[Senate Hearing 113-480]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 113-480

   THE RELATIONSHIPS BETWEEN MILITARY SEXUAL ASSAULT, POST-TRAUMATIC 
     STRESS DISORDER AND SUICIDE, AND ON DEPARTMENT OF DEFENSE AND 
  DEPARTMENT OF VETERANS AFFAIRS MEDICAL TREATMENT AND MANAGEMENT OF 
                        VICTIMS OF SEXUAL TRAUMA

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


                                HEARING

                               before the

                       SUBCOMMITTEE ON PERSONNEL

                                 of the

                      COMMITTEE ON ARMED SERVICES
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           FEBRUARY 26, 2014

                               __________

         Printed for the use of the Committee on Armed Services




        Available via the World Wide Web: http://www.fdsys.gov/

                               __________

            
                     U.S. GOVERNMENT PRINTING OFFICE 

91-318 PDF                     WASHINGTON : 2014 
-----------------------------------------------------------------------
  For sale by the Superintendent of Documents, U.S. Government Printing 
  Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; 
         DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, 
                          Washington, DC 20402-0001




                      COMMITTEE ON ARMED SERVICES

                     CARL LEVIN, Michigan, Chairman

JACK REED, Rhode Island              JAMES M. INHOFE, Oklahoma
BILL NELSON, Florida                 JOHN McCAIN, Arizona
CLAIRE McCASKILL, Missouri           JEFF SESSIONS, Alabama
MARK UDALL, Colorado                 SAXBY CHAMBLISS, Georgia
KAY R. HAGAN, North Carolina         ROGER F. WICKER, Mississippi
JOE MANCHIN III, West Virginia       KELLY AYOTTE, New Hampshire
JEANNE SHAHEEN, New Hampshire        DEB FISCHER, Nebraska
KIRSTEN E. GILLIBRAND, New York      LINDSEY GRAHAM, South Carolina
RICHARD BLUMENTHAL, Connecticut      DAVID VITTER, Louisiana
JOE DONNELLY, Indiana                ROY BLUNT, Missouri
MAZIE K. HIRONO, Hawaii              MIKE LEE, Utah
TIM KAINE, Virginia                  TED CRUZ, Texas
ANGUS KING, Maine

                    Peter K. Levine, Staff Director

                John A. Bonsell, Minority Staff Director

                                 ______

                       Subcommittee on Personnel

               KIRSTEN E. GILLIBRAND, New York, Chairman

KAY R. HAGAN, North Carolina         LINDSEY GRAHAM, South Carolina
RICHARD BLUMENTHAL, Connecticut      KELLY AYOTTE, New Hampshire
MAZIE K. HIRONO, Hawaii              MIKE LEE, Utah
TIM KAINE, Virginia                  SAXBY CHAMBLISS, Georgia
ANGUS KING, Maine                    ROY BLUNT, Missouri

                                  (ii)



                            C O N T E N T S

                               __________

                           february 26, 2014

                                                                   Page

The Relationships Between Military Sexual Assault, Post-Traumatic 
  Stress Disorder and Suicide, and on Department of Defense and 
  Department of Veterans Affairs Medical Treatment and Management 
  of Victims of Sexual Trauma....................................     1

Arbogast, Lance Corporal Jeremiah J., USMC (Ret.)................     4
Kenyon, Jessica, Former Private First Class, USA.................     6
Bell, Margret E. Ph.D., Director for Education and Training, 
  National Military Sexual Trauma Support Team, Department of 
  Veterans Affairs...............................................    54
McCutcheon, Susan J. RN, Ed.D., National Mental Health Director, 
  Family Services, Women's Mental Health, and Military Sexual 
  Trauma, Department of Veterans Affairs.........................    58
Guice, Karen S. M.D., M.P.P., Principal Deputy Assistant 
  Secretary of Defense for Health Affairs; Nathan W. Galbreath, 
  Ph.D., M.F.S., Senior Executive Advisor, Department of Defense 
  Sexual Assault Prevention and Response Office; and Jacqueline 
  Garrick, LCSW-C, BCETS, Director, Department of Defense Suicide 
  Prevention Office..............................................    60
Questions for the Record.........................................    81

                                 (iii)

 
   THE RELATIONSHIPS BETWEEN MILITARY SEXUAL ASSAULT, POST-TRAUMATIC 
     STRESS DISORDER AND SUICIDE, AND ON DEPARTMENT OF DEFENSE AND 
  DEPARTMENT OF VETERANS AFFAIRS MEDICAL TREATMENT AND MANAGEMENT OF 
                        VICTIMS OF SEXUAL TRAUMA

                              ----------                              


                      WEDNESDAY, FEBRUARY 26, 2014

                               U.S. Senate,
                         Subcommittee on Personnel,
                               Committee on Armed Services,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:02 a.m., in 
room SR-222, Russell Senate Office Building, Senator Kirsten E. 
Gillibrand (chairman of the subcommittee) presiding.
    Committee members present: Senators Gillibrand, McCaskill, 
Blumenthal, Hirono, Kaine, King, Graham, and Ayotte.

