[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]





  SAFETY FOR SURVIVORS: CARE AND TREATMENT FOR MILITARY SEXUAL TRAUMA

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         FRIDAY, JULY 19, 2013

                               __________

                           Serial No. 113-31

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida            Minority Member
DAVID P. ROE, Tennessee              CORRINE BROWN, Florida
BILL FLORES, Texas                   MARK TAKANO, California
JEFF DENHAM, California              JULIA BROWNLEY, California
JON RUNYAN, New Jersey               DINA TITUS, Nevada
DAN BENISHEK, Michigan               ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MARK E. AMODEI, Nevada               GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana

            Helen W. Tolar, Staff Director and Chief Counsel

                                 ______

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

DAVE P. ROE, Tennessee               JULIA BROWNLEY, California, 
JEFF DENHAM, California              Ranking Minority Member
TIM HUELSKAMP, Kansas                CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana             RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               GLORIA NEGRETE MCLEOD, California
VACANCY                              ANN M. KUSTER, New Hampshire

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 
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both printed and electronic versions of the hearing record, the process 
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unintentional errors or omissions. Such occurrences are inherent in the 
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                            C O N T E N T S

                               __________

                             July 19, 2013

                                                                   Page

Safety For Survivors: Care And Treatment For Military Sexual 
  Trauma.........................................................     1

                           OPENING STATEMENTS

Hon. Dan Benishek, Chairman, Subcommittee on Health..............     1
Hon. Julia Brownley, Ranking Minority Member, Subcommittee on 
  Health.........................................................     2
    Prepared Statement of Hon. Brownley..........................    50
Hon. Jackie Walorski, U.S. House of Representative...............     4

                               WITNESSES

Victoria Sanders, Veteran........................................     4
    Prepared Statement of Ms. Sanders............................    50
    Lisa Wilken, Veteran.........................................     6
    Prepared Statement of Ms. Wilken.............................    56
    Brian Lewis, Veteran.........................................     8
    Prepared Statement of Mr. Lewis..............................    57
    Tara Johnson, Veteran........................................     9
    Prepared Statement of Ms. Johnson............................    60
Michael Shepherd M.D., Physician, Office of Health Care 
  Inspections, Office of the Inspector General, U.S. Department 
  of Veterans Affairs............................................    29
Prepared Statement of Dr. Shepherd...............................    62
    Accompanied by:

      Karen McGoff-Yost, LCSW, Associate Director, Bay Pines 
          Office of Healthcare Inspections, Office of the 
          Inspector General, U.S. Department of Veterans Affairs
Jonathan M. Farrell-Higgins, Ph.D., Chief, Stress Disorder 
  Treatment Program, Colmery-O'Neil VA Medical Center, VA Eastern 
  Kansas Health Care System, Veterans Integrated Service Network 
  15, Veterans Health Administration, U.S. Department of Veterans 
  Affairs........................................................    30
Carol O'Brien, Ph.D., Chief, Post Traumatic Stress Disorder 
  Programs, Bay Pines VA Healthcare System, Veterans Integrated 
  Service Network 8, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................    32
Rajiv Jain, M.D., Assistant Deputy Undersecretary for Patient 
  Care Services, Office of Patient Care Services, Veterans Health 
  Administration, U.S. Department of Veterans Affairs, Prepared 
  Statement only.................................................    66
    Accompanied by:

      David Carroll, Ph.D., Acting Chief Consultant, Mental 
          Health Services, Office of Patient Care Services, 
          Veterans Health Administration, U.S. Department of 
          Veterans Affairs

      Stacey Pollack, Ph.D., National Mental Health Director of 
          Program Policy Implementation, Mental Health Services, 
          Office of Patient Care Services, Veterans Health 
          Administration, U.S. Department of Veterans Affairs
Karen S. Guice, M.D., M.P.P., Principal Deputy Assistant 
  Secretary of Defense for Health Affairs, Office of Health 
  Affairs, U.S. Department of Defense, Prepared Statement only...    70

                       STATEMENTS FOR THE RECORD

The American Legion..............................................    72
Disabled American Veterans (DAV) on Behalf of the Independent 
  Budget.........................................................    76

                        QUESTIONS FOR THE RECORD

Letter From: Hon. Julia Brownley, Ranking Member, Subcommittee on 
  Health, To: Hon. Eric K. Shinseki, Secretary, U.S. Department 
  of Veterans Affairs............................................    83
Questions from Rep. Dina Titus, U.S. House of Representatives....    84
Letter From: Hon. Julia Brownley, Ranking Member, Subcommittee on 
  Health, To: Hon. George J. Opfer, Inspector General, Department 
  of Veterans Affairs............................................    84
Questions from Rep. Dina Titus, U.S. House of Representatives....    84

 
  SAFETY FOR SURVIVORS: CARE AND TREATMENT FOR MILITARY SEXUAL TRAUMA

                         Friday, July 19, 2013

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 9:57 a.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Benishek, Roe, Denham, Wenstrup, 
Walorski, Brownley, Ruiz, and Kuster.
    Also present: Representatives Kirkpatrick, O'Rourke, and 
Speier.

           OPENING STATEMENT OF CHAIRMAN DAN BENISHEK

    Mr. Benishek. Good morning, everyone. The Subcommittee will 
come to order. Before we begin, I would like to ask unanimous 
consent for my friends and fellow Committee Members, Gus 
Bilirakis, Ann Kirkpatrick, Dina Titus, Tim Walz, Beto 
O'Rourke, and Doug Lamborn, and our colleague Jackie Speier, to 
sit at the dais and participate in today's proceedings. Without 
objection, so ordered.
    With that, I welcome you to today's hearing, ``Safety for 
Survivors: Care and Treatment for Military Sexual Trauma.'' I 
am grateful to you all for being here today.
    When the men and women of our armed forces sign up to 
defend our freedom, they willingly accept the threat of danger 
from our enemies. But what they should never have to accept is 
the threat of sexual assault from their fellow servicemembers. 
Perpetrators of military sexual trauma should be aggressively 
pursued, prosecuted, and punished. I, along with many of my 
colleagues here, are working to advance legislation to reform 
and improve the military justice system. Just as important as 
that effort, however, is the one we turn to today: listening 
to, caring for, and supporting the healing of those who have 
suffered this terrible crime.
    According to the DoD, there were roughly 38 incidents of 
sexual assault among male servicemembers and 33 incidents of 
sexual assault among female servicemembers per day last fiscal 
year. Let me repeat, last fiscal year that were roughly 71 
incidents of sexual assault every single day among those who 
wear our uniform. To say this is unacceptable does not 
adequately describe the terrible reality of military sexual 
assault and the lasting effects it can have on the lives of 
those who experience it. A servicemember who is a victim of 
sexual assault is often hesitant to disclose their experience 
or seek the supportive services that they need and deserve.
    While this is troubling to me, it is even more troubling to 
listen to the personal stories of those who have taken the 
brave step to come forward and find that those departments 
tasked with caring for them, the Department of Veterans Affairs 
and the Department of Defense are unresponsive, uncoordinated, 
and unable to meet their obligations to these survivors.
    In January of this year, the Government Accountability 
Office issued a report which found, among other things, that 
DoD sexual assault coordinators, who are allegedly the single 
point of contact for sexual assault survivors, and who are 
tasked with managing their medical needs within the Department 
of Defense are, quote, ``not always aware of the health care 
services available to sexual assault victims at their 
respective locations.'' The GAO also found that military health 
care providers did not have a consistent understanding of their 
responsibilities to care for sexual assault victims.
    Further, a VA Inspector General report issued last December 
found that, among other things, VA's military sexual trauma 
coordinators, who are the single point of contact for veterans 
who have experienced military sexual trauma within VA 
facilities, report as little as 2 hours a week to conduct 
outreach to and monitoring of those veterans who have screened 
positive for military sexual trauma.
    What confidence can assault survivors have when, at their 
lowest moment, DoD and VA fail to understand their own 
responsibilities to provide care, fail to provide the health 
care options that are available, and fail to empower their most 
direct point of contact with the knowledge, authority, and the 
tools to be effective, not just present?
    The answer to that question lies in the voices of our 
veterans themselves. In preparing for this hearing, we spoke 
with many veteran survivors of military sexual trauma and those 
who work closely with them. Their frustrations and concerns 
were legion. I am honored to have four such veterans with us 
this morning. These veterans represent four branches of the 
services, the Army, the Air Force, the Navy, and the Marine 
Corps, and eras of service from the Vietnam war to the 
conflicts in Iraq and Afghanistan.
    These brave men and women have endured firsthand the 
heartbreak and pain associated with military sexual trauma. 
They know better than anyone how very long and difficult the 
journey to healing can be. Each of them has braved public 
scrutiny and the reliving of very painful memories to be here 
today, to share with us their experiences, in the hopes that we 
might do better for those that come after them.
    Your contribution here today will bring out of the shadows 
and into the light a much-needed call for change. I thank each 
of you for your honorable service to our Nation and to your 
fellow veterans, a service which began in uniform years ago and 
continues here today.
    I will now yield to our Ranking Member, Julia Brownley, for 
any opening statement she may have.

            OPENING STATEMENT OF HON. JULIA BROWNLEY

    Ms. Brownley. Thank you, Mr. Chair.
    And good morning to everyone. I would like to thank all of 
you for attending today's hearing focused on examining the care 
and treatment available to survivors of military sexual trauma. 
The Subcommittee will also be looking at the coordination of 
care and services offered to the victims of MST through the 
Department of Veterans Affairs and the Department of Defense.
    Many MST victims who have suffered through an ordeal such 
as sexual assault, oftentimes, are reluctant to discuss their 
situation and seek help. Those that finally gather the courage 
to speak up find that their story is often dismissed or treated 
indifferently, unjustly, becoming the victim again.
    As many of you know, the Pentagon reported earlier this 
year that an estimated 26,000 cases of unwanted sexual contact 
occurred in 2012, up from 19,000 in 2011. With only 13.5 
percent of incidents reported, it is clear that we must do a 
better job in both preventing and treating MST. These 
servicemembers and veterans often continue to experience 
debilitating physical and mental symptoms from MST which can 
follow them through their lives.
    Focusing on prevention, however, is only part of the 
solution. It is critical that we do everything that is 
necessary to do, to make it easier for victims of MST to access 
needed benefits and services and receive treatment. Compassion 
and care are a significant part of healing those that have been 
sexually assaulted.
    I applaud the legislative efforts of our colleagues who 
have introduced legislation, H.R. 1593, the Sexual Assault 
Training Oversight and Prevention Act, and H.R. 671, the Ruth 
Moore Act. These bills seek to ensure stronger protections are 
in place, so that the safety and well-being of our men and 
women in uniform is assured. We must begin to take these 
important steps to end sexual assault. As a proud cosponsor of 
both bills, I believe we are headed in the right direction, but 
we still need to do more.
    I was saddened to read the testimonies of our first panel. 
The pain and suffering was evident in the personal stories 
written. I know that this is hard for all of you, and I commend 
all of you on your bravery to speak up and be here today. We 
need to hear firsthand the experiences of veterans who have 
found the system unfriendly and intimidating so that we can 
make it better. I look forward to hearing from our witnesses 
today.
    Again, I thank you for being here. This is a very important 
issue for us to tackle here in Congress.
    And I thank you, Mr. Chairman, and I now yield back.

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

    Mr. Benishek. Thank you, Ms. Brownley.
    I would now like to formally welcome our first panel to the 
witness table. Will the panelists please come forward?
    Joining us today is Victoria Sanders from Novato, 
California. Ms. Sanders is a veteran of the United States Army 
and a former registered nurse.
    Thank you very much for being here and for your service.
    I will now yield to my friend and colleague from Indiana, 
Jackie Walorski, who will introduce our next veteran witness, 
Lisa Wilken.

           OPENING STATEMENT OF HON. JACKIE WALORSKI

    Mrs. Walorski. Thank you, Mr. Chairman. Thank you for 
yielding and for your commitment and the commitment we share 
with this Committee in addressing this critical issue for the 
survivors of military sexual trauma. And I want to thank every 
Member up here for voting yes on the whistleblower protection 
bill that we passed through the House with a huge bipartisan 
group, and many of the cosponsors are sitting here today.
    It is my honor to introduce Lisa Wilken from Westfield, 
Indiana, a United States Air Force veteran who was sexual 
assaulted and consequentially, 100 percent disabled as a result 
of the trauma endured from her horrific attack. Lisa is more 
than just a wonderful wife and a dedicated mother. She is a 
survivor. She is a survivor who has made it a mission to bring 
other victims out of the isolation and the shadows that they 
suffer through. She is also a veteran, and she has the right to 
receive access to meaningful treatments.
    Lisa, Victoria, Brian, and Tara, thank you for having the 
courage to testify before this Committee today. Thank you for 
your tireless efforts to hold the VA accountable for treating 
victims of military sexual trauma.
    Mr. Chairman, I yield back.
    Mr. Benishek. Thank you, Jackie.
    And thank you, Ms. Wilken, for being here today and for 
your service.
    Our next veteran witness is Brian Lewis from Baltimore, 
Maryland. Mr. Lewis is a veteran of the United States Navy and 
a recent graduate of Stevenson University.
    Mr. Lewis, thank you very much for being here and thank you 
for your service.
    We are also joined by Tara Johnson. Ms. Johnson was born 
and raised in New Jersey, and currently resides in Lake Mills, 
Wisconsin. She is a veteran of the United States Marine Corps 
and currently serves her fellow veterans as an Army wounded 
warrior advocate.
    Ms. Johnson, thank you very much for being here, and thank 
you for your service.
    Ms. Sanders, would you please proceed with your testimony? 
The way it works is, you have 5 minutes to testify, and we 
would like to try to stick to that, to be polite with our time. 
Thank you.

STATEMENTS OF VICTORIA SANDERS, VETERAN; LISA WILKEN, VETERAN; 
        BRIAN LEWIS, VETERAN; AND TARA JOHNSON, VETERAN

                 STATEMENT OF VICTORIA SANDERS

    Ms. Sanders. Thank you. Thank you, Mr. Chairman, 
Representatives and panel. I want to thank you for this chance 
to speak before this Committee. It is like a birthday gift from 
Congress because yesterday was my 58th birthday.
    Thirty-eight years ago, on my 20th birthday, I arrived at 
my only active duty station in Fort Carson, Colorado. One month 
later, I was raped. In the middle of the legal battle around 
the rape, I was thrown into a custody battle. After basic 
training, I separated from my husband and had one child. No 20-
year old private in the military should ever have to fight 
these battles alone, but that is what I did. I was diagnosed 
with PTSD in 2004. It has been a long, hard road, and I am 
hoping my testimony today will help me come full circle.
    My rapist confessed to enough of his crimes that he was 
reduced in rank, lost pay, and was confined to barracks. This 
is an example of chain of command harassment because the 
barracks he was confined to was the one where I worked and he 
still worked in the office next door.
    When you report a rape you become public enemy number one. 
No one will talk to you. And if they do, it is to tell you, you 
got what you deserved. You are called names, you internalize 
what happened, and it feels like it is your fault. Even if your 
rapist is punished, harassment is limitless. It followed me 
through three transfers in 9 months.
    I had an out because my custody battle made me a single 
mother. At the time single parents were discharged quickly. 
They let me go. But I began the slow decline in mental health 
known as post-traumatic stress disorder. When you are raped it 
takes a piece of your soul. Being raped by a fellow 
servicemember is a double betrayal, but not being backed up 
about your commanders is the hardest betrayal of all.
    Because the innocent are treated as criminals, we have lost 
good people on each step of this journey. Today, I want to 
mention two: Carri Goodwin and Sophie Champoux. They did not 
live long enough after being raped to become veterans.
    My experience with the VA mental health was at first 
supportive, caring, trained professionals. We had a great PTSD 
clinic in San Jose. I watched it go from a thriving program for 
both men and women to a ghost town. I was one of a group of 
five women who were not eligible to go for inpatient treatment 
for various reasons. Dr. Alana Pavar and her student Mylea 
Charvat started a process group for the five of us. This is 
usually only done in an inpatient setting. Three weeks into the 
program, she was told by her boss that she could not continue 
this therapy with us. She did, however, finish out the 17-week 
program. She was not going to leave us. Our world was crushed.
    The student who worked with her watched us, and as she 
watched she decided to change her focus to trauma, and 
specifically military sexual trauma. She went to work at the VA 
after she completed her studies. Mylea worked there until she 
was offered a job at Stanford that allowed her the time to 
spend with patients, to be available, and consult for a program 
in Santa Barbara. It does intensive therapy using EMDR 
processing therapy and many things not available at most VA 
facilities.
    This shows me we patients are powerful, but only when we 
are allowed to have meaningful therapy, not just the same basic 
skills. How many times can a person take the same information 
in the same form from a student reading from a book. That is 
not therapy.
    Since I have moved my care to the San Francisco VA, I have 
only seen two actual full-fledged doctors. The rest were 
interns, residents, doctoral candidates, doctoral fellows that 
were not licensed and trained in specific trauma therapy. I was 
retraumatized on many occasions. All of that is outlined in my 
written testimony.
    I believe Paula J. Caplan was right when she said being 
devastated by an assault is not a mental illness. Furthermore, 
it has been well documented that psychiatric diagnosis is not 
scientifically grounded, does not improve outcome--that is, 
does not reduce human suffering--and carries tremendous risks 
of many kinds. Assault survivors should be offered services 
without the requirement they be given psychiatric labels. These 
can be arbitrary and very subjective.
    Further complicating matters is there in no universally 
accepted ideal treatment for PTSD. Having a diagnosis of PTSD 
does nothing without comprehensive care.
    As for the future of this problem from the military to the 
VA, what I see is more of the same. Most of the chiefs of 
staffs were cadets when I was raped in 1975. This year at West 
Point they had to disband the rugby team for inappropriate 
behavior. The number of failures this year alone is too long to 
list. This climate must change. Every day, 71 more people are 
assaulted and 22 veterans commit suicide and we don't know how 
many of those are because of assaults and rapes.

    [The prepared statement of Victoria Sanders appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Ms. Sanders. I truly 
appreciate your words.
    Ms. Wilken, please go ahead.

                    STATEMENT OF LISA WILKEN

    Ms. Wilken. Thank you. I am a United States Air Force 
veteran. I was medically separated after a sexual assault, and 
I am currently rated 100 percent service-connected by the 
Department of Veterans Affairs. I am a wife and a mother, and 
more importantly, I am a military sexual trauma veteran. In my 
opinion, that is the DoD and the VA's way of categorizing us as 
we are rape survivors of friendly fire. And I use those terms 
not to make a joke of it, but to bring it home that we were 
assaulted by someone who wore the uniform as we wore and not 
all people wear the uniform as honorably as you do.
    Thank you for giving me the opportunity to speak today. I 
have struggled for many years to be proud of my service because 
of the experience that I had in the military, but speaking out 
about this topic makes it so that if another veteran doesn't 
have to suffer and struggle with the things that I have 
struggled with, it is important for me to do so. And not a day 
goes by that I don't deal with something that is a result of 
the sexual assault.
    Why is PTSD from assault so long lasting? I believe the 
reason for that is that it is not properly treated or dealt 
with at the time. The treatment that we receive when we report 
an assault in the military, it is as if we are the perpetrator. 
We are the ones who are put under the microscope. And that is 
something that needs to stop. It is almost as if your chain of 
command sets out to do some type of emotional blackmail on you, 
or emotional trauma, and that is something that a rape survivor 
can't handle at that time. You are in a closed society.
    Most people don't realize how much the VA treatment 
facilities mirror our military treatment facilities. And so 
that is one of the big hurdles that the VA must start with, is 
recognizing that there are a lot of men and women that will not 
come to the VA for treatment because of the experience that 
they had in the military or because at the time there wasn't 
the whistleblower protection and they didn't report it. But now 
that they are older and having problems, they won't come to the 
VA because of their experience in the military.
    You are going to hear me speak a little bit about outside 
treatment facilities. We need the ability to go outside of the 
VA, if services are not available for us at that VA medical 
center, so that we don't have to suffer in silence. We need 
groups at our VA medical centers for support, and we need 
groups outside of VA facilities.
    Most people don't realize that sexual assault is not 
something that you can be treated for. It is not like a broken 
arm where your arm is in a cast for 6 weeks and then you are 
fine. Military sexual assault or sexual assault in general, is 
something that changes a person from that point forward. It 
takes the opportunity of what you could have become and changes 
it to what it makes you.
    Why is it so important that we speak out about this topic? 
The reason that it is so important that we speak out about this 
topic is so that other men and women who are currently wearing 
the uniform understand that they are not alone and that there 
are people out there that will stand up for them.
    One of the things that is important to realize is in our 
treatment we need better resources. And those resources can be 
outside of the VA in our local communities. Right now, at our 
Indianapolis VA medical center, the wait to get into see 
someone to treat you for military sexual trauma is almost 2 
years. If we could utilize our local health care providers and 
mental health providers, I know the men and women in Indiana 
would utilize that. Unfortunately, getting approval from the VA 
to go outside is a difficult process, and it is not something 
that is done easily.
    We have MST coordinators at all of our VA facilities. 
Unfortunately, they are generally just one person and they have 
other assigned duties. We need military sexual trauma 
coordinators at all of our VA facilities that have a staff, 
that they are able to do things more than just push the 
paperwork for those veterans; that they are able to interact 
with that veteran and make sure that the veteran is receiving 
the care that they need, and if they are not, have the ability 
to stand up for that veteran. Because those are the things that 
we didn't get while we wore the uniform. And being able to have 
those services available to us now can change people's lives.
    Thank you for your time.

    [The prepared statement of Lisa Wilken appears in the 
Appendix]

    Mr. Benishek. Thank you very much for your testimony.
    Mr. Lewis, please proceed with your testimony.

                    STATEMENT OF BRIAN LEWIS

    Mr. Lewis. Chairman Benishek, Ranking Member Brownley, 
distinguished Members of the Subcommittee, and Members of 
Congress sitting with the Subcommittee, it is a privilege and 
honor to be testifying before you here today. I would like to 
thank my partner Andrew Beauchene, who could not be here today. 
Our significant others allow us to do so much, and they receive 
so little credit for the time, effort, and energy that they put 
into us as survivors. And I want to acknowledge that before I 
start.
    I would also like to thank the Subcommittee for treating 
the issue of military sexual trauma in a gender-inclusive way. 
As the Chairman pointed out in his opening statement, about 
14,000 of the 26,000 sexual assaults on active duty are male 
victims. This gender-neutral conduct places the Subcommittee 
further ahead than the White House and very much ahead of the 
Veterans Health Administration. Indeed, it has been my 
experience that the Veterans Health Administration 
discriminates against male survivors of military sexual trauma 
solely because of their gender. This is a practice that needs 
to be brought to light and stopped by the Subcommittee.
    Currently, the Veterans Health Administration operates 
about 24 residential treatment programs for post-traumatic 
stress disorder. Only about 12 were designed specifically for 
the treatment of military sexual trauma. Of those 12, only one 
accepts male patients. That facility, the Center for Sexual 
Trauma Services at VA Medical Center Bay Pines is 
coeducational. Put simply, male survivors have no single-gender 
residential treatment program designed specifically for 
military sexual trauma. I know, I tried. There was nothing 
available for me in a single-gender capacity.
    This made it very difficult to process the issues when I 
was at VA Bay Pines. I join the American Legion in saying that 
the coeducational model of residential treatment programs needs 
to be overhauled, and quickly.
    In the outpatient environment, care for male survivors of 
military sexual trauma can be spotty at best. While there are 
counselors available for us, receiving care such as peer 
support groups and being allowed to speak about military sexual 
trauma in mixed gender and/or mixed trauma groups, by which I 
mean combat PTSD and military sexual trauma mixed together, can 
be very difficult for any veteran, male or female. This needs 
to stop. Male survivors are the equals of female survivors and 
need to be treated as such by the Veterans Health 
Administration.
    I have placed more substantive data in my written testimony 
about my personal treatment at VA Bay Pines and at the 
Baltimore VA Medical Center, and I will leave that in there. 
The next topic I would like to touch upon is the overall 
supervision of military sexual trauma.
    The overall supervision of military sexual trauma programs 
within the Veterans Health Administration has been vested in 
the Director of Women's Mental Health, Family Services, and 
Military Sexual Trauma. This oversight protocol denigrates the 
experience of male survivors and reinforces the concept that 
the Veterans Health Administration sees military sexual trauma 
as a, quote/unquote, ``women's issue.'' That is not the case. 
Male survivors have just as much right to seek and be treated 
at the VA as any other survivor.
    Another harmful practice is personality disorders. As this 
Subcommittee is well aware, personality disorders have been 
used, along with adjustment disorders, bipolar disorders, and 
many other forms of errant and weaponized psychiatric diagnoses 
to push survivors of military sexual trauma out of the 
military. And it has far-reaching consequences. For example, 
survivors attending the Topeka, Kansas, facility are asked to 
defend their discharge and explain it on the application to 
enter Topeka, Kansas' program. A survivor who has been pushed 
out with one of these weaponized diagnoses does not want to do 
that.
    So I strongly urge the Subcommittee Members to support H.R. 
975, the Servicemember Mental Health Review Act, offered by 
representative Tim Walz. This legislation would give veterans 
like myself who have been misdiagnosed with personality 
disorders to apply for potential military retirement and shift 
some of these costs back to where they belong.
    In conclusion, the Veterans Health Administration 
fundamentally fails male survivors of military sexual trauma 
every single day. They have proven their inability to 
adequately care for us. That is why me and several other 
survivors have founded Men Recovering from Military Sexual 
Trauma, an organization designed to help and advocate for male 
survivors. We respectfully request Congress to legislate 
equality in practice for male survivors of military sexual 
trauma.
    Thank you, Mr. Chairman.

    [The prepared statement of Brian Lewis appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Lewis, for your testimony. I 
truly appreciate your efforts here.
    Ms. Johnson, would you please go ahead?

                   STATEMENT OF TARA JOHNSON

    Mr. Johnson. Chairman Benishek, Ranking Member Brownley, 
and Members of the Subcommittee, thank you for the opportunity 
to speak today. I proudly served in the Marine Corps for 10 
years and achieved the rank of Major. I am now 40 years old, 
and this is the first time I have ever disclosed my experiences 
regarding MST and the care I received or did not receive from 
DoD and the VA.
    I joined the Marine Corps because I wanted to serve my 
country. My first incident of MST occurred when I was an 
officer candidate and I was sexually assaulted by a senior 
officer. Throughout my career in the Marine Corps, I endured 
several more incidents of MST. I did not disclose these 
experiences, as I had seen the unfair treatment of those who 
had reported incidents to their command.
    Despite these experiences, I excelled in the Marine Corps 
and lived the motto so familiar to Marines as suck it up and 
press on. I spent almost 8 years in active duty. I returned as 
a reservist on active duty in 2009. Again, I experienced an 
incident of MST. I began to suffer from depression, anxiety, 
and panic attacks.
    During this period, I did find the courage to approach my 
command regarding these incidents. My statements were simply 
dismissed, and I endured even more harassment and abuse. I 
sought and received medical treatment for panic attacks, 
medication, but I was never asked about MST by medical 
personnel. I was put on medication to relieve depression and 
anxiety. It got so bad I requested early release from these 
active duty orders because the situation was just so difficult 
I felt I could not endure it any longer.
    This decision to leave active duty early placed me, as well 
as my children, in an extreme fragile financial state for a 
very significant period of time. The complete pride I have felt 
as a Marine in the past is now riddled with shame, self-doubt, 
and distrust. In October 2010, I sought treatment from the 
Madison, Wisconsin VA. I received extremely limited treatment 
for the depression, anxiety, and panic, and I was mainly 
prescribed medications. While it was evident through 
screenings, I had severe symptoms of PTSD, I was never asked by 
a provider if I had experienced MST. So basically, I came in, I 
had undergone these screenings for PTSD, but yet, I wasn't a 
combat veteran, but yet no one looked at these symptoms and 
these screenings and said, well, what is actually causing this? 
What is happening here?
    For the first time in my life I contemplated suicide, but I 
knew I needed to continue to cope for the sake of my children. 
While the psychiatrist I saw was helpful, it was extremely 
difficult for me to receive consistent treatment at this time 
as I was not yet service-connected, and I received little to no 
medication monitoring. And I sincerely feel that the medication 
caused even more depression and more anxiety and was the reason 
I had contemplated suicide.
    In December 2010, I had my comp and pen exam for mental 
health. I entered this exam with the hope that the provider 
would address MST and I would finally be able to receive help. 
The doctor spent 20 minutes with me. He was extremely abrupt 
and impersonal and did not once ask me about anything related 
to MST. I was not given the opportunity to disclose my 
experiences. He ended our appointment very quickly, stating he 
was sure I would be fine, and my hope deflated.
    The next few months, as I waited for service-connection, I 
was informed that because of my income the prior year, even 
though I was currently unemployed, I would have to pay for any 
care that I received from the VA during this time. I was not 
yet financially stable and could not afford extra costs as a 
single mother of two boys. I then contacted the transition 
patient advocate at Madison and disclosed my MST experience. He 
immediately contacted the regional office and attempt to have 
MST added to my claim. I was directed by the regional office to 
prepare and submit a statement that described the details of my 
assault and other incidents. Though extremely difficult, I 
completed and submitted this statement. I was hopeful the 
information I provided would allow me to receive another 
examination where I could address my experiences of MST.
    Despite fulfilling their requests, I was not granted 
another exam. I continued to struggle my symptoms and memories 
as well as severe side effects from medication. Because MST was 
not addressed in any of my exams, I was told I was not able to 
utilize the local vet center.
    Several months later, I did receive my service-connection 
and was able to meet with a provider. During intake for the 
PTSD program, the VA provider again did not ask about MST, but 
I decided I needed to disclose my experiences. I was extremely 
detailed and candid. This provider informed me that I did 
appear to have severe PTSD and would really benefit from 
treatment. My sense of relief quickly disappeared as she 
informed me the wait list for PTSD treatment was at least 4 
months long.
    When I did get the opportunity to begin treatment, my 
provider was only at the VA twice a week. I was a working 
single parent and it was extremely difficult to schedule 
consistent appointments. There were instances I would take time 
off work and arrive at an appointment only to be told it was 
canceled. I was also made aware that even though the hospital 
had canceled these appointments, my patient record reflected I 
had no showed or canceled myself. This was simply not the 
truth. I grew more distrustful and frustrated.
    I was then informed I was non-compliant, because I felt I 
couldn't participate in a therapy called prolonged exposure 
therapy for fear that it would increase my symptoms, panic 
attacks, and affect me personally and professionally.
    Throughout this period, I also received limited medical 
care at the VA through the women's health program. No VA nurse 
or doctor ever asked me if I had experienced MST, though 
several of my medical conditions have been directly correlated 
with MST. During this time, I was also employed at the VA in 
the same program. MST was not addressed. And though there was 
an MST coordinator at this hospital, I had never had the 
opportunity to speak with her, and I had never witnessed any 
collaboration between the women's health program manager and 
the MST coordinator. I attempted to speak to my program manager 
several times regarding the need to address the issues of MST 
with our veterans, but I was unsuccessful.
    In 2012, I decided to attempt to engage in treatment at the 
VA once again. I was assigned a male provider who was new to 
the VA. During my first appointment, through tears and fear, I 
again disclosed my experience with MST. The provider looked at 
me, widened his eyes, sat back in his chair and said, ``Well, 
do you really think you were raped?'' I could not bring myself 
to return to the VA. And it was at this time that I began to 
utilize my private insurance. I now pay out of pocket for all 
of my therapy.
    Based on my experiences and those of other veterans I have 
worked with and spoken with, I recommend the VA reconsider 
their approach to MST screening, acknowledgment, and treatment. 
The VA needs to become a safe environment where MST is 
acknowledged. If I had only been asked about my experiences 
with MST, I would have provided full disclosure. I, like many, 
was never asked.
    Thank you.

