Bhagwati, MPP
    Executive Director, Service Women's Action Network
    Former Captain, United States Marine Corps

    cc: Brigadier General Allison Hickey, Undersecretary, U.S. Dept. of 
Veterans Affairs

    Major General Irene Trowell-Harris, Director, U.S. Dept. of 
Veterans Affairs Center for Women Veterans

    Dr. Patricia Hayes, Chief Consultant, U.S. Dept. of Veterans 
Affairs Women Veterans Health Strategic Healthcare Group

    Susan McCutcheon, RN, EdD, Director, U.S. Dept. of Veterans Affairs 
Family Services, Women's Mental Health and Military Sexual Trauma

    Members, Senate Veterans' Affairs Committee Members, House 
Committee on Veterans' Affairs Representative Chellie Pingree (D-ME)

                                 

    In 2011, the Service Women's Action Network (SWAN), in conjunction 
with the American Civil Liberties Union (ACLU), filed a Freedom 
oflnformation Act (FOIA) to obtain data from the Veterans 
Administration (VA) on gender differences in claims and compensation 
award for MST- related PTSD claims over the past 10 years. The VA 
provided the requested data for the fiscal years 2008, 2009 and 2010.
    Upon analysis SWAN discovered that during that time only 32.3% of 
all PTSD claims related to sexual trauma were accepted. Conversely, 
54.2% ofPTSD claims overall are accepted. This overall percentage 
correlates with secondary data obtained by Veterans for Common Sense 
which shows that 53% of all PTSD claims filed by Iraq and Afghanistan 
veterans are accepted.
    Additionally, a series of difference of proportions test revealed 
that across 2008-2010 and in each individual year, women are more 
likely than men to be granted compensation for lv!ST-based PTSD claims. 
When looking at how much compensation men and women receive, women 
awarded compensation are more likely than men to receive 10-30% 
ratings, while men who are awarded compensation are more likely to 
receive 70-100% ratings.

                             Gender differences by year SA/SH Claims by Fiscal Year
----------------------------------------------------------------------------------------------------------------
               Year                   Percent granted--Men     Percent granted--Women              PIN
----------------------------------------------------------------------------------------------------------------
2008                                                    22%                       34%                2587
----------------------------------------------------------------------------------------------------------------
2009                                                    25%                       37%                3108
----------------------------------------------------------------------------------------------------------------
2010                                                    27%                       36%                3825
----------------------------------------------------------------------------------------------------------------

                         Count of Unique Veterans with Initial PTSD Grant By Fiscal Year
----------------------------------------------------------------------------------------------------------------
                         Year                                                  Granted(%)
----------------------------------------------------------------------------------------------------------------
2008                                                                                                      52.9%
----------------------------------------------------------------------------------------------------------------
2009                                                                                                      53.3%
----------------------------------------------------------------------------------------------------------------
2010                                                                                                      56.4%
----------------------------------------------------------------------------------------------------------------

                                              Rates of Evaluation Percentage ofSA/SH PTSD Claims by Gender
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                              10%                 30%                 50%                 70%                100%
--------------------------------------------------------------------------------------------------------------------------------------------------------
Men                                                                  5%                 25%                 28%                 26%                 14%
--------------------------------------------------------------------------------------------------------------------------------------------------------
Women                                                              6.5%                 34%                 31%                 19%                  8%
--------------------------------------------------------------------------------------------------------------------------------------------------------

                                                                         Sexual Assault/Harassment PTSD Claims, FY08-10
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
               Sexual Trauma/Harassment                                     FYO8                                          FY09                                          FY10
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                          Grant      Denial     Total                   Grant      Denial     Total                   Grant      Denial     Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
A. GranUDenial Summary                          Male         186        651        837                     242        740        982                     350        943       1293
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                              Female         601       1149       1750                     787       1339       2126                     919       1613       2532
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                             Unknown           8         16         24                       5         26         31                      12         32         44
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
B. Grant Detail                                %Eva!        Male     Female    Unknown       Total        Male     Female    Unknown       Total        Male     Female    Unknown       Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                   0           1          6                      7           1          9                     10                      9                      9
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                  10          13         53                     66           5         48                     53          21         50                     71
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                  20                                             0           1          1                      2                      1                      1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                  30          49        221          4         274          69        263          2         334          80        306          4         390
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                  40                                             0           1                                 1                      2                      2
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                  SO          51        177          2         230          63        242          1         306         107        298          5         410
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                  60                                             0                                             0                                             0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                  70          40        102          2         144          72        157          1         230          94        175          1         270
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                  80                                             0                                             0                                             0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                  90                                             0                                             0                                             0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                 100          32         42          1          75          30         67          1          98          48         78          2         128
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


```