  OPENING STATEMENT OF SENATOR KIRSTEN E. GILLIBRAND, CHAIRMAN

    Senator Gillibrand. The subcommittee meets today to receive 
testimony about the relationship between military sexual 
assault, post-traumatic stress disorder (PTSD) and suicides, 
and the Department of Defense (DOD) and Department of Veterans 
Affairs (VA) medical treatment and management of victims of 
sexual trauma.
    There is zero doubt that sexual violence is occurring at an 
unacceptable rate within our military. Too often, our service 
men and women find themselves in the fight of their lives not 
in a theater of war, but in their own ranks, among their own 
brothers and sisters.
    While Congress is not in full agreement on the extent of 
the reforms required to solve this crisis, last year's National 
Defense Authorization Act (NDAA) took positive steps forward, 
including 36 separate provisions to address sexual assault in 
the military, which were supported unanimously, and additional 
important legislation is still under consideration, including 
my bill, the Military Justice Improvement Act.
    No matter where any one person falls in this debate, we can 
all agree that we must fully understand the long-term 
psychological toll on the survivors of sexual trauma in the 
military and the best practices for effective treatment.
    Sexual assaults are obviously very traumatic events for 
victims, traumatic events that have long-lasting, frequently 
lifelong consequences, including PTSD and suicides. Heath 
Phillips, a constituent of mine, shared his experience with me 
recently.
    Heath grew up in a family that was devoted to the military. 
He joined the Navy shortly after he turned 17 and was excited 
to be part of the Navy family. When he reported to his duty 
station after boot camp, there was no one there to register 
him. So they told him he would have to come back.
    He met a couple of other sailors from the ship and went 
into New York City with them. They went out drinking, and he 
blacked out. When he came to, the other sailors were sexually 
assaulting him. They threatened him and told him no one would 
believe him.
    He went back to the ship, where he reported the assault, 
only to be told that it was his own fault because he had been 
drinking and that he was lucky to not be in trouble for 
underage drinking. The sexual assaults continued aboard the 
ship. When his commanders allowed these assaults by his 
shipmates to continue without any repercussions, Heath went 
absent without leave (AWOL).
    Ultimately, he accepted a dishonorable discharge to end his 
torture. Not only was he suffering from PTSD, which led him to 
flee the ship, but now he is not eligible for VA benefits.
    It is stories like these that motivated me to have this 
hearing. I want to make sure this doesn't happen to anyone else 
and that people like Heath aren't forced to choose between 
their mental health and the benefits they have earned from the 
United States Government.
    This is not just an issue of anecdotal evidence. One study 
of Iraq and Afghanistan veterans found that, ``Female veterans 
with a history of military sexual assault or harassment were 
five to eight times more likely to have current PTSD, three 
times more likely to be diagnosed with depressive disorders, 
and two times more likely to be diagnosed with alcohol use 
disorders compared to female veterans without military sexual 
trauma (MST).''
    Another study of Iraq and Afghanistan veterans seen at the 
VA found that women and men who reported a history of MST were 
significantly more likely than those who did not to receive a 
mental health diagnosis, including PTSD, other anxiety 
disorders, depression, and substance use disorders.
    I also want to address today how DOD and the VA handling of 
sexual assault reports impact survivors' mental health. The 
VA's own Web site says that how the military handles military 
sexual assault has actually made PTSD worse.
    ``Many victims are reluctant to report sexual trauma, and 
many victims say that there were no available methods for 
reporting their experiences to those in authority. Many 
indicate that if they did report the harassment, they were not 
believed or encouraged to keep silent about the experience. 
They may have had their reports ignored or, even worse, have 
been themselves blamed for the experience. Having this type of 
invalidating experience following a sexual trauma is likely to 
have significant negative impact on the victim's post-trauma 
adjustment.''
    I am alarmed by the following statistic, as should every 
person in this room. On average, 22 veterans commit suicide 
every single day. Twenty-two brave men and women commit suicide 
every single day.
    It is critical that we look at the links between sexual 
assault and harassment and PTSD and its role in the intolerable 
number of suicides. Today, the subcommittee meets to discuss 
these links, their consequences, and how they are addressed.
    On our first panel, we have two survivors of sexual 
assault. Lance Corporal Jeremiah J. Arbogast, who is medically 
retired from the Marine Corps, and Private First Class Jessica 
Kenyon, who served in the U.S. Army. We have invited them to 
tell us about their experience as survivors of sexual assaults 
that occurred while they served in the military.
    Did they suffer from PTSD? Did they consider suicide? If 
so, what kind of help did they receive to address these 
conditions? We hope to learn what worked, as well as what 
didn't work, and what we in the U.S. Senate can do to improve 
the care of survivors when sexual assaults unfortunately occur.
    On the second panel, we have DOD and VA officials who will 
testify about the programs DOD and VA have in place to address 
the needs of sexual assault survivors, including medical 
therapies for PTSD and suicide prevention efforts of these 
departments. We understand that DOD and VA maintain an 
evidence-based joint clinical practice guideline on the 
management of PTSD. We would like to learn more about how this 
works in practice and how DOD and VA ensure continuity of care 
when victims transition from Active Duty to veteran status.
    From DOD, we have Dr. Karen S. Guice, the Principal Deputy 
Assistant Secretary of Defense for Health Affairs; Ms. 
Jacqueline Garrick, Director of the Department of Defense 
Suicide Prevention and Response Office; and Dr. Nathan W. 
Galbreath, Senior Executive Adviser, Department of Defense 
Sexual Assault Prevention and Response Office.
    From the VA, we have Dr. Susan J. McCutcheon, National 
Mental Health Director, Family Services, Women's Mental Health 
and Military Sexual Trauma; and Dr. Margret E. Bell, Director 
of Education and Training, National Military Sexual Trauma 
Support Team.
    I would like to thank all of you in advance for your 
testimony and for your dedication on behalf of our 
servicemembers. These are not easy issues to deal with, but 
they are real consequences of these horrific crimes that are 
far too common in our military.
    There is no greater responsibility for Congress and the 
military leaders than to care and provide for our 
servicemembers and their families. The Nation entrusts their 
sons and daughters to our military, and we must ensure that 
their service is safe from sexual assault, and if they are 
assaulted, that they receive best care and treatment possible 
while at the same time holding perpetrators accountable for 
their criminal actions.
    I look forward to the testimony of our witnesses on the 
first panel. I encourage you to express your views candidly and 
to tell us what is working and what is not working. Help us to 
understand what we can do to address this unacceptable problem 
of sexual assaults in the military.
    I want to thank Senator Graham. It has been a privilege to 
work with him as ranking member of this subcommittee. I have 
great admiration for Senator Graham's passion on behalf of our 
military servicemembers and families. When he joins us, he can 
deliver his opening remarks.
    Mr. Arbogast, would you like to read your testimony?

 STATEMENT OF LANCE CORPORAL JEREMIAH J. ARBOGAST, USMC (RET.)