    [The prepared statement of Tara Johnson appears in the 
Appendix]

    Mr. Benishek. Thank you very much for your testimony.
    Unfortunately, they called votes on the House floor. So we 
will be back in session as soon as they conclude. I truly 
appreciate all of your testimony, and the bravery that you all 
have shown to come here and testify about these deeply personal 
and difficult events.
    We will be in recess until I get back.
    [Recess.]
    Mr. Benishek. The Subcommittee is called to order. I am 
going to yield myself 5 minutes for questions.
    Frankly, the testimony that I heard from all of you today 
is, really, really revealing and tragic, and I know that there 
is bipartisan support in the Subcommittee to make significant 
changes in the way DoD and VA treat victims of sexual trauma.
    I think maybe the most interesting--and I heard this before 
from other cases--of the testimony that I heard from you, Ms. 
Sanders, was the fact--and I think this sort of came out in all 
of your testimony--that you never get someone at VA, if you 
ever get into counseling, that is a consistent provider. I know 
how difficult that is trying to talk to somebody that doesn't 
know your case.
    Can you expand on your testimony there, Ms. Sanders, and 
make us all aware how difficult it is to get a consistent 
provider, even once you have gotten a provider, or has it been 
so bad that you never were able to get anybody consistently?
    Ms. Sanders. When I first entered the system, there was a 
fantastic clinic, and they treated us very well. They went out 
of their way to make sure we got the treatment we needed. But 
it was led by a very dynamic person. That was dismantled, and 
we were left with scraps. Ended up, I was the only person going 
to that clinic and was seeing a social worker, and 
unfortunately she passed away, so I was left with no care.
    I moved to north of San Francisco because I had a 
grandchild and I started care at the San Francisco VA because I 
can't drive very far, and I have had no real care in 2 years. I 
asked for a fee basis. I got a fee basis at one point. I took 
it to our local county. They closed the county office the 
second day I was there. And it was a facility that treated both 
civilians and military sexual trauma victims, and people who 
were coming out of jail and trying to get off of drugs and 
trying to get their children back.
    I have since asked again for a fee basis. I was told, you 
have got a fee basis for two sessions. I was never told where 
to take that fee basis. I was never told who to contact. I 
attempted to say, okay, I have Medicare, can we get some 
movement on that? I received a phone call. They said, go on the 
computer and look up caregivers in your--
    Mr. Benishek. That was all the guidance you got?
    Ms. Sanders. Excuse me?
    Mr. Benishek. That was all the guidance that you got?
    Ms. Sanders. I have in front of me a fee basis that I was 
supposed to receive from May. I never got the letter in the 
mail. I called after 6 weeks because I was told, we don't know 
how long it will take. And she said, oh, it is already expired. 
So they sent it to me and it expired July 17th. I still have no 
one to take it to, no help to find anyone to take it to. I 
asked if a social worker could sit down with me and make the 
phone calls if they didn't want to do it, but I alone cannot 
just sit down and call every provider in my county to find out 
who will take the VA's fee basis.
    The one person I contacted said it would cost me $450 for 
the first session and $280 for every session after that, and 
she had to have the money up front, and I had to go get the 
money from the VA. And then I came here.
    So I am hoping that by coming here and telling you guys 
that a measly two fee basis is not going to get me anywhere. No 
decent provider is going to say, oh, yes, I will see you twice 
and then we will wait and see how long it takes for them to get 
back to us. A real provider wants to give care consistently and 
comprehensively, and that can't be done with two fee basis at a 
time.
    Mr. Benishek. Yeah, of course.
    Ms. Sanders. Does that answer your question?
    Mr. Benishek. Well, yes, it gives us a feeling of what is 
going on because it is just so frightening, frankly, the 
testimony that we have heard here this morning. And I know that 
there is great bipartisan support to make this better. But, my 
frustration persists.
    I thank you. And I am out of time.
    Ms. Brownley, you have 5 minutes for questioning.
    Ms. Brownley. Thank you, Mr. Chair.
    And again, I want to thank all four of you for being here 
today and sharing your story with us. It is extremely important 
in terms of our work moving forward.
    I want to say, certainly as a new Member of Congress, I am 
a new Member of Congress, and I just want to personally 
apologize to all of you because we should have done and we need 
to do a much better job in support of what has happened to you 
as you have served our country. And your bravery today is to be 
commended, and your duty as soldiers in the military and your 
service to our country, but the bravery that you have 
demonstrated today, I think, is really beyond the call of duty, 
and I am very, very grateful for your participation.
    And there is no question in my mind that there is a lot of 
work that needs to be done. I mean, we need to address the 
culture that takes place in the military. That needs to be 
fixed. We need to address the transition from leaving the 
service to becoming a veteran. And then certainly, if there is 
trauma that takes place, then we need to eradicate that from 
happening in the first place, but if something does happen, 
then as a veteran who has served our country, we need to figure 
out how to best provide and service all of you to the very best 
of our ability and to mimic best practices that are happening 
outside of the VA, and what is really happening, you know, in 
facilities across our country when one is sexually assaulted.
    So I am not even really sure where to start on the 
questioning, but I guess, you know, I certainly would like to 
hear your positions, or your suggestions, I guess, vis-a-vis 
how we can improve. There has been conversation about sort of 
case management, so that we, if someone is sexually assaulted 
in the military, that we transition them with continuity of 
care to make that transition as best as it could possibly be. 
But I would just, you know, I offer suggestions, really, from 
all four of you in terms of, as you have had your own 
experiences and knowing what the system is today, how can we 
improve upon it?
    Mr. Lewis. Thank you, Ranking Member Brownley.
    My first suggestion is that fee basis care needs to be made 
available at the request of the veteran. As our testimony has 
demonstrated, VA is fundamentally incapable of providing care 
to survivors of military sexual trauma in the current 
environment. There are provisions in section 1720B that allow 
fee basis care to be offered if it is clinically inadvisable, 
and that is currently the case in a lot of VAs.
    I know one VA where male survivors of military sexual 
trauma are seeking care in the women's clinic. That is not best 
practice. That is horrible practice. These ladies as survivors 
deserve a space to be safe and to not be triggered potentially 
by male veterans. I, in turn, deserve the same place to go and 
not have--if my perpetrator were a female, which happens a lot 
more often than we would think, I deserve that same place to go 
and not potentially be triggered. I also deserve to have, in 
essence, my manhood respected by not having to seek my care in 
a woman's clinic.
    I also deserve to have a treatment program designed 
specifically, and that is an area where VA can do a lot more 
research. There is very little medical literature out there, as 
I am sure the Chairman well knows, about male survivors of 
sexual trauma of any sort, and that is an area VA can be 
leading research and they are not doing it.
    The other suggestion I would have is to make sure that 
there is continuity of care, as the previous question 
suggested. Just today, I received a phone call from my current 
provider. He had been out of the office intermittently on and 
off due to health care problems, but still that makes it 
difficult. When I returned back from Bay Pines, their facility 
was to ensure that I received continuity of care. They failed 
at that. I went for 2 months after leaving Bay Pines without 
seeing a medical doctor or a psychologist.
    What sort of system do we have where we consistently fail 
our veterans? I cannot in good conscience recommend VA to any 
survivor of military sexual trauma at this time. Thank you, 
Ranking Member.
    Ms. Brownley. Thank you. Has my time expired?
    Mr. Benishek. Yes, unfortunately so.
    Ms. Brownley. I yield back.
    Mr. Benishek. Dr. Wenstrup, you have 5 minutes.
    Mr. Wenstrup. Thank you, Mr. Chairman. You know, in the 
Army we have an acronym, LDRSHIP: Loyalty, duty respect, 
selfless service, honor, integrity, and personal courage. And, 
you know, that means addressing wrongs that take place, and 
wrongs that not only exist in the world as a military, but 
wrongs that exist within our military. And what has happened to 
you is literally a form of devastating trauma.
    And I know I speak for all my colleagues on this Committee 
that taking care of our troops is not just a nice thing to say 
and not just a nice thing to do. It is our obligation to do so. 
And I really appreciate your courage today, and I think it is 
up to us to have the courage to change policies and attitude.
    My question to you today, and I think I know the answer 
from your testimonies, but I would like to hear from you 
directly on this. Do you feel that currently that you would be 
more comfortable getting care inside or outside of the VA? And 
I think you just answered that.
    Mr. Lewis. Let's all answer together. Aye.
    Ms. Sanders. Aye.
    Ms. Johnson. Aye.
    Ms. Wilken. Aye. Receiving care outside of the VA 
accomplishes a couple of things. One thing that it 
accomplishes, it puts us in the hands of people who are trained 
to treat sexual assault victims. Unfortunately, the VA doesn't 
have a protocol set up to train their employees of how to 
interact with military sexual trauma veterans, therefore a lot 
of times they trigger symptoms and make our PTSD worse.
    Also, with fee basis being sent outside of the VA, fee 
basis reimburse at Medicare rates. And so I have a fee basis 
card. I received that card because I had an unnecessary surgery 
at our VA hospital in Indianapolis due to a nurse looking at 
the wrong lab results. And as a result of that my mental health 
care provider, my psychiatrist, and my GYN and primary care 
physician wrote consults for me to be able to seen outside of 
the VA. Originally it was denied. The second decision they 
approved me to go outside for GYN services, but not for any 
other services.
    When I appealed that decision, then I was given my fee 
basis card and it says all medical conditions. The difficult 
part in that is finding a provider in your local area that will 
accept that fee basis because there is no partnership with the 
VA. And so if they are a provider that does their own billing, 
they don't want to see you because they don't want to have to 
deal with pushing the papers to the VA or waiting for that 
reimbursement, or if you are a provider and you can bill 
private insurance $85 for an hour session, but you are going to 
get back $19 for Medicare at the reimbursement rate, would you 
as a treating physician take that patient on?
    And so there needs to be a partnership between fee basis 
and our local community, and more importantly, also with a 
national chain of pharmacies. Because when we see an outside 
provider in your fee basis and you are given a prescription for 
medication, you have to mail that in to the VA and wait for 
them to mail your medications to you. A lot of times those 
medications need to be started immediately. You have the option 
of going to your local pharmacy and paying for it yourself, but 
then you are uninsured and you pay the full rate for that 
medication.
    You can then have the VA reimburse you, but as responsible 
veterans, the majority don't do that. They mail it in, and they 
wait for it to come back. And it seems as though the VA doesn't 
look for those commonsense solutions, and that is what I would 
like to ask the Committee to do today.
    Mr. Wenstrup. Thank you.
    Go ahead. Please, go ahead.
    Mr. Johnson. In speaking very briefly about my employment 
and time with the women's health program, one of my primary 
responsibilities was to do outreach calls. And the outreach 
calls were literally to get numbers for women veterans who are 
up-to-date on mammograms and Pap smears, and if they were not, 
the process for them to go outside of the VA, you know, through 
fee basis and through working partnerships with hospitals in 
more remote areas was so simple, I was dumbfounded. But yet 
there is still no simple way for someone who has experienced 
MST to go outside of the VA and receive counseling and therapy 
and medications.
    So if we are doing it in one program, that tells me that it 
is possible to do it for others, too.
    Mr. Wenstrup. Again, that is exactly the type of input that 
I wanted to get.
    Mr. Lewis. Congressman, one thing I would like to address 
briefly before your time expires is the use of interns and the 
use of students, medical students to provide care in the VA. I 
know at my home VA they are heavily dependent on medical 
students, and that is simply not a good practice with survivors 
of such complex trauma as military sexual trauma.
    There is a place for medical learning. When I was at Bay 
Pines, my primary counselor there was a psychology postgrad, 
and I found her when I was sitting there trying to disclose 
details of my trauma, sitting there clicking her tongue ring as 
I was talking about my trauma. To me, that is horribly 
disrespectful. And another instance at my home VA in Baltimore, 
a psychology student was running a group and was allowing 
combat veterans to talk about their trauma while not allowing 
MST veterans to talk about theirs--it was me and one or two 
others--because the VA focuses on combat trauma, in her own 
words.
    Quite honestly, there are some four- or five-letter words I 
could say to that, but for the purposes of the Committee we 
need to be looking at the proper use of students and residents 
in providing MST care and we need to be giving a hard look at 
that. Thank you, Congressman.
    Mr. Wenstrup. Thank you.
    Mr. Benishek. Thank you.
    The gentlewoman from New Hampshire, Ms. Kuster.
    Ms. Kuster. Thank you very much, Mr. Chair, and thank you 
to all of the Members of the Committee for convening this 
hearing. I was one of the Members that requested that this 
happen, having spoken to veterans in my area, New Hampshire.
    One message I want to convey, along with Ms. Brownley and 
Mr. Wenstrup and Ms. Walorski and Ms. Kirkpatrick, is that we 
are recently elected, Ms. Kirkpatrick coming back, but we are 
new Members to Congress and so we are arriving here right at a 
time when the public is very focused on this issue. And I want 
you to know that we are going to work with Ms. Speier, who has 
been working on this issue for a long time, and with a number 
of other colleagues in both the House and the Senate.
    I really appreciate the chair for holding this hearing. 
This is a significant issue, and we have made a real strong 
commitment to work in a bipartisan way. And I want to thank my 
colleague, Ms. Walorski, for leading what was truly an 
extraordinary effort on this whistleblower protection, and I 
want you to know that we take that very seriously. We passed 
that bill 2 weeks ago 423-0 in the House. That is the kind of 
support you have when we come together and find common ground. 
So I know that we can help you, and I join Ms. Brownley in 
apologizing to you that you haven't been heard previously.
    So my question, I have been trying to jump start my 
education on this by going and visiting facilities. New 
Hampshire is the only State without a full service veterans 
hospital, but fortunately, we share the hospital in Vermont, 
White River, Vermont. They have a brand new, newly opened care 
center. And I hear, Mr. Lewis, your concerns, and I want to 
address that. But in this case, it is a brand new women's 
support center where they have listened to victims and 
survivors about literally the architecture, but particularly 
the programming that they want. I also visited a Manchester 
veterans center where they have really outstanding treatment 
and provision of counseling and groups and such there.
    And so I want to ask you, I respect the recommendation for 
care outside of the VA, and if that is the direction we go, 
then that makes sense to me, because I understand we can't 
bring the training up all across the country. But if you were 
in a position to advise us of what best practices would look 
like if we could get to that place in the VA system, what is it 
that you would recommend be included? And this would be either 
in a hospital setting, in a med center, in a vet center 
setting, in a clinic setting, what are the components that you 
would recommend to us?
    Mr. Lewis. Congresswoman, I appreciate the question. And to 
hear about the program at White River Junction, quite honestly, 
almost makes me want to cry.
    Ms. Kuster. It was truly incredible, and I was given the 
tour by a victim that had been a part of a task force and they 
had addressed a lot of the issues that you are talking about 
including, you know, literally, the entrance, making sure that 
it is glass, that the women can see who is coming in. The only 
treatment providers are female in that entire section. And so 
what are some of the elements that we could be addressing?
    Mr. Lewis. I will defer to some of the women veterans 
sitting here to talk about the components of the women's 
veterans program, but I think that the first thing that White 
River Junction would do, to bring it to your area, is to do 
that same thing for male survivors. We don't deserve to have to 
walk through the same sea that the women veterans have 
complained about and be looked at in a demeaning tone because 
we are not combat veterans. We also don't deserve to be mixed 
in with the women only because VA cares that little about male 
survivors.
    Other components that I would suggest is MST programming 
needs to be conducted in mental health. As a man, if I go to 
women's services, they are triggered, I am certainly triggered 
because I feel a lot less than a man being respected as a 
survivor. I would also recommend getting away from the current 
practice of teaching by the manual and hoping our objective 
scores go down. That is not right. It is an experience, it did 
cause psychological damage, and it deserves to be looked at 
holistically, not out of a manual where you go from one method 
to the next, to the next.
    And that takes a whole-person concept. That takes peer 
supporters. That takes a whole range of things. And I would be 
happy at some future point to talk to you about that, and I 
will defer to the lady survivors here about the women's side.
    Ms. Sanders. I would like to see satellite clinics. My 
mother lives in Kansas. They have a satellite clinic that 
comes. It is only a distance of 35 miles to the hospital. But 
twice a month they come, and so the people can come to that 
satellite clinic and get their medications renewed or get 
whatever it is they need. And I think that that model should be 
used for military sexual trauma. I think that if you could say 
on Mondays we have a women's clinic at this address where it is 
not the VA, and it is just for women, or men, and you can rent 
a room, it is inexpensive that way, you are not building a 
facility, we are not asking you to build us the Taj Mahal, we 
are just asking you to provide us a safe space close enough to 
our home that we feel comfortable in going that distance.
    For me, an hour away is too far at this point. I can't make 
it. The vet center in my county has one man that works there, 
and he can't even answer the phone because he is so busy. He is 
afraid to work with female survivors because he is afraid, 
because he is a big body-building man, that they are going to 
be afraid. When I came out in the newspaper we had a long 
discussion and he said, I am afraid of what will happen if you 
come out in our local paper and women call expecting there to 
be a woman here. And there isn't.
    The vet centers need to be supported, and the idea of a 
satellite clinic needs to be explored, which could eliminate 
some of the fee basis. If you take the trained people you have, 
send them to Trinity County for Wednesdays and Humboldt County 
for Tuesdays and provide the care where the people are. I was a 
nurse and I was taught, you always meet the patient where they 
are. You do not expect the patient to come up to wherever you 
are. I said in my written testimony, at times it feels like you 
are saying to us, if you get close enough, I will fix that 
broken leg of yours, but until you walk over here, I can't help 
you.
    Ms. Kuster. Right. Thank you.
    Mr. Chair, I have gone over my time.
    Mr. Johnson. Could I add one more quick comment? While I 
agree with the other witnesses here, and their suggestions, I 
think it goes back to basics too. I was never asked. I was 
never screened.
    Ms. Kuster. Right.
    Mr. Johnson. I was never given the opportunity or that 
trust-building period to disclose my experiences, for whatever 
reason. If you can't get your foot in the door and doors keep 
slamming in your face, you are either going to give up, you are 
going to go elsewhere, or something worse is going to happen.
    So I really think we need to look at the basics, and start 
with consistent--I am reading testimony from, you know, others 
that are going to talk today saying MST screening, MST 
screening. In my experience, I didn't receive that. So if we 
can find a more consistent--
    Ms. Kuster. Yeah, that needs to be the standard.
    Mr. Johnson.--then we can get in the door and then we can 
decide where the treatment is coming in. But we need to look at 
the very, very beginnings of putting that first step, putting 
your foot into the door of that VA hospital, the people that 
are supposed to know everything and help you.
    Ms. Kuster. Thank you so much for your courage.
    And thank you, Mr. Chair, for your indulgence.
    Mr. Benishek. The gentlewoman from Indiana, Ms. Walorski, 
you have 5 minutes.
    Mrs. Walorski. Thank you, Mr. Chairman.
    And again, to you all for coming today, thank you so much. 
I would like to echo what Representative Kuster was saying. We 
are committed to eradicating sexual trauma in the military. And 
we are new, and we are all young Members here, but our passion 
and our commitment to you today is that, you know, the bravery 
that you have exhibited by being here today, the courage on 
shining a light in the darkness makes a difference. We get 
calls every day now that we have talked about this from the 
time we have been here, every day there are new people coming 
forward and sharing their stories. And your stories are going 
out today around the country, and that is why we are thankful 
that you made the trek. And just to let you know that we are 
standing with you and we are fighting for you. And thank you 
for your service to our Nation. It is our turn to fight for 
you, and you have my commitment to continue to do this until we 
eradicate this from our military.
    Lisa, I wanted to ask you particularly because you are well 
informed and you have made it a mission in the State of Indiana 
to find out the scope of the weaknesses, the strengths of the 
VA. How would you describe, overall, in the State of Indiana, 
treatment for MST victims as you pursued it, not only from your 
perspective, but because you know, you have a wealth of 
information about how our State runs? How would you overall say 
the conditions are with treatment of MST?
    Ms. Wilken. Overall, in the State of Indiana, if I had to 
rate it on a scale of 1 to 10, I would give it a 3, because 
they are making an effort. We have a military sexual trauma 
coordinator at the VA medical center in Indianapolis who is 
wonderful, but she is one person. We need more services of what 
has been talked about today, whether it is satellite clinics or 
using outside treatment facilities, but the issue needs to be 
addressed, not only on a State level, but on a national level 
with you here today.
    Mrs. Walorski. I appreciate it. And also if I could follow 
up on that, Lisa. And I can just tell you the information we 
have heard from here today is tragic. It is just such a tragic 
story. And so we hear all these stories and we see all the data 
and we are listening to you. There is such a growing need to 
treat victims of MST.
    Why do you think, Lisa, as you have gone through this 
maneuvering process, what do you think the biggest issue is 
with the VA being so resistant to this information, and despite 
the pleas from veterans, thousands of veterans around the 
country?
    Ms. Wilken. I wish I could answer that and give you an 
answer of why, but I can't answer that because it doesn't make 
any sense to me. If the treatment is already set up in your 
local community or you have avenues in your local community, 
but the VA doesn't have the services available, common sense 
would tell you, treat the veteran, treat the survivor, and we 
are not seeing that right now. And so going out into our local 
communities, while the VA is developing their process, would be 
something that would be beneficial.
    Mrs. Walorski. And let me ask you this. You know, our hope 
is--we passed this whistleblower protection law, as you are 
familiar with, and you were a helpful story with that as well. 
With whistleblower protection, you know, hopefully being valid 
and signed into law in January of 2014, and if we can move this 
Congress to get those outside services and those things 
provided outside of VA, do you think we will see an influx of 
folks reporting because they will feel like they have a safe 
haven on one end in the military from retribution and on the 
second side not be incumbent upon going to the VA for services 
that don't exist?
    Ms. Wilken. I think you will see MST veterans and survivors 
come out the woodwork. There are men and women across this 
country who wore the uniform and were proud to serve, but 
haven't been proud of their service because of the experience 
they had, and if you give them the opportunity to give them 
skills to deal with years of unattended PTSD symptoms, I know 
these men and women will reach out and want to help themselves 
and their families.
    Mrs. Walorski. I appreciate it.
    Anybody else want to crime in? We have 50 seconds.
    Mr. Lewis. Thank you, Congresswoman. You asked earlier 
about treatment at VA. One of the main problems is there is 
simply too few providers. I go to the Baltimore VA, and we are 
talking a big city here, and there are very few MST providers 
that are specifically trained in this area. You have heard of 
all of us talk about our MST coordinators. It is a collateral 
duty. At a big city VA, even at the smallest VA, that is a 
full-time job. I guarantee you, we could fill this room to 
overflowing with veterans who could talk about horrible 
treatment at the VA, and we are giving this collateral duty to 
one person. That is wrong.
    So let's get a lot more people in there that are trained 
and are willing to provide quality care, and let's get 
researchers in there that are willing to do the research, 
especially with male survivors. Thank you, Congresswoman.
    Mrs. Walorski. I appreciate it.
    Thank you, Mr. Chairman.
    Mr. Benishek. My colleague from California, Dr. Ruiz.
    Mr. Ruiz. Thank you very much, Chairman.
    I first want to say, thank you so much, Ms. Sanders, Ms. 
Wilken, Mr. Lewis, and Ms. Johnson for having the courage to 
come up and tell your story once again. And I want to say how 
very proud I am that today you have given voice to so many 
women and men who have suffered this atrocious experience.
    It is a triple assault that many of our veterans face. One 
is the trauma of war or the trauma of feeling that they could 
die at any moment through an experience from war, which is PTSD 
related. The second is the trauma of the MST experience. And 
what I am hearing now is that we have a third incident, and 
that is the trauma of the lack of coordinated, sensitive, and 
appropriate care.
    That as a physician sometimes I know that the treatment can 
make things worse. And so as a physician, it is absolutely 
unacceptable. As a congressman, it is absolutely unacceptable. 
And I know I speak on behalf of everybody on this panel, I know 
the hardships that many patients face, men and women who come 
to the emergency department because of sexual trauma.
    I agree that sexual trauma is a holistic illness that is 
not something acute that can be treated with a pill. It is not 
a one-time shot. It is not a one-time treatment. It is a 
lifetime struggle. And part of the illness of this is the sense 
of powerlessness, and part of the treatment is to regain that 
power as an individual, to be empowered, to feel like you are 
back in that control room. And so I appreciate it because what 
you are doing today is giving that empowerment to a whole lot 
of people around our country, and I thank you for doing that.
    A side victim in all of this is the family and 
relationships that you have with your spouses, your significant 
other, your children, issues of trust, issues of being able to 
communicate. And I know that it is very difficult. Has the VA 
addressed treatment with your significant others, your 
families, and your closest friends?
    Ms. Wilken. I will answer that. Not to my knowledge. I 
don't know that there is any type of program set up for family 
members, spouses, or children. But thank you for bringing that 
up. It is something that most certainly needs to be addressed.
    We all talk about it as military sexual trauma. We are all 
rape survivors. No one wants to use the word ``rape'' because 
it brings with it all the ugliness that rape brings into your 
life. It was brought into our lives, and we brought that into 
our family's lives, and our families need support. They are our 
biggest support network. Issues need to be addressed with our 
significant others and with our children. It could be modeled 
after an Al-Anon program who gives support to family members of 
alcoholics. We need that support so that we have a strong 
support system. They need a support system also.
    Intimacy issues need to be addressed. That is something 
that we don't like to have to talk about, our intimacy issues 
that we have with those who have stood by us and who have loved 
us through this process, but it is important and they deserve 
that. And so if I could ask the panel to take a look at that 
issue, it needs to be done.
    Mr. Lewis. And if I could follow up on that?
    Mr. Ruiz. Yes, sir.
    Mr. Lewis. A significant barrier in that is veterans who 
are identified as gay, lesbian, bisexual, transgender, services 
in that department can be very difficult. I do know the VA in 
St. Louis, through the work of Terri Odom, is starting in that 
area, but it is not a national trend yet and that really needs 
to be addressed, because there can be a lot of gender 
confusion, a lot of sexual confusion after a sexual trauma, and 
that really needs to be addressed.
    And I would also like to pick up on your point about 
survivors having power again. A lot of times the VA takes our 
power away from us or asks us to use it in inappropriate ways. 
I was asked to take a nerve block to relieve some of my chronic 
pain, and I was asked to take this nerve block transrectally. 
Imagine a mail survivor being asked to take a nerve block with 
a doctor. You are in an OB/GYN chair. Your legs are up, and you 
are having something inserted through your rectum and pushed 
into a nerve in your prostate to remove your pain. That is the 
type of pain I live with.
    My psychologist would not step in knowing what that 
procedure would do. That power should not have been needed to 
be exercised by me. That should have been my psychologist 
stepping up and saying, no, this is contraindicated. So 
sometimes that power is used in both ways.
    And you are right, Congressman. You know who was there for 
me? It wasn't the VA. It was not anyone at the VA. It wasn't 
even the doctor that gave me the injection. It was my partner 
that got me out of that building. And he gets no recognition 
from the VA for that effort. And they need it badly. Thank you, 
Congressman.
    Mr. Benishek. Thank you.
    My colleague, Dr. Roe, 5 minutes.
    Mr. Roe. Yes. I thank the Chairman.
    And thank you all, the entire panel, for being here today.
    You know, I go back as a young military medical officer 
during the Vietnam era, and I was thinking, as I was listening 
to the testimony, what training I had had, and I am an OB/GYN 
doctor, and what training did I have going into the military as 
a drafted doctor and what training did I get in the military to 
treat this.
    And I can tell you, in the military I received none, and 
one of the reasons was military sexual trauma was occurring, it 
didn't start now, it has been going on, but it was not 
recognized. I mean, I never heard it mentioned. And just 
logically thinking about it, you knew it occurred outside the 
military, why in the world wouldn't it have occurred in the 
military. But it was one of those, I mean, if you just think 
logically about that, why all of a sudden one day I am out in 
the civilian world and I get drafted and sent in the military 
and the next day it is not an issue.
    In today's military there are a lot more women serving. I 
have been to Afghanistan with Dr. Benishek and others, and it 
is amazing how many women now are doing a phenomenal job in the 
military. And so there is that issue there. And I think what we 
have to do as a scientist, you identify the problem, you 
identify and try to determine what the incidence of that 
problem is, and then you try to find a solution to that 
problem.
    And I think, Ms. Sanders, you brought up something--and I 
don't think the VA has ever been equipped to do that. I look at 
my--we have a VA medical center in my hometown, and it is 
woefully undergunned in this. I can tell you right now. There 
is no way on this earth they are prepared. It doesn't mean that 
those folks are not willing to do it. It just means that they 
are not prepared to do it adequately right now.
    I think Ms. Sanders as a nurse brought this out very, very 
eloquently in your testimony--or answer, I should say--is that 
you want to get that chair to as close to home where you feel 
safe and so forth as you possibly can. It is intimidating 
enough to go a doctor's office or to a large medical center. I 
mean, I am going to have a physical next week, and I have 
already got sweaty palms about it, and I have done thousands of 
them. So I understand exactly what you are saying.
    I think either we take the treatment to the patient, but as 
Dr. Ruiz said, you can't take the wrong treatment to the 
patient. You have done them harm, not good, as Mr. Lewis 
pointed out. So I think we identify the problem and then look 
for victims, like yourself, who have suffered military sexual 
trauma, and come up with a plan of how to better treat these 
patients, and right now we don't have it. And whether it is, as 
Ms. Wilken says, outside the VA, if that is where the best 
therapy, that is where the patient should be able to go, where 
they get the best treatment.
    And I guess, Ms. Johnson, I was looking at your testimony 
and you have said that the treatment you received at the 
Madison, Wisconsin VA was extremely limited, and what did you 
mean by that?
    Ms. Johnson. It had to do with the fact that I was not yet 
service-connected, so I was continuously told that I couldn't 
receive consistent treatment there until my service-connection 
came through.
    Mr. Roe. Okay.
    Ms. Johnson. That being said, the problem with that was 
that MST was never addressed, so who knew that that was part of 
the issue.
    Mr. Roe. Never connected the dots.
    Ms. Johnson. Exactly. Not through, you know, my primary 
care physician when I started having GYN issues, to include 
emergency room visits, not mental health. And as I said in my 
oral testimony, I was not a combat veteran. So to have all of 
these symptoms going on and still not be screened for MST, so 
that I could receive treatment and therapy while waiting for my 
service-connection really put me behind, and it was really a 
travesty because every time I had to go there, I built myself 
up for a week before saying, I am going to tell my story, this 
is it, I am going to be able to do it, and then I would be 
deflated. And then it would take me another week to really come 
down from that experience. And, you know, it was different 
providers every time I went. The most often I had ever seen the 
same provider was twice.
    Mr. Roe. I think you hit the nail. I stayed in the same 
spot for 31 years before I was elected to Congress, and I have 
had patients that I had known for 20 or 25 years that finally 
told me something after 25 years, and it was like--I mean, they 
knew me well and knew me very well and had seen me, and maybe I 
delivered their children, whatever. And it was like a load of 
bricks being lifted from their back. And I think you could see 
their life open up in front of them. And I didn't see that one 
time. I saw it multiple times.
    And as I point out to you all, I did numerous sexual trauma 
evaluations on patients that had been assaulted in the private 
sector. And as I think back to my time and the 2 years I spent 
in the military, I didn't do a single one. You know it was 
there, but it was just so under the carpet, nobody talked about 
it. I think the fact that you all have done that have really 
been helpful, maybe the most helpful thing, and I think the 
other things you all can do is give us ideas about how we can 
help the VA be better.
    And we found out how doing it not right for you 
individually helps, and I suspect that your story is not that 
much different. Everybody is an individual, but still there is 
a common theme here that I am hearing.
    I yield back, Mr. Chairman. Thank you.
    Mr. Benishek. Thank you.
    Mrs. Kirkpatrick.
    Mrs. Kirkpatrick. Thank you, Mr. Chairman, for holding this 
hearing.
    Thank you, Ranking Member Brownley, for this opportunity to 
hear from you.
    And thank you for showing up and your courage to testify 
before Congress. I am just so sorry for what has happened to 
you.
    I am a former prosecutor. I have prosecuted rape cases, and 
I just want to know if any of your perpetrators were ever 
charged.
    Ms. Wilken. My perpetrator was charged. I went through the 
Article 32 hearing, which is the equivalent of a grand jury 
hearing, and he was charged with five charges. Went through the 
rest of the investigative process, and he was given an other 
than honorable discharge in lieu of court martial.
    The special prosecutor that was brought in from the 12th 
Air Force to prosecute the case on Offutt Air Force Base 
explained to me the night before we were headed to trial the 
next morning, they called me in for another meeting, and sat me 
down and explained that, Lisa, I can prove that he raped you, 
but the rape wasn't violent enough for him to get any real jail 
time. And what this gentleman was doing was giving me a message 
of what I was in for the next day. He knew what I had been 
through, through the investigation and the Article 32 hearing, 
but that was his compassionate way of letting me know that we 
can go forward with this, and we can prosecute him, but what 
they are going to do to you in the meantime is not at all going 
to compare to what they do to him.
    But he would not agree to giving him an other than 
honorable discharge unless I agreed to it. And I was 22 years 
old at the time with no victim advocate because they didn't 
allow them on the base at the time, and I agreed, because I 
knew what I was in for, and if it wasn't going to result in him 
getting any jail time, there was no reason to put myself 
through that.
    So they had him processed and out of the United States Air 
Force and off base within 1 week, and then I found out that he 
had attempted to do the same thing at his previous base. So 
they put a repeat offender out into the civilian world with no 
criminal history.
    And so it is important that you are having this hearing 
today so that victims have an opportunity to realize that 
people are listening now, and hopefully, we can make a change 
so that someone younger than myself doesn't have to make the 
same mistakes that I have made over the years trying to deal 
with PTSD.
    Mrs. Kirkpatrick. Thank you for sharing that with us.
    And you know, Dr. Ruiz, I just want to add to your list of 
traumas. I think there is a fourth trauma here, and that is 
that these perpetrators got away with it, and there has been no 
justice. And I suggest to the Chairman and Ranking Member, 
maybe that is a topic that we could have a future hearing on 
because, you know, they got away with it, and that is just not 
right. And again, I am so sorry.
    Ms. Wilken. And if I might, the decision, you being a 
former prosecutor, the decision of which cases get prosecuted 
right now is currently in the chain of command. That is 
something that this Congress is hopefully going to continue to 
take up. The Whistleblower Act is a wonderful thing that is out 
there so that victims can feel confident that if they do decide 
to report, that they won't be retaliated against. But common 
sense again tells us, if you can't get a commander to prosecute 
rape, a crime of violence, why would a victim have any 
confidence that that commander is going to protect them when 
they come forward? So thank you for bringing that topic up. It 
is important.
    Mrs. Kirkpatrick. That is exactly my concern. Thank you 
very much.
    Mr. Lewis. Ms. Kirkpatrick?
    Mrs. Kirkpatrick. I yield--go ahead. Yeah.
    Mr. Lewis. If I might, Ms. Wilken is very--I hate to use 
the wrong word here, but she has seen some measure of justice. 
A lot of survivors really do not see justice at all. I know in 
my case, I was threatened under the ``don't ask, don't tell'' 
policy, and that is a huge concern, especially in the veteran--
in the male survivor community, is that we were told, if you go 
forward with this, you will be outed as a gay man, regardless 
if you are or not, and pushed out of the military, or you will 
be given some sort of weaponized diagnosis like personality 
disorder or border line adjustment or whatever.
    Another aspect of your question is the current process to 
change your discharge. The military's favorite line is, if this 
person is dissatisfied with their discharge, tell them to go to 
the Board for Correction of Military Records. I am here to tell 
you that is a joke, and that is really deserving of this 
Congress' attention. Less than 10 percent of all upgrade 
petitions are adjudicated favorably. Imagine the psychological 
damage that does to a veteran when they get--first off, they 
are traumatized in the military, then they have to go back to 
the military and say, we were hurt, we deserve our PTSD because 
these people rated us as at 100 percent and these people gave 
us a general discharge. And then the military says, oh, no, we 
were totally right in doing it.
    That is another area that totally needs to be addressed, 
and that is also a good reason to pass H.R. 1593, the STOP Act, 
just as quickly as possible, is to stop some of those actions 
and to really enforce the whistleblower laws, because if you go 
ahead, especially in the military, you are going to be pushed 
out and then you are going to be told you can't get your 
discharge changed. And that has implications in the VA for 
receiving care. Thank you.
    Mrs. Kirkpatrick. Thank you very much. I yield back. Thank 
you, Mr. Chairman.
    Mr. Benishek. The gentlewoman from New York, Ms. Speier.
    Ms. Speier. Actually, it is California, Mr. Chairman.
    Mr. Benishek. California. Oh, sorry, bad advice.
    Ms. Speier. The other coast. Mr. Chairman, thank you, and 
Ranking Member Brownley, thank you as well and all of the 
Members for showing such a deep and committed interest in this 
issue.
    To you survivors, you are American heroes, and we owe you a 
great debt of gratitude, because you are speaking on behalf of 
500,000 veterans who have been sexually assaulted, raped, in 
the military. I want to ask you a series of questions so that 
we can get a sense, because I think I know the answers, but I 
think it would be important for all of us to go beyond the 
numbers.
    Eighty-seven percent of victims don't report, and they 
don't report for a very obvious reason: Because they don't get 
justice. So, let me ask this. How many of you were raped early 
in your military careers?
    How many of you were under the age of 25?
    How many of you were under the age of 20?
    Mr. Lewis. I was 20.
    Ms. Sanders. Twenty.
    Ms. Speier. How many of you were raped multiple times?
    Ms. Sanders. Pardon?
    Ms. Speier. How many of you were victims multiple times of 
rape?
    Ms. Sanders. No.
    Ms. Speier. How many of you were sexually harassed?
    How many of you endured an Article 32 hearing? Now, an 
Article 32 hearing in the military allows the defendant's 
attorney to question the victim about their prior sexual 
history. Now, we have rape shield laws in this country that 
prevent that from going on in civilian society, but in Article 
32 hearings they are able to raise that.
    How many of your assailants were in the chain of command?
    All right. This is really important because this makes the 
case that if we keep it in the chain of command, the likelihood 
of any victim getting the kind of fair evaluation, it is just 
not going to happen.
    How many of you were your assailants associated with, or 
friends of, or known by someone in your chain of command? So in 
your case, Ms. Wilken, you are the only person that was raped 
outside your chain of command, it looks like.
    How many of you were treated only by medication?
    How many of you were overly treated by medication?
    How long after your assaults, your rapes, were you 
discharged?
    Mr. Lewis. One year.
    Ms. Wilken. Two years.
    Ms. Sanders. Nine months.
    Ms. Johnson. Ten years.
    Ms. Speier. How many of you have a DD-214, which indicates 
that you have a personality disorder, adjustment disorder, or 
something like that?
    How many of you believe that for this issue to be dealt 
with appropriately in the military we have to take it out of 
the chain of command?
    All right. How many of you, when you entered the VA system, 
were asked specifically, if you had been raped or sexually 
assaulted in the military?
    How many of you received one-on-one counseling?
    Ms. Sanders. What?
    Ms. Speier. One-on-one mental health counseling in the 
military.
    How many of you were in a sexual--an MST program that was 
reflective of your gender?
    Ms. Wilken. It was also--it was a rape survivor and incest 
survivors group. They put us together.
    Ms. Speier. Okay. Very briefly, if you could, speak about 
the violence in your rapes, because we tend to overlook that 
because we focus on the numbers, and most of these rapes have a 
level of violence that we have no conception of.
    Ms. Sanders. I was pushed into a room by three men. One of 
the men got inside with me, he pushed me down, he tore my 
pants, he--you know, there was evidence that they could have 
collected, but he was given nonjudicial punishment.
    Ms. Speier. And you were locked in that room, were you not, 
by the two other--
    Ms. Sanders. I was locked in that room by the outside. 
There were two padlocks on the outside doors, and his two 
friends were not to open it until he said so.
    Ms. Speier. Ms. Wilken.
    Ms. Wilken. Some people might say that I am a lucky victim, 
that I was asleep when the assault started, so I woke up to it 
happening. So there are parts of the assault that I wasn't 
awake for but that were evident. And so a lot of people think 
that if you are not aware of the assault, that it is not as 
bad, but rape itself is a crime of violence, and to have 
someone put their hands on your, or be able to put themselves 
inside of your body without your permission in itself is 
violent. And so a lot of people think that it is not as bad if 
you don't know exactly what happened to you, but not knowing 
sometimes makes it worse.
    And to bring up the point that you talked about, about 
using your sexual history against you. In my case, during the 
investigation, I was interviewed by the Office of Special 
Investigation that does things in the United States Air Force. 
I was interviewed for 4 hours in an 8-by-8 room with two male 
OSI officers, and I had to go through my entire sexual history 
from the time I lost my virginity until the night that I was 
assaulted, and I had to answer questions about that at the 
Article 32 hearing. And so it revictimizes you.
    Ms. Speier. So my time has expired, but Mr. Chairman. Is it 
all right if the last two witnesses?
    Mr. Benishek. There is a little time for more.
    Mr. Lewis. My perpetrator used a weapon to obtain my 
compliance. He used a knife. Had I resisted, I would not be 
here. I would be 6 feet under, and I knew that looking in his 
eyes.
    There is a lot of victimization that goes on physically and 
mentally when senior members of your chain of command come down 
and say you will not file a report, official report with Naval 
Criminal Investigative Service. That is a victimization almost 
as bad as the one. I don't remember a whole lot because my 
perpetrator hit me over the head and knocked me unconscious. I 
have been trying to get evaluated for head issues ever since, 
and VA has never done it.
    So there is physical violence and there is the violence 
that comes after when your command says you are not going to do 
this, and then the doctors in the military say, oh, you are 
fine, let me push you a boatload of pills and send you back out 
to sea. Or the doctor that we go to in the military that says, 
oh, you are lying about what happened, and by the way, here is 
your personality disorder and a bag of pills to last you 90 
days on your way out.
    I took enough pills when I was stationed at 32nd Street in 
San Diego to float a ship. I often called it a shuffle, because 
I didn't feel my feet could touch the floor. And that is 
violence as well, and I know you meant the physical kind, but 
that violence needs to be addressed as well.
    And there is no gender-sensitive care for male veterans 
anywhere. That is why me, and a few other survivors, are 
standing up Men Recovering from Military Sexual Trauma, because 
men don't have anywhere to go. We are emasculated when we have 
to talk about this and we don't deserve that in this culture. 
Men deserve the right to be supported, too.
    Thank you, Congresswoman.
    Ms. Johnson. My situation was as a young officer candidate, 
and it was actually out in a social situation that it started. 
And for many years, I did not disclose it, because it was more 
of a date rape situation, and I was told afterward, you know, 
that I pretty much deserved it and brought it on myself. And 
for whatever reason, I sincerely believe that I was given 
something so that I wouldn't remember or so that I would be 
more compliant.
    Growing up in New Jersey, being a Marine, I am not a very 
compliant person anyway. But I don't remember much of it. But 
if someone comes too close to me or I feel that someone invades 
my personal space, or I smell a certain kind of smell, I become 
so agitated and scared to the point where I can't function, and 
I feel like I am going to throw up. And that can happen 
anywhere. So while it wasn't really--I didn't come out with 
bruises. I came out with pain and I came out with invisible 
wounds.
    When it happened years later with somebody else, it was 
sort of the same situation, and I was told, well, it is not 
rape. But I said, no, no, it is not rape. And so while neither 
incident was outright violent, I was not physically harmed in 
such a way as the other witnesses, it still--the violence in it 
for me was questioning my judgment and questioning who I was as 
a person and believing for so long that it was my fault and 
that I couldn't tell anybody.
    And how you think at 22, and how you think at 40, when you 
are trying to raise two young men, really impacts the way you 
look at things. And when I knew, I said would I want one of my 
sons to treat a woman like that or that to ever happen? And my 
answer to myself was, absolutely not. And at that point I knew 
that, you know, what I had experienced, and I was still 
traumatized from it and that it was wrong. So completely 
different situation, but long-lasting effects.
    Ms. Speier. Thank you.
    Mr. Chairman. Thank you for your indulgence.
    Mr. Benishek. I want to thank you all so very much for 
coming to Washington and telling your stories. You have been 
very helpful to us in trying to correct this problem. It is 
particularly frustrating to me to hear these stories one after 
another. And while your individual experiences are unique, the 
challenges and barriers that you spoke of in facing VA and DoD 
are very similar. I hope that the administration officials in 
the audience were listening as closely as I was to your 
testimony.
    Thank you very much, and you are excused.
    Ms. Sanders. Thank you.
    Mr. Benishek. I would now like to welcome our second panel 
to the witness table. Joining us on the second panel is Dr. 
Michael Shepherd, a physician at the Office of Health Care 
Inspections at the VA Office of the Inspector General. Dr. 
Shepherd is accompanied by Karen McGoff-Yost, the Associate 
Direction of Bay Pines Office of Health Care Inspections. Also 
on our second panel is Dr. Jonathan Farrell-Higgins, the Chief 
of the Stress Disorder Treatment Program at the VA Eastern 
Kansas Health Care System, and Carol O'Brien, Chief of the 
Post-Traumatic Stress Disorder Program at Bay Pines.
    Welcome.
    Dr. Shepherd, 5 minutes for your testimony.