    Mr. Arbogast. Madam Chairman, distinguished members of this 
subcommittee, I am saddened to be here, but thankful for the 
opportunity to share my testimony. I wouldn't be here without 
the love and support of my amazing wife and caregiver, Tiffany 
Arbogast.
    Before I begin, I want to acknowledge the MST survivors who 
struggle day-to-day with losing their will to live while 
fighting for much-needed benefits, stability, and validations 
for the crimes committed against them, along with the MST 
victims who are no longer with us due to suicide.
    I am a medically retired lance corporal who served in the 
U.S. Marine Corps. I am compelled by my oath to speak out about 
the injustices that have been done to survivors. The oath that 
I took has no expiration date. I urge each of you to stand with 
survivors of military sexual assault and to take proactive 
steps to fix the broken system of justice and survivor 
response.
    I am a male survivor of MST. I was drugged, rendered 
incapacitated, and sexually assaulted by my former staff 
sergeant from a previous command, a fellow marine, while on 
Active Duty. After this heinous crime, I was humiliated at the 
thought of my helplessness while a man and fellow marine took 
advantage of me sexually.
    After 2 months of nightmares, anxiety, depression, and 
confusion, my world as I knew it was falling apart. I feared 
being blamed and retaliated against, and I was embarrassed. 
With the last shred of dignity, I turned to a base social 
worker, who felt it was her obligation to report the sexual 
assault to the Naval Criminal Investigative Service (NCIS).
    When NCIS started the investigation, they informed me I 
needed to provide proof of the assault. I felt humiliated 
because other individuals were now aware of what happened.
    At a point during the investigation, I was forced to 
provide proof by confronting my rapist to try to get a 
confession. I was asked to make repeated recorded phone calls 
and then go to his home while wearing a body wire. I asked him 
to tell me what happened. I got a full confession.
    My perpetrator was arrested and charged with several 
counts, including sexual assault and sodomy. The trial lasted a 
week.
    Even with overwhelming evidence, the court found him guilty 
of lesser charges. The court decided he would receive a bad 
conduct discharge, no jail time, and they took his 23 years of 
service as kudos.
    He was ordered to NCIS headquarters for fingerprinting, 
where they determined he had gnawed the skin from his 
fingertips on both hands so he could not be fingerprinted. He 
refused to register on the sex offenders database by simply 
saying, ``No, I don't have to.''
    Nothing was done, and to this day, I don't know where my 
perpetrator is. Not knowing his location leaves me looking over 
my shoulder for the rest of my life.
    I was not afforded the same rights as rape victims in the 
civilian world. Where are my choices?
    While my perpetrator walked away with minimal consequences, 
I was formally retired from the U.S. Marine Corps due to MST 
and PTSD. I joined the Marine Corps in order to serve my 
country as an honorable man. Instead, I was thrown away like a 
piece of garbage.
    According to the American Psychiatric Association, 90 
percent of all rapists and serial rapists will commit an 
average of 3 to 600 rapes in a lifetime. This is not just a 
problem within the military. It becomes a societal and national 
security risk to us all.
    While I tried to survive and hoped that my life would get 
better, even years later, the constant stigmatization, personal 
attacks, ostracism, and PTSD was never ending. Choosing death 
was my way of taking responsibility for my circumstances. I 
simply haven't found the resources to cope.
    I sit here before you in this wheelchair due to a spinal 
cord injury that resulted in paraplegia from a self-inflicted 
gunshot wound from a 9mm handgun. I felt my death would spare 
my wife, daughter, and myself the dishonor the rape brought 
upon us.
    This should send a clear statement of just how bad things 
can get in the lives of sexual assault survivors when they feel 
no hope and are not being offered the appropriate clinical 
support needed for them and their families. The Armed Forces 
were severely remiss and still are today in the treatment of 
MST survivors.
    The VA healthcare system is overloaded and fails to keep up 
with the sheer growing number of MST victims. The VA mental 
health system lags in offering male MST survivors male-specific 
support groups, which is badly and urgently needed for millions 
of male veterans suffering from MST.
    Twenty-two veterans are taking their lives every day, only 
12 of which are combat related. The American Psychiatric 
Association estimates that men who are denied proper counseling 
after rape are likely to attempt suicide at least twice in 
their lifetime. Therefore, DOD and VA providers and all 
military leaders need specific training in the nuances of 
trauma-related sexual assault, human sexuality, and the 
different effects of rape on both men and women.
    The belief system about rape must change within the Armed 
Forces, and it will only change when the perpetrators are 
consistently prosecuted and no longer given leniency in their 
sentencing by their commanders.
    In a recent article in the Military Times, a DOD Sexual 
Assault Prevention and Response Office (SAPRO) official was 
quoted as saying, ``We need to tell perpetrators 'don't 
rape.''' This approach will not stop rape in the military. You 
can't train rapists not to commit rape, but you can stop them 
from harming anyone else. Haven't we heard enough stories of 
broken lives and lives lost that have been told in front of 
these committees?
    This is an epidemic. In 2012, approximately 14,000 men and 
12,000 women were sexually assaulted in the Armed Forces, 
according to DOD's own Sexual Assault Prevention and Response 
Report. DOD has been claiming to try to fix this problem for 
over 20 years and to no avail. Sorry to say we cannot take the 
attitude of wait and see, not even for 1 more year, which was 
the recommendation from our Commander in Chief.
    Half measures do not work, and neither do false promises. 
We need Congress to move past ego and political stalemates. 
These perpetrators must be stopped from continuing in their 
planned acts of terrorism against their fellow servicemembers. 
We need a justice system that ensures these criminals are held 
accountable for their crimes and prevented from victimizing any 
other servicemembers.
    The first step to fixing this problem and ensuring the 
health and welfare of our servicemembers must be creating a 
professional impartial justice system because sexual assault is 
not an occupational hazard. I and countless others have lost so 
much in this battle. These losses are nothing unless DOD and VA 
leadership hear our pleas for more accountability, an end to 
victim blaming and retaliation, and access to humane care for 
survivors.
    Our servicemembers deserve the same duty, honor, and 
courage from you in solving this epidemic and its consequences 
that they have shown through their selfless sacrifices for this 
country. We expect nothing less from Congress when it comes to 
accountability in providing adequate care to our Nation's 
warriors. Your help is needed so our military can continue to 
be the finest fighting force this world has known.
    Before I close, I would like to leave you with some words 
from Gandhi. ``You must be the change that you wish to see in 
this world.''
    Thank you.
    Senator Gillibrand. Thank you. Next, Ms. Kenyon.