   STATEMENTS OF MICHAEL SHEPHERD M.D., PHYSICIAN, OFFICE OF 
HEALTH CARE INSPECTIONS, OFFICE OF THE INSPECTOR GENERAL, U.S. 
  DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY KAREN MCGOFF-
YOST LCSW, ASSOCIATE DIRECTOR, BAY PINES OFFICE OF HEALTH CARE 
 INSPECTIONS, OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT 
OF VETERANS AFFAIRS; JONATHAN M. FARRELL-HIGGINS, PH.D., CHIEF, 
 STRESS DISORDER TREATMENT PROGRAM, COLMERY-O'NEIL VA MEDICAL 
    CENTER, VA EASTERN KANSAS HEALTH CARE SYSTEM, VETERANS 
INTEGRATED SERVICE NETWORK 15, VETERANS HEALTH ADMINISTRATION, 
   U.S. DEPARTMENT OF VETERANS AFFAIRS; CAROL O'BRIEN PH.D., 
 CHIEF, POST TRAUMATIC STRESS DISORDER PROGRAMS, BAY PINES VA 
   HEALTHCARE SYSTEM, VETERANS INTEGRATED SERVICE NETWORK 8, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

                 STATEMENT OF MICHAEL SHEPHERD

    Dr. Shepherd. Mr. Chairman, Ranking Member Brownley, and 
Members of the Subcommittee, thank you for the opportunity to 
discuss our recent IG report on residential treatment for 
female veterans with MST-related mental health conditions. I am 
accompanied today by Ms. Karen McGoff-Yost, Associate Director 
in our Bay Pines Office of Healthcare Inspections.
    I first want to also thank the four veterans on the first 
panel for their courage in sharing their experiences and their 
insights. I want to briefly mention why we did this review and 
offer a few observations.
    This inspection was undertaken in response to a request 
from the Senate Veterans' Affairs Committee. The report was 
intended to describe the care of female veterans discharged 
during the 6-month period from 14 programs listed by VA as 
having the ability to treat mental health conditions related to 
MST. Although the request and the report specifically focused 
on treatment of female veterans, I do want to acknowledge the 
incidence and distressing impact on both male and female 
survivors.
    In terms of the age range and service era of program 
participants, somewhat surprisingly, the average age was 44, 
with the 46- to 50-year-old age group as the most common. Four 
percent of the patients were under 25 and a quarter were OEF/
OIF veterans, with the remaining three-quarters other service 
era veterans. And I think this demographic data highlights the 
impact across service eras and also highlights the pressure on 
the system to simultaneously plan for and serve the growing 
mental health needs of recent vets and also aging other era 
vets.
    Second, I want to comment on the clinical complexity of 
patients served by these programs. Ninety-six percent of the 
patients in our review had two or more mental health diagnoses 
in addition to multiple physical diagnoses. In fact, 8 percent 
had concomitant eating disorders. After treatment in these 
programs, patients tended to return to the clinic and facility 
at which they received pre-program care; 22 patients were 
readmitted to either an acute mental health unit or to another 
residential program.
    For me, the real takeaway is that for these patients, 
effective treatment is not a linear one-stop in an intensive 
program and done solution, but rather requires a coordinated 
and longitudinal effort, building the foundation of care in the 
outpatient setting, having adequate coordination forward to 
optimize residential treatment, and then integrating treatment 
back to the outpatient setting to effectively build on gains 
achieved.
    Third, largely, all but three programs treated patients 
from all over the country. There was a national draw to these 
programs. On site visits, though, we found that difficulty 
obtaining travel funding authorization was a consistent theme. 
MST policy dictates care for veterans, even those not otherwise 
eligible for VA services, and that residential MST care should 
be available. But VA's travel beneficiary policy is restricted 
to veterans meeting certain eligibility requirements and favors 
treatment at the nearest facility.
    We found the two policies do not align. For some patients, 
this lack of alignment may delay program access. We recommended 
the Under Secretary review existing policy pertaining to 
authorization for veterans seeking mental health MST treatment 
in these programs. VHA concurred, established a work group to 
review issues and provide recommendations. As of the last 
quarterly update, the work group was continuing its review of 
this issue.
    Finally, on site visits, MST coordinators consistently 
reported their concerns that given their direct patient care 
responsibilities, they did not have time to perform their 
collateral MST coordinator duties, including outreach, 
coordination, and tracking of patients with positive MST 
screens.
    In conclusion, the programs reviewed do serve clinically 
complex patients who come for treatment from across the system. 
Ideally, these women and men would be engaged in a coordinated, 
integrated, comprehensive, and longitudinal treatment effort.
    Mr. Chairman, thank you again for this opportunity to 
testify. I would be pleased to answer any questions that you or 
Members of the Subcommittee may have.

    [The prepared statement of Michael Shepherd M.D. appears in 
the Appendix]

    Mr. Benishek. Thank you, Dr. Shepherd, for your testimony.
    Dr. Farrell-Higgins, you may proceed.

            STATEMENT OF JONATHAN M. FARRELL-HIGGINS

    Mr. Farrell-Higgins. Good afternoon, Chairman Benishek, 
Ranking Member Brownley, and Members of the Committee.
    The Eastern Kansas Health Care System is comprised of two 
medical centers 65 miles apart, nine community-based outpatient 
clinics, and is a tertiary psychiatry facility. I am the chief 
of the Stress Disorder Treatment Program, a 7-week inpatient 
unit for veterans with post-traumatic stress disorder and other 
stress-related problems. This 24-bed unit is designed to help 
veterans deal more effectively with traumatic experiences that 
occurred during their military service. The unit is physically 
located within the medical center at Topeka.
    As program chief and as one of two PTSD mentors for VISN 
15, I am pleased to share my reflections from the field 
concerning MST treatment. Our Topeka program is best described 
as an integrated mixed trauma model for mixed gender. We 
provide inpatient treatment services for male and female 
veterans from all branches and all areas of service, as well as 
active duty military personnel.
    Trauma issues addressed include those related to combat, 
MST, nonsexual assault, and training incidents. The unit is 
designated as a national resource Specialized Inpatient PTSD 
Unit, or SIPU. The program's overarching treatment goal is to 
help veterans maximize their post-traumatic growth and recovery 
with ultimate reintegration back into families, workplaces, and 
communities.
    Here is some key program data. In fiscal year 2013 to date, 
the unit has treated 119 patients; 28, or 24 percent of these 
patients self-identified at admission as MST survivor 
referrals. Additional, patients self-identified after admission 
as having sexual trauma issues, in addition to other presenting 
trauma issues. One hundred percent of the identified MST 
admissions have had a PTSD primary diagnosis.
    More MST admitting cohorts are already scheduled for 
admission in the fourth quarter. Of the fiscal year 2013 MST 
referrals, 24, or 86 percent have been men, and 4, or 14 
percent, have been women. MST patients include those who served 
in Vietnam, Iraq, Afghanistan, and other locales.
    Of our MST referrals, males heavily outweigh females, 
outnumber. As is common in other inpatient and residential 
programs, we experience a higher percentage of MST admission 
no-shows and cancellations than for other traumas. This speaks 
to multiple issues, including high comorbidities, readiness 
issues, and travel difficulties.
    The program is staffed 24/7 by a terrific multidisciplinary 
treatment team. They provide multiple evidence-based 
psychotherapies, gender-specific care, same-gender therapists, 
diverse psychoeducational programming, complimentary 
alternative medicines, or CAM, such as yoga, mind flush 
meditation and exercise, and medication management.
    As a national resource program, MST referrals are 
nationwide. A rolling admissions format is employed wherein MST 
referrals are admitted in many cohort groups in order to 
provide for maximum comfort and group cohesion. In fiscal year 
2013, we have not encountered any aborted on-site admissions 
due to safety, comfort, or acceptance concerns.
    Treatment highlights include these things. First, the 
program's core value of treating diverse individual works. MST 
is destigmatized by virtue of side-by-side trauma treatments. 
MST is not regarded as a second class source of PTSD, but as a 
primary problem in its own right.
    Second, the program achieves a powerful sense of community 
and acceptance of all individuals with PTSD regardless of 
gender and trauma demographics. The in vivo aspect of the 
treatment environment is normalizing, essential to veterans' 
recovery efforts, and facilitates reintegration into the real 
world.
    Third, treatment outcome data supports the mixed trauma 
model. Outcome data for MST patients are comparable to non-MST 
patients for PTSD, anxiety, and depression symptoms.
    Last, treatment gaps and challenges include these. First, 
active duty personnel. Our program is 1 hour from two military 
installations and we receive active duty referrals for combat 
trauma treatment. However, referrals for MST are infrequent. 
Patients report fear of stigma and concerns about career 
advancement. These are worthy issues to be further addressed.
    Transportation. Some MST referrals have struggled with 
transportation problems to our program and to other programs. 
One non-VISN female veteran who could not afford transportation 
to our program was eventually flown to and from our site by a 
volunteer veteran support organization. Beneficiary travel 
policy and MST policy must work together so program access is 
not a problem.
    Capacity. Greater understanding is needed of the multiple 
factors that contribute to unfilled MST beds. MST specialized 
programs are encouraged to share best admission practices that 
improve bed utilization.
    And last, research. More multi-site, multiprogram research 
is needed to best discern the critical treatment components 
that yield the most robust treatment outcomes.
    In closing, I am pleased to be part of the growing national 
efforts to treat MST, and I appreciate the opportunity to 
appear before you today. I am prepared to respond to any 
questions you may have.
    Mr. Benishek. Thank you.
    Dr. O'Brien, please proceed.