  STATEMENT OF JESSICA KENYON, FORMER PRIVATE FIRST CLASS, USA

    Ms. Kenyon. Distinguished members of the subcommittee, I 
want to thank you for having me and affording me the 
opportunity to speak today. I feel it is my duty, as someone 
who is able and willing to speak on behalf of myself and those 
who are unable.
    I want to thank my loving husband, Brendan Brinkman, for 
his continued efforts in supporting me through this extremely 
difficult struggle, being there throughout unconditionally. I 
also want to thank the rest of my family who has been there for 
me and those families who do all they can for other survivors 
with very little support for themselves.
    I joined the military as an Apache crew chief in 2005, a 
year after the implementation of the new sexual assault 
regulations. During the initial training, none of us received 
any training about what to do regarding a real sexual assault 
situation. The truth was, at that point, I had to Google what 
to do when it happened to me.
    I immediately experienced the flaws and repercussions. From 
there, it was instance after instance of a failed system in 
which I became ostracized, singled out, publicly shamed, 
disciplined for getting treatment, and treated as though I was 
the one who did something wrong.
    From my experience, I can speak clearly to the loopholes in 
the current system that allows commanders, perpetrators, 
investigators, and anyone with outside influences and conflicts 
of interest to distort justice and degrade military discipline 
and readiness.
    These loopholes perpetuate a current state of affairs that 
when a case is handled or mishandled, I, like many others to 
this day, can be made an example of and held up as what will 
happen if you report anything. This shows other victims, as 
well as perpetrators, how their crimes will be handled.
    This prompted me to leave the military and inspired me to 
expose the injustices they allow. I did not want anyone else to 
be put through what I was put through, but I also saw the 
potential for much worse situations, and I could not stand for 
it whether I was ready to leave the military or not. Given the 
situation I was put in, I felt no other option than to 
regretfully leave the military.
    My work to help other survivors and families and fix this 
broken system is my way to continue to serve our country. Since 
my honorable medical discharge, I have worked with thousands of 
veterans, Active Duty servicemembers, and their families.
    I currently suffer from severe depression, bouts of 
insomnia, debilitating memories, thoughts, triggers of all 
sorts, anger, chattering in my head, constant anxiety to the 
point that I am forced to use all of my focus to appear normal, 
which hinders my abilities to read, write, have a conversation, 
and remember much of anything in the short term. This level of 
keeping my head above water is where I have found what passes 
for a level of peace.
    While I do hope to improve it, it is a very hard road, and 
some days I am not able to maintain my composure, and my 
husband and loved ones bear the brunt of it. I have to live 
with that guilt every day. I am just praying my son doesn't 
ever know me like this or, worse, what I was like before I 
gained some balance.
    Most of my scars are invisible. So my needs are treated as 
less than important.
    The current command environment makes it hard to keep 
outside influences away from all criminal cases in a command, 
regardless of the commander's view or the unit's view of them 
as commanders. Removing all judicial punishment decisions from 
the command will keep them clear of all repercussions, 
including to their command, their career, and the general 
morale of the unit.
    Leaving judicial punishment with commanders is not just a 
problem in the mishandling of sexual assault cases with the 
victim blaming, and I have experienced it as well as others. A 
command environment is simply not a top-down environment.
    A new commander may take command in an established 
structure, and the disruption of the structure, regardless of 
how honorable their intentions, can lead to challenges in that 
command. This removal of judicial punishments from the command 
would remove conflicts both to and from the commander.
    This also prevents a commander from lessening the charge to 
whatever keeps it in the command or at its lowest levels, 
either out of concern that the accused's talents would be lost 
or the command would look bad.
    As of right now, there is no accountability for those who 
mishandle cases. But even if the commander wants to do the 
right thing, there is often pressure from the top to make it go 
away or downplay the severity. Discipline problems within a 
command will usually be reflected on the service record and 
cost them promotions. This is not an environment for justice 
for victims, for perpetrators, or commanders.
    As it currently stands, the VA handles sexual assault in 
the military similar to civilian cases. But it is critical to 
note psychologically they are very different. I have found it 
is much closer psychologically to the results of incest and 
should be treated as such.
    As a civilian, sexual assault does not address the inherent 
trust victims give their command, nor the betrayal of that 
trust when a sexual assault occurs and the subsequent case is 
mishandled. This continues to be true even if the case is 
handled properly.
    Survivors of sexual assault, like many others who suffer 
from PTSD, are rarely in a state emotionally, financially, or 
otherwise, to navigate the complex and detailed paperwork and 
procedures that the VA requires for rating. This paperwork 
barrier to receiving assistance often exacerbates the 
survivor's issues and all too often drives them to the point of 
poverty, homelessness, alcohol and drug abuse, and much, much 
more.
    Rather than proper counseling, it is often the case that 
medications are prescribed. Many times, pills are almost 
immediately prescribed by various VA caregivers with no 
experience of what they might actually do to the mental health 
of the individual other than the list of warnings, which are 
often not taken seriously.
    These mountains of drugs are also being mixed and matched 
constantly and most of which were never supposed to be mixed 
with anything other, let alone the numbers in which the VA 
doles them out. It is not uncommon to hear of veterans being 
prescribed dozens of medications at a time.
    In more than a few cases, caregivers will refuse treatment 
if an individual refused to take the prescribed drugs, despite 
their helping or making things worse. The survivors have little 
to no recourse if things were to go wrong.
    For those of us who do not wish to be drowned in 
psychoactive drugs, many of our cases are left to wither and 
our wellness opportunities are hard to come by or are too 
expensive or unavailable. There is no right way to have PTSD, 
and therefore, cookie-cutter treatment is not what is most 
needed. Offering and supporting programs and caregivers outside 
of the VA would go a long way to lifting their burden.
    I also want to point out that servicewomen are more than 
twice as likely to have PTSD, but only half as likely to get 
diagnosed with it. They are more likely to be diagnosed with a 
personality disorder or an adjustment disorder.
    Thank you.
    Senator Gillibrand. Thank you very much for your testimony.
    I would now like to turn it over to the ranking member. 
Senator Graham?