                   STATEMENT OF CAROL O'BRIEN

    Ms. O'Brien. Thank you for giving me the opportunity to 
discuss the Bay Pines VA Healthcare Systems' efforts to provide 
the very best care to our Nation's heroes, specifically those 
affected by military sexual trauma.
    I will begin by providing a general overview of our health 
care system, the fourth busiest VA health care system in the 
country. The Bay Pines VA Healthcare System serves a 10-county 
area in southwest Florida, includes a large medical center 
located in Bay Pines and 8 outpatient clinics located in 
communities within our catchment area. Our health care system 
includes 3,500 employees who are dedicated to serving the more 
than 100,000 men and women who come through our doors every 
year.
    I am the section chief of the health care system's post-
traumatic stress disorder programs, which include residential 
and outpatient services to treat PTSD resulting from war-
related trauma and from military sexual trauma. Our Center for 
Sexual Trauma Services is the section of the PTSD programs that 
specifically treats PTSD resulting from sexual assault incurred 
during military service.
    I began treating veterans with problems related to MST in 
1993 shortly after the passage of Public Law 102-805. As a 
result of our experiences, a colleague and I requested and 
received a VHA innovative programs grant to establish the Bay 
Pines Residential Military Sexual Trauma Treatment Program in 
the year 2000. We initially had capacity for eight female 
veterans and subsequently expanded the program to treat an 
equal number of male veterans and to provide a wide range of 
outpatient services. At present, we treat approximately 100 
veterans with military sexual trauma each year through our 
residential program, and our outpatient services provide care 
to approximately 400 veterans annually.
    Our CSTS team provides evidence-based psychotherapy for 
PTSD as well as gender-specific treatment interventions and 
other therapeutic modalities to treat the unique aspects of 
MST-related PTSD. Because an overarching goal of treatment is 
community reintegration, our residential program has a strong 
focus on interpersonal skill development and recovery that is 
defined by the veteran's goals and values, and we incorporate 
concepts from therapeutic community models of care.
    The Center for Sexual Trauma Services was the first MST-
specific residential PTSD program to be established within VHA. 
In addition to providing excellent patient care for veterans 
who come to us from across the Nation, we initiated a national 
clinical training program in 2001, that has been attended by 
hundreds of MST clinicians from other VA facilities and from 
vet centers. In addition, our program has included ambitious 
clinical research initiatives since its inception and provides 
training for interns and residents from many disciplines.
    Our residential treatment community includes equal numbers 
of men and women. Length of stay varies based on treatment 
needs and goals, and the patients take responsibility for the 
functioning of their residential community through mentoring 
and coaching each other, identifying shared community values 
and related behavioral goals, and focusing on independent 
problem-solving and management of difficult emotions.
    We also focus on the gender-specific issues related to 
military sexual trauma. Our male and female patients meet 
separately to process the impact of military sexual trauma on 
important aspects of life, including sexuality, perceptions of 
others, and interpersonal relationships, and then come together 
to recognize that sexual assault affects both men and women and 
is not a problem of gender. Through their relationships with 
each other, they begin to trust again and they develop an 
eagerness to move forward with their lives.
    As we continue to work to advance the understanding of the 
impact of MST and to develop increasingly effective treatment 
models, I respectfully make the following suggestions.
    We have made huge progress in the availability of evidence-
based treatments for PTSD, and these treatments have 
demonstrated efficacy for MST-related PTSD, but we need 
programs to specifically address the complex family problems, 
behavioral issues, and co-occurring disorders that are 
typically seen in this group of veterans.
    We need to provide treatment earlier. Most of our patients 
receive treatment years, and even decades after the sexual 
assault. Many of our veterans tell us that the MST resulted in 
the loss of their hoped-for military career.
    VA and DoD need to prioritize effective early treatment 
interventions to preserve the quality of life and the potential 
contributions of military servicemembers who experience 
military sexual trauma.
    We need more treatment options for men. We know that for 
men who are raped, the reporting rates are lower, the incidence 
of PTSD is higher, functioning in relationships and work roles 
is more impaired, and treatment is less effective.
    Finally, we need to understand more about the causes and 
the predictors of military sexual trauma. We need additional 
VA-DoD collaborative research initiatives to understand the 
problem from the perspectives of both the victims and the 
perpetrators, so that we can design interventions relevant to 
the military environment to ameliorate this problem, so that 
there are no more victims.
    Thank you again for the chance to testify.
    Mr. Benishek. Thank you, Dr. O'Brien.
    I will yield myself 5 minutes.
    Dr. Shepherd, were you here for the testimony on the 
first--
    Dr. Shepherd. Yes, sir.
    Mr. Benishek. It was certainly dramatic testimony. You are 
with the Office of the Inspector General. Is the Inspector 
General's Office doing anything about this? Are they reviewing 
what the VA has been doing? It was pretty dramatic. I would 
think that you would have been on this in some way.
    Dr. Shepherd. Well, as I mentioned in my statement, we did 
do a review in the last year of residential treatment for 
patients with MST-related conditions. We have done a review 
about 2 years ago looking at treatment for women with combat 
stress and--
    Mr. Benishek. It doesn't sound like you are answering that 
you reviewed what the VA is doing with military sexual trauma 
in view of the testimony that we had before.
    Dr. Shepherd. Yeah.
    Mr. Benishek. Let me ask you this. Are you aware of the 
number of inpatient beds there are in the VA system for 
inpatient treatment of military sexual trauma, or that would 
have availability appropriate for MST victims, how many 
inpatient beds are there in the country?
    Dr. Shepherd. I don't know the exact number.
    Mr. Benishek. Do any of you know that number?
    Let me ask you, the doctors that are involved with clinics 
themselves, are your clinics always full then?
    Mr. Farrell-Higgins. As I mentioned--thank you for the 
question, Mr. Chairperson--I mentioned in my remarks that we do 
experience some people who do not show up for treatment that is 
scheduled for them on our waiting-to-be-admitted list, but the 
advantage of us having a rolling admissions format as we do is 
that we are able to then pull people forward and fill those 
positions fairly quickly.
    Mr. Benishek. How often does somebody have to typically 
wait? You mentioned that you have somebody waiting for 
admission--you have people scheduled for the fourth quarter, I 
thought you said.
    Mr. Farrell-Higgins. We do. Of course, we are in that 
territory. So we keep a waiting-to-be-admitted list so folks 
can get their personal affairs lined up and prepared to come 
into a program. It takes some doing to get family and work and 
so forth.
    Mr. Benishek. How long does this typically take?
    Mr. Farrell-Higgins. So I would say that we are running 
about a month to 40 days right now.
    Mr. Benishek. And so what is the census in your facility 
today?
    Mr. Farrell-Higgins. It varies.
    Mr. Benishek. Today. Right.
    Mr. Farrell-Higgins. It runs from 80 to 95 percent.
    Mr. Benishek. Dr. O'Brien.
    Ms. O'Brien. Again, we typically run over 85 percent 
occupancy rate. The Bay Pines residential program is considered 
the premier program in the country. We get probably more 
referrals than other programs do. But a couple of weeks ago, we 
admitted a female veteran directly to our program from the 
inpatient psychiatry unit with absolutely no wait.
    Mr. Benishek. We haven't heard from you, Ms. McGoff-Yost. 
Do you have anything you want to add to that?
    Ms. McGoff-Yost. Yes. Thank you, Mr. Chairman.
    As far as with our review, we looked at 14 different 
programs, VA facility programs, and we had to estimate the 
capacity because some of the programs are women's only and some 
of the programs are mixed gender.
    For purposes of our review, we only looked at beds 
available for women with MST, and our estimated capacity was 
approximately 600. We did obtain data, both while we were on 
our site visits, and also, we looked at VA self-reported data 
that had to do with the capacity, and we were consistently told 
while we were on site, that these programs were somewhat 
underutilized.
    The time period for which we did our review was the first 
two quarters of fiscal year 2012, which would be October 1st, 
2011, through March 31st, 2012, and during that timeframe, the 
data provided by VHA's Northeast Program Evaluation Center for 
these particular programs reflected an occupancy rate ranging 
from 42 percent through 81 percent. The programs that had a 
higher occupancy rate included Bay Pines, Lyons, New Jersey, 
and Sheridan, Wyoming.
    As far as your questions about how long it takes to access 
the programs, we can get you that information. We reviewed 166 
medical records as part of our review, and within our report, 
we do have the data stratified by facility of how long it took 
from the time that a patient was referred to the program until 
the patient entered one of the residential programs, and it did 
vary considerably.
    Mr. Benishek. Do you think that the IG going to, in view of 
the testimony we had today, do you think you would entertain a 
plan to try to inspect how VA is doing things? With the 
dramatic testimony of coordinators, shouldn't the Inspector 
General be involved in that?
    Dr. Shepherd. I very much appreciate the testimony, and 
when I return today to the office, I will begin dialogue with 
my superiors about possible inspections we might do in this 
area.
    Mr. Benishek. I would appreciate follow-up to the 
Committee. Thank you.
    Ms. McGoff-Yost. It is something that has been discussed. 
When we--he initially looked at doing this review, we chose to 
look at the residential programs. Because these programs were 
identified by VHA as being specialized treatment resources 
specific for this population, one of the things we did consider 
was looking at outpatient services, which is a little bit more 
challenging because it is so broad. Because every facility is 
required to offer MST-related care at every facility at every 
CBOC, it was a challenge to figure out to objectively measure 
what they were doing, and there can be so much variability from 
site to site.
    Mr. Benishek. Right.
    Ms. McGoff-Yost. One of the things that we considered, 
currently VHA facilities have a screening program where they 
are supposed to be doing a screening. It is an electronic 
screening called a clinical reminder, where it is once in a 
lifetime, they screen a veteran for the presence of military 
sexual trauma. Currently, the clinical reminder consists of two 
questions to just determine if a patient met a criteria, at 
which point they are supposed to be verbally prompted to see if 
they would like to talk to someone further.
    We were told that VHA is in the process of adding a third 
question to the reminder that would actually document whether 
or not the person would like to seek help or further assistance 
related to a positive screen. One of the things that we have 
discussed is that once the clinical reminder is in place, there 
would actually be an objective way for us to measure how many 
veterans requested help. Then we could go back and see how many 
got the help they asked for and how long it took.
    So we are kind of keeping an eyeball to see when that 
reminder might be getting ruled out. We were told during fiscal 
year 2012 that it was under process. As far as we know today, 
it has not yet been rolled out nationally.
    Mr. Benishek. Thank you for your testimony.
    I yield to Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chairman.
    And thank you all for your testimony.
    You know, hearing the first panel for me was disconcerting, 
devastating, and your response to the testimony, it didn't seem 
to me that that sense of urgency really is there. I mean, we 
heard about big gaps in care, long wait times, uncaring 
providers, employees that didn't seem to know what the policies 
were, issues around family support, gender-sensitive care, the 
fact that PTSD and MST therapies were combined, the need to get 
access outside of the VA, victims not being screened.
    And the data that we know, in terms of the victims who are 
out there and the victims, 87 percent, I think, who actually 
were victimized but don't come forward, it just doesn't seem 
that--your testimony and the data that we know about are 
really, you know, aligned here, and somehow, I think we have 
got to, you know, find those nexus points so that we are doing, 
you know, a better job.
    So I feel like this hearing is just beginning to scratch 
the surface, and we still need to drill down further on so many 
of these issues to figure out how we can provide immediate 
service, caring service, the right services, the best 
practices, and I am sort of struggling with that.
    I appreciate your testimony. I feel like it was, you know, 
prepared in advance, which I understand one has to do, but it 
didn't feel as though it was really responding to what we 
heard.
    So I would just like to hear from you, from all of you, 
really, what some of your responses are. And I know in the case 
of Mr. Lewis, who testified, and, Dr. O'Brien, you know, he 
gets services from your facility and, you know, if we could 
hear a little bit more from you about some of his testimony and 
some of his experiences.
    Ms. O'Brien. Thank you. And I, like you, reacted with a 
great deal of concern and compassion for the testimony of not 
only the male victim, but the entire panel. And as we move 
forward with this, a part of what we need to do within VA, is 
to talk with our veterans, to listen to those concerns, to 
continue to work with them in order to improve our programs to 
meet every single individual veteran's needs.
    One of the things that we are doing right now in VA that I 
think will be especially helpful is that we are hiring a large 
number of peer technicians, peer counselors to work with our 
programs, and we will have one coming to our program at Bay 
Pines as well. And again, that allows us to hear the veteran's 
perspective. And I think the closer we get to the words of the 
veteran, the more we will be able to improve and continue to 
improve our treatment programs.
    Ms. Brownley. Any other comments?
    Ms. McGoff-Yost. I actually have a comment, Ranking Member 
Brownley. When we did our review, we looked specifically at 
women, at the request of the Senate VA Committee, and we looked 
specifically at specialized inpatient and residential treatment 
programs. So in a manner of speaking, we have a skewed sample, 
because we looked at those patients who made it into a very 
specialized program, whereas I think that the veterans in the 
first panel who spoke so openly and courageously about their 
experiences, from what we could gather from their testimony it 
sounded like only one of the four made it into one of these 
specialized programs. So while we can discuss the 
characteristics and the patterns from what we saw in our sample 
of women in our view, it may not be reflective of the women who 
aren't making it into these residential treatment programs.
    We did find evidence, both in the medical records, and also 
through interviews and site visits, we did hear about barriers, 
and many of the barriers that we heard from staff were very 
similar themes to what we heard from the veterans who spoke 
earlier today. We consistently heard that the MST coordinators, 
there is one at each facility, that is what we found in our 
review, that is what is required, however, the directive that 
mandates this role to exist does not mandate the amount of FTE 
or time dedicated to the role that it needs to have.
    We were consistently told on-site that--most coordinators 
said that they are mapped at about 10 percent of their time to 
doing MST coordination. For instance, at the Bay Pines 
facility, their MST coordinator is a very busy lady, she wears 
many hats. She is a full-time clinician, she works with 
patients in the residential program, she is the MST 
coordinator, and she is also the VISN point of contact for MST, 
and that is one person.
    So we were told by most of them it is 10 percent. A few 
said it was as few as two hours a week they are afforded to do 
the outreach that they need to do. And I think that when you 
listen to the examples we heard from the prior panel, a lot of 
them echoed that, had there been a lot more outreach and a lot 
more focusing up front on coordination and reaching out to 
patients when they are coming into the system, that perhaps 
could have ameliorated some of the issues related to their 
coordination of care.
    Ms. Brownley. Thank you. I yield back.
    Mr. Benishek. Thank you, Ms. Brownley.
    I yield 5 minutes to Dr. Wenstrup.
    Mr. Wenstrup. Thank you, Mr. Chairman. Thank you all for 
being here today.
    I know it is difficult, but always necessary in everything 
that we do to self-critique ourselves, and I just wonder how 
you would describe or rate, on a national level, your customer 
service as far as those with MST and what is it that you need 
that is not provided to you today to improve upon that? Anyone 
can take that.
    Mr. Farrell-Higgins. Thank you for the question, 
Congressman. I believe in Topeka, our customer service is 
outstanding. We have an excellent team, and the feedback that 
we get repeatedly, both from veterans who have come through the 
program, especially from our referral services as well, is that 
they are very pleased with the care that they have received 
from us.
    I think we can always do better. We have brought on a peer 
support specialist this past year to help us out. I think it 
has been a very strong move for us. We are continuing to look 
at how we can link in better with local community resources to 
help become more linked in with things such as recreational 
activities. Some staff dollars would help with that, but I 
think we can do some improvement there.
    Mr. Wenstrup. Thank you.
    Anyone else care to comment?
    Ms. McGoff-Yost. I have a comment, since both of the 
panelists from VHA mentioned the peer technicians and peer 
counseling is such a positive recovery movement that is being 
rolled out in VHA. That is something that we noticed when we 
looked at the medical records for these women with MST who are 
in a residential program. We did find the presence in many of 
the programs we looked at, that there was peer counseling 
available or a peer support technician who was there. However, 
from what we could see in the medical record documentation, and 
we were looking at veterans who were women, we only saw one 
female peer support technician who was working in these 
particular programs, and I believe that was in the program in 
Cincinnati. And I know that VA has mandated that the 
residential programs need to get ready to have up to 15 percent 
of their population be female. However, they have no set 
threshold for what number of their peer support technicians 
need to be female.
    Mr. Wenstrup. Thank you very much. And I yield back.
    Mr. Benishek. Ms. Kuster, 5 minutes.
    Ms. Kuster. Thank you very much, Mr. Chairman. I will be 
more mindful of my time. Thank you.
    Thank you so much for coming before us today and for the 
work that you do. I understand that you are very committed to 
it. And, Dr. O'Brien, I admire you being a part of this for a 
long, long time.
    And, Dr. Farrell-Higgins, I am impressed by the program you 
described. And thank you to our friends that are looking into 
this deeper.
    So my question, I want to focus in on a comment that you 
made, Ms. McGoff-Yost, about--you used a phrase ``once in a 
lifetime screening,'' and I guess the comment that I would have 
is, it is very clear to me from our first panel that once in a 
lifetime screening would not be adequate. And I think actually 
Dr. Roe spoke very eloquently about this, of knowing his 
patients for 30 years and it takes 25 years to have this 
conversation.
    So what would you recommend that could be done across the 
board throughout the VA to be more mindful of the challenge of 
bringing this situation forward, that it is not just saying, I 
broke my arm, can you fix it?
    Ms. McGoff-Yost. I think that part of this issue has to do 
with the MST coordinators and the time that they are afforded 
to follow up on screenings, and also when they are working 
with--when a patient does disclose in whatever venue it is, to 
make sure that the coordinator is aware and that the screening 
then gets put back to being positive in the medical record.
    A clinical reminder, they can be set in the electronic 
medical record at certain intervals. We were told by VHA that 
currently this is something that occurs once. When a person, 
male or female veteran, comes into a VA medical center for 
enrollment, they are screened for many different conditions. 
MST is one of them. There are two questions in the screening, 
and as I mentioned earlier, we were told they are in the 
process of adding a third question.
    We would probably need to defer to VHA for more specific 
information about their future plans for the clinical reminder. 
We did have some dialogue with VHA staff at central office 
about the clinical reminder and the pros and cons of having it 
come up more often than annually.
    We did find in our particular sample all of the veterans 
had been screened. We did find that out of our 166 patients, 
161 were actually veterans, three were active duty, and two 
were reservists. So of the 161 for whom the clinical reminder 
would have been turned on in the medical record, for seven, it 
was still marked negative. And that has an impact on VA 
collecting data because they make tremendous efforts to collect 
data on these patients. If the clinical reminder is marked 
negative, then some of the data that they collect would be 
lost.
    Ms. O'Brien. Could I add also that, although in VA we have 
the requirement to ask once to do the reminder, that is not the 
only way that we reach out to our veterans to let them know 
about the availability of treatment and so on. We have 
brochures, we have posters, we have events for Sexual Assault 
Awareness Week. In multiple modalities we reach out to our 
veterans to let them know that the care is available and to 
encourage them to seek care.
    I had a veteran say to me the other day that he had said no 
to the clinical reminder, and then he saw a poster at our 
facility that we have hanging right inside the door that says 
it takes the strength of a warrior to seek help, and that gave 
him the courage to come to us and say, I was sexually assaulted 
in the military and I hear I can get some care from you.
    Ms. Kuster. Great. My time is short, but I do want to take 
the opportunity to introduce an expert from my region in New 
Hampshire who is here with us today at the hearing, Victoria 
Banyard, Ph.D., from the University New Hampshire.
    Ms. Kuster. But with regard to your comment, Dr. Farrell-
Higgins, I think the connection to the services that are 
available in the community, including in academia, in 
programming, the issue of sexual assault and rape is not new in 
our society. And one of my biggest concerns across the board, 
both with regard to DoD and the VA, is that there is this 
effect of a total vacuum of the military and the Veterans 
Administration seemingly dealing with these issues in a vacuum.
    And so, I would encourage all of you, and certainly we will 
encourage the Veterans Administration and the DoD, to work with 
the civilian population, because it is very unique, both with 
regard to coming forward and telling the story and all the way 
throughout. And so, our concern is with this multiple trauma, 
that we learn best practices from people who have worked. Dr. 
Banyard has been working for 20 years in this field, and I am 
very honored to have her with us here today.
    Thank you. And I yield back.
    Mr. Benishek. Thank you very much.
    I will yield 5 minutes to the gentlewoman from Indiana, Ms. 
Walorski.
    Mrs. Walorski. Thank you, Mr. Chairman.
    And I have to agree with Ranking Member Brownley in sharing 
her frustration. I feel like we are in two separate worlds. We 
just heard absolutely gut-wrenching testimony from extremely 
courageous people whose lives have been ruined, and I am 
frustrated sitting on this Committee.
    I have been asking questions about this issue to the VA 
since I have been here with no answers. So with all due 
respect, Dr. Higgins, the customer service is going great? 
Well, maybe for those who actually access the program. But to 
the people that are sitting here representing tens of thousands 
of people, it isn't working and I am just frustrated.
    But I want to direct my attention to Dr. Shepherd. In the 
report produced by the Office of the Inspector General, it is 
recommended that, quote, ``The Under Secretary for Health 
review existing VHA policy pertaining to authorization of 
travel for veterans seeking MST-related treatment as 
specialized inpatient residential programs outside of the 
facilities where they are enrolled. The VHA agreed with this 
recommendation and promised to have a recommendation completed 
for the Under Secretary for Health no later than April 30, 
2013.'' Has the VHA provided you with that status update?
    Dr. Shepherd. A quarterly update, which was in May, they 
were still working on it and haven't come up with a list of 
recommendations.
    Mrs. Walorski. And let me just interject. That is exactly 
what I expected to hear, because the questions that we have 
been asking in the 7 months that I have been here still fall on 
deaf ears; no response, no report. When we are dealing with 
this issue of MST, the reason these stories are so gut 
wrenching, I think, is because we have thousands of people 
falling through a crack in the system and we can't even get 
answers to the Congressional Committee that is in charge of 
watchdogging and making sure that these people get treatment.
    Dr. Shepherd. In fact, in the last few days, with a lot of 
pressing, we got a response that they recently had developed 
some recommendations that the Under Secretary would be 
reviewing in the last few weeks. So I agree with the 
congresswoman's comments and I very much understand the 
frustration.
    Mrs. Walorski. Did the VHA give any reason for failing to 
fulfill their promise?
    Dr. Shepherd. No, ma'am.
    Mrs. Walorski. Does their failure to address the situation 
demonstrate their inability to provide the necessary services 
to MST victims, in your estimation?
    Dr. Shepherd. It is hard to say. Certainly we would like to 
see a prompt response to the recommendation we had, and we 
would like to see what they have recently proposed get 
implemented, because we think that will help improve access for 
veterans needing these programs.
    Mrs. Walorski. Thank you.
    And, Mr. Chairman, I yield back my time.
    Mr. Benishek. Ms. Kirkpatrick.
    Mrs. Kirkpatrick. Thank you, Mr. Chairman.
    Dr. O'Brien, how many of the 3,500 employees at your 
facility are psychiatrists?
    Ms. O'Brien. Thank you for the question. I would need to 
take that for the record and get back to you on the exact 
number.
    Mrs. Kirkpatrick. Can you give me a ballpark number?
    Ms. O'Brien. I can tell you that in our PTSD program 
itself, we have two psychiatric ARNPs and two full-time 
psychiatrists, with a position open for yet another 
psychiatrist.
    Mrs. Kirkpatrick. I don't have your written testimony, but 
I am recalling from your testimony that you said you treat 
100,000 inpatients at the facility and 400,000 outpatients, is 
that correct?
    Ms. O'Brien. I indicated that we have 100,000 male and 
female veterans who come to our facility each year.
    Mrs. Kirkpatrick. And how many of them are seeking mental 
health care?
    Ms. O'Brien. Again, I don't know the exact number. I can 
get that information to you.
    Mrs. Kirkpatrick. I would appreciate that.
    Dr. Higgins, can you answer those questions for me for your 
facility?
    Mr. Farrell-Higgins. Thank you for the question. I find 
myself in a similar situation as Dr. O'Brien. On the inpatient 
PTSD unit, we have a full-time PA and an ARNP, with a 
psychiatrist who supervises that work. I will have to get back 
to you with respect to the total number of psychiatrists in the 
facility.
    Mrs. Kirkpatrick. Can you give me a ballpark?
    Mr. Farrell-Higgins. Let me get back to you about that.
    Mrs. Kirkpatrick. Okay.
    Mrs. Kirkpatrick. Ms. Yost, you talked a little bit about 
staffing in a previous question. Do you think we have a 
sufficient number of psychiatrists in the VA system to treat 
these issues?
    Ms. McGoff-Yost. Under our review, we looked at the 
staffing specifically of particular residential programs, so I 
would not be able to comment on the adequacy of staffing for 
the other 140 VA facilities as far as the availability of 
outpatient services. We found that there was adequate staffing 
for the particular programs that we reviewed which were 
residential inpatient in nature.
    Mrs. Kirkpatrick. I am really concerned about the testimony 
we heard from the first panel, that they are being seen by 
medical students, by untrained professionals, and really would 
like an answer back about whether or not we have adequate 
professionals within the VA system to deal with military sexual 
trauma.
    Mrs. Kirkpatrick. Also, in the written testimony of one of 
the first panelists, she says some women are not going to come 
to the VA because of a lack of treatment or a bad experience 
with the VA, and we have heard in other hearings about women 
being hesitant to go to the VA. And I would just like to know 
from the panel, what efforts the VA is taking right now to 
address that, to make it a pleasant experience for women, 
someplace where they would feel protected and welcome.
    Ms. O'Brien. Thank you. I think one of the things that VA 
has done over the years is the creation of women's health 
centers. Every VA facility has a women veterans program manager 
whose job it is to advocate for women veterans throughout the 
facility. And I will talk about the Bay Pines women's clinic. 
It is a separate clinic dedicated to the health care of women 
veterans, and in that clinic there are also mental health 
providers. So that if a woman veteran comes to ours facility 
and feels uncomfortable getting care in a general mental health 
clinic or another setting, they can get virtually all of their 
care in the women's clinic.
    Mrs. Kirkpatrick. Dr. Shepherd, are you aware of anything 
that is going on within the VA to make it user friendly for 
women?
    Dr. Shepherd. I think ideally that is a question answered 
by the two panelists from VA. But I can say, going back 4 or 5 
years ago, in these residential programs, there was really 
concern about physical safety, or that, that was more of an 
issue, and many of the programs did put, you know, like keypad 
or other type devices to try to bolster security. I can offer 
that, but I really think that is probably best answered by the 
VA panelists.
    Mrs. Kirkpatrick. Ms. Yost, do you have any comment on 
that, maybe some ideas about what could be done better?
    Ms. McGoff-Yost. Just to echo the sentiments of Dr. 
Shepherd. Our Office of Healthcare Inspections, when they do 
scheduled site visits, called CAPS, at approximately 50 VA 
medical centers each year, they are looking at the safety and 
security of the mental health residential treatment programs. 
They found very high compliance with the standards pertaining 
to the safety and security for women veterans in those venues 
as far as required alarms, door locks, rooms and bathrooms 
being able to lock, CCTV at building entrances and whatnot.
    I do know that the OIG is looking--always has a component 
relevant to women's health, typically in our scheduled site 
visits both for medical facilities and on our CBOC reviews, so 
it is something they are keeping an eye on. I cannot personally 
comment on the adequacy of their efforts overall as far as 
being more welcoming to women.
    Mrs. Kirkpatrick. Dr. Higgins, can you describe what is 
going on in your facility with that regard?
    Mr. Farrell-Higgins. I would be happy to. We also have a 
women's health clinic where a full comprehensive range of 
services is available. With respect to our unit, we do indeed 
have alarms on doors, and doors can be locked at night and so 
forth, so to maintain the physical security of those rooms.
    I think that the message is best delivered every time we 
interact with a female who comes into the VA, it is that 
individual contact that makes the difference. And our staff, I 
know staff on my end, is well-trained and committed to that, 
because we do understand the gravity of the stories that are 
going to unfold before us as we work with these women and men 
who have been sexually traumatized.
    Mrs. Kirkpatrick. Thank you.
    And, Mr. Chairman, thank you for indulging me to exceed my 
time. Thank you.
    Mr. Benishek. Thank you very much, Ms. Kirkpatrick.
    I would like to yield a couple more minutes to the Ranking 
Member, Ms. Brownley from California. She has an inquiry.
    Ms. Brownley. Thank you, Mr. Chairman. This inquiry is 
really to the Office of the Inspector General, Dr. Shepherd.
    We have heard today, in today's testimony, a lot, but one 
area that I wanted to focus on is the transition area from DoD 
to the VA for military sexual assault victims. So I know, my 
understanding anyway, that back in 2009 there was a DoD-VA 
mental health summit, and from that summit, there was, I think, 
an agreed-upon strategy coming out from the DoD and the VA, but 
we really don't know anything about it and really what has 
happened with that. We don't know what the strategy is, et 
cetera.
    So I think, and I think the Chairman agrees with me, that I 
would certainly like the Inspector General to look into this 
issue around transition, and how the DoD and the VA are going 
to work together to service our military men and women who have 
been sexually assaulted and report back to us in the official 
capacity out of the Office of Inspector General, and would like 
that to happen and to have a report that would come back to us.
    Dr. Shepherd. In light of all the heartfelt concerns 
expressed and shared by the first panel, I personally would be 
honored to work on that.
    Ms. Brownley. Thank you, sir.
    Mr. Benishek. I would like to thank all of you very much 
for coming to testify before us today, and you are hereby 
excused from the panel.
    I would like to call up the third panel. We have from the 
Department of Veterans Affairs Dr. Rajiv Jain, VA's Assistant 
Deputy Under Secretary for Patient Care Services. Dr. Jain is 
accompanied by Dr. David Carroll, the Acting Chief Consultant 
for Mental Health Services for the Office of Patient Care 
Services, and Dr. Stacey Pollack, the National Mental Health 
Director of Program Policy Implementation for the Mental Health 
Services of the Office of Patient Care Services. That is a long 
title. We are also joined by Dr. Karen Guice, who is the 
Principal Deputy Under Secretary for Defense for Health 
Affairs.
    I want to thank you all for being here today. We have your 
complete written statements as part of our hearing record.
    Mr. Benishek. And given the gravity of the testimony and 
personal experiences that we have heard in the previous panel, 
I would like to go straight to questions, if you don't mind.
    You were all here for the testimony of the first panel, I 
take it. To me, it is very, very frustrating to hear that, and 
to know there are many out there that we haven't heard today, 
that have the same complaints. And I know that I have received 
constituent letters about how people have been sexually 
assaulted in the Vietnam war, but still haven't reported it to 
their VA contact because they are just afraid. And they didn't 
reveal it until they wrote me the letter. This testimony is 
just so devastating.
    I know you have a statement there, but maybe, Dr. Jain, you 
can tell me, what was your reaction to the earlier testimony, 
and what do you think that the first thing you are going to do 
after this hearing to try to fix this is going to be?
    Dr. Jain. Thank you, Mr. Chairman, for the question. I 
think there is no question that our testimony that we 
submitted, as you said, is already somewhat dated based on the 
testimonies that have been provided by the four veterans on the 
first panel. I think they really present a very powerful story, 
and I think that they point out that inasmuch as we in the VA 
have done a lot for survivors of MST over the last few years, 
we also feel that there are significant gaps that have been 
pointed out by the panel that we need to really look, careful 
look and address and see how best we can meet the needs of all 
of our veterans in a sensitive manner.
    Mr. Benishek. Wouldn't you agree that this is an emergency, 
that there should be rapid action taken?
    Dr. Jain. Yes, sir, I would agree, and we would certainly 
go back and take a very critical look at how we have structured 
services and what can we do to address some of the gaps. And, 
frankly, they made a lot of wonderful suggestions that we also 
would want to consider.
    Mr. Benishek. Do you know who would be in charge of that? 
Is there someone in charge of this VA? I get confused with the 
principal deputy, assistant director, those type of terms. I 
get confused. So is there someone that you can name that is in 
charge of fixing this?
    Dr. Jain. Well, sir--
    Mr. Benishek. Is that you?
    Dr. Jain. That is in charge of the patient care services? I 
would certainly be willing to take that responsibility on the 
behalf of the VHA, because all of the mental health services 
and the MST services are part of the mental health services and 
patient care services. So I would certainly be personally 
willing to take that responsibility to do a careful assessment, 
working with our leadership on the operations side, to make 
sure that we have all of the appropriate--the staffing that we 
need to make sure that we provide the services in a sensitive 
manner.
    Mr. Benishek. Well, you have to have some caveats in there, 
I understand, Dr. Jain. But to tell you the truth, I really 
appreciate your answer, the fact you are willing to sit there. 
And I worked at the VA as a consultant for 20 years, and I know 
sometimes a straightforward answer that you gave doesn't happen 
that often, even with the caveat.
    I will yield the remainder of my time and allow Ms. 
Brownley to go on.
    Ms. Brownley. Thank you, Mr. Chair, and I certainly share 
your sense of urgency here today.
    Earlier in the hearing, there was some discussion about the 
chain of command, and I think certainly this issue, we need to 
go up the chain of command within the VA and within the DoD to 
make sure that we are addressing some of these issues, and that 
we are really providing the very best practices to our men and 
women who have served us so bravely and have so bravely 
testified in today's hearing.
    I wanted to go back to some of the specifics from panel one 
that were suggestions, and one is going outside of the VA for 
services, to access services that may be closer to home, to 
access perhaps services that are best practices if it does not 
exist within the VA. And it seems to me that if we do have 
these gaps in care and so forth, and we want to address this 
with that sense of urgency, that perhaps one solution could be 
is to look at the utilization of outside services for our men 
and women within their areas of which they reside. It seems to 
me, if those best practices are out there and being provided, 
that this may be a way in which to provide those services in a 
very efficient and expeditious way. And just wanted to hear any 
comments from you with that.
    Dr. Jain. Thank you, Congresswoman, for that question. Let 
me start the discussion on that particular topic. I think, as 
you say, our VA medical center leadership at all of the 
facilities have a range of options available to them in terms 
of looking at how to provide services in a timely manner. And 
clearly the veterans on the panel have pointed out that fee 
basis care is one of the options.
    I would also submit to you that we have telehealth 
services, and I think that was pointed out, that we could have 
these clinics. As you know, we have lots of community-based 
outpatient clinics. Over the last several years, mental health 
has now become a component of the primary care services that 
are provided at our CBOCs.
    What we have done over the last few years is, we have added 
the telemental health services to further expand the reach of 
the experts that we have at the medical centers, to make sure 
that higher level of expert services is available in our 
clinics.
    But listening to the testimony of one of the veterans, it 
is clear that there are some areas of gaps. There are some 
areas where perhaps the veteran was not able to reach a 
community-based outpatient clinic, where there was also a 
combination of mental health services and other types of expert 
services for survivors of MST that may be available.
    The issue of fee based services is certainly there and 
clearly, as you say, is one of the options. The challenge that 
one faces, though immediately, is that you have to look at 
whether there are the right professionals available to make 
sure that service is available in a timely manner. I think the 
veterans pointed out the challenge of the exchange of medical 
record information. When the services are provided within the 
VA or when we partner with HRSA, for example, or when we 
partner with Indian Health Services, you know, we have done 
several projects now where the VA in partnership is working 
with those types of agencies to make sure that we share 
resources and we provide the care in a timely manner to where 
the veterans are.
    So I think there is a range of options, and clearly one of 
the options would have to be fee based services. But let me ask 
Dr. Carroll if he would like to add anything.
    Ms. Brownley. Well, I would like to go on further with 
another question, if you don't mind.
    Dr. Jain. Sure. Please.
    Ms. Brownley. The other issue is around screening, and to 
me that seems like that can just be a simple fix, to make sure 
across the country that we are doing the screening. And it was 
very concerning to hear Ms. Johnson, who is our most recent 
servicemember and veteran, who clearly was not screened. And so 
we say we are screening, but yet I think from the testimony, we 
can conclude that it is not a fail-safe program, that every 
single man and woman are not being screened. It is something 
that is not complicated, it is just a matter of making sure 
that we are doing it.
    I also think vis-`-vis screening that screening is 
something that it is not just a one-time thing. We have to 
continue to sort of follow up, and there probably needs to be 
other places in the process where they are screened again so it 
is not a one-time thing, so that it is more of a check and 
balance and more of a fail-safe system.
    The other thing that has come to mind in listening to the 
first panel is having advocates for these men and women that 
can access the system, to prioritize their needs within the 
system to get the services that they need and when they need 
it, and can help in the coordination, also in making sure that 
from every place, wherever it may be, that they are getting 
what they need.
    And just would ask if you could comment on any of those.
    Dr. Jain. So, Congresswoman, thank you very much for those 
comments. And I fully agree with you, I think that there are 
many points that our veterans made, in terms of suggestions, 
that we would take to heart, and we will go back and review our 
current policies and procedures to strengthen.
    For example, screening, as you point out, I think there are 
some things that we would need to look. I was very surprised to 
see that none of the four veterans. Now, in some ways the 
possible explanation could be that maybe the screening was 
conducted a few years earlier when the screening was not fully 
in place, but that is still not a reason not to do that again.
    I think you point out a very good thing here, and I think 
the veterans have indicated that we need to look at our 
procedures for screening, to see if there is a way we could 
offer some kind of another chance to have the screening done in 
a simpler way. So I would fully agree with that.
    I think your other point also makes sense in terms of 
veterans having options available, i.e., some kind of a coach 
or a coordinator, and I think we are toying with some of those 
ideas in our primary care clinic, in our PACT Program. We have 
recently introduced the concept of coaches or health coaches, 
and these are over and above the OEF/OIF coordinators we have. 
As you know, the OEF/OIF coordinators help in the transition of 
the servicemembers coming into our system, but they also assist 
in coordinating care, whether it is coordination with other 
specialty clinics, or coordination between the VA and the 
community. You know, a lot of our PACT teams have these post-
deployment counselors that also sort of provide a similar kind 
of a role.
    But I think that what we are beginning to do now is to add 
some more coaches that can help to further strengthen this 
element of coordination of services because of a lot of the 
dual care that happens in our system.
    Ms. Brownley. Thank you. And if the chair would allow me a 
little bit more time, I would like to just ask the DoD to 
respond to some of these issues as well.
    Dr. Guice. I think there is a lot that we have done 
recently. We have a new DODI instruction which kind of talks 
about the roles and responsibilities of everyone in the 
Department of Defense to specifically address sexual assault, 
prevention, and response. That was just issued in April. The 
services are in the process of fully implementing it. We know 
they are compliant with the health care provisions in there. So 
we know that providers are trained, we know that they are 
meeting the standard for providing 24/7 coverage, that there 
are SAFE kits in all of the MTFs.
    So I think we have actually responded in a thoughtful way 
to what we also heard from survivors in our focus groups in the 
Department of Defense to kind of fix some of the problems that 
were articulated. We are just kind of seeing if we have solved 
some of the problems certainly that were articulated for the 
health care parts of it. I know we still have some outstanding 
issues with regards to some of the other things that you all 
have articulated here.
    But I just want to articulate my thanks to the first panel. 
It is only through their eyes that we actually see us as we 
are, and that is how we fix things. So I am very grateful to 
their willingness to come forward today and help us and see 
things the way they see it. That is only how we get better.
    Ms. Brownley. Well, thank you. Thank you for that. I think 
we all walk away today, hopefully the Congress, DoD, and the 
VA, walk away with a sense of urgency today that we have a lot 
of work ahead of us.
    Thank you, Mr. Chair. I yield back.
    Mr. Benishek. Ms. Kirkpatrick.
    Mrs. Kirkpatrick. Our Committee has heard that a stigma 
exists in the military that deters active servicemembers from 
getting mental health care. One of our veteran panelists 
suggests that there be a Mental Health Day where professionals 
are brought together so that servicemembers can seek mental 
health care that day and actually see professionals. Dr. Guice, 
has that recommendation been explored before?
    Dr. Guice. I have actually not heard of that particular 
recommendation. We have done a lot in the past several years to 
provide embedded mental health providers, both in the deployed 
environment, we have embedded behavioral health specialists in 
our primary care teams for the patient-centered medical home. 
So I think we are doing a pretty good job of trying to 
penetrate and provide our behavioral health specialists where 
they need to be, and so that they are not seen as something 
different, but they are just part of your group. And I think 
that that is going to go a long way.
    We actually have seen in the Department an increase in 
people accessing services for mental health, which I think is a 
good news story. That, I think, means that we are addressing 
stigma. Have we totally fixed it? Probably not. But I think 
some of the maneuvers and some of the choices that we have made 
are actually making some inroads into it. So I am quite 
positive.
    But I will take back the idea of a Mental Health Day and we 
will see how people respond to that.
    Mrs. Kirkpatrick. I represent a very large rural district 
in Arizona, and we are using more and more telemedicine. And I 
am finding that patients are very open to that and find it is a 
very positive experience. I am just thinking that telemedicine 
may be a way for some of our veterans to seek mental health 
treatment in the privacy of their home without having to go to 
a facility.
    Dr. Jain, would you address that idea?
    Dr. Jain. Thank you, Congresswoman, for that question. I 
think the potential for telehealth is still, I would say, in 
its infancy, so we really can take this to many different 
levels. I think the point that you are making and the veterans 
have made, providing care where the veterans live in that 
community, I think is a message that we have taken to heart. 
And we have done a lot, but we need to do a lot more.
    I think that the days of asking the veterans to drive 200 
miles or 150 miles to come to the mother ship and be able to 
receive care, I think has to be a passe, and we need to move on 
to the point where we are able to provide more services either 
in our community-based outpatient clinics or potentially in 
their homes.
    So, yes, that is certainly an area that we are looking at 
very actively, and we will continue to expand that.
    Mrs. Kirkpatrick. Thank you. And again thank the panelists 
for being here today. And I yield back.
    Mr. Benishek. I am going to ask just a couple more closing 
questions.
    Dr. Guice, looking at this GAO report from January of this 
year, it says we found that military health care providers do 
not have a consistent understanding of their responsibilities 
in care of sexual assault victims.
    Did the testimony of the first panel, did that affect you 
in your thoughts of how things are going in the system?
    Dr. Guice. I think the testimony of the first panel was 
compelling and heartwrenching. I think that the things that we 
have addressed in our new guidance to the field, though, will 
go a long way to actually try to remedy some of the things that 
they articulated.
    All health care providers who come in contact who have any 
kind of role or responsibility for sexual assault and treating 
those patients are required--required--to have an initial 
treatment and an annual refresher course. Those that actually 
perform the SAFE exam, which is the forensic examination, are 
required to have very specific training to a national standard, 
which is the Department of Justice.
    Mr. Benishek. Let me just ask you one quick, short question 
here. There has been some concern about people who have 
survived MST and their inability to stay on active duty because 
there is maybe not quite the treatment protocol to allow them 
to do that. Is there some way that we are addressing that in 
the DoD?
    Dr. Guice. I would have to actually go back and talk to 
people about that just to make sure that we have got something 
in place that is directly addressing that particular question, 
sir.
    Mr. Benishek. All right. I would appreciate getting back to 
me about that.
    Mr. Benishek. I want to thank you all for joining us this 
afternoon. I truly appreciate it. And I hope that, as I said 
earlier, that the testimony of the first panel affects you all 
in your zeal to make things better from every aspect of VA and 
DoD, because I know it is certainly affecting us here on the 
Committee, and we are going to work on improving it from our 
end. But I would hope that this would inspire you to work 
harder in making it happen.
    So with that, you are excused. Thank you.

    [The prepared statement of Rajiv Jain, M.D. appears in the 
Appendix]


    [The prepared statement of Karen S. Guice, M.D. appears in 
the Appendix]

    Mr. Benishek. I will ask unanimous consent that all Members 
have 5 legislative days to revise and extend their remarks and 
include extraneous material.
    Without objection, so ordered.
    Mr. Benishek. I would like to once again thank all of the 
witnesses and the audience members for joining us here today 
for these important conversations. And this hearing is hereby 
adjourned.