              STATEMENT OF SENATOR LINDSEY GRAHAM

    Senator Graham. Thank you, Madam Chairman.
    I appreciate both of your testifying before the 
subcommittee.
    I think there is almost unanimous support, I would hope, in 
the Senate for finding a way to provide treatment to people who 
have been victims of sexual assault. I know it has to be one of 
the most traumatic experiences one could go through, and I do 
appreciate your sharing with us what you see as flaws in the 
current system, the VA counseling.
    I really look forward to hearing from the second panel. I 
think there have been some major monumental changes in the 
military about how we deal with this problem in terms of 
reporting, treatment, and awareness.
    The one thing I would say, with all due respect to our 
witnesses and to my fellow colleagues, from my point of view 
that this is a problem that will never be solved if you tell 
the commander, ``this is no longer your problem.''
    I have been in the military for 31 years. I do believe that 
the role of the commander, when it comes to dispensing military 
justice, is essential, and there is accountability in the 
reforms we have made.
    That when sexual assault cases are brought to a commander 
and they refuse to prosecute after a lawyer says we should go 
forward, that decision goes all the way up to the Secretary of 
the Service. When the lawyer and the local commander say no to 
moving forward in an allegation of sexual assault, it goes up 
to the next level of command, which I think is a very good 
signal to take this seriously.
    I would just say to both witnesses, from a military point 
of view, to tell the commander that this is no longer your 
problem, would be an absolute disaster for fixing the problem 
and, I think, erode what the military is all about. It is the 
commander's problem. It is their responsibility, and we expect 
them to do their job.
    Thank you both, and thank you, Madam Chairman. I look 
forward to hearing from the next panel.
    Senator Gillibrand. Thank you very much for your testimony.
    I want to talk a little bit about the type of mental health 
services you did receive. Mr. Arbogast, could you talk a little 
bit about what type of mental health treatment you received 
through DOD after your assault and whether you thought it was 
adequate care, if there are any improvements specifically to 
that?
    Then, after separating from the military, what was the 
mental health treatment like at the VA? Were there any 
challenges, any inadequacies there? What recommendations would 
you make to this subcommittee for DOD or VA to improve the type 
of mental health services you receive after a sexual trauma?
    Mr. Arbogast. Thank you.
    After my assault, I was pretty much tossed to a back room, 
I would say, and just left floating around a command after I 
was transferred. As for care, I didn't receive adequate care 
from DOD at all for the simple fact is, at the time of my rape, 
you felt like a dirty little secret that they just wanted to do 
away with.
    The psychologist at Walter Reed Bethesda, they wanted to 
either put you in groups that were either combat related or 
other mental illnesses. When you are in these groups and you 
are talking about this, you just don't feel comfortable talking 
about it.
    Then they move you to outpatient care, which is the same 
thing. They throw drugs at you, and it could be four or five 
different prescription drugs. The thing is, is they don't want 
you to commit suicide, but what are the side effects of these 
medications? For a lot of these medications it is suicide.
    As for DOD, they did absolutely nothing for me but just 
pretty much gave me a 30 percent discharge from DOD for PTSD 
and sent me on my way. As for the VA, I only saw one counselor 
through my whole therapy, who was not trained in MST. He mostly 
treated Vietnam vets.
    I looked for different treatment facilities and different 
programs at my VA hospital. They were women-oriented, which was 
fine. But then I asked what can they do for men? She said, 
``Well, we don't have a men's group yet. We are still in the 
process of putting that together.'' This was just last year.
    So her recommendation was to go through cognitive therapy, 
and that is traveling down every day for 6 weeks. That is 90 
miles from my home.
    Senator Gillibrand. After you attempted suicide, what type 
of treatment did you receive then? Was it a different kind of 
treatment, or did you receive better care through the VA?
    Mr. Arbogast. I received--with my spinal cord injury and my 
paralysis, I receive excellent care regarding that. I go to 
Richmond at Hunter Holmes McGuire VA Medical Center for their 
spinal cord clinic, and it is top notch.
    Their psychologists there are very good listeners, but 
again, they are not trained about MST. You bring it up, and 
they are like ``oh.'' That is like their first thing, their 
first expression. At that point, you feel like--I am just this 
dirty thing that they happened to stumble on.
    Not that I am downing any of them, it is just the fact that 
it is a stigma that I feel personally when you get a reply of 
``oh,'' when you say that you were sexually assaulted.
    Senator Gillibrand. Thank you.
    Ms. Kenyon, can you share with us your experience in terms 
of what type of mental health treatment you received and 
whether it was better in the VA or whether it was better in 
Active Duty under DOD and whether your records were transferred 
well, and what impact that treatment had on you?
    Ms. Kenyon. Yes, thank you.
    During my Active Duty service, the recommendation was to go 
to mental health, and whenever I did, I would get a counseling 
statement for not doing my job. So after one or two, I believe, 
I stopped going because of the repercussions in my command.
    Senator Gillibrand. Did your case go to trial, Ms. Kenyon?
    Ms. Kenyon. It did not. The Army Criminal Investigation 
Command (CID) investigated, and he denied everything. Then he 
was caught lying on his sworn statement later, and they gave 
him a charge of lying on a sworn statement and indecent 
assault. He was given an Article 15 punishment and extra duty. 
So he had no jail time, he lost rank, and that was it.
    But my repercussions and the fact that I could not go to 
treatment, I was punished for going to treatment. So I did not 
pursue it while I was in the military. However, when I went 
out, I did. When I was discharged, I did try to go to the VA 
multiple times and was redirected to other locations, other 
services, and eventually gave up.
    I restarted recently trying to get more help and get 
support. What I have found in helping myself and other 
veterans, is that good counselors are the stuff of legends. 
They are always 50 miles away.
    Survivors are always saying, ``I heard of this magical 
counselor somewhere out of reach.'' Those types of things 
happen and are told to other veterans, and they do try and 
pursue them. But if they are any good, they have a very long 
list.
    Senator Gillibrand. A wait list. During your trial, were 
your mental health records used?
    Ms. Kenyon. Not to my knowledge, and it was just my 
commander, it was no formal trial.
    Senator Gillibrand. Do you know, Mr. Arbogast, if your 
mental health records were used in your Article 32 hearing or 
during your trial?
    Mr. Arbogast. I am not quite sure. But they did use mental 
instability. The defense tried that approach when they drilled 
me on the stand.
    Senator Gillibrand. But your trial was unique. You had 
taped evidence----
    Mr. Arbogast. Correct.
    Senator Gillibrand.--of your perpetrator admitting the 
crime of drugging you and then raping you. So you had more of 
an airtight case. But again, for those who joined our hearing 
later, your assailant received no jail time.
    Mr. Arbogast. None. Due to his 23 years of service, they 
thought that was kudos for him. To me, it was disgusting 
because----
    Senator Gillibrand. Which is one of the reasons why members 
of this subcommittee are working so hard to remove the good 
soldier defense.
    Mr. Arbogast. Right. I think that is very important because 
of the simple fact of when I am brought in and I am told that, 
``oh, well, he is just a lance corporal. I am a staff sergeant. 
This is how many years I have served.'' Then you use that good 
soldier defense, then that weighs upon the jury or the judge, 
whoever has the case.
    Then they are like, ``oh, well, he has had this one case.'' 
But that doesn't mean that he hasn't had cases in the past.
    Senator Gillibrand. Thank you.
    Senator Graham?
    Senator Graham. Thank you very much.
    Do both of you agree that if you had access to civilian 
counseling services, that would be beneficial--if the VA would 
pay for it?
    Ms. Kenyon. If I had a little more choice outside of where 
I did not feel I had to go to the VA and possibly endure other 
male soldiers who are always threatening to me--it is just a 
trigger--I do believe that I could see the benefit in not only 
other outside counselors, but other alternative healthcare, as 
prescriptions are not sufficient.
    Senator Graham. Do you know of anything in your local 
community that you think would be beneficial to you?
    Ms. Kenyon. I have heard and seen a lot of benefits to 
things like meditation or yoga--in combination with a 
counselor--push through balance and well-being and taking those 
triggers and those moments of panic and being able to maintain 
them much better.
    Senator Graham. I don't want to butcher your last name. 
Lance Corporal?
    Mr. Arbogast. Arbogast, Senator.
    Senator Graham. Arbogast. Do you think that would be 
helpful to you to have access to civilian counseling if VA is 
inadequate?
    Mr. Arbogast. I actually do that. I use my TRICARE and 
Medicare to do that because of the VA counselors not having 
that expertise.
    Senator Graham. Okay. So TRICARE does provide that access 
to you?
    Mr. Arbogast. Correct.
    Senator Graham. In your case, Ms. Kenyon, that is not the 
case?
    Ms. Kenyon. I currently do not receive anything like that, 
and I pay out-of-pocket for any counseling.
    Senator Graham. Okay. Did you get a disability rating at 
all?
    Ms. Kenyon. I have not received a rating.
    Senator Graham. Is that still ongoing?
    Ms. Kenyon. It is still ongoing, Senator.
    Senator Graham. Okay. What was the date of your assault? Do 
you recall what time period?
    Ms. Kenyon. I hate to say this, but which one?
    Senator Graham. I mean the one that is the subject of the 
Article 15.
    Ms. Kenyon. The one that received the most justice, I 
suppose, would be in July 2006.
    Senator Graham. 2006. Now you said you received letters of 
counseling going for treatment. Is that correct?
    Ms. Kenyon. Yes, Senator.
    Senator Graham. Would you be willing to make those letters 
available to the subcommittee?
    Ms. Kenyon. If I have received a copy of them, I will.
    Senator Graham. Okay. I would like to see the letter of 
counseling, who wrote it, and what they said, if possible.
    [The information referred to follows:]