    [Whereupon, at 1:45 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

               Prepared Statement of Hon. Julia Brownley 
    Good morning. I would like to thank everyone for attending today's 
hearing, focused on examining the care and treatment available to 
survivors of military sexual trauma . The Subcommittee will also be 
looking at the coordination of care and services offered to the victims 
of MST through the Department of Veterans Affairs and the Department of 
Defense.
    Many MST victims who have suffered through an ordeal such as sexual 
assault often times are reluctant to discuss their situation and seek 
help. Those that finally gather the courage to speak up find that their 
story is often dismissed or treated indifferently, unjustly becoming 
the victim again.
    As many of you know, the Pentagon reported earlier this year that 
an estimated 26,000 cases of unwanted sexual contact occurred in 2012, 
up from 19,000 in 2011. With only 13.5 percent of incidents reported, 
it is clear that we must do a better job in both preventing and 
treating MST. These servicemembers and veterans often continue to 
experience debilitating physical and mental symptoms from MST, which 
can follow them throughout their lives.
    Focusing on prevention, however, is only part of the solution. It 
is critical that we do all that we can to make it easier for victims of 
MST to access needed benefits and services and receive treatment. 
Compassion and care are a significant part of healing those that have 
been sexually assaulted.
    I applaud the legislative efforts of our colleagues who have 
introduced legislation, H.R. 1593, the Sexual Assault Training 
Oversight and Prevention Act and H.R. 671, the Ruth Moore Act. These 
bills seek to ensure stronger protections are in place so that the 
safety and well being of our men and women in uniform is assured. We 
must begin to take these important steps to end sexual assault. As a 
proud cosponsor of both bills, I believe we are headed in the right 
direction.
    I was saddened to read the testimonies of our first panel. The pain 
and suffering was evident in the personal stories written. I know that 
this is hard for all of you and I commend you on your bravery to speak 
up today. We need to hear, firsthand, the experiences of veterans who 
have found the system unfriendly and intimidating so that we can make 
it better.
    I look forward to hearing from our witnesses today. Thank you, Mr. 
Chairman, and I now yield back.

                                 
                 Prepared Statement of Victoria Sanders
    I paid a big price to be asked to be here today. I belong to an 
exclusive club. The kind no one wants to be a lifetime member of, 
vacations are permitted but PTSD will always be there. Each step along 
the way we have lost good people. Some have died at the hands of their 
rapist before they could ever report anything. Sophie Champoux died 
while on active duty of a gunshot wound to the head. She was raped two 
times by the same man. He confessed went to Leavenworth was to be 
released very near the time that Sophie's headstone was delivered. 
Carri Goodwin died 5 days after being discharged. A combination of 
medication, given to her by the military before discharge, and alcohol 
killed her. I attempted suicide in 1985 just 10 years after my rape. I 
was lucky that attempt failed.
    It took almost 20 more years of slowly increasing symptoms until a 
woman was raped 15 feet from my front door and my life came close to 
ending again. In 2004 I talked to my mother and told her for the first 
time about the rape in 1975. I had never told anyone. If they would 
have given me the survey about sexual assaults in the military I would 
have said I was not sexually assaulted. The guilt, shame, and self-
blame would not allow me to see what I now understand more clearly. My 
symptoms are still bad. The nurse training I got with my G.I. Bill 
helped me to be able to put on a brave face and go out to the world. 
The woman who inspired me to become a nurse worked at the VA and on bad 
days she might say ``I could make a lot more money someplace else but 
those boys need me.'' This was in the late 60's early 70's the height 
of the Vietnam War. I expect the same from my care givers.
    I was lucky at Palo Alto I had people who did things for me to keep 
me going. The first appointment I got was with a PhD who stayed after 
hours to see me. The woman at the vet center did me the favor to call 
the PhD. I was lucky. No matter how hard it is for me I know how lucky 
I am. I can ask for what I need. I know how to handle the symptoms but 
can't always keep them under control. I was raised by a single mother 
with no high school diploma. As I tell people I was born in Georgia and 
we were dirt poor. We moved to Kansas and we could not even afford 
dirt. I am lucky that my mother told me to go to the VA, lucky that the 
first person I saw asked the right question. Tell me about your time in 
service. Everything fell out of my mouth. The rape, the harassment, the 
custody battle, years of denial all came to an end that day.
    Again I was lucky after my fiance Alan Seidler died his family 
cared enough about me to give me money every month. Homelessness was 
not an issue. At a certain point I was afraid to be alone so I moved in 
with family friend. Dr Betty Mudock was an 80 year old women who had 
Alzheimer's. I needed her she needed me.
    When Dr Irene Trowell Harris came to Palo Alto with a large group 
of Washington people I told her I was lucky that I got the care I 
needed when I needed. That I was able to verbalize what other can't. 
That a part of me can, as I am doing today, put on the suit of armor 
and go on through the battle. Later I will lick my battle wounds and 
revert to isolation, fear, anxiety, flashbacks, anger, not being able 
to open my mail. Not being able to be the mother I want to be the 
grandmother I want to be, the sister I want to be, the daughter I want 
to be.
    When Samantha Gonzalez said to me, tell me about your VA care. Out 
poured the frustration of the gaps in care I outlined.
    My medical care San Francisco VA:

    2011

    May 26 - SFVA ER intake

    Jun 1 - SFVA intake

    Jun 27 - SFVA women's clinic

    July 11 - Zwelling They looked up appointment and said appointment 
was in the computer for the 12th 9am. I became very upset a social 
worker saw me and took me into an office he contacted Zwelling who said 
``it says in my notes I made appointment for 11th'' had about 15 
minutes to talk with her about finding someone to use the two fee basis 
appointment. Made appointment for the 25th of July then she called and 
change appointment to Aug 1 so I could attend a group meeting that day 
and see her.

    Aug 1 - Zwelling called me to say she was going home ill 
rescheduled for Aug 4 at 2pm. At this point I felt I could not continue 
to try to see this provider in one month she missed appointment, failed 
to tell me where her office was, then changed appointment to Aug 4 
(what I was wanting her to do is help me find a provider for the fee 
basis I was given). I felt that after the 20 days of changes missed 
opportunity and confusion I could not trust her with my mental health 
care. I communicated this to my primary provider.
    The next thing that happened was not a missed appointment but a 
combination of county budget cuts and lack of services for women in the 
area.

    Aug 10 - signed up for Marin Services for Women

    Aug 12 - attended first session of MSW

    Aug 15 - attended second session of MSW around 11 am leaders come 
into the room and say we have announcement the MSW outpatient service 
is closing in 3 weeks. I was outraged that this group claimed they had 
no idea until that morning this facility was closing. So then I was 
left with no fee basis not even the two they had given me and no mental 
health help. [Exhibit A]

    Sep 12 - Dr Hasser (when arrived clerk did not know I had 
appointment it took about 15 minutes to contact Dr to find out I did 
have appointment)

    Sep 19 - Pain Clinic 4 hr appointment-these 4hour long appointments 
are very difficult for a person with chronic pain.

    Oct 24 - Dr Chin

    The following list are appointments with Christine Celio (Post 
Doctorate Fellow) appointments made in person weekly on Fridays for 
either 10 or 11 am. She worked in pain clinic. When she asked me what I 
was trying to gain from sessions my answer was I want to feel safe when 
I come here. It is a very scary place, many men, early failures, no 
groups available at a time that would work for me.

    Dec 9, Dec 16, Dec 30

    2012

    Jan 27, Feb 10, Feb 24, Mar 9, Mar 23, Mar 30, Apr 6, Apr 13, Apr 
20, May 4, Jun 1, Jun 8, Jun 15.

    Jan 23 - Dr at women's clinic the clerk was a not aware had 
appointment again had to check with Dr, then said oh you do have 
appointment

    May 14 - women's clinic asked for mammogram was told not done every 
year but every other year. I had a notice from Stanford where I had 
mammograms since 2004 telling me it was time to do my test. Dr said no, 
new thing done every other year.

    July 25 - VASF Dr Hasser. This appointment was made by phone 
message left for me by Dr Hasser. When I arrived I was told I did not 
have appointment Dr with another patient. Showed my notes to clerk 
about phone messages left for me by Dr Hasser. She said maybe it was 
not with Dr Hasser and told me there were no appointment for me in 
system. Left clinic 7 out of 10 angry. I was called back to the clinic 
saying they would see me.

    Aug 8 - VASF Dr Mesa

    Aug 22 - VASF Gynecology (resident) was told by Dr only have 15 
minutes

    Aug 27 - VASF women's clinic

    I had shoulder surgery Sept 19 outside of VA care this prevented me 
from being able to access help. I had learned the year before that fee 
basis was not going to happen. There are still no services in Marin and 
choices are gotten slimmer. A few calls to local programs all would 
require fee on sliding scale basis would not even accept fee basis if 
available. My mental health was declining more isolation, unable to 
open mail or answer phone.

    Oct 18 - Called for medication refill I left message for Dr 
Kerlikowske that I was running short and needed her to reorder it so I 
would get what I needed.
    The source of this problem come because the pharmacy will say ``we 
sent you a month's supply the 1st of October so the next should not be 
sent out until November 1st.'' The problem with this thinking is if you 
send me a 30 day supply and there are 31 days in the month I will run 
out. I was told the only way to get the drug sooner was to call the 
clinic and ask the doctor for an RX. I told them that is what I had 
done and they told me she order it to be shipped on Nov 2. I asked that 
a pharmacist call me to discuss.

    Oct 22 - I got a call from the pharmacist my frustration was 
growing. I was told the Dr had written for me to get the next shipment 
sent out on November 2nd, now leaving me with 3 days without 
medication. I was told it was written by the doctor that way and I 
would have to contact them again. I asked for a face to face meeting 
with a pharmacist. Told that could not happen for a couple of weeks. So 
I asked what would happen if it was a new drug for me and I needed 
information, it would still be a couple of weeks. I got a call back 
later saying I could not have appointment ``it does not meet the 
requirements'' for a face to face meeting. It was the way the doctor 
ordered it. Also told that if I needed a change I would have to call 
clinic back. That the doctor had made an error by not ordering it for 
October 31st. Then I asked if the doctor had ordered 8000mg and it 
should have been 800mg would you call me and tell me to call the clinic 
or would the pharmacy take care of the problem before it got to the 
patient. That ordering the wrong date is just as wrong as ordering the 
wrong dose.

    Oct 23 - got call back from pharmacy (I think Susan) said she would 
give this to a supervisor.

    Oct 23 - I called Patient Advocates office and never got a call 
back.

    Oct 30 - When I received the medication the dosage was changed from 
200 mg three times a day to 300 mg two times a day. I called the 
pharmacy again spoke to Debbie she said ``it was reviewed and 
changed''. ``It was a dosing adjustment''. When I asked why the answer 
was shocking. They don't want to have so many pills in the pharmacy. I 
asked if the 200 mg was being taken out of the stock, the answer was no 
we sent you a letter to explain. [Exhibit B] At this point I made 
appointment to see Dr at women's clinic the first available appointment 
December 3.

    Dec 3 - SFVA women's clinic made appointment to discuss the change 
in dose for my pregabalin the Pharmacy made from 200mg TID (three times 
a day) to 300mg BID (two times a day)

    Dec 7 - received wrong dose of medication. Dr Kerlikowske ordered 
200mg BID (two times a day) Called Dr at women's clinic told them about 
mistake. Did not receive return phone call. [Exhibit C]

    Dec 10 - Called women's clinic again, explained their actions were 
hurting me, causing me to be more emotionally unbalanced because I 
cannot be sure that anyone is communicating or listening to me. That I 
had gone to see the dr because of a change made by pharmacy without 
discussing with either my doctor or myself.
    Was called back later by women's clinic nurse she said she was 
sorry for error and will send what I needed.

    Dec 18 - called Pharmacy spoke to Ed to see when I would get the 
rest of the medication. Timir from the pharmacy called me later to tell 
me medication was being sent out today.

    2013

    Jan 28 - SFVA women's clinic to discuss the error that was made 
when she changed the order that the Pharmacy had changed.

    Mar 14 - SRVA intake Nicole Randall Phd fellow said no process 
groups available maybe in July. No individual therapy available 
possible 6 month waiting list. Offered Anger management group Friday 2 
pm (this is a very difficult time to drive north on highway 101) given 
paper from last year listing groups that are possible at the SRVA. On 
the list was the was Women's coping skills show to meet on Tuesday at 
11:30

    Mar 15 - anger management group- Leader Nicole Randall held in 
large room where the veterans are all sitting next to each other with 
our backs to windows. Group leader did little more than read the last 
lesson in the book. Came time for relaxation exercise that is when I 
realized the chairs were much too large my feet would not touch the 
floor when I sat back. I pointed this out to the group leader when I 
was asked how the relaxation was. I looked for a different size chair 
in the room and there were none. I am not sure who this room is 
outfitted for but not a good place for me. It felt again like I was not 
being considered. That an average height woman 5'5'' cannot sit in a 
chair and have her feet hit the floor. This has never happened to me 
before in any office I have been in, I was very confused about why we 
were not able to find a nice small room where we could make eye contact 
with each other and feel like we are not on display for everyone who 
walks into the clinic.

    Mar 22 - Anger management. Was called at the end of session by Dr 
Hiroto. Met her after she invited me to a new group starting the next 
week. I agreed to coming noted it on my calendar but somehow failed to 
get the time written down.

    Mar 25 - called SRVA to confirm group time was told 11:30

    Mar 26 - Arrived at SRVA checked in at desk asked where and when 
the group would start. The man at the desk said they would be meeting 
in an office right off the lobby at 11:30. At 11:40 went to desk to ask 
about the group since no one had showed up. The lady I spoke to again 
said it would be 11:30 in the room off the lobby and pointed where I 
had been waiting. I told her it was past 11:30 and no one showed. She 
then got on the phone and asked. She then told me the group was at 2 
pm. I got very angry and told her I need to talk to someone right now 
or I was going to be 10 out of 10 angry. At that point the security 
guard came over and said ``we not going to have that in here''. I 
assured him I would leave if I got to a 10. Let me add I made no threat 
other than I was angry and needed to see a person. A few minutes later 
Dr Hiroto came out and started to talk to me in the lobby. I asked her 
to join me in the conference room. I told her about all the mistakes 
that had been made that are listed here. How frustrated I have been 
because of the chronic pain from multiple sources. That just driving an 
hour sitting and hour and then driving an hour would not help me. That 
I need help in my county within a 10 to 15 minute drive. I am sure I 
did not make a good impression. I called patient advocate office to ask 
them to document yet another appointment that was miss-handled.

    Mar 27 - received phone call from Megan McCarthy. Explained all of 
the above briefly told her the problem is I need relevant content. Not 
basic skills. I need process group and individual therapy. She said 
these are not available long waiting list. We discussed the idea of me 
using my Medicare benefits to have someone in my community help me.
    I am not sure who I spoke to but I was asked if I would take an 
appointment with a doctor. The person asked me if I would come up to 
Santa Rosa and have a Skype with a Doctor in San Francisco. I asked why 
I could not drive to San Francisco to see him there it seemed silly to 
drive 40 miles to Skype with someone who is working 35 miles from me in 
the other direction. I was then given an appointment to see Dr 
Threllfall in Santa Rosa April 10 at 9 am. I asked if that was the only 
time I could come. I was told that this kind of appointment was always 
at 9 am.

    April 10 - arrived just before 9 am checked in at desk told to go 
to waiting area. I waited for 45 minutes before I went back to the 
desk. I was told they would contact the doctor to go back and wait. 
About 5 minutes later I was called in to the office. Dr Threllfall said 
he was sorry but he did not know he had an appointment.

    (a side note here after he said that all I could think was, you 
work for the VA, mental health is overwhelmed to point of no 
appointments available, this is not just a problem here by VA wide and 
has been in the news, why would you be here getting a paycheck if you 
did not have appointments at 9 am on a Wednesday.)

    The session was a disaster, he asked why I was there. I told him 
about the mix up with appointment that the VA is not just not helping 
me but it is hurting me. He left the room several time and each time 
returned asked another question that I know I have answered many times 
and should be well documented. Things like, how was your childhood? Do 
you have hallucinations? What medication are you on? What is the 
biggest problem for you today? I told him anxiety due to my lack of 
care and being forgotten and pushed under the rug again just like when 
I was raped, not just by him today but by the system. He gave me a 
prescriptions. I never took it, why should I need to be medicated when 
they system is failing me.

    Apr 11 - received a call from Chantell asking me to make 
appointment with Dr Threllfall. I told her that he gave me a pink paper 
to take to the front desk. I did and they gave me an appointment card 
for the date and time she was trying to make the appointment for. I 
told her this is really shaking my confidence if the Dr first ``doesn't 
know he had an appointment then forgets that he made appointment with 
me in his office.
    I refused to see him again.

    May 8 - Still in need of care I made contact with the Cheryl 
Wernell Women Veteran Coordinator. Explained the difficulty I was 
having both getting to the VA facility and the problems I have had when 
I go there. She said she would make attempt to get me fee basis again. 
The fee basis is not useful to me unless there is a person who will 
take it for payment. I explained that I was not able to call every 
provider in Marin County to find one who would and I needed help with 
this. She said she would ask around and call me back.

    May 22 - Another call with Cheryl Wernell she gave me the news that 
the fee basis for 2 visits was approved she did not know how long it 
would take to get it mailed out. She gave me 2 names. I watched my mail 
very closely the next few weeks finally on June 18 I had still not 
received the fee basis papers called Cheryl Wernell again. She told me 
that the fee basis had expired but she would see if she could get it 
extended. I finally got a copy in the mail on June 22nd. It was 
postmarked June 19th It was extended until July 17th. When I called the 
number I was given one was disconnected the other called back after 
three phone calls in a week and said I had to pay a fee of $450 for the 
1st visit and $280 for each session and she would not take the fee 
basis as payment.

    Jun 18 - called to get refill on prescriptions had to call women's 
clinic I cannot just call the pharmacy for a refill of pregabalin

    July 1 - had not received medications so called to see why. I was 
told they were never got the message. I called again on July 8 and was 
told first that it went out Friday, then after checking the pharmacist 
said it was filled on Friday but was being mailed on the 8th. Received 
on the 9th of July.
    I have kept notes both on my calendar and in notebooks. I have 
copies to back up everything I have said here. I am sure the medical 
records do not contain the information about the mix ups and my 
impression of my care at the San Francisco VA. Along the way I tried to 
contact the patient advocate. Many of my messages were not answered I 
received a letter from the Chief of Quality Management to apologize for 
some of these events. [Exhibit D]

    Summary: the act of trying to get care that meets me where I am as 
a patient is not happening. The system is out of touch and things as 
simple as the pharmacy emailing a doctor about a problem is not the 
policy. When I am told to come back in three months cannot make 
appointment in person before I leave the answer is ``we will send you a 
card to remind you to make appointment''. When you get the card in 
three months it takes 6 weeks after that to get an appointment. That 
makes it really 4 and 1/2 months not 3. This starts the cycle all over. 
I was told at one point that the Women's Clinic Doctor is only in on 
Monday and Thursday. The rest of the time she does research. The system 
is set up to fail. The failures of the caregivers I have had in the 
last 2 years is unacceptable. If you look at appointments that I made 
over the phone or were made for me out of twenty one, seven of them had 
major problems that triggered me and made my life more difficult. That 
is 1/3 of my appointments causing problems not making them better. The 
only successful time was when I was the 17 appointments every Friday in 
the pain clinic. When I made the appointment face to face for the next 
week. This was just a temporary help not long term supportive and not a 
trauma processing time. It was with a doctorate fellow (in training) 
and her time was done there. Continuity of care cannot be given by 
student that leave after a few months. In mental health care it takes 
time to trust both the care giver and people you meet while getting 
care in a group setting.

    Everything that has occurred from my first visit when I was told 
the patients park in the overflow and take a bus from there. (I am not 
getting on a shuttle bus with a bunch of men). My question why don't 
the employees park there? To quote the phone message you get when you 
call ``where we put veterans first''. If you put them first there would 
be parking for them and the employees would take a shuttle bus. To the 
pharmacy policy to have the patient correct doctor/pharmacy 
miscalculations. No groups No individual therapy. No fee basis. ``Where 
we put veterans first''? It seems the veteran is last, and women 
veterans don't even make the list. Called Mister, having to wade 
through a sea of men for every appointment. The first appointment I had 
at the women's clinic there were only 4 chairs 3 of them taken by men, 
yes 3 out of 4 chairs filled with men inside the women's clinic. I am 
not last I am not even on the list
    One constant idea that I find unable to rectify is the physician 
says it is a mental health issue, the psychologist, or psychiatrist say 
it is in your body. I have to remind them both that I can't take off my 
head when I walk into the Dr for medical care and leave my body behind 
when I walk into mental health care. The concept of a whole body 
thereby a holistic approach is out the window. Everyone has a specialty 
and you can only talk about the one problem. I went to a specialist, 
well specialist in training and was told very clearly that I was only 
allowed 15 minutes for an exam. When the doctors at the VA spend their 
time supervising students we are paying them to teach not give care. A 
veteran sees a student the supervising Dr will look at the notes signs 
off and never looks at the patient. The students do not know how to put 
appointments into the computer. Student care is not giving the veteran 
the best. Things like acupuncture and chiropractic care are either 
offered at the VA or fee basis are given for these things. I have seen 
Osteopaths for over 20 years on a nearly monthly basis. I know without 
asking that fee basis would never be considered for that care. It is 
very helpful to me and calms both the tension in my body and mind. I am 
lucky I have other insurance that takes care of me. Not all veterans 
are as lucky as I am.
    Another problem is the idea that you must get help for substance 
abuse before you get help for being raped. The substance abuse is to 
kill the pain. You want them to give up the pain killer before they get 
help for the problem which they are killing the pain. It would be like 
saying. I will fix your broken leg if you walk over here close enough.
    The entire VA application process feels like a dance. You have to 
ask for things a certain way, on certain forms, asking for certain 
forms. The military and the VA have access to all those files so it 
felt like I was playing guess what we have and guess form it is on, 
guess how you have to ask for it. This is the reason the backlog 
exists. If a trained professional sat down with the records and the 
veteran it could be a simpler process. The way that files disappear or 
pages get taken out of medical records makes the job harder for the 
Veteran and anyone helping them find ways to prove claims. It should 
not take an act of a congressperson to get files about criminal actions 
or medical visits while on active duty. When I saw my file at the C&P I 
was finally given after over 3 years it was 2 feet high.
    The collection of information process can include things like in my 
case. I was unable to access any of the medical records from the time I 
was a dependent of active duty. There was no way for me to request 
these records without his social security number. Almost 10 years of my 
medical history was lost. The critical years just after my rape. I was 
lucky that the Criminal Investment report was still available. It took 
two letters to Congressman Honda to get these files that proved my 
claim. Even then the 1st C&P gave me a rating of 50%. My counselor 
wrote a letter as soon as she saw it and said the rater was wrong. That 
my symptoms were more severe, more often, and unrelenting. Even though 
I put on a brave face all the symptoms of PTSD plague me. Hyper 
arousal, depression, fear, avoiding everything even fun things. 
Flashbacks where I feel trapped in the room again with man who raped 
me, I can see his face and smell the smell of old tents. Isolation from 
people I love like my son and daughter, granddaughter, mother, sisters, 
not being able to maintain an intimate relationship. I have been 
married three times and find now I don't want anyone to invade the safe 
space. The emotional roller coaster of feelings never knowing if in an 
hour something someone says will cause me to become angry. When a 
system fails it takes me back to the place where the commanders had me 
in a room telling me they knew what was best.
    A suggestion I would like to put forth is the idea of Mental Health 
days while on active duty. Where a combination of tests and talking to 
mental health professionals. Most of the people affected by PTSD are 
young and too proud to ask for help. The stigma of needing mental help 
would be removed because everyone does it. Early signs of traumatic 
brain injury, depression, sexual assaults, and battle PTSD are 
difficult to diagnose without a trained professional. The tests can be 
made that will show signs of all the problems that plague our active 
duty military people. The talking can help unit cohesion instead of 
picking on the ones who seem troubled the unit can get behind the 
person in need. You do not have to wait until someone is suicidal to 
help. Just like you don't send someone into battle without body armor 
and a gun. Sending young people in harm's way without mental health 
care is reckless. We know better now so we need to do better. Getting 
to the patient sooner improves the outcomes. There is no disease that I 
know of that will get better by ignoring the obvious problems. Natural 
disasters, bombing, mass shooting when these happen trained mental 
health people are sent in to the patients as soon as possible. It has 
shown that to improve symptoms of PTSD in all age groups.

    Enclosures: Exhibits A-D


                                 
                  Prepared Statement of Lisa A. Wilken
    I am a USAF Veteran. I was medically separated from the USAF after 
a sexual assault and am currently rated 100% Service Connected Disabled 
by the DVA. I am a wife of almost 18 years to my wonderful husband, 
Robert. We have been blessed with two sons, Joel, 12 and Benjamin, 3. I 
do Veteran Advocacy as a volunteer.
    Thank you for giving me the opportunity to speak with you. I am a 
USAF Veteran and I am rated 100% Service Connected and I am a MST 
Veteran. I have struggled for many years to be proud of my service 
because of my experience, but by speaking out about my experience I 
hope to make a difference so that another young person in uniform won't 
feel the way I did for so long. I was 22 years old when I was raped. I 
am 42 now and a wife and mother of two sons. Not a day passes that I 
don't deal with something related to the assault.
    Why is it so long lasting? I believe due to it not being treated 
properly from the time of the assault compounded the problem and lack 
of services by DOD magnifies the problem and by the time the VA 
receives us we are already behind in our recovery. Studies show that 
women are at a higher risk for PTSD due to trauma if their experience 
was severe or life threatening, were sexually assaulted, were injured, 
reacted severely at the time or experienced stressful events after the 
event or if there isn't a good social support network. MST Veterans 
have had all of those things on top of their assault.
    Study us while we are in treatment. Studies are needed, but 
treatment needs to come with those studies.
    We need groups at VAMC's and outside facilities. You will hear me 
bring up using our civilian medical professionals a lot. Some women are 
not going to come to the VA because of lack of treatment or a bad 
experience with the VA. Most people who have never been in the military 
don't realize how much the VA system mirrors it. That can be a negative 
when trying to get a MST Veteran to come in for treatment. There are 
programs for treatment through the VA, but there are not many and they 
are 6 weeks long. What mother can leave their family and would an 
employer tolerate it? What about shorter, more intensive therapy 
weekends that give MST Veterans the tools they need to deal with the 
results of years of unattended PTSD. There are things that need 
attention in most of their lives that are a result of their PTSD due to 
MST and some of them don't make the connection or realize that it can 
be better if they have the tools. Some have no support network and that 
is something that is crucial. To have someone to talk to about things 
you can't talk about with your spouse can save lives. Events could be 
held through each VAMC and coordinated with local heath care providers. 
Using outside health care providers I believe would be a great asset to 
getting more women in for treatment and have a higher success rate as a 
local provider may not trigger a trust issue that the VAMC may pose to 
a MST Veteran. I believe if you open up treatment for MST Veterans to 
go outside of the VA you will see a larger number of Veterans apply for 
those services.
    Protocols need to be developed for MST Veterans and follow up to 
ensure that VAMC employee's understand PTSD due to MST and are aware of 
the Veterans they are giving care to and following VAMC standards. I 
hear from many women of how their MST symptoms are overlooked or even 
ignored while in VAMC's on other wards, but also when inpatient on 
psychiatric units. Group therapy requirements for MST Veterans need to 
be looked at. If you don't participate in group, you are seen as not 
cooperative; when it is just that you are not going to talk in an open 
group. Sleeping in a room with a stranger can be a problem. Some MST 
Veterans still sleep with the light or the TV or some sort of 
distraction mechanism to get to sleep. To be required to sleep with a 
stranger in your room, even of the same sex, can sometimes trigger 
other PTSD symptoms. Nightly checks of rooms that are done can trigger 
an MST Veteran. These are a few examples of issues that arise due to 
VAMC employees not being trained or recognizing MST Veteran issues.
    As always, more GYN services need to be available at each VAMC, but 
here again is an area that our local medical community should be 
utilized.
    Therapy for family and spouses is needed to help them to understand 
why they see some of the things they do and understand what is 
happening. Someone for family members to ask questions of other than 
their parents who are struggling with getting the answers right. Kids 
see and know more than any of us realize and sometimes when it is 
realized, it is too late and damage is done. My 12 year old son Joel 
has seen his mother many times upset or angry for reasons he is too 
young to understand fully.
    Spouses need a support network also. Some may need more than 
others, but it takes a strong person to put up with PTSD from MST. 
There is no reasoning with PTSD. No matter how much love you give it, 
sometimes it won't let an MST Veteran love you back. Intimacy issues 
need to be addressed. It is an important part of marriage and is 
affected either physically or emotionally.
    MST coordinators at VAMC need help. I am not sure if there is one 
at each facility, but I do know some have other duties. Our MST 
Coordinator, Laura Malone, is wonderful, but we need help for her. She 
is one lady and is overworked and under recognized for what all she 
does and for how many MST Veterans she helps and their families.
    I can't stress enough how utilizing our local medical communities 
could be the answer to help the VA deal with the much needed addition 
of more treatment for MST. As always, money will be a big factor, but 
if the problem is going to be address, money will be spent on adding 
services at VAMC's or utilizing our civilian medical community and 
their expertise. It may also serve a dual role and get more people 
informed about issues facing our men and women who volunteer to serve 
in our all voluntary forces.
    Thank you for your time.
    Lisa A. Wilken

                                 
                   Prepared Statement of Brian Lewis
    Chairman Benishek, Ranking Member Brownley, and Distinguished 
Members of this Subcommittee;
    It is a privilege and honor to be the first male survivor of 
military sexual trauma to testify before the Subcommittee about this 
issue. I would like to thank my partner Andy who could not be here 
today. I want to make it clear that I am not here representing the gay 
and/or lesbian community or their issues. I am here as a veteran who 
was raped while I was active duty. Our significant others allow us to 
do so much and receive so little credit for their sacrifices. I would 
also like to thank the subcommittee for treating the issue of military 
sexual trauma in a gender inclusive way. This places the subcommittee 
farther ahead than the White House, and very much ahead of the Veterans 
Health Administration. Indeed, the VHA discriminates against male 
survivors of military sexual trauma because of their gender in a 
multitude of ways and this is a practice that needs to be brought to 
light and stopped by this committee.
    I was raped while serving aboard the USS FRANK CABLE (AS-40). I was 
discharged a year later after a Navy psychiatrist determined I was 
suffering from a Personality Disorder. After moving home and almost 
committing suicide multiple times, I turned to the Veterans Health 
Administration for assistance with my post-traumatic stress disorder. 
It was almost 6 years before I received PTSD specific care.
Residential Care
    Currently the Veterans Health Administration operates about twenty-
four residential treatment programs for posttraumatic stress disorder. 
Only about twelve are designed specifically for the treatment of 
military sexual trauma. Of the twelve designed specifically for victims 
of sexual trauma, only one accepts male patients. That facility, the 
Center for Sexual Trauma Services at VAMC Bay Pines, is coeducational. 
Put simply, male survivors have no single gender residential program 
designed specifically for survivors of military sexual trauma. A 
complete listing is attached as Exhibit ``A'' to my written testimony. 
The Veterans Health Administration should not officially sanction 
gender discrimination.
    Information on these programs is very hard to obtain. Three days 
before this hearing, I used the PTSD Locator on the National Center for 
PTSD's webpage to find programs treating exclusively military sexual 
trauma. I used Bay Pines' PTSD program as a baseline because I knew 
where it was and its mission. I was not able to access a separate 
listing for programs dealing exclusively with military sexual trauma. 
In fact, when I clicked on the state of Florida, the Bay Pines program 
is listed as a Women's Trauma Recovery Program (Inpatient). \1\ For a 
male survivor, knowing his services are received through a women's 
program is very demoralizing and discriminatory. More often than not, 
there is no printed listing available as to what programs specifically 
serve military sexual trauma survivors. For veterans without Internet 
access, a printed listing may be the only hope they have of accessing 
residential care for their military sexual trauma. We strongly 
recommend that each Military Sexual Trauma Coordinator be required to 
keep hard copies of a list promulgated by the Veterans Health 
Administration as to what programs are available to treat military 
sexual trauma.
---------------------------------------------------------------------------
    \1\ http://www.va.gov/directory/guide/state--PTSD.cfm?State=FL 
(accessed July 16, 2013)
---------------------------------------------------------------------------
    I attended the Bay Pines VA Center for Sexual Trauma Services 
residential program in June 2009. I attended this program because it 
was and is the only residential program specific to military sexual 
trauma that male survivors can access in the Veterans Health 
Administration. Unfortunately, upon arrival I discovered the program 
was co-educational. This presented many barriers to effective treatment 
in that program. I witnessed men and women engaging in romantic 
liaisons during their participation in the program. These emotional 
entanglements proved to be a distraction to many survivors who were in 
the program with me at the time. I personally was uncomfortable sharing 
the details of my trauma in the same group where women were present. I 
can only imagine the damage which would be caused by requiring a male 
survivor whose perpetrator was a woman to attend an integrated program. 
Upon discharge from this program, they failed to ensure a mental health 
provider was following me. This caused me significant setbacks because 
I had to wait almost two months to be seen after returning to Baltimore 
and became suicidal during the time I was waiting for care.
Outpatient Care
    In the outpatient environment, I have received less than stellar 
care. Until this year, the Baltimore Division of the VA Maryland Health 
Care System did not have an outpatient group for male MST survivors. 
This same VA hospital has had a group for female survivors for several 
years. When I asked about joining the female MST group, I was denied 
for no other reason than I was a man. I was forced into mixed trauma 
groups. These groups permitted me no opportunity to discuss my personal 
trauma. I also felt stigmatized by the combat veterans there. In one 
mixed trauma group, the facilitator allowed the combat veterans to 
bring up their trauma because ``the VA focuses on combat issues'' in 
her words.
    The Veterans Health Administration has very few resources outside 
the residential treatment setting for male survivors of military sexual 
trauma. Outpatient groups are common for female survivors of military 
sexual trauma. However, very few groups are available for male 
survivors. I consistently hear from male survivors seeking peer support 
groups. The groups that male survivors can attend are more often than 
not a more general PTSD group where combat veterans are mixed with 
sexual trauma survivors. In these general groups, generally no sharing 
of the reason behind the PTSD is permitted. This marginalizes male 
survivors by forcing them to maintain their silence about their 
experience.
Overall Supervision
    The overall supervision of military sexual trauma programs within 
the Veterans Health Administration is vested in the Director of Women's 
Mental Health, Family Services, and Military Sexual Trauma. This 
oversight denigrates the experience of male survivors and reinforces 
the concept that military sexual trauma is a ``women's issue.'' We 
strongly urge that military sexual trauma be created as an independent 
directorate within the Veterans Health Administration.
    Within the VHA, an overwhelming majority of Military Sexual Trauma 
Coordinators are women. Especially in the case of men who are assaulted 
by women, this presents an often-insurmountable barrier to care. We 
recommend that there be both a male and female MST coordinator in each 
facility.
Research and Training
    More research needs to be conducted by the Veterans Health 
Administration concerning male military sexual trauma. Currently there 
is very little literature available on successfully treating male 
survivors of adult sexual assault.
    The current sequester mandated by the Budget Control Act is harming 
our veterans in an indirect way through the training budget. Direct 
care providers are finding it difficult to attend training necessary to 
keep current on the latest information available in treating survivors.
Personality Disorders
    I urge the Subcommittee members to support H.R. 975, the 
Servicemember Mental Health Review Act, offered by Rep. Tim Walz (D-MN 
1). This legislation would give veterans, like myself, who have been 
misdiagnosed with personality disorders the opportunity to apply for a 
potential military retirement from the Department of Defense. Utilizing 
TRICARE for military sexual trauma related care could remove some of 
the cost of providing that care from the Veterans Health 
Administration, which is currently estimated at $872 million.
    This diagnosis made it hard for me to receive VHA care at first. 
This diagnosis creates a stigma around the survivor as a condition that 
predates service. I have even heard survivors tell me they have been 
denied military sexual trauma related services at the DC VA Medical 
Center because of their erroneous personality disorder diagnosis. In 
fact, the Topeka, Kansas Stress Disorder Treatment Program requires 
veterans to furnish a copy of their DD-214 in order to access treatment 
and explain on their application why they received a less than fully 
honorable service characterization. This application is attached as 
Exhibit ``B'' to my testimony. With these facts in mind, I fear for 
what kind of reception I will receive at the Minneapolis VA Medical 
Center when I move there. Will I be denied MST services there because 
of an erroneous medical diagnosis designed to save the military money?
Conclusion
    In the last few years I have done much to better my life. I 
graduated in May 2013, from Stevenson University with a Bachelor of 
Science degree in Paralegal Studies. My master's thesis on military 
sexual trauma is under consideration for publication in Stevenson 
University's Forensic Journal. I will graduate in December with my 
Master of Science degree in Forensic Studies. I will apply to attend 
Hamline University School of Law in Saint Paul, Minnesota, next year. I 
help administrate MenThriving.org, an online community designed to help 
men heal from the wounds of sexual trauma whenever received. I am an 
Advocacy Committee member with Protect our Defenders, an organization 
dedicated to transformational change in the military's handling of 
sexual assault. I am the President of Men Recovering from Military 
Sexual Trauma, a group dedicated to advocating for and raising 
awareness of male survivors of military sexual trauma. Unfortunately, 
these accomplishments are not the result of treatment provided by the 
Veterans Health Administration. This progress is the result of finding 
nonprofits dedicated to helping survivors in general, building 
resources to address the lack of current credible resources available 
for male survivors, and finding other survivors to help support me as I 
struggle, and finding a partner who has stayed by my side regardless of 
all the hurt I have caused.
    The Veterans Health Administration fundamentally fails male 
survivors of military sexual trauma every single day. They have proven 
their inability to adequately care for us. We respectfully request 
Congress to legislate equality in practice for male survivors of 
military sexual trauma.

                                 
                   Prepared Statement of Tara Johnson
    Chairman Benishek, Ranking Member Brownley, and members of the 
Subcommittee, I am honored and grateful to have the opportunity to 
speak to you today regarding my experiences with Military Sexual Trauma 
and care and treatment from the Department of Veterans Affairs. I 
proudly served in the United States Marine Corps for ten years and 
achieved the rank of Major. While no longer in the Marine Corps, I am 
now employed as an Army Wounded Warrior Advocate, serving severely 
wounded Army veterans and families. It is not my intent to discredit 
the Marine Corps and the Department of Veterans Affairs. It is my goal 
to bring awareness to critical areas that require improvement, in order 
to better serve our Veteran population.
    While in college, I decided I would be honored to serve my country. 
I decided on the United States Marine Corps because it was, I believed, 
the most challenging and the best branch of service. I experienced my 
first incident of Military Sexual Trauma as an Officer Candidate. This 
incident was a sexual assault by a senior Officer. Throughout my career 
in the Marine Corps, I endured several more incidents of MST and 
witnessed other Marines suffer from incidents of MST. These incidents 
included assaults, attempted assaults, abuse and harassment. I did not 
disclose my experiences, as I had seen the unfair treatment of those 
who had disclosed incidents to their commands. Despite these incidents, 
I excelled in the Marine Corps and lived the motto so familiar to 
Marines of ``suck it up and press on''.
    I spent almost 8 years on Active Duty and returned after my 
children were born, to serve as a Reservist on Active Duty in 2009 to 
work with severely wounded Marine Veterans and their families. I again 
experienced incidents of MST, and began suffering depression, anxiety, 
panic attacks, increasing self -doubt and disgust with the situation. 
During this period of Active Duty, I did find the courage to approach 
my command regarding these incidents. It was not a positive experience 
for me to say the least. My statements were dismissed by my chain of 
command. Because I had approached my command, and nothing was done, I 
endured more harassment and abuse. During this period I was also in the 
midst of a divorce from another active duty Marine. I endured incidents 
of harassment and abuse from him as well as his counterparts who shared 
my work space and some who were in my direct chain of command. I sought 
and received medical treatment for panic attacks, but was never asked 
about MST by medical personnel. I was put on daily medication to 
relieve depression and anxiety. I requested early release from my 
Active Duty orders because the situation became so difficult, I truly 
felt I could no longer endure and was discharged from the Marine Corps 
in August 2010. The request to terminate my orders early, prior to 
obtaining full time employment and VA Care and Compensation placed me, 
as well as my children in an extremely fragile financial and emotional 
state for a significant amount of time, however I could not tolerate 
the continuous feeling of being belittled and victimized. I felt I had 
to protect myself, as well as my children, as they deserved a 
consistent, loving mother who was not afraid to go to work and did not 
suffer episodes of panic in their presence. I have since been offered 
opportunities to return to Active-Duty and though I respect the Marine 
Corps, I am no longer able to return due to these experiences. The 
complete pride I have felt as a Marine in the past is now riddled with 
shame, self-doubt, distrust and financial stress and uncertainty.
    In October 2010, I sought treatment from the Madison, Wisconsin VA 
Medical Center. I was able to receive extremely limited treatment for 
depression, anxiety and panic. Treatment mainly consisted of 
prescribing medications. I dutifully completed the PTSD questionnaire 
at each appointment, and while it was evident I suffered from severe 
symptoms of PTSD, I was never asked by a provider if I had experienced 
MST. While I truly understand that the VA's focus is on our OEF/OIF 
Combat Veterans, and do not want to minimize their need for treatment, 
I believe someone should have asked me, based on my lack of recent 
combat deployments and my symptoms. I pride myself in being a very 
strong woman, and when I was not asked about MST, I did not feel it was 
appropriate to reveal this information. I was also put on different 
medications throughout the next few months, some of which actually 
increased my depression. For the first time in my life I contemplated 
suicide, but knew I needed to continue to cope for the sake of my 
children. I did disclose that I had thoughts of suicide to my 
psychiatrist, but did also assure her that I did not have an actual 
plan. While this psychiatrist was responsive and helpful, it was 
extremely difficult for me to receive consistent treatment at this 
time, as I was not yet service connected, and received little to no 
medication monitoring.
    In December 2010, I had my Compensation and Pension Exam for Mental 
Health. I entered this exam with hope that someone would ask about MST 
and I would finally be relieved of the secret I had held for so long, 
and then receive help. I was ``examined'' by a male psychologist. The 
doctor spent twenty minutes with me. He was extremely abrupt and 
impersonal, and did not once ask me about anything related to MST. 
Again, I did not feel this was a safe environment to disclose my 
experiences. He ended our appointment very quickly, stating he was 
going out of town for the weekend, stating he was ``sure I would be 
fine''. My hope deflated. I recall sitting in my car almost an hour in 
the parking lot, before I felt I could even drive. This appointment set 
the precedent for what I felt I could and should say to the VA.
    I was not able to receive counseling throughout the next few 
months, as I was waiting for my service connection. I was informed that 
I would have to pay for any care I did receive from the VA during this 
interim period, and I was not yet financially stable and could not 
afford extra costs. I did finally contact the Transition Patient 
Advocate at Madison and disclosed my MST experience. He immediately 
took action, and attempted to contact the Regional Office to have MST 
added to my claim. The Regional Office directed me to prepare and 
submit a statement that described the details of my assault and other 
MST incidents. Though extremely difficult, I completed and submitted 
this statement to the Milwaukee Regional Office. I became hopeful that 
I would be able to receive another examination where I could disclose 
my experiences, but despite fulfilling their request, I was not granted 
another exam. I continued to struggle with symptoms and memories as 
well as side effects from medications. Because MST was not addressed in 
any of my exams, I was not able to utilize the local Vet Center. I even 
spoke with a local Vet Center provider regarding our military 
experiences. I did mention that I was enrolled at the VA, but was 
having a difficult time obtaining appointments. The provider then said 
``Well, you are not a combat veteran, or a victim of MST so you cannot 
come to the Vet Center''. I remember feeling very discouraged that she 
had just assumed I had no experience with MST, and if she said that to 
me, then how many others had she said this to? I would have entered 
treatment outside of the VA, but I did not have private health 
insurance at this time.
    I was able to meet with a provider months later in Spring 2011, 
after I became service connected. My appointment was an intake for the 
PTSD Program. I was not asked about MST by the provider, but finally 
disclosed that I believed I had experienced MST. I was extremely 
detailed and candid with this provider for over an hour, in hopes I 
would receive treatment. When this appointment concluded, the provider 
informed me that I did appear to have severe PTSD and would benefit 
from treatment. As she said that, I felt a weight had been taking off 
my shoulders, and relief that I would get help. I was then informed the 
``wait list'' for consistent PTSD treatment was four months. I remember 
feeling completely deflated, that I had opened up and would have to 
wait for treatment.
    I was afforded the opportunity to meet with a part time provider 
for counseling at this time. This provider was only there twice a week. 
I was a single parent and worked part time, so it was extremely 
difficult to schedule consistent appointments. I was not afforded any 
alternatives by the VA. There were several instances where I would take 
time off work and arrive at an appointment only to be told it had been 
cancelled, even though I had not received a cancellation call from VA. 
I was also made aware that even though the hospital had cancelled these 
appointments, my Patient Record reflected I had ``no-showed'' or 
cancelled myself. This was simply not the truth, and I grew more 
distrustful and frustrated. I was also told I should engage in 
Prolonged Exposure Therapy. I explained to the provider that I was 
afraid to do this type of therapy, as I was concerned it would increase 
my symptoms and impact my ability as a mother and at my job if I was 
having increased panic attacks. I was subsequently informed I was 
``non-compliant''. I stopped seeking treatment at the VA following this 
experience.
    During this period, I had also received limited primary care at the 
VA, through the Women's Health program. I was treated for simple 
medical issues as well as gynecological care. No provider ever asked if 
I had experienced MST, though several of my conditions have been 
directly correlated with MST. It was during this period that I was also 
employed at the VA, in the Women's Health Program. The primary focus of 
this program appeared to be the monthly number of women Veterans who 
had mammograms and pap smears. I was given the mission to ensure we met 
our numbers for completed mammograms and pap smears as if the survival 
of this program was dependent upon those statistics. There was no 
mention of MST, and though there was a MST Program Manager at this 
hospital I had never spoken with her, nor had I ever seen the Women's 
Health Program and the MST Program collaborate in any way. This lack of 
awareness further proved to me that MST continued to be shameful and 
was not to be acknowledged. I attempted to speak with the program 
manager several times regarding the need to address the issue of MST 
with our woman veterans, but was unsuccessful.
    I obtained full time employment in June 2011, serving severely 
injured Veterans and their families. I began to feel stronger and more 
confident each day, despite lack of real PTSD/MST Treatment. In spring 
2012, I attempted to engage in treatment at the VA once again. I was 
assigned to a male provider, who was new to this particular VA. During 
my first appointment, through tears and fear, I disclosed my first 
experience regarding MST. I informed this provider that I believed I 
had been sexually assaulted. The provider looked at me, widened his 
eyes and asked, ``Well, do you really think you were raped?'' I could 
not bring myself to return to him or the VA and it was at this time I 
began to utilize my private insurance to receive therapy. I now pay out 
of pocket to receive care.
    Based on my experiences, and those of other women Veterans I have 
spoken with, I recommend the VA reconsider their approach to MST 
screening, acknowledgement and treatment. The VA needs to strive to be 
a safe environment where MST is acknowledged. If I had been asked about 
my experiences with MST, I would have been relieved to speak of my 
experiences, but I was not asked. MST should also be consistently 
addressed, as PTSD is, so that Veterans who require more time to build 
trust with VA Providers, have the opportunity to do so, before they 
disclose their experiences. It is my opinion that VA providers should 
be experienced and or educated in military culture, especially for 
women. Veterans should be afforded greater access to care and 
flexibility in scheduling and receiving care. Veterans deserve the 
ability to advocate on their own behalf regarding types of therapy, as 
what may work for some, does not work for all.
    MST needs to be acknowledged and addressed in the primary care 
setting as well. There are direct correlations between certain medical 
conditions and MST, such as Fibromyalgia, GYN issues, headaches, 
fatigue, substance abuse and eating disorders. When a Veteran presents 
with a specific physical symptom or clusters of symptoms providers must 
be ready to assess, identify and acknowledge the possibility of MST, 
and initiate screening.
    My experiences with MST were extremely difficult to acknowledge. I 
was in denial for many years. I witnessed many other women endure 
various incidents while in the military. It became `the way it was'. 
Experiences such as this have the ability to change the way even a very 
strong person perceives themselves. It creates self -doubt and distrust 
not just strangers, but people who say they are ``here to help''. When 
I had appointments at the VA where MST was not addressed and/or 
acknowledged, I felt victimized and belittled again. MST has lifelong 
effects, and is truly an invisible wound. Just recently, I had 
difficulty completing annual Sexual Harassment and Prevention training, 
required by my employer. During this instruction we were shown a 
``YouTube'' video of a young soldier who had a similar MST experience. 
For the remainder of that day, I was agitated and anxious which 
affected my ability to serve other Veterans. As I stated earlier, I am 
a strong woman and I am still surprised when I am affected like this.
    MST has become part of my life and part of the woman and mother I 
am today. While I never expected the VA to take care of me completely, 
that is ultimately my responsibility, I yearned for validation in a 
safe environment. I did not get this. I am not here today for me. I am 
here for those who are not ready to tell their stories and those who 
have not been given the opportunity to tell their stories. I am here 
for those who have survived MST and those who will experience MST. MST 
does not just affect individual Veterans; it affects their families, 
children and our society as a whole. I am not able to get back time I 
have lost with my children due to severe side effects from medications, 
panic attacks or traveling to appointments that had been cancelled. It 
is my hope to prevent another Veteran from losing that precious time. I 
thank you for your time and I am grateful for the opportunity to tell 
of my experiences, in hopes it will improve the care that other 
Veterans receive from the VA.

                                 
            Prepared Statement of Michael L. Shepherd, M.D.
    Mr. Chairman, Ranking Member Brownley, and Members of the 
Subcommittee, thank you for the opportunity to discuss the Office of 
Inspector General report, Inpatient and Residential Programs for Female 
Veterans with Mental Health Conditions Related to Military Sexual 
Trauma (December 2012), and the care and treatment available to 
survivors of military sexual trauma (MST). I am accompanied today by 
Ms. Karen McGoff-Yost, Associate Director, Bay Pines Office of 
Healthcare Inspections.
BACKGROUND
    The Veterans Health Administration (VHA) estimates that 
approximately one in every five female veterans enrolled in VHA 
responded ``yes'' when screened for MST. MST is not a diagnosis in 
itself. It is an experience that is associated with patterns of 
psychological and/or physical symptoms. MST is a predictor of 
psychological distress and is associated with several mental health 
(MH) diagnoses, most frequently Post-Traumatic Stress Disorder (PTSD). 
Research on the effects of trauma has found that the experience of rape 
can be equal to or greater than other stressors, including combat 
exposure, in the risk of developing PTSD. MST has also been linked to 
an increased likelihood of diagnoses of anxiety disorders, depressive 
disorders, eating disorders, bipolar disorder, substance use disorders, 
and personality disorders.
    Not everyone experiencing MST will have the same response. Some 
individuals who have been victims of traumatic experiences, including 
MST, develop few symptoms. Others develop severe and complex chronic 
physical and MH issues. Because the experience of MST may result in a 
range of physical and psychological symptoms, treatment related to MST 
may occur in a variety of clinical settings depending on the 
individual's needs.
    VHA requires that veterans and eligible individuals have access to 
residential or inpatient programs that are able to provide specialized 
MST-related MH care, when clinically needed, for conditions resulting 
from MST. Residential programs (also known as MH Residential 
Rehabilitation Treatment Programs) generally offer more intensive 
treatment than typical outpatient MH programs.
    In response to a request from the United States Senate Committee on 
Veterans' Affairs, we reviewed 14 inpatient/residential programs from a 
list compiled by VHA's MST Support Team that identified themselves ``as 
having expertise with MST and/or sexual trauma more generally and the 
ability to provide treatment targeting these issues in a residential or 
inpatient setting.'' Because the request was specific to services 
available to women veterans who experienced military sexual trauma, the 
scope of our inspection focused on the care provided to a cohort of 
female veterans prior to, during, and after discharge from these 
programs. While male veterans were not within the scope of our review, 
we want to take this opportunity to acknowledge the incidence and 
distressing impact of military sexual trauma on both female and male 
survivors.
    We reviewed the electronic health records (EHR) of 166 female 
veterans with a history of MST who were discharged from these programs 
during the 6-month period between October 1, 2011, and March 31, 2012. 
Patients were included if they met the eligibility criteria for MST-
related care as defined by VHA Directive 2010-033, MST Programming. As 
a result, we included five women who were not veterans; three women who 
were active-duty military; and two who had served in the Reserves but 
were otherwise ineligible for VHA care. We also visited eight program 
sites representing a mix of geographic regions, facility sizes and 
complexities, and urban and rural locations.
    Inspection objectives were to describe the nature of services 
provided to these veterans, the characteristics of these veterans, the 
characteristics of providers, and geographic referral patterns and 
factors influencing access. We also assessed compliance with VHA 
requirements pertaining to MST care.
    The programs highlighted in this inspection represent a higher 
intensity of care provision than utilized by patients with a history of 
MST who seek only outpatient treatment. While not covering the entire 
population of female veterans who have experienced MST, the review 
provides valuable insights into the clinical complexity, access, and 
care issues impacting veterans with MST.
INSPECTION RESULTS
Patient Age and Service Era
    Patients ranged in age from 23 to 65 years with an average age of 
44 years old. The most common age range was 46 to 50 years. Slightly 
less than 4 percent of participants were 25 years old or younger and 4 
percent were between 61 and 65 years old. In terms of service era, 38 
percent of patients served in the post-Vietnam era, 27 percent each in 
the Persian Gulf War and Operation Enduring Freedom/Operation Iraqi 
Freedom/Operation New Dawn (OEF/OIF/OND) service eras, and 6 percent 
during the Vietnam era. Among the 44 OEF/OIF/OND-era patients, ages 
ranged from 23 to 51 years with an average age of 34. These patients 
represent veterans who served in the military during the OEF/OIF/OND-
era whether or not they were deployed. A few had also served in prior 
eras but for purposes of the review, patients were categorized by their 
most recent era of service.
Mental Health Diagnoses
    The patients in our review were clinically complex and most had 
multiple mental health diagnoses. PTSD, depression, and alcohol/
substance use or dependence were the most common diagnoses. Ninety-six 
percent of patients had a diagnosis of PTSD, 63 percent had been 
diagnosed with a depressive disorder, and 70 percent had an alcohol or 
substance use disorder. Approximately 27 percent of patients also had a 
diagnosis of borderline personality disorder, further adding to the 
complexity of clinical presentation. Only 4 percent of patients had a 
single MH diagnosis. The remaining 96 percent had two or more MH 
conditions. Of the 160 women with PTSD, only four had this as a sole 
diagnosis. All of the women with an alcohol and/or substance use 
disorder were dually diagnosed with one or more MH conditions. 
Additionally, 13 patients were diagnosed with some form of eating 
disorder.
Parental, Employment, and Housing Status
    Because parental responsibility and job commitments could be 
factors affecting participation in a treatment program lasting several 
weeks or months, we examined the percentage of patients with 
responsibility for minor children and/or who were employed at the time 
of admission. Approximately 16 percent of the 166 patients were 
responsible for the care of minor children, and only approximately 5 
percent were employed. Nineteen percent of patients in our review were 
homeless at the time of program admission.
Service Connection
    Seventy-one percent of participants in our review were service-
connected for any condition (physical or mental health-related) and 55 
percent were service-connected for a MH condition.
VHA Treatment Preceding Program Admission
    We reviewed aspects of patients' MH care immediately prior to 
residential program treatment. We found almost 90 percent received 
outpatient VA MH treatment in the 3-month period preceding program 
participation. Of the patients not in outpatient care just prior to 
admission, approximately two-thirds were either in another residential 
program or were receiving treatment on an acute mental health unit. 
Most patients received outpatient treatment solely at a VA Medical 
Center (VAMC) or a Community Based Outpatient Clinic (CBOC). Seventeen 
percent were receiving treatment at more than one outpatient venue 
(e.g., VAMC and Vet Center).
    More than three-quarters of the patients were engaged in two or 
more types of outpatient treatment (individual therapy, group therapy, 
medication management, mental health intensive case management, 
psychosocial rehabilitation recovery center programs) during the 3-
month time frame. Seventy-two percent received individual therapy, 67 
percent received medication management, and 37 percent participated in 
group therapy.
    We reviewed the gender of outpatient MH providers seen prior to 
admission. Most female patients (83 percent) received outpatient MH 
treatment from a female therapist or clinician during the 3-month 
period prior to program participation. Of the 138 patients seen for 
primary care, 75 percent were seen by a female primary care provider, 8 
percent by a male provider, and for 17 percent the gender of the 
provider was unclear from the EHR.
Referral to Specialized Programs
    From EHR review we categorized geographic referral patterns. 
Although three programs largely served only patients from within the 
same VISN, most programs drew patients from all areas of the country 
and these programs appeared to function as a resource for nationwide 
referral of patients with an MST-related MH conditions.
Program Structure and Treatment Characteristics
    Across programs, we found a diversity of structures, program 
emphases, and treatment approaches through which programs address 
treatment of female veterans with MST related conditions. Treatments 
utilized varied by site, but generally included either formalized 
evidence based therapies (EBPs), mixed therapies comprised of 
underlying treatment principles from different EBPs, or both, in 
conjunction with supportive therapies and medication management. Most 
sites offered cognitive processing therapy as the dominant approach for 
trauma processing but incorporated other EBPs into the curriculum.
    For approximately 60 percent of patients, treatment planning 
documentation included provision of individual psychotherapy. In 
programs where individual therapy was provided, we consistently found 
that the clinician providing the treatment was female. All of the 
patients participated in one or more types of group therapy. At some 
sites, clinicians told us that they saw the group milieu as central to 
the treatment process and therefore emphasized group-based over 
individual treatment. Both male and female clinicians facilitated 
groups. We found that groups that focused on discussion of patients' 
trauma were usually led by female clinicians.
    In recent years, VHA has increased emphasis on the use of peer 
support in the recovery process. We found peer support technician 
documentation in the EHR (typically as a co-facilitator of a weekly 
recovery group) at some of the programs we reviewed.
    There were differences in the philosophical stance towards same-
gender treatment versus mixed-gender treatment. Proponents of women's 
only treatment programs argue the benefits of the psychological safety 
inherent in an all-female environment as women veterans explore 
traumatic experiences. Other clinicians favor mixed-gender treatment. 
In this model, the presence of men is believed to be normalizing, 
prepares women to be better able to integrate into the real world 
environment after program completion, and provides a means to help 
women confront their fears while in a therapeutic environment. Some 
program staff we spoke to were in favor of a blended approach. For 
example, a female veteran may start MST-related PTSD treatment in an 
all-female environment, but as progress continues, the team may 
incorporate male staff or add a mixed-gender group to the treatment 
plan so that the patient can try out new challenges and increase 
exposure to stimuli that may be typically avoided.
Aftercare
    Our EHR review showed that aftercare (follow-up MH services after 
program discharge) was almost always arranged before women left the 
program. Generally, aftercare was provided by the referring facility 
where the veteran had been receiving outpatient MH services prior to 
admission to the program. This was true whether the referring facility 
was a medical center, CBOC, Vet Center, or any combination of the 
above. We usually did not find that treating program staff remained 
engaged with the veteran after she returned home unless she received 
her outpatient care at the same facility as the program. Ten women 
received aftercare from program therapists on an outpatient basis after 
they relocated to the area where the program was located.
    Twenty-two patients were readmitted to an inpatient unit or 
residential setting within 30 days of program discharge. Three were 
admitted to medical units, 7 to an acute psychiatry unit within 7 days 
of discharge and 12 went directly to another MH Residential 
Rehabilitation Treatment Program program at discharge.
Outreach, Access, and Potential Actions to Enhance Program Utilization
    Outreach and Utilization - Cohort based admissions involve 
admitting a group together and keeping the group intact through program 
completion in order to promote group cohesion. For cohort-based 
programs, capacity can be estimated by multiplying the number of beds 
by the number of cohorts offered annually. Program capacity is more 
difficult to determine with rolling admissions. During site visits and 
from interviews with program leaders, we found that many of the 
available beds were not occupied. This corresponds with data from VHA's 
Northeast Program Evaluation Center that indicates most of these 
programs do not maintain a full census. A challenge commonly cited by 
facility staff related to maintaining an adequate volume of women 
veterans in the programs reviewed. Program staff indicated a need for 
greater outreach to ``get the word out'' in order to attract an 
appropriate and consistent stream of referrals.
    Availability of Timely Program Resource Information - The MST 
Support Team intranet site includes a list of inpatient/residential 
treatment resources for patients with MST. During our site visits, some 
program staff noted discrepancies and/or outdated information about 
their programs on the intranet site. The MST Support Team periodically 
surveys programs to verify information posted is accurate, but 
otherwise the team relies on facilities to report changes. Some program 
staff reported an inordinate amount of time spent reviewing and 
eliminating referrals inconsistent with program focus. Maintaining a 
current, accurate, coordinated resource list available with 
comprehensive program descriptions will serve to facilitate awareness 
and outreach and increase the flow of appropriate referrals from VA 
clinicians and coordinators.
    Role of MST Coordinators - We met with MST Coordinators during our 
site visits and frequently heard they had limited time (as little as 2 
hours per week in some cases) remaining for outreach activities and/or 
tracking of patients with positive MST screens, which is a key 
component of their function as outlined by VHA policy. This occurred 
because most MST Coordinators' time was dedicated to direct patient 
care responsibilities.
    Aligning VHA MST and Travel Policies - We found that patients were 
referred to programs in facilities outside of their Veterans Integrated 
Service Network (VISN) and geographic region. During site visits, 
difficulties obtaining authorization for patient travel funding was a 
consistent theme. From EHR review, we noted one veteran whose start 
date was postponed to the next cohort as the referring facility and 
treating facility were debating responsibility for transportation 
costs. One program with a wide national patient distribution indicated 
that having to pay for roundtrip travel is a challenge, but putting 
patients first, the program had unilaterally decided to provide funding 
for bi-directional transportation.
    A review of the current policy for MST and the current policy for 
Beneficiary Travel reveals that the two do not align. The Beneficiary 
Travel policy indicates that only selected categories of veterans are 
eligible for travel benefits and payment is only authorized to the 
closest facility providing a comparable service. Those eligible for 
travel pay include veterans who: (1) travel for treatment related to a 
service-connected condition; (2) are service-connected at a rate of 30 
percent or more for treatment of any condition; (3) travel for 
Compensation and Pension examinations; (4) receive a nonservice-
connected pension; or (5) are low income as defined by income not in 
excess of the VA pension rate.
    VHA requires that veterans and eligible individuals have access to 
residential or inpatient programs that are able to provide specialized 
MST-related mental health care, when clinically needed, for conditions 
resulting from MST. The MST Directive also states that ``at a national 
level, there is a need to consider developing a number of these 
programs as national resources and to arrange processes for referral, 
discharge, and follow-up.'' The directive requires that ``all health 
care for treatment of mental and physical health conditions related to 
MST, including medications, is provided free of charge'' and that fee 
basis should be available when indicated.
    We recommended that the Under Secretary for Health review existing 
VHA policy pertaining to authorization of travel for veterans seeking 
MST-related MH treatment at specialized inpatient/residential programs 
outside of the facilities where they are enrolled. VHA concurred with 
our recommendation and established a workgroup to review issues and 
provide recommendations to the Under Secretary for Health by April 30, 
2013. As of VHA's last quarterly update in May 2013 to the OIG on the 
implementation status of our recommendation, VHA reported the workgroup 
was continuing its review.
CONCLUSION
    The programs reviewed are a valuable resource available to serve 
clinically complex veterans with a history of MST and associated mental 
health and psychosocial burden. VHA should establish a centrally 
coordinated, comprehensive, and descriptive MST program resource list; 
ensure that MST Coordinators have adequate time to fulfill their 
outreach role; and review existing travel funding for this population. 
These efforts may promote fuller utilization by those women veterans 
who have experienced MST and whose individual clinical course indicates 
the need for a more intensive level of care than is available on an 
outpatient basis.
    Mr. Chairman, thank you again for this opportunity to testify. I 
would be pleased to answer questions that you or other Members of the 
Subcommittee may have.