    Ms. Kenyon was unable to provide copies of the letters of 
counseling as requested by Senator Graham.

    Senator Graham. Thank you both. I hope that we can find a 
way to broaden the treatment options available for those who 
find themselves in your circumstances. I think there are a lot 
of things outside the VA, outside DOD, that may be beneficial 
not just in this situation, but in other situations, but 
particularly in this situation.
    Thank you for sharing your testimony with the subcommittee.
    Senator Gillibrand. Senator Hirono?
    Senator Hirono. Thank you, Madam Chairman.
    Thank you both for testifying this morning.
    One of the concerns that this subcommittee and the full 
committee has is the fact that thousands and thousands of these 
sexual assaults occur, and they are never reported. Would you 
share with us particularly from your own experience why this is 
so, and what we can do to enable more of the survivors to 
report these crimes?
    Starting with you, Mr. Arbogast.
    Mr. Arbogast. Senator, could you elaborate that question 
again?
    Senator Hirono. The figures are some 22,000-plus sexual 
assaults occur in the military in a given year, and only a very 
insignificant number of these crimes are ever reported to the 
chain of command. I wanted to ask for your thoughts on why this 
is so, and what we can do to enable more people to report these 
crimes, enable more servicemembers to report these crimes.
    Mr. Arbogast. In DOD, reporting to the chain of command, it 
is horrific. It could be a perpetrator in your chain of 
command. It could be your direct supervisor.
    In my case, it was my previous supervisor. He used his 
influences to try to get to me, torment me over the time that I 
was raped and to the time that the investigation was going on.
    Then I endure going to his home wearing a body wire, and 
then I had to endure the Article 32. Then I had to endure the 
court martial. So you can see the patterns of different traumas 
that I was subjected to.
    Anybody that would see something like that, any 
servicemember would be like, I am not going to report this. The 
VA finds thousands of veterans a year that finally report MST, 
and I don't have the exact numbers, but I know it is alarming.
    Regarding taking it out of the chain of command, I have 
talked to some Active Duty commanders, and they have 
specifically said if I don't have to deal with sexual assault 
and I can continue going on with what my mission is, to make 
the unit ready and deal with these everyday problems of what 
needs done in whatever their command is, whether it be 
engineering, motor, or transport, they would like to do that, 
concentrate on that. Because a sexual assault is more or less a 
burden on the command, and then it creates a morale problem and 
a cohesion problem.
    It is just that is the only thing I can think of that would 
get that, and going back to my testimony where it says that 
SAPRO official made the comment that, let us just tell 
perpetrators: ``don't rape.'' Okay. So you get all the 
perpetrators in a room and tell them ``don't rape,'' but you 
are still going to allow them to serve?
    Senator Hirono. I note in your testimony that one of those 
observations you made is that there should be some very 
specific specialized training in working with survivors of MST. 
I do agree with you because on the civilian side, there are 
many States that require prosecutors, for example, to get very 
specialized training when they deal with rape victims, for 
example. Apparently, that is something that you would suggest 
for the military.
    Ms. Kenyon, would you like to give us your thoughts on my 
question?
    Ms. Kenyon. Yes, thank you, Senator.
    I would add, generally, sexual assault is underreported in 
the civilian world as well and that is not to disregard the 
military environment in which makes it even more hostile.
    I would also point out that I can only correlate it with to 
make an understanding, who would a cop report a rape to within 
their own that wouldn't cause other police officers to possibly 
spread a rumor? That is the only civilian thing I could 
possibly think that would correlate with a perversion of 
justice this way.
    I would also stop publicly putting posters up with rape 
myths like ``wait until she is sober.'' These types of things 
are a different type of candy-coated victim blaming.
    There are a lot of studies in regards to the perpetrators 
being repeat offenders. They prey on this. It is not a sexual 
act. It is a power act. It is not about the sex. It is about 
usually taking victims down a notch.
    Senator Hirono. Would you agree it should also be treated 
as a crime?
    Ms. Kenyon. Oh, absolutely.
    Senator Hirono. That is what it is. You work with survivors 
of MST. So during the period when you had to undergo repeated 
traumas, have there been some positive changes to how the 
military helps survivors of MST?
    Ms. Kenyon. I do believe the 2004 implementation of the 
SAPRO office, despite it not having power, the option to report 
unrestricted and restricted did open a few doors. However, the 
loopholes are so great that the command can still exploit them 
regardless.
    For example, if you were a survivor of sexual assault and 
you wanted to go to a counselor, but you reported restricted, 
which is all within your rights, what would you tell your 
commander? Giving that information to a commander allows them 
to investigate it and go further with an unrestricted report 
whether they cooperate or not. This was threatened to me.
    Already being ostracized based on a previous investigation, 
I could not allow the commander who threatened to question 
everybody in my hangar--that is 260 people--and create that 
kind of environment which everybody knew what was going on, not 
just most of them.
    Senator Hirono. So while there have been some improvements, 
then given the severity of the problem, more can be done?
    Ms. Kenyon. We have a very long road ahead, it is an amount 
of baby steps. I do hope that we can take it step-by-step, and 
public prosecutions will go a long way to showing both victims 
and survivors or perpetrators as justice can and will be done.
    Senator Hirono. You, too, support removing the chain of 
command from the decision to prosecute these crimes?
    Ms. Kenyon. Absolutely. I believe that there is enough on 
the commander's plate, and the fact that there is just entirely 
too many conflicts of interest, and even if they do want to do 
the right thing, there is pressure from every direction that 
creates an almost impossible environment in which justice could 
be served, and I hate to say this, but even to the 
perpetrators.
    Senator Hirono. Thank you.
    Thank you, Madam Chairman.
    Senator Gillibrand. Senator Kaine?
    Senator Kaine. Thank you, Madam Chairman.
    Questions in two areas that have been raised by just 
listening to your testimony and answers to questions. First, I 
will just thank you for being here today. This is hard to do, 
and I appreciate your courage in coming and letting us ask 
questions so that we can understand the situation and better 
decide how to improve it.
    Ms. Kenyon, you raised a point in your testimony, and I 
want to make sure I understood what you meant. You said that 
you think to some degree, sexual assault in the military gets 
treated like any other sexual assault, a civilian sexual 
assault. You said that you thought the better analogy was an 
incest analogy, and I just want to make sure I understood what 
you meant when you said that.
    Ms. Kenyon. Absolutely. Thank you.
    I love talking about this in regards to how I even talk to 
survivors who contact me. In doing that, the betrayal aspect 
that is very uncommon in the civilian sexual assault is one of 
the reasons that I left the military feeling, almost 
crushingly, the betrayal of my command.
    We are at this point an all-volunteer military. So they go 
in, and there is an inherent trust. There is a trust in the 
system. You are fighting next to your brothers and your 
sisters. These guys are in charge of your well-being, your 
food, your exercise, your clothes, everything. Everything in 
the same psychological aspects as an adult that it would be as 
a child.
    Boot camp is literally there to break you down, to build 
you back up as a soldier, an airmen, et cetera. That being 
said, if you were assaulted by your brother, which in many 
cases psychologically is quite similar, you go to your father, 
your commander, and what if he didn't want to report it. How 
would you deal with that?
    It is very easy for victims to start blaming themselves 
because they don't know the perpetrator. So I teach them about 
the perpetrator so they can put the blame where it belongs and 
process that correctly.
    Both of those go a long way into getting into the right 
head space long enough so they can work through this 
bureaucratic system, which is extremely difficult, and it is 
like a safe. If you get it wrong, you have to start over.
    Senator Kaine. So that is very helpful to understand the 
analogy, the environment that creates a bond. It is not only a 
crime of violence, but it is also a betrayal of a relationship. 
So whether in the civilian context, whether it is incest or 
whether it is sexual assault by someone you know, which a huge 
percentage of sexual assaults in the civilian context are. The 
survivors tend to know the perpetrator.
    Ms. Kenyon. Right.
    Senator Kaine. There is an additional betrayal element. 
That helps me understand what you meant.
    Both of you, Ms. Kenyon, in your testimony and, Corporal 
Arbogast, in one of your answers to the question, you touched 
upon a topic that I want to have each of you address a little 
bit. That is the issue of in the treatment phase, concerns that 
you both have about overmedication.
    I just was curious. Is that a concern that you have about 
the way PTSD is treated from sexual assaults or a more general 
concern you are sharing with us about the way DOD or VA 
approaches mental health issues? This is part of a much larger 
discussion, obviously, about the way we as a society tackle 
mental health issues. Are we too heavy into just take this 
prescription and then take two or three more?
    I am curious as to whether you think that this might be 
really focused on the PTSD issue, or is it a more general kind 
of complaint about the way we do mental health in the military 
context?
    Mr. Arbogast. Thank you, Senator.
    That context not only goes with combat-related PTSD to MST 
PTSD. You hear from both groups that they are overly medicated, 
and you have severe side effects to all these medications.
    So you go to these appointments, and you get these 
medications, you have 6-month gaps before you see a 
psychologist or psychiatrist. So there are too many long gaps 
there. Then when you go there, you spend 5 minutes in their 
office.
    So if you live far away, you travel 90 minutes to spend 5 
minutes in an office for them to, ``Oh, we are going to throw 
this drug at you,'' or ``We are going to throw that one at 
you.'' Like I said before, these side effects are just 
astronomical in what they can cause.
    Ms. Kenyon. Thank you, Senator.
    Definitely I can speak personally in the PTSD realm. 
However, in the survivors that I have dealt with, it does bleed 
over into other--when it comes to like traumatic brain injury 
(TBI), to any sort of personality disorders, any diagnosed 
depression, all of these just get--any sort of pain even. Even 
if you say, ``Oh, I hurt my foot,'' they will throw a pill at 
you, at least one.
    What happens is it usually starts with one or two, ``Oh, 
let us try this out.'' Like Jeremiah pointed out, there are 
long spans in getting back in; to take yourself off of some of 
these drugs is extremely dangerous, and to mix and match is 
also even worse.
    Then you come up with new symptoms, saying, ``Well, I dealt 
with this, but I still--now I feel like I am under water all 
the time.'' They will throw another pill at you instead of 
fixing the one that they previously gave you.
    Senator Kaine. We are seeing a huge epidemic of things like 
heroin addiction these days in broader society that often 
begins with prescription drug addiction. Then prescription 
drugs are more expensive than heroin now, and so this 
prescription drug thing is a significant issue.
    If I hear you correctly, as you describe it, you worry a 
little bit that this overmedication is driven by, we don't have 
enough counselors to meet with you enough, and so if it is 
going to be 6 months until you have an appointment, we have to 
do something. So, here, try this.
    It is a stopgap. Probably isn't the best diagnosis, 
probably isn't the best strategy, but we have to do something 
because there are not enough counselors to deal with your 
mental health needs. So there is an issue of probably the 
number of counselors, the kind of training they get, and you 
worry that the medications are just being, ``Here is something 
to get you by for a while.''
    Ms. Kenyon. Yes, a band-aid, basically. Even then, it is a 
band-aid that could kill you.
    Senator Kaine. Yes.
    Ms. Kenyon. Some of them are just--the medications 
snowball--I personally have looked this up, but I can't find 
accurate correlations with civilian versus military treatment 
in medications and how they are doled out. I think that would 
be important to study----
    Senator Kaine. Yes.
    Ms. Kenyon.--as well as the survivors that have contacted 
me, out of curiosity, the ones who would volunteer their list 
of medications, and my husband being a neuroscientist, I hand 
them over. He says, ``How are they still alive?'' It is amazing 
to read just the side effects from some of these things.
    Senator Kaine. My time is up, but I think that this raises 
an interesting area that we probably should explore. If we were 
able to determine, for example, that folks in the military who 
are seeking treatment for mental health issues, PTSD or others, 
were dramatically more medicated than those who were seeking 
mental health services in the civilian world, that would really 
strike a big alarm.
    That would suggest to us that maybe something is not being 
done right, and the way you have made that testimony, you have 
pointed at a potential problem that we ought to explore 
further.
    Thank you for your testimony today.
    Senator Gillibrand. Thank you, Senator.
    Senator McCaskill?
    Senator McCaskill. Thank you. First and most importantly, I 
always stand in awe of those of you who have been victimized by 
this horrific crime and step out of the shadows and not only 
try to see justice, but then go on and try to do even more. I 
think while there are some policy differences in the Senate, I 
think we all are such fans of your courage and your tenacity. 
So I want to thank you very much for that.
    As somebody who spent years as a sex crimes prosecutor and 
walked into the courtroom hand-in-hand with hundreds of 
victims, I am painfully aware of the shortcomings of victim 
services for this crime no matter where it occurs.
    One of the things I wanted to visit briefly with both of 
you about is, first, I want to thank the military because I 
think it is the research and the recognition of PTSD that has 
allowed the civilian criminal justice system to begin to get 
their arms around the fact I think most of the victims I worked 
with in the late 1970s and 1980s and 1990s were suffering from 
PTSD, and those that were victims of domestic violence were 
suffering from PTSD. Our ability to treat this and prevent 
suicide as a result of this absolutely insidious illness should 
be at the top of all of our lists.
    I think that at least now we are beginning to recognize the 
problem. We have a ways to go, obviously, with having the 
services tailored to the type of stress and trauma that has 
brought about this illness, and I think that is what we are all 
focused on trying to do now.
    If either one of you at the moment you reported, whether it 
was to a social worker or at a hospital or wherever, whether 
restricted or unrestricted, if at that moment you had gotten 
your own lawyer whose only job was to look out for you, do you 
think it could have made a difference in terms of how you were 
treated as you navigated this difficult process and the 
services that you might have been provided?
    Ms. Kenyon. Thank you, Senator.
    I do believe a lawyer would be helpful, especially one that 
is impartial and not in my command or any way related. I have 
personally been working on almost a type of Miranda rights 
where you can go to anybody as a survivor of sexual assault, 
and they have to tell you what your rights are before you move 
forward.
    That way, you didn't accidentally go to your commander, and 
then now you can't report restricted. I mean, that was 
something that happened to me and that my commander then later 
made promises that made me confident in the fact that he would 
lie to me.
    That being said, between the lawyer as well as like just 
being very upfront, commanders, priests, clergy, lawyers, 
anybody involved in that system should be upfront with what a 
survivor is allowed to do at that point before he or she can 
make a decision in that regard.
    Senator McCaskill. Do you think it would have helped you, 
Lance Corporal?
    Mr. Arbogast. Senator, I really don't know because I was 
young at the time. I can't say because everything was fast 
paced.
    Senator McCaskill. Right.
    Mr. Arbogast. I went from falling apart to where do I go 
and going to a social worker and everything just trickling down 
from there. Was I told about anything about, hey, these are 
your rights, and you could have your own attorney, I think that 
would have helped as being somebody that was advocated that was 
not biased within the chain of command for the simple fact is, 
because you don't know if that person that may be advocating 
for you, or your so-called lawyer--I don't know if you are 
referring to a civilian lawyer or a military lawyer. But you 
don't know if that is a golfing buddy or somewhere down the 
line that they know each other, and they go back and tell your 
personal information.
    Then where I have had this happen is people found out about 
my situation from being talked about, and it is like how did 
they find out?
    Senator McCaskill. Right. I know that when I was a 
prosecutor, there were sometimes victims that declined to go 
forward even after we had gone through a lot of the process and 
I felt very strongly that the case could be successfully 
prosecuted. The victim, for a lot of reasons, including mental 
health issues, PTSD issues, said, ``No, I am done.''
    At that moment in time, the lack of trust that victim may 
have had in me because I was part of a system. I was associated 
with the police, if they had had their own independent lawyer 
that would have been giving them advice just for them, a little 
bit like we do with court-appointed special advocates for 
children in the juvenile system in the civilian cases, where 
there is a lawyer, an advocate for the child that is not 
associated with any of the other parties in the conflict.
    I am hoping that what we have done, which is remarkable 
that we are going to require this for all victims, is going to 
set a standard. First of all, this has never been done anywhere 
in the world. I am really hopeful that it will once again show 
the way to the civilian system that we have to find the 
resources. In the civilian system, the victims have no 
guarantee of any mental health services. None, zip, nada.
    There is nothing there. A lot of them don't have insurance. 
So you have to try to cobble together.
    I want to say we are determined to get rid of the good 
soldier defense. I am confident that is going to happen if not 
within the next month, then certainly with the next NDAA. I 
have not encountered opposition to this idea. So I want you to 
know that before you go.
    Finally, we are going to work on this overmedication thing. 
When I went to Walter Reed after the big scandal there, and I 
went from room to room in Fisher House and other places over 
there, every single room, the dresser was all alcohol bottles 
and pill bottles, and I didn't see one sign for group therapy 
for addiction treatment. I began then realizing we have a huge 
overmedication problem when it comes to mental health in the 
military.
    Mr. Arbogast. If I could ask you about your question about 
the attorney. You have my testimony about what I went through, 
going from reporting to the Article 32. I had nobody, nobody at 
all.
    The thing is that when it came to court martial time, I was 
drilled. I am being traumatized so many times and being 
revictimized so many times. I had the prosecutor, but he can 
only do so much.
    But when you are up there and you are getting drilled by 
this perpetrator's defense attorney, and they are playing the 
recorded tape that I got on him and saying, ``Listen to this. 
Did you ask for this? You wanted this.'' The judge does not 
intervene, it was disgusting.
    Senator McCaskill. Believe me, I have been in a courtroom 
as a prosecutor when a judge didn't intervene when there was 
inappropriate questions, when I have made the objection on rape 
shield statute and others. The judge just completely did not 
make the right ruling.
    I think judges are better today than they were 20 years 
ago. We are working now to make sure that the victims today and 
going forward have that independent lawyer that can be there 
for them and advise them, and I am very excited about that 
reform. We all worked very hard on it together. I am really 
proud of it.
    I don't think that how big it is actually has been 
comprehended by most people because we have been focused on a 
policy difference rather than on the monumental historic 
changes that we just got signed into law.
    Mr. Arbogast. I believe it would help tremendously to have 
somebody there along supporting you because I had nobody.
    Senator McCaskill. Right.
    Ms. Kenyon. May I say to have that as well, that person not 
be subject to rank. That is very important. I had lawyers who 
were captains or lieutenants, and they were unable to confront 
my commander because they were outranked. Or even the SAPRO 
office, who had no rank and were civilian, cowered under anyone 
with any bars on them. So to have independence somehow.
    Senator McCaskill. We have to make sure that happens. You 
are absolutely right, Ms. Kenyon.
    Thank you both very much.
    Ms. Kenyon. Thank you.
    Senator