                                 
                 Prepared Statement of Rajiv Jain, M.D.
    Good morning, Chairman Benishek, Ranking Member Brownley, and 
Members of the Committee. Thank you for the opportunity to discuss the 
Department of Veterans Affairs (VA) strong commitment to assisting 
Veterans who experienced sexual trauma while serving on active duty or 
active duty for training. VA refers to these experiences as military 
sexual trauma (MST). I am accompanied today by Dr. David Carroll, 
Acting Chief Consultant for Mental Health Services; and Dr. Stacey 
Pollack, National Mental Health Director of Program Policy 
Implementation both from the Veterans Health Administration (VHA).
    The statutory definition of MST comes from Title 38 United States 
Code, Section 1720D and is ``psychological trauma, which, in the 
judgment of a mental health professional employed by the Department, 
resulted from a physical assault of a sexual nature, battery of a 
sexual nature, or sexual harassment while the veteran was serving on 
active duty or active duty for training.'' Sexual harassment is defined 
as ``repeated, unsolicited verbal or physical contact of a sexual 
nature which is threatening in character.''
    VA is committed to ensuring eligible Veterans have access to the 
counseling and care they need to recover from MST. Since the passage of 
Public Law 102-585 in 1992, which added section 1720D to title 38, 
United States Code, VA has been developing and executing initiatives 
to: provide counseling and care to Veterans who experienced MST; 
monitor MST-related screening and treatment; provide VA staff with 
training on MST-related issues; and engage in outreach to Veterans 
about available services.
    All VA health care services (inpatient, outpatient, and 
pharmaceutical services) for physical and mental health conditions 
related to experiences of MST are provided at no cost to Veterans. 
Veterans do not need to have a VA disability rating or other 
documentation that the experience occurred to receive these services. 
Nor do these Veterans need to be enrolled in VA's health care system to 
be eligible to receive MST-related counseling and care under section 
1720D. For fiscal year (FY) 2012 the total number of Veterans who 
received MST-related care was 85,474. This is an increase of 
approximately 10.7 percent (from 77,198 in FY 2011). These Veterans had 
a total of 896,947 MST-related treatment encounters in FY 2012, which 
represents an increase of approximately 13.1 percent (from 792,813 in 
FY 2011).
    My written statement will describe how VA delivers high-quality, 
state-of-the-art health care to Veterans who have experienced MST, 
provides education and training for VA staff providing these services, 
collaborates with the Department of Defense (DoD), and engages in 
outreach to Veterans who have experienced MST about services VA has 
available to assist them in their recovery.
I. VA's Capabilities to Provide MST-related Care
Organizational Structure
    VA has an organizational infrastructure that oversees MST-related 
programming at the national, regional, and facility levels. Every VA 
medical center has a designated MST Coordinator who serves as a point 
person for MST issues at the facility and ensures that national and 
network-level policies related to MST screening, treatment, monitoring, 
and education and training are implemented. MST Coordinators serve as 
contact persons for MST-related issues and can help Veterans find and 
access VA services and programs. Network-level MST Points of Contacts 
monitor implementation and facilitate communication at a regional 
level. At a national level, the Veterans Health Administration (VHA) 
Office of Mental Health Services has program responsibility for MST. 
The Office of Mental Health Services has a national MST Support Team 
that monitors MST screening and treatment, oversees MST-related 
education and training, and promotes best practices in care for 
Veterans who experienced MST. This MST Support Team also consults with 
VHA's Office of Mental Health Services on MST-related policy issues and 
responds to information requests from VA leadership and other 
stakeholders.
MST Screening
    Recognizing that many survivors of sexual trauma do not disclose 
their experiences unless asked directly, it is VA policy that all 
Veterans seen for health care at a VA facility are screened for 
experiences of MST. Screening is conducted in a private setting by 
qualified providers who have been trained on how to screen sensitively 
and respond to disclosures. Veterans who report having experienced MST 
are offered a referral to local mental health services for further 
assessment and/or treatment.
    The proportion of Veterans screened for experiences of MST across 
all VHA facilities has increased every year since the national MST 
Support Team began monitoring it. In FY 2012, approximately 98.7 
percent of Veterans seen in VHA outpatient care had a completed MST 
screen and all VHA facilities met or exceeded the national MST 
screening target of 90 percent. In FY 2012, 72,497 or approximately 
23.6 percent of female Veterans and 55,491 or approximately 1.2 percent 
of male Veterans seen for health care at a VA facility had reported a 
history of MST when screened by a VA health care provider.
MST-Related Counseling and Treatment
    Every VHA facility provides outpatient MST-related counseling and 
care to both female and male Veterans. All Veterans seen in VA who 
screen positive for MST are offered a referral for MST-related 
treatment. Because MST is an experience, not a diagnosis, not all 
Veterans who screen positive will need or want treatment. In FY 2012, 
approximately 72.9 percent of women who screened positive for MST 
received outpatient care for either a mental or physical health 
condition related to MST; this rate was approximately 58.8 percent 
among men who screened positive.
    Although VA provides free treatment for both physical and mental 
health conditions related to MST, my testimony focuses in particular on 
the mental health services that VHA has available for Veterans who 
experienced MST, as the majority of the care that VHA provides related 
to MST is for mental health conditions. Specifically, in FY 2012, 
approximately 56.7 percent of women and 41.5 percent of men who 
screened positive for MST received outpatient care for a mental health 
condition related to MST. All VHA health care facilities provide MST-
related mental health outpatient services, including psychological 
assessment and evaluation, psychopharmacological treatment, and 
individual and group psychotherapy. In addition to general mental 
health services, specialty mental health services are also available to 
target problems such as Post-traumatic Stress Disorder (PTSD), 
substance abuse, and depression. Every facility has providers who are 
knowledgeable about mental health treatment for the aftereffects of 
MST. Because MST is associated with a range of mental health problems, 
VA's general services for PTSD, depression, anxiety, substance abuse, 
and others are important resources for MST survivors. In addition, many 
VA facilities have specialized outpatient mental health services 
focusing specifically on sexual trauma. Many community-based Vet 
Centers also have specially trained sexual trauma counselors.
    For Veterans who need more intensive treatment, many VA facilities 
have Mental Health Residential Rehabilitation and Treatment Programs 
(MHRRTP). VA also has inpatient programs available for acute care needs 
(e.g., psychiatric emergencies and stabilization, medication 
adjustment).
    VA's Uniform Mental Health Services Handbook specifies that 
evidence-based mental health care must be available to all Veterans 
diagnosed with mental health conditions related to MST. The Office of 
Mental Health Services is currently conducting national initiatives to 
train VA clinicians in a number of evidence-based practices for mental 
health treatment. Two of the therapies that are being disseminated, 
Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are 
treatments for PTSD. There are also national training initiatives in 
Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral 
Therapy (CBT), which are evidence-based psychotherapies for anxiety and 
depression, two mental health conditions that can result from the 
experience of sexual trauma. The training initiatives consist of 
experiential workshop training followed by ongoing clinical case 
consultation.
    Because PTSD, depression, and anxiety are commonly associated with 
MST, these national initiatives have been an important means of 
expanding MST survivors' access to cutting-edge treatments. 
Furthermore, several of these treatments were originally developed in 
the treatment of sexual assault survivors and have a particularly 
strong research base with this population. As such, the MST Support 
Team has worked with each of these national initiatives to ensure 
inclusion of materials relevant to MST survivors and to promote 
attendance by clinicians working with MST survivors.
MST Readjustment Counseling Service (Vet Centers)
    Veterans who experienced MST may also receive assessment, 
counseling, and referral services through Vet Centers run by VHA's 
Readjustment Counseling Service (RCS). RCS is nearing its goal to have 
a qualified MST counselor on staff at each of its 300 Vet Centers 
nationwide. To qualify to provide this special mental health service at 
Vet Centers, the clinician must meet the criteria in the RCS MST Staff 
Training and Experience Profile (STEP). The MST STEP criteria includes 
MST-related clinical education and supervision, as well as the 
professional licensure requirement in a mental health related field. 
All Vet Center clinical staff are required to complete VA's mandatory 
training on MST.
    In FY 2012, Vet Center staff supported over 5,400 Veterans with 
over 47,700 visits related to MST. This represents approximately a 25 
percent increase in the number of Veterans and a 21 percent increase in 
the number of visits when compared to the previous fiscal year.
II. MST-related Education for Staff
    All VA mental health and primary care providers are required to 
complete mandatory training on MST. Also, VHA's national MST Support 
Team hosts monthly continuing education calls on MST-related topics 
that are open to all VA staff and available online afterwards. Since 
2007, the MST Support Team has hosted an annual, multi-day in-person 
training focused on MST-related program development as well as the 
provision of clinical care to Veterans who experienced MST. The MST 
Resource Homepage is a VA intranet community of practice Web site where 
VA staff can access MST-related resources and materials, review data on 
MST screening and treatment, and participate in MST-related discussion 
forums. In addition, all VA staff have access to an online independent 
study course on MST and other Web-based training materials.
    Since 2008, the MST Support Team has engaged in national activities 
to support and encourage facilities to host events as part of Sexual 
Assault Awareness Month (SAAM) in April. These activities include the 
selection of a national theme, dissemination of support materials, 
publication of information about SAAM in the VAnguard magazine and 
other outlets, and hosting a special national MST training call in 
April designed to be of general interest to VA staff. At a facility 
level, MST Coordinators may host medical education conferences and 
other educational presentations, distribute newsletters or fact sheets, 
and engage in other activities.
III. Outreach to Veterans
    To help ensure information about MST-related services is readily 
available to Veterans, VA has developed outreach posters, handouts, and 
educational documents for Veterans, secured inclusion of information 
about MST on relevant va.gov Web sites, and developed an MST-specific 
Internet Web site (www.mentalhealth.va.gov/msthome.asp). Also, VA's 
national MST Support Team has conducted an ``Answer the Call'' campaign 
to ensure that Veterans calling VA medical centers with MST-related 
questions, including about initiating treatment, can reach the facility 
MST Coordinator. Members of the team conduct test calls to VA medical 
centers in order to verify that frontline staff such as telephone 
operators and clinic clerks are familiar with the terms ``military 
sexual trauma'' and ``MST,'' are readily able to identify and direct 
callers to the MST Coordinator, and are sensitive to Veterans' privacy 
concerns. Facilities receive ratings of Satisfactory, Marginal, or 
Unsatisfactory based on the results of calls; facilities with less than 
satisfactory ratings are provided with additional feedback about team 
members' experiences during the calls and are required to submit action 
plans to address problems identified.
    VA has identified transitioning Servicemembers and newly discharged 
Veterans as high priority groups for outreach in FY 2013. VA is 
collaborating with the Department of Defense (DoD) Sexual Assault 
Prevention and Response Office and other national VA program offices to 
ensure that these Veterans are aware of MST-related services available 
through VHA.
    At the facility level, MST Coordinators engage in local outreach 
efforts to raise awareness about the availability of MST-related 
services. Tip sheets from the MST Support Team help facilitate these 
efforts. MST is included in ``Make the Connection'' 
(www.maketheconnection.net) and ``About Face'' (www.ptsd.va.gov/
aboutface) Web sites featuring Veterans' stories of recovery.
IV. MST Among Special Populations
    VA produces annual reports on MST screening and treatment among 
Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn 
(OEF/OIF/OND) Veterans to help ensure adequate capacity is available to 
provide MST-related care among this high-priority population. Among 
OEF/OIF/OND outpatients in FY 2012, 11,107 women (approximately 20.5 
percent) and 3,256 men (approximately 0.9 percent) screened positive 
for MST. Among these Veterans with positive screens, approximately 60.4 
percent of women and 53.0 percent of men received outpatient MST-
related mental health treatment in FY 2012.
    VA also conducts annual special analyses on the rates of MST 
screening and treatment among homeless Veterans. These analyses 
revealed that homeless Veterans who use VHA services have higher rates 
of experiencing MST compared to all Veterans who use VHA. They also 
receive MST-related mental health care through VA at higher rates, 
compared to all Veterans who use VA care. Among homeless Veterans using 
VHA outpatient care in FY 2012, 6,890 (approximately 38.3 percent) 
women and 6,147 (approximately 3.5 percent) men reported MST. Among 
these homeless Veterans with positive screens, approximately 87.3 
percent of women and 80.4 percent of men received outpatient MST-
related mental health treatment.
V. Capacity to Provide MST-Related Care
    VA monitors its capacity to provide MST-related mental health care 
among all Veterans utilizing VA care. The monitoring data shows that 
all VA facilities provide MST-related care to both female and male 
Veterans and all facilities have mental health providers knowledgeable 
in the treatment of MST-related mental health conditions. MST-related 
mental health outpatient treatment rates for women and men have 
increased every year since the VA began monitoring them.
    The Office of Mental Health Services' national MST Support Team 
conducted a comprehensive analysis and determined that the minimum 
number of full-time equivalent employees (FTEE) required to meet the 
outpatient MST-related mental health treatment needs of Veterans was 
0.2 FTEE per 100 Veterans who screened positive for MST. Comparison to 
this standard found that approximately 99 percent of VHA facilities 
were at or above the target level. The MST Support Team has conducted 
follow-up with the facilities that did not meet the minimum staffing 
threshold, and those facilities have submitted action plans directed at 
improving their staffing levels for MST-related mental health 
treatment.
    More generally, the MST Support Team regularly provides technical 
assistance and consultation to all facilities to ensure the highest 
capacity and quality of mental health care for Veterans who have 
experienced MST. This includes developing materials to assist 
facilities in assessing strengths of their current programming, 
identifying gaps in services, and implementing best practices.
VI. Identifying Gaps In MST-related Services
    The DoD and VA Integrated Mental Health Strategy (IMHS) derives 
from the 2009 DoD/VA Mental Health Summit and joint efforts in 2009 and 
2010 between DoD and VA subject matter experts. The IMHS includes 28 
Strategic Actions (SA) focused on establishing continuity between 
episodes of care, treatment settings, and transitions between the two 
Departments. IMHS SA #28 was specifically tasked to explore gaps in 
delivery and effectiveness of prevention and mental health care, for 
women Veterans and for Veterans (both male and female) who experienced 
MST. This workgroup is currently engaged in identifying disparities, 
specific needs, and opportunities for improving treatment and 
preventive services for women Veterans and Veterans who experienced 
MST. This workgroup includes VA and DoD clinicians, researchers, and 
other subject matter experts.
    In addition to the work being done through IMHS SA #28, VA is in 
the midst of focused efforts to address two other gaps in VA's MST-
related services. First, 38 U.S.C. Section 1720D, as currently written, 
only authorizes VA to provide services to Veterans who experienced 
sexual trauma while on active duty or active duty for training. This 
does not include members of the National Guard or Reserves who might 
have experienced sexual trauma while on weekend drill training. As 
such, these Veterans are not eligible for free MST-related care through 
VA. Therefore, the FY 2014 budget includes a legislative proposal to 
expand the population eligible for free MST-related care through VA to 
those Veterans who experienced sexual trauma while on inactive duty for 
training.
    Finally, VA's Office of Inspector General (OIG) conducted an 
inspection to review VHA services available to women Veterans who have 
experienced MST. In examining treatment through inpatient and 
residential programs, the VA OIG found that women often needed to 
travel to programs outside their Veterans Integrated Service Network in 
order to receive appropriate specialized care. However, travel funding 
often served as a barrier to receiving this care, because Veterans who 
experienced MST were not necessarily eligible to receive Beneficiary 
Travel funding through VA. To better align Beneficiary Travel and MST 
policy, VA has established a workgroup to make recommendations 
regarding this issue.
Conclusion
    Mr. Chairman, our work to effectively treat Veterans who 
experienced MST continues to be a priority. VA remains focused on 
providing Veterans timely access to high-quality health care services. 
We appreciate your support and encouragement in identifying and 
resolving challenges as we find new ways to care for Veterans. VA is 
committed to providing the high quality care which our Veterans have 
earned and deserve. We appreciate the opportunity to appear before you 
today. My colleagues and I are prepared to respond to any questions you 
may have.

                                 
                 Prepared Statement of Dr. Karen Guice
    Mr. Chairman, Members of the Committee, thank you for the 
opportunity to discuss the Military Health System's roles and 
responsibilities in serving the medical needs of survivors of military 
sexual trauma. Together, with our colleagues at the Department of 
Veterans Affairs (VA), we provide the necessary health care and related 
services to ensure that appropriate care is timely, sensitive, and 
coordinated for these individuals.
    The Department of Defense is committed to ensuring our Service 
members, as well as other survivors of sexual assault for whom we have 
responsibility, receive comprehensive, high quality, and compassionate 
medical services where and when they are needed worldwide, and this is 
what we will focus on today.
    We have, just this year, issued a new Department of Defense 
Instruction (DoDI), 6495.02, that establishes clear guidelines, 
standards and processes, along with training and reporting 
requirements, to ensure that a structured, competent and coordinated 
continuum of health care and related services are available to every 
sexual assault survivor. This continuum of care begins when a survivor 
seeks health care services in of our military treatment facilities and 
extends as they transition to VA care. It is the Department's policy 
that survivors are treated with dignity and respect, and that those 
that provide their health care are trained, competent and readily 
available.
    We require that health care is provided in a timely and 
standardized manner across the Services. Sexual assault survivors who 
seek care at one our military medical treatment facilities will be 
treated as an emergency. This means that they will be seen and examined 
immediately regardless of evidence of physical injury. Once any 
emergency treatment has been provided, trained medical staff members 
talk to the individual about sexual assault forensic exams and offer to 
perform the exam, or arrange for the individual to get the exam 
elsewhere. The health care provider also notifies the Sexual Assault 
Response Coordinator or Victim Advocate and arranges for any necessary 
and requested health care treatment. This includes appropriate testing 
and prophylactic treatment options for human immunodeficiency virus 
(HIV) and other sexually transmitted diseases; access to emergency 
contraception; referral to mental health services, as well as any 
follow on care for physical injuries. When feasible, and with the 
individual's consent, subsequent medical management and care is 
referred to the patient's own primary care team to facilitate 
continuity of care and support.
    Procedures for conducting sexual assault forensic exams (SAFE) 
follow the current U.S. Department of Justice Protocol and all medical 
providers are trained according to this national standard. We require 
that all military medical treatment facilities stock standardized SAFE 
kits and that our health care providers use these kits when conducting 
an exam. Providers are also required to document their examinations 
using the most current edition of Department of Defense Form 2911 (DD 
291), ``DoD SEXUAL ASSAULT FORENSIC EXAMINATION REPORT''. If the 
military medical facility does not have appropriately trained providers 
available to conduct the forensic exam, they must have an agreement 
with a local civilian facility. All completed forensic exam specimens 
are properly labeled and provided to the appropriate Military Service 
law enforcement agency or Military Criminal Investigative Organization, 
depending on the type of reporting requested by the survivor.
    Sexual Assault Response Coordinators or SARCs have the primary 
responsibility for coordinating care and services for survivors of 
military sexual assault and are available to respond and speak to these 
individuals at any time. SARCs are also responsible for counseling the 
individual on the choice between unrestricted and restricted reports, 
and for coordinating actions following the individual's reporting 
decision. When the individual elects to restrict reporting, 
confidentiality of information is protected through the use of a 
restricted reporting control number for specimen labeling following a 
forensic exam. This maintains the chain of custody for evidence should 
the individual chooses to proceed with unrestricted reporting at a 
later date.
    We have recently reviewed the Services' compliance with policies 
and guidance issued in the March 28, 2013 DoDI. The Services are in 
full compliance with the provider availability and training standards. 
Sexual assault medical forensic examiners are available 24 hours a day, 
either within the MTF or through current signed agreements with local 
civilian facilities. Each Service has written policies addressing the 
specific medical response requirements in accordance with the DoDI.
    We recognize that the long-term needs of sexual assault survivors 
often extend beyond the period in which a Service member remains on 
active duty. Ensuring that these individuals have a successful and 
sensitive transition to services and care provided by the VA is 
essential. For those individuals leaving military service through the 
Integrated Disability Evaluation System, ongoing health care needs are 
identified and information is provided about access to health care in 
the VA. Those military members who leave service outside of IDES 
receive in depth presentations about VA health care and how to access 
those services through the Transition Assistance Program.
    If the individual is still receiving behavioral health care at the 
time of separation from the Service, s/he will be linked to the DoD 
inTransition Program to help ensure that continuity of care is 
maintained. This program assigns Service members an inTransition 
support coach to bridge of support between health care systems and 
providers through coaching assistance services by phone worldwide. The 
coach does not deliver behavioral health care or perform case 
management, but is an added resource to health care providers and case 
managers and supports a seamless transition.
    In sum, our DoD health care policies are clear and the Military 
Departments have been leaning forward and diligent in executing these 
policies and monitoring compliance. Our approach is structured and 
aligned with the responsibilities of other stakeholders on military 
installations and within the community- to include commanders, the 
personnel community, the legal community, law enforcement, and local 
civilian authorities.
    Mr. Chairman, Members of the Committee, I want to again thank you 
for the opportunity to appear before you today and discuss this very 
important issue.

                                 
                       Statements For The Record

                          THE AMERICAN LEGION
    Sexual Assault results in sexual trauma. The Department of Veterans 
Affairs (VA) reports that approximately one in five women and 1 in 100 
men \1\ have reported to their healthcare provider they have 
experienced sexual trauma while in the military. In recent months, 
military sexual assault cases have dominated national headlines, and 
sexual assault victims are coming forward in droves. Every sexual 
assault results in sexual trauma, which is sometimes suffered 
physically, and nearly always suffered mentally.
---------------------------------------------------------------------------
    \1\ http://www.va.gov/WOMENVET/2011Summit/Breakout-
ResourcesforMSTSurvivors2011.pdf
---------------------------------------------------------------------------
    VA provides treatment programs for veterans suffering from Post-
Traumatic Stress Disorder (PTSD) to address the mental anguish 
associated with military sexual trauma (MST). The problem is that VA 
doesn't have a separate program to work with PTSD patients who 
contracted PTSD as a result of MST. The reason this is a problem is 
because VA's PTSD therapy is a co-ed treatment program that groups male 
and female patients together. Trying to address sexual trauma issues in 
a co-ed setting, in many cases is serving to further exacerbate 
symptoms and in some cases discouraging patients from remaining in the 
program. Some female victims have reported to The American Legion that 
this co-ed residential treatment program is not conducive to their 
recovery, and that there is not enough separation of men and women 
participating in the programs to feel confident they will not be 
victimized again even if sleeping areas are separate.
    Nationwide, The American Legion has over 2,600 accredited service 
officers, which enables us to receive real-time feedback of what is 
transpiring in the field. One service officer reports that one of his 
clients, a female veteran receiving treatment for MST-related PTSD, was 
further traumatized while in the co-ed inpatient facility when one of 
the male patients reached for a TV remote control that was sitting in 
her lap. This seemingly benign incident illustrates the intensity of 
the issues faced by victims of MST, and The American Legion fears that 
co-ed treatment may only serve to exacerbate these issues in many, if 
not most cases.
    VA has only seven residential treatment programs in the United 
States fully dedicated to women veterans - specific to the treatment of 
PTSD. The American Legion believes that the co-ed approach needs to be 
reconsidered, given the complications associated with this particular 
issue, and that there should be an expansion of inpatient women veteran 
treatment programs, in order to address the issues unique to sexual and 
PTSD trauma victims.
    During The American Legion's System Worth Saving site visit at the 
Coatesville (Pa.) VA Medical Center (VAMC), we were briefed on a 
program that we believe to be a model for women veterans, called the 
Power Program. The Power Program is a residential dual diagnosis unit 
that provides inpatient and residential treatment to eligible female 
veterans with substance abuse disorders, mental health problems, and 
homelessness struggles. The program's mission is to prepare female 
veterans for a lifestyle that supports continued recovery of mind, body 
and spirit. Patients come from as far away as Denver, Colorado to 
enroll in the program, and female veterans enrolled in the program 
stated that they receive excellent care and would recommend the program 
to other women veterans.
    PTSD and sexual trauma are major problems facing women veterans, 
and we recognize that outpatient programs have received funding and 
support, and have enjoyed recent expansion. Nevertheless, women veteran 
inpatient programs are still lacking and women have to leave the local 
facility or region - and their families - to receive care in a VA site 
across the country.
    The American Legion believes that it is important to remember that 
this is not an issue that only affects women; far from it. According to 
surveys of 14 VA medical facilities conducted by The American Legion in 
the first half of 2013, nearly half of those being treated for MST were 
men. According to VA, while it is true that MST proportionally affects 
more women than men, ``because of the disproportionate ratio of men to 
women in the military there are actually only slightly fewer men seen 
in VA that have experienced MST than there are women.'' \2\ This fact 
is often overlooked in the discussion of this issue. The American 
Legion believes that the issues faced by all veterans should be 
considered and addressed, regardless of gender.
---------------------------------------------------------------------------
    \2\ http://www.womenshealth.va.gov/WOMENSHEALTH/facts.asp
---------------------------------------------------------------------------
    At our 2012 National Convention, The American Legion passed 
resolution number 295, entitled ``Military Sexual Trauma (MST)'', 
wherein we urged VA to ``ensure that all VA medical centers, vet 
centers, and community-based outpatient clinics employ a MST counselor 
to oversee the screening and treatment referral process, and to 
continue universal screening of all veterans for a history of MST''. 
While we recognize that this does not address the issue of the lack of 
facilities; victims may still need to travel to a remote facility if 
they prove to be in need of treatment for MST. We believe that a 
counselor at each facility will go a long way toward ensuring that this 
issue gets the recognition it deserves, and that these veterans receive 
the care they deserve. Furthermore, universal screening both recognizes 
that this is not an issue which pertains to women only, and helps to 
reduce the stigma which may be associated with MST.
    All this, however, assumes that victims of MST are able to 
demonstrate service-connection for their MST-related PTSD, such that 
they are able to receive VA care and/or compensation. In October 2008 
the Government Accountability Office released a report entitled 
``Additional Efforts Needed to Ensure Compliance with Personality 
Disorder Separation Requirements,'' which found that the Department of 
Defense (DOD) was not doing enough to ensure that service members who 
were being separated for various personalities were not wrongly denied 
recognition of a traumatic brain injury (TBI), PTSD and/or MST which 
may have led to their discharge. Those who have these kinds of injuries 
as a result of their service may be denied VA healthcare related to 
these injuries.
    At the May 2013 National Executive Committee meetings, The American 
Legion passed resolution number 26, entitled ``Mischaracterization of 
Discharges for Servicemembers with Traumatic Brain Injury (TBI) and 
Post Traumatic Stress Disorder (PTSD) and Military Sexual Trauma 
(MST)''. Outlined in it is a short history of the ``less than honorable 
discharge'', which can be used to deny veterans benefits. 
Unfortunately, discharges that results from a personality disorder 
diagnosis denies the veteran any recourse toward receiving the 
treatment they may be entitled to, if their condition is found to be 
service connected.
    The American Legion is extremely concerned that a great many 
veterans who experience MST while in the service are being denied care 
in the VA system. The character of the discharge resulting from the 
incident in service paradoxically prevents them from accessing care 
from the VA. The American Legion believes that this must be changed.
    In conclusion; in addition to the recommendations set forth in the 
resolve clauses of the guiding resolutions attached to this testimony, 
The American Legion recommends more single sex treatment options, and 
offer care that is gender sensitive and gender specific. We also call 
on VA to create more gender specific inpatient dormitories that are 
physically separated by enough physical structure to ensure the 
reality, as well as the perception of safety for the patients is 
paramount. And finally, The American Legion calls on this committee to 
direct VA to carefully review all claims for PTSD that indicate the 
possibility of sexual assault while on active or reserve duties to 
ensure that they are not denied the care they need and deserve.
    As this issue continues to develop, The American Legion looks 
forward to working with the Committee, as well as DOD and VA, to find 
solutions. For additional information regarding this testimony, please 
contact Mr. Shaun Rieley at The American Legion's Legislative Division, 
(202) 861-2700 or [email protected]
                   NINETY-FOURTH NATIONAL CONVENTION
                                   OF
                          THE AMERICAN LEGION
                         Indianapolis, Indiana
                        August 28, 29, 30, 2012
    Resolution No. 295: Military Sexual Trauma (MST)

    Origin: Convention Committee on Veterans Affairs and Rehabilitation

    Submitted by: Convention Committee on Veterans Affairs and 
Rehabilitation

    WHEREAS, Military Sexual Trauma (MST) impacts thousands of brave 
men and women in the Armed Forces; and

    WHEREAS, In FY2010, Department of Defense (DOD) estimated that only 
13.5 percent of MST incidents were reported; and

    WHEREAS, In addition, reporting of MST is frequently followed by 
lackluster investigation and prosecution, with many resulting in 
administrative or dishonorable discharge rather than Uniform Code of 
Military Justice prosecution; and

    WHEREAS, DOD does not have a policy of permanently maintaining 
files of reported incidents of MST, creating evidentiary roadblocks for 
future Department of Veterans Affairs (VA) claims; and

    WHEREAS, A history of MST has correlations to many health and 
economic consequences, including PTSD, sexually transmitted infections, 
homelessness, and substance abuse; and

    WHEREAS, According to a 2010 report published by the VA Office of 
Inspector General, entitled ``Review of Combat Stress in Women Veterans 
Receiving VA Health Care and Disability Benefits,'' Women Veterans 
Coordinators (WVCs) are frequently underutilized due to lack of public 
awareness of the services and assistance provided by WVCs; and

    WHEREAS, According to the same OIG report, women veterans are 
disproportionately granted Post Traumatic Stress Disorder (PTSD) claims 
based on MST; for instance, 9 percent of PTSD claims granted to women 
veterans by Veterans Benefits Administration (VBA) were on the basis of 
MST, compared to only 0.1 percent of male veterans; and

    WHEREAS, MST claims and treatment involve delicate, sensitive 
emotional issues; and

    WHEREAS, VBA lacks a complete assessment of its system-wide MST-
related workload and outcomes, without which it cannot determine if 
additional MST-specific training and testing is necessary; now, 
therefore, be it

    RESOLVED, By The American Legion in National Convention assembled 
in Indianapolis, Indiana, August 28, 29, 30, 2012, That The American 
Legion urge the Department of Defense (DOD) to improve its 
investigation and prosecution of reported cases of Military Sexual 
Trauma (MST) to be on par with the civilian system; and, be it further

    RESOLVED, That The American Legion urge the DOD to examine the 
underreporting of MST and to permanently maintain records of reported 
MST allegations, thereby expanding victims' access to documented 
evidence which is necessary for future Department of Veterans Affairs 
(VA) claims; and, be it further

    RESOLVED, That The American Legion urge the VA to ensure that all 
VA medical centers, vet centers, and community-based outpatient clinics 
employ a MST counselor to oversee the screening and treatment referral 
process, and to continue universal screening of all veterans for a 
history of MST; and, be it further

    RESOLVED, That The American Legion urge the VA to review military 
personnel files in all MST claims and apply reduced criteria to MST-
related PTSD to match that of combat-related PTSD; and, be it further

    RESOLVED, That The American Legion urge the VA to employ additional 
Women Veterans Coordinators (WVCs) and to provide MST sensitivity 
training to claims processors and WVCs; and, be it finally

    RESOLVED, That The American Legion urge the VA to conduct an 
analysis of MST claims volume, assess the consistency of how these 
claims are adjudicated, and determine the need, if any, for additional 
training and testing on processing of these claims.
                      NATIONAL EXECUTIVE COMMITTEE
                                   OF
                          THE AMERICAN LEGION
                         INDIANAPOLIS, INDIANA
                            MAY 8 - 9, 2013
    Resolution No. 26: Mischaracterization of Discharges for 
Servicemembers with Traumatic Brain Injury

    (TBI) and Post Traumatic Stress Disorder (PTSD) and Military Sexual 
Trauma (MST)

    Origin: Veterans Affairs and Rehabilitation Commission

    Submitted by: Veterans Affairs and Rehabilitation Commission

    WHEREAS, In 1916, the military began using ``blue discharges'' 
which was a form of administrative and less than honorable military 
discharge whereby servicemembers were subsequently denied the benefits 
of the G.I. Bill by the Veterans Administration and had difficulty 
finding work because employers were aware of the negative connotations 
of their blue discharge; and

    WHEREAS, The American Legion lobbied the military and Congress in 
the original GI Bill legislation that led to the creation of an 
independent military discharge review board as well as ensured 
servicemembers with ``blue discharges'' or other than dishonorable 
discharges were entitled to their earned veterans benefits; and

    WHEREAS, Later during the 1940s to early 1970s, the United States 
military used Separation Personnel Codes (SPN) or ``spin codes'' to 
categorize servicemembers based on discriminatory ailments or 
behavioral issues that had occurred during their military service; and

    WHEREAS, These controversial SPN codes were later overturned 
through the work of The American Legion and Congress as it unjustly 
prevented employers from hiring veterans after their military service; 
and

    WHEREAS, Today with the current conflicts in Operation Iraqi 
Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn 
(OND), the military has again come under intense scrutiny by Congress, 
veteran service organizations and the media for their discharge 
policies and reclassification of discharges as either personality 
disorder, pre-existing and/or adjustment disorders, when these medical 
conditions did not exist prior to a member's service; and

    WHEREAS, In February 2012, Madigan Army Medical Center 
servicemembers were subjected to a forensic psychiatry team for several 
years to prevent them from being discharged with a medical retirement 
due to post traumatic stress disorder (PTSD) or other mental health 
illnesses incurred in service; and

    WHEREAS, Then Senate Veterans Affairs Committee Chairman Patty 
Murray directed these 1,500 Madigan servicemembers to be reevaluated 
for their symptoms and 285 of these cases were reversed to ensure they 
received the proper care and benefits for their injuries and illnesses; 
and

    WHEREAS, In October 2008, the Government Accountability Office 
(GAO) published a report, ``Additional Efforts Needed to Ensure 
Compliance with Personality Disorder Separation Requirements,'' as well 
as a follow up study in September 2010 which found that DOD does not 
have reasonable assurance that its key personality disorder separation 
have been followed by the military service branches; and

    WHEREAS, It continues to remain unclear what each of the military 
service branch's directives, policies and protocols are in place for 
administering personality and adjustment disorders, particularly for 
servicemembers that are diagnosed with traumatic brain injury, PTSD, 
and/or who are victims of military sexual trauma; now, therefore, be it

    RESOLVED, By the National Executive Committee of The American 
Legion in regular meeting assembled in Indianapolis, Indiana, on May 8-
9, 2013, That the Veterans Affairs and Rehabilitation Commission and 
National Security Commission staff conduct a study of existing 
Department of Defense policies and procedures for character of 
discharge for servicemembers that served during time of war and were 
susceptible or diagnosed with traumatic brain injury, post traumatic 
stress disorder, are victims of military sexual trauma, and/or any 
other personality related disorders.

                                 
  DISABLED AMERICAN VETERANS (DAV) on Behalf of The Independent Budget
    Messrs. Chairman and Members of the Subcommittee:
    Thank you for inviting the DAV (Disabled American Veterans) to 
testify on behalf of the Independent Budget Veterans Service 
Organizations (IBVSOs) at this oversight hearing. We appreciate the 
Subcommittee's focus on the care and treatment available to survivors 
of military sexual trauma (MST), and the current capabilities of the 
Department of Veterans Affairs (VA) and Department of Defense (DoD) to 
provide a structured and coordinated continuum of care to facilitate 
the recovery of MST survivors, from the time of the incident through 
transition to veteran status. This testimony is adapted from our 
discussion of MST in the Fiscal Year 2014 Independent Budget.
    For a number of years, the IBVSOs have advocated greater 
collaboration between VA and DoD to identify best practices for health 
care services and claims processing for conditions related to MST. 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. We note 
legislation is pending in the Senate that would make changes related to 
the Uniform Code of Military Justice related to our concern.
    This topic is extremely sensitive to 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 injured from 
personal or sexual violence, often perpetrated by a fellow service 
member, military authorities and society in general respond in a very 
different way.
What is the Department of Defense (DoD) Doing About MST?
    In 2005 DoD established the Sexual Assault Prevention and Response 
Office (SAPRO) to ensure that each military service activity 
responsible for handling sexual assault complies with DoD policy. SAPRO 
serves as a single point of oversight of these policies, provides 
guidance to service branches, and facilitates resolution of common 
issues that arise in military services and joint commands. The 
objective of SAPRO is to enhance and improve prevention through 
training and education programs, ensure treatment and support of 
victims, and enhance system accountability.
    Through SAPRO, DoD has taken a number of steps to improve the 
situation that confronts service members who have been personally 
assaulted. These include better reporting, enhanced training and more 
complete information about the scope of the problem and what needs to 
be done about it throughout the military command structure.
    According to SAPRO, 86.5% of sexual assaults go unreported, meaning 
that official documentation of many assaults may not exist. Prior to 
the new records retention laws passed in the 2011 National Defense 
Authorization Act (NDAA), the services routinely destroyed all evidence 
and investigation records in sexual assault cases after two to five 
years, leaving gaping holes in MST-related claims filed prior to 2012. 
\1\    \2\
---------------------------------------------------------------------------
    \1\ Rachel Kimerling, PhD, Julie Karpenko, MSW; Military Sexual 
Trauma Support Team, VA Office of Mental Health Services, National 
Center for PTSD, VA Palo Alto Health Care System; ``Mental Health Care 
for Women Veterans and Treatment for Military Sexual Trauma,'' 
PowerPoint May 16, 2012 http://www.naswvc.com/attachments/article/82/
2012%20PTSD%20Dr.%20Kimerling.pdf
    \2\ Testimony of Anu Bhagwati, Executive Director, Service Women's 
Action Network; U.S. House of Representatives, Committee on Veterans 
Affairs, Subcommittee on Disability Assistance, ``Invisible Wounds: 
Examining the Disability Compensation Benefits Process for Victims of 
Military Sexual Trauma,'' July 18, 2012 http://veterans.house.gov/
witness-testimony/ms-anu-bhagwati-0
---------------------------------------------------------------------------
    The President signed an Executive Order in December 2011 that added 
Military Rule of Evidence (MRE) 514 into military law which took effect 
on January 12, 2012. DoD views MRE 514 as a rule structured to protect 
the communications between a victim and a victim's advocate when a case 
is handled by a military court. This rule allows victims to trust that 
what is shared with professionals will remain protected, whereas prior 
to the advent of MRE 514, DoD victim advocates and sexual assault 
response coordinators in some cases were compelled to testify about 
their private communications with survivors. \3\
---------------------------------------------------------------------------
    \3\ Witness Testimony of Col. Alan Metzler, Deputy Director, Sexual 
Assault Prevention and Response Office, U.S. Department of Defense; 
United States House of Representatives, Committee on Veterans' Affairs, 
``Invisible Wounds: Examining the Disability Compensation Benefits 
Process for Victims of Military Sexual Trauma,'' July 18, 2012 http://
veterans.house.gov/witness-testimony/col-alan-metzler
---------------------------------------------------------------------------
    Military sexual assault survivors are also informed by military 
authorities that they now have a new option to request permanent or 
temporary transfers from their assigned commands or bases, or to 
different locations within their assigned commands or bases. Procedures 
for this new expedited transfer option were issued in December 2011. 
The Services were also directed to make every reasonable effort to 
minimize disruption to the normal career progression of service members 
who report that they are victims of sexual assault, and to protect 
victims from reprisal or threat of reprisal for filing reports. \4\
---------------------------------------------------------------------------
    \4\ Ibid.
---------------------------------------------------------------------------
    In April 2012 Secretary of Defense Panetta announced the 
establishment of independent special victims units to investigate 
incidents of MST in the military and indicated that DoD would address 
some of its historic problems in archiving confirming records. Central 
to the proposed regulations is the elevation of the most serious 
reports to the attention of a Special Court Martial Convening 
Authority, a uniformed officer holding at least the rank of Colonel or 
equivalent. In addition to new training for uniformed personnel and 
their commanders, the proposed regulations include new centralized 
records of disciplinary proceedings stemming from these incidents, as 
well as more therapeutic outlets for survivors. \5\ Also, DoD will 
require that sexual assault policies be explicitly communicated to all 
service members within 14 days of their entry onto active duty. DoD has 
proposed that commanders be required to conduct annual organizational 
climate assessments to measure whether they are meeting the 
Department's goal of a culture of professionalism and maintaining zero 
tolerance for sexual assault within all commands; and that a mandate 
will be enforced for wider public dissemination of available sexual 
assault resources, such as DoD's ``Safe Helpline,'' 
www.safehelpline.org. \6\
---------------------------------------------------------------------------
    \5\ ABC News, ``Panetta Introduces Initiatives to Fight Sexual 
Assault in the Military,'' April 16, 2012 http://abcnews.go.com/blogs/
politics/2012/04/panetta-introduces-initiatives-to-fight-sexual-
assault-in-the-military/
    \6\ Lisa Daniel, American Forces Press Service, ``Panetta, Dempsey 
Announce Initiatives to Stop Sexual Assault,'' April 16, 2012 http://
www.defense.gov/news/newsarticle.aspx?id=67954
---------------------------------------------------------------------------
What Data Does DoD Possess on Reported Sexual Trauma?
    Many service members who experience MST do not disclose it to 
anyone until many years after the fact, but frequently exhibit 
lingering physical, emotional or psychological symptoms. When service 
members experience sexual assault during military service there are a 
number of unique factors that can prevent or discourage them from 
coming forward and reporting the incident. \7\
---------------------------------------------------------------------------
    \7\ Garry Trudeau and Loree Sutton, The Washington Post, ``Breaking 
the Cycle of Sexual Assault in the Military,'' June 29, 2012 http://
www.washingtonpost.com/opinions/breaking-the-cycle-of-sexual-assault-
in-the-military/2012/06/29/gJQAK0wNCW--story.html
---------------------------------------------------------------------------
    A report required by the FY 2011 NDAA for the period from October 
1, 2011 to September 30, 2012 (FY 2012) showed the military branches 
received a total of 3,374 reports of sexual assault. Of these, 2,558 
were unrestricted reports and 816 were restricted reports. This data 
represents a six percent increase since FY 2011. \8\
---------------------------------------------------------------------------
    \8\ Fact Sheet on DoD Sexual Assault Prevention & Response 
Strategic Plan & Annual Report on Sexual Assault in the Military for FY 
2012, May 7, 2013
---------------------------------------------------------------------------
    Of the 1,713 alleged offenders under the legal authority of the 
Department, commanders had sufficient evidence to take disciplinary 
action against 66 percent of them, an increase from 57 percent in FY 
2009. Of those whose court-martials were concluded in FY 2012, 79 
percent were convicted of at least once charge, 19 percent had charges 
dismissed, and 25 percent were granted a discharge or resignation in 
lieu of court-martial. \9\
---------------------------------------------------------------------------
    \9\ Ibid.
---------------------------------------------------------------------------
What Data Does VA Possess on Veterans Who Report MST?
    In its health care system, VA screens all enrolled patients for 
MST. National screening data show that about one in five women and one 
in 100 men respond that they had experienced MST.
    According to VA for FY 2012, 23.6% of women (72,497) and 1.2 
percent of men (55,491) treated in VA facilities screened positive for 
MST. 72.9% of women who screened positive for MST received outpatient 
MST-related care of any kind; 56.7% received MST-related outpatient 
mental health care. 58.8% of men who screened positive for MST received 
outpatient MST-related care of any kind; 41.5% received MST-related 
outpatient mental health treatment.
    Of OEF/OIF/OND veteran VHA users, 20.5% of women and 0.9% of men 
screened positive. Among veterans with positive MST screens, 60.4% of 
women and 53.0% of men received outpatient MST-related mental health 
treatment in FY 2012. According to VA this population utilizes MST-
related mental health care at higher rates than other Veterans, 
suggesting targeted outreach efforts to this population have resulted 
in higher utilization of VHA services.
    These rates are almost certainly an underestimate of the actual 
rate of MST, given that in general sexual trauma is frequently 
underreported. Also, these data address only the rate of MST among 
veterans who have chosen to enroll in VA health care; they do not 
address the actual rate for the veteran population in general. Although 
veterans who respond ``yes'' when screened are asked if they are 
interested in learning about MST-related services available, not every 
veteran necessarily consents to treatment. \10\
---------------------------------------------------------------------------
    \10\ Department of Veterans Affairs, National Center for PTSD, 
Military Sexual Trauma Fact Sheet, August 2012 http://
www.mentalhealth.va.gov/docs/mst--general--factsheet.pdf
---------------------------------------------------------------------------
    Rates of veterans utilizing MST-related mental health outpatient 
care have been increasing over time; and recently discharged veterans 
utilized MST-related mental health services at higher rates than other 
veterans. \11\    \12\
---------------------------------------------------------------------------
    \11\ Rachel Kimerling, PhD, Julie Karpenko, MSW; Military Sexual 
Trauma Support Team, VA Office of Mental Health Services, National 
Center for PTSD, VA Palo Alto Health Care System; ``Mental Health Care 
for Women Veterans and Treatment for Military Sexual Trauma,'' 
PowerPoint May 16, 2012 http://www.naswvc.com/attachments/article/82/
2012%20PTSD%20Dr.%20Kimerling.pdf
    \12\ Amy Street, PhD; , VA Office of Mental Health Services, 
National Center for PTSD; ``VHA Response to Military Sexual Trauma,'' 
PowerPoint Presentation, April 10, 2012.

       % of veterans with a positive MST screen who have at least one MST-related Mental Health encounter
----------------------------------------------------------------------------------------------------------------
                                                                   Women                              Men
----------------------------------------------------------------------------------------------------------------
All veterans                                                                          55.3%               39.6%
----------------------------------------------------------------------------------------------------------------
OEF/OIF/OND veterans                                                                  58.9%               51.0%
----------------------------------------------------------------------------------------------------------------

    Homeless veterans who use VHA services also report higher rates of 
MST compared to all veterans and they receive MST-related mental health 
care at higher rates compared to all veterans who use VA care. \13\
---------------------------------------------------------------------------
    \13\ Rachel Kimerling, PhD, Julie Karpenko, MSW; Military Sexual 
Trauma Support Team, VA Office of Mental Health Services, National 
Center for PTSD, VA Palo Alto Health Care System; ``Mental Health Care 
for Women Veterans and Treatment for Military Sexual Trauma,'' 
PowerPoint May 16, 2012 http://www.naswvc.com/attachments/article/82/
2012%20PTSD%20Dr.%20Kimerling.pdf


----------------------------------------------------------------------------------------------------------------
                                                                   Women                              Men
----------------------------------------------------------------------------------------------------------------
% of homeless veteran VHA users with a                                                39.3%                3.3%
 positive screen for MST....................
----------------------------------------------------------------------------------------------------------------
% of homeless veterans with a positive                                                88.9%               79.4%
 screen for MST who have at least one MST-
 related MH encounter.......................
----------------------------------------------------------------------------------------------------------------

What is VHA doing to Help Veteran Survivors of MST?
    Every VA health care facility employs an MST coordinator to answer 
questions veterans might raise about MST services. A variety of 
resources have been developed and distributed for the use of MST 
coordinators, including tip sheets, posters, handouts, and contact 
cards. Emphasis has been placed on the importance of ensuring this 
information is available at key entry and access points (e.g., 
telephone operators, information desks, clinic clerks, facility 
websites). Each facility also has care providers who are knowledgeable 
about treating MST patients. Many VA facilities have developed 
specialized outpatient mental health services focusing specifically on 
sexual trauma, and VA's 300 Vet Centers also offer sexual trauma 
counseling. VA has almost two dozen programs nationwide that offer 
specialized MST treatment in residential or inpatient settings for 
veterans who need more intense treatment and support. Because some 
veterans are not comfortable in mixed-gender treatment settings, some 
facilities maintain separate programs for men and women; and all 
residential and inpatient MST programs require separate sleeping areas 
for men and women. \14\    \15\
---------------------------------------------------------------------------
    \14\ http://www.mentalhealth.va.gov/msthome.asp
    \15\ Rachel Kimerling, PhD, Julie Karpenko, MSW; Military Sexual 
Trauma Support Team, VA Office of Mental Health Services, National 
Center for PTSD, VA Palo Alto Health Care System; ``Mental Health Care 
for Women Veterans and Treatment for Military Sexual Trauma,'' 
PowerPoint May 16, 2012 http://www.naswvc.com/attachments/article/82/
2012%20PTSD%20Dr.%20Kimerling.pdf
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What are the Challenges in VA for Veterans Who Experience MST?
    According to VA, victims of MST present a wide variety of treatment 
needs. \16\ Although posttraumatic stress disorder (PTSD) is commonly 
associated with MST, it is not the sole diagnosis resulting from MST. 
Across a range of studies, VA research indicates that men and women who 
report sexual assaults or harassment during military service were more 
likely to be diagnosed with mental health challenges. Women with MST 
had a 59 percent higher risk for mental health problems; the risk among 
men was slightly lower, at 40 percent. \17\ The most common conditions 
linked to MST were depression, PTSD, anxiety, adjustment disorder, and 
substance-use disorder. \18\
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    \16\ Department of Veterans Affairs, National Center for PTSD, 
Military Sexual Trauma Fact Sheet, August 2012 http://
www.mentalhealth.va.gov/docs/mst--general--factsheet.pdf
    \17\ Department of Veterans Affairs, VA Research Currents. 
November-December 2008. http://www.research.va.gov/resources/pubs/docs/
va--research--currents--nov-dec--08.pdf
    \18\ Department of Veterans Affairs, National Center for PTSD, 
Military Sexual Trauma Fact Sheet, August 2012 http://
www.mentalhealth.va.gov/docs/mst--general--factsheet.pdf
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    In December of 2012, the Office of the VA Inspector General issued 
a health care inspection report, Inpatient and Residential Programs for 
Female Veterans with Mental Health Conditions Related to Military 
Sexual Trauma. The IG concluded that women veterans were often admitted 
to specialized programs outside their Veterans Integrated Service 
Network (VISN) and that obtaining authorization for reimbursement of 
travel expenses was frequently cited as a problem for both patients and 
staff. The Beneficiary Travel policy indicates that only selected 
categories of veterans are eligible for travel benefits, and payment is 
authorized only from the veteran's home to the nearest facility 
providing a comparable service. The IG noted the current directive is 
not aligned with the MST policy. The directive states that patients 
with MST should be referred to programs that are clinically indicated 
regardless of geographic location. Some programs cited challenges 
maintaining an adequate volume of appropriate referrals; others 
reported to the IG that managing women with eating disorders was a 
particular challenge. Additionally, many MST Coordinators they 
interviewed reported that they had insufficient time to adequately meet 
their women's outreach responsibilities.
    We concur with the IG's recommendations that the Under Secretary 
for Health review existing VHA policy pertaining to authorization of 
travel for veterans seeking MST related mental health treatment at 
specialized inpatient/residential programs outside of the facilities 
where they are enrolled.
    Although this Subcommittee is primarily focused on the coordinated 
continuum of health care for MST survivors between DoD and VA, we offer 
our comments on the Veterans Benefits Administration's (VBA) claims 
process for MST-related conditions since there are several gaps that 
exist between the Departments that are of concern to the IBVSOs and 
veterans. Many veterans indicate their frustration with the claims 
process, particularly in cases when the sexual assaults were not 
officially reported. They express feeling ``re-traumatized'' in their 
efforts to gain help from VBA even when they have provided significant 
evidence; statements from witnesses, friends or family; detailed 
accounts of the incidents; along with VA and non-VA diagnostic and 
treatment records--only to see their claims denied.
    Compensation and pension examinations can also be traumatic for 
veterans who have been personally assaulted because examiners often 
require them to recount in detail these devastating experiences, and to 
do so with someone uninvolved in their VA care or therapy. These 
experiences often take years for veterans to overcome. Veteran 
survivors of MST repeatedly tell us they should not be forced to repeat 
their experiences about the trauma to strangers who often lack the 
sensitivity or professional qualifications to counsel survivors of 
sexual trauma. The trust that is built between an MST counselor or 
mental health provider and a patient is one that should not be 
trivialized or ignored. Because of the special nature of these 
particular conditions, VBA should employ the clinical and counseling 
expertise of sexual trauma experts within VHA or other specialized 
providers during the compensation examination phase. \19\
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    \19\ Testimony of Anu Bhagwati, Executive Director, Service Women's 
Action Network; U.S. House of Representatives, Committee on Veterans 
Affairs, Subcommittee on Disability Assistance, ``Invisible Wounds: 
Examining the Disability Compensation Benefits Process for Victims of 
Military Sexual Trauma,'' July 18, 2012 http://veterans.house.gov/
witness-testimony/ms-anu-bhagwati-0
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    In response to hearing continued complaints about disparities in 
MST-related PTSD claims, VA acknowledged that due to the personal and 
sensitive nature of the MST stressors in these cases, victims often 
fail to report or document the trauma of sexual assault. If the MST 
event subsequently leads to post-service PTSD symptoms and a veteran 
files a claim for disability, the available evidence is often 
insufficient to establish the occurrence of a stressor event. To remedy 
this, VA developed regulations and procedures that allow more liberal 
evidentiary documentation requirements and more sensitive adjudication 
procedures for these particular claims. \20\
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    \20\ Testimony of Thomas Murphy, Department of Veterans Affairs, 
Director of C&P Service, U.S. House of Representatives, Committee on 
Veterans Affairs, Subcommittee on Disability Assistance, ``Invisible 
Wounds: Examining the Disability Compensation Benefits Process for 
Victims of Military Sexual Trauma,'' July 18, 2012 http://
veterans.house.gov/witness-testimony/mr-thomas-murphy-2
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    In its new procedures and similar to adjudicating other PTSD 
claims, VBA initially reviews the veteran's official military personnel 
records (including military health records) for evidence of MST. 
According to VBA, such evidence may include: 1) DD Form 2910, Victim 
Reporting Preference Statement; and 2) DD Form 2911, Sexual Assault 
Forensic Examination Report). Unfortunately, based on several years of 
work in this field, the IBVSOs have ascertained that DD Forms 2910 and 
2911 are not made part of service members' official military personnel 
records, but are retained in confidential files that have generally 
been unobtainable, even by a survivor who filed them.
    The VBA regulation also provides that evidence from sources other 
than service records may support a veteran's account of an incident, 
such as evidence from law enforcement authorities; rape crisis centers; 
mental health counseling centers; hospitals; physicians; pregnancy 
tests; tests for sexually transmitted diseases; and statements from 
family members, roommates, fellow service members, etc. \21\
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    \21\ Ibid.
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    Documented behavioral changes are another type of relevant evidence 
that may establish that an assault occurred, such as requests for 
reassignment; deterioration in work performance; substance abuse; 
depression, panic attacks, or anxiety without an identifiable cause; 
and unexplained economic or social behavioral changes. Veterans are 
requested to submit or identify any such evidence they may possess. 
When this type of evidence is obtained, VA is required to schedule the 
veteran for an examination with a mental health professional and 
requests 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. 
\22\
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    \22\ Ibid.
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    VBA reports it is taking steps to assist veterans with resolution 
of these claims and has placed a primary emphasis on informing VA 
regional office personnel of the issues unique to MST, and is providing 
training in improved claims development and adjudication. During August 
2011, VBA reviewed a statistically valid sample of approximately 400 
MST-PTSD claims with the goal of assessing current processing 
procedures and formulating methods for improvement. This led to 
development of an enhanced training curriculum with emphasis on 
standardizing evidentiary development practices, as well as issuance of 
a new training letter and other information to all VA regional offices. 
\23\ The training focused on how to identify circumstantial evidence 
(called ``markers'') indicating that the claimed MST stressor may have 
in fact occurred. As a result of these and other actions, VBA is 
reporting the post-training grant rate has risen from about 38 percent 
to over 50 percent. This change compares favorably with the overall 
PTSD grant rate of 55-60 percent, according to VBA. Additionally, in 
December 2012, VBA's national quality assurance office completed a 
second review of approximately 300 PTSD claims based on MST that were 
denied following medical examination. The review showed an overall 
accuracy rate of 86 percent, which is roughly the same as the current 
national benefit entitlement accuracy level for all rating-related end 
products. \24\
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    \23\ Ibid.
    \24\ Testimony of Curtis L. Coy, Deputy Under Secretary for 
Economic Opportunity, Veterans Benefits Administration, Department of 
Veterans Affairs, United States Senate Committee on Veterans' Affairs, 
``Pending Benefits Legislation Hearing,'' June 12, 2013 http://
www.veterans.senate.gov/hearings.cfm?action=release.display&release--
id=6d839502-3b01-4a1f-9dd2-6292724455a0
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    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 local VA health care facilities 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. \25\
---------------------------------------------------------------------------
    \25\ Testimony of Thomas Murphy, Department of Veterans Affairs, 
Director of C&P Service, U.S. House of Representatives, Committee on 
Veterans Affairs, Subcommittee on Disability Assistance, ``Invisible 
Wounds: Examining the Disability Compensation Benefits Process for 
Victims of Military Sexual Trauma,'' July 18, 2012 http://
veterans.house.gov/witness-testimony/mr-thomas-murphy-2
---------------------------------------------------------------------------
    However, because earlier denied claims did not get the benefit of 
these new nationwide training resources, the Under Secretary for 
Benefits determined that VBA would contact those veterans who had 
received denials and offer them an opportunity to have their claims re-
adjudicated. The IBVSOs have been informed that VBA has sent an 
outreach letter to 2,556 veterans who had been denied service-
connection for MST-related conditions.
    Unfortunately, VSOs were not notified prior to the letter being 
sent out to these veterans. The IBVSOs asked VBA officials to inform us 
of the names of the veterans for whom we hold Power of Attorney (POA), 
and thus represent, so that we can properly assist them if they wish 
VBA to re-adjudicate their claims. VSOs are a critical partner in the 
claims process and ensuring that the veteran fully understands what 
evidence is necessary or can support their claim, and to ensure these 
claims are properly re-evaluated by VBA. We also note that the letter 
that went out contained no information about how VBA has tried to 
improve the processes, sensitivity and understanding of MST related 
claims and minimal information about why VBA was inviting re-evaluation 
of these claims. Finally, the IBVSOs pointed out the letter directs the 
veteran to contact his or her local regional office to request review 
of their previously denied claim, but did not provide any contact 
information. While we are pleased with the Under Secretary for 
Benefits' efforts to improve claims processing for these complex claims 
we urge continued Congressional oversight to ensure VBA in fact has a 
consistent and comprehensive approach, throughout the system, to 
properly address these claims and more importantly set up a case 
management system to work with individual veteran survivors of MST in a 
more sensitive manner so they that they are not re-traumatized during 
the claims process. For veterans without a VSO/ POA, having a 
designated person or point-of-contact in VBA would make it much easier 
and more comfortable for the veteran to have questions answered about 
correspondence from VBA regarding their claim.
What Are the Challenges Ahead?
    Under DoD's confidentiality policy, military victims of sexual 
assault can file a restricted report and 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 a veteran survivor. One 
of the IBVSOs' primary concerns is that VA be able to access restricted 
DoD records (with the veteran's 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, the IBVSOs believe DoD should provide VA adjudicators 
access to all MST records, whether restricted or unrestricted, to aid 
VBA in adjudicating these cases.
    The IBVSOs strongly believe that survivors of sexual assault during 
military service deserve recognition and assistance in developing their 
claims and compensation for any residual conditions found related to 
the assault. These cases need and deserve special attention and due to 
the circumstances of these injuries, and survivors who have 
courageously come forward need to be consistently and fairly recognized 
by the government.
    The IBVSOs are pleased with the progress VA has made with the 
increased attention on MST-related information that encourages veterans 
to have more informed conversations with VA staff about the many 
available services, benefits, and treatment options. On the other hand, 
while DoD is moving more forcefully to stem sexual assault events in 
the ranks, DoD and VA need to resolve their differences with regard to 
MST-related records availability, both to VA health care professionals 
and to VBA adjudicators.
Summary
    The Subcommittee expressed interest in learning about the 
coordinated efforts between DoD and VA regarding a continuum of care to 
facilitate recovery of MST survivors from the point-of-incident through 
veteran status. The IBVSOs have no knowledge that a structured or 
defined program exists between the two Departments in this regard. 
SAPRO governs how each of the military services under DoD handles 
sexual trauma reporting options and access to treatment, but each of 
the military branches is responsible for developing its own sexual 
assault and response prevention campaign to address this pressing 
issue. The IBVSOs are unaware of any specific protocol for interagency 
hand-off of MST survivors, but we note that DoD included in the revised 
April 2013 Sexual Assault Prevention and Response Strategic Plan the 
goal of collaborating with VA and the veterans service organization 
community to develop a victim continuity of care protocol for service 
members who are being discharged from military service due to sexual 
assault. The IBVSOs are supportive and urge the implementation of this 
plan, and we look forward to working with DoD to accomplish it. We also 
recommend that DoD, VA, or both agencies inform a service member 
following the report of a sexual assault, or prior to discharge, about 
the benefits and health care services that are available in VA, and to 
offer assistance in connecting with an MST coordinator at a local VA 
medical facility or Vet Center.
    For the Subcommittee's purposes, the IBVSOs have developed a number 
of recommendations for Congress, VBA and VHA in improving health care 
and benefits procedures related to MST treatment and benefits claims. 
To conclude our testimony, we offer those recommendations for the 
Subcommittee's consideration:

      We urge VBA to identify and map all claims by gender 
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, and to make 
this information available to the public.
      VBA must properly train its claims staff to be compliant 
with the VBA procedures and policies intended to assist veterans in 
producing fully developed claims; and VBA should conduct continued 
oversight to review these claims to ensure the directives that have 
been issued are in fact being followed.
      Given the complexity of MST-related claims, VBA should 
revise the current work credit system for rating specialists, which 
seems to reward speed over accuracy in claims determinations, to ensure 
these particular claims related to MST are adequately researched and 
properly resolved.
      VBA should establish a designated person or point-of-
contact in VBA for veterans to have questions answered about 
correspondence from VBA regarding their MST-related claims.
      VA should establish a presumption of soundness of MST-
related diagnoses made by VA's own physicians and counselors who are 
caring for MST survivors in VA facilities; VBA claims reviewers should 
not be enabled to second-guess evaluations by these VA medical and 
counseling professionals, or to discount established and official VA 
treatment records, in favor of single point-in-time compensation and 
pension evaluations made by contract examiners who may be unfamiliar 
with the nuances associated with MST.
      The Under Secretary for Health review existing VHA policy 
pertaining to authorization of travel for veterans seeking MST related 
mental health treatment at specialized inpatient/residential programs 
outside of the facilities where they are enrolled.
      DoD and VA need to resolve their differences with regard 
to MST-related records availability, both to VA health care 
professionals and to VBA adjudicators.
      Congress should continue its oversight and hearings to 
stimulate VA and DoD to improve their policies and practices for MST 
care and claims compensation.
      Given the dual nature of this problem as pointed out in 
our testimony, and the obstacles that affect both health care and 
benefits of MST survivors, the IBVSOs urge this Subcommittee to 
coordinate closely with the Subcommittee on Disability Assistance and 
Memorial Affairs, as well as the Committee on Armed Services, in a 
combined effort to find ways to further improve VA's coordination with 
DoD on these difficult and challenging cases.

    Mr. Chairman and Members of the Subcommittee, this concludes my 
testimony on behalf of the Independent Budget veterans service 
organizations.

                                 
                        Questions For The Record
   Letter From: Hon. Julia Brownley, Ranking Member, Subcommittee on 
   Health, To: Hon. Eric K. Shinseki, Secretary, U.S. Department of 
                            Veterans Affairs

    July 24, 2013

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

    Dear Mr. Secretary:

    In reference to our Subcomittee on Health hearing entitled, 
``Safety for Survivors: Care and Treatment for Military Sexual Trauma'' 
that took place on July 19, 2013, I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on 
August 26, 2013.

    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.

    Due to the delay in receiving mail, please provide your response to 
Jian Zapata at [email protected] If you have any questions, 
please call (202) 225-9756.

    Sincerely,

    Julia Brownley
    Ranking Member
    Subcommittee on Health

    JB:cw

                                 
                     Questions from Rep. Dina Titus
    Questions for Rajiv Jain M.D., Assistant Deputy Undersecretary for 
Patient Care Services, Office of Patient Care Services, VHA, VA

    1. As Ranking Member of the Disability Assistance Subcommittee, I 
am working every day to improve VBA. On this issue, VBA plays a role 
along with VHA to provide the support veterans need.

    a. What is the extent of the coordination between VHA and VBA on 
issues of military sexual trauma?

    b. What can be done to improve this coordination?

    c. What information is provided to veterans who are victims of MST 
to ensure they are aware of benefits that may be available through VBA?

                                 
   Letter From: Hon. Julia Brownley, Ranking Member, Subcommittee on 
  Health, To: Hon. George J. Opfer, Inspector General, Department of 
                            Veterans Affairs

    July 24, 2013

    The Honorable George J. Opfer
    Inspector General
    Department of Veterans Affairs
    Office of Inspector General (50)
    810 Vermont Avenue, NW
    Washington, DC 20420

    Dear Mr. Opfer:

    In reference to our Subcomittee on Health hearing entitled, 
``Safety for Survivors: Care and Treatment for Military Sexual Trauma'' 
that took place on July 19, 2013, I would appreciate it if you could 
answer the enclosed hearing questions by the close of business on 
August 26, 2013.

    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.

    Due to the delay in receiving mail, please provide your response to 
Jian Zapata at [email protected] If you have any questions, 
please call (202) 225-9756.

    Sincerely,

    Julia Brownley
    Ranking Member
    Subcommittee on Health

    JB:cw

                                 
                     Questions from Rep. Dina Titus
    Questions for Michael Shepherd M.D., Office of the Inspector 
General, VA

    1. What types of investigations do you perform at individual VA 
health facilities to ensure that MST services are being provided in the 
most effective and time efficient way possible? For example, what will 
you do to examine the newly opened VA hospital in Southern Nevada?

    2. One of your recommendations to VHA was to establish a centrally 
coordinated, comprehensive, and descriptive MST program resource list. 
What has been the response from the VA? Please elaborate as to how you 
see such a clearinghouse being structure.

    3. VA policy requires that veterans who have MST-related PTSD be 
informed that they may use information from sources other than their 
service records to establish credible evidence of the stressors from 
MST they have endured before VA can deny their claim.

    a. In your observation and experience with MST cases, is this being 
done?

    b. How is this policy playing out when veterans attempt to bring 
this evidence to bear?

                                 [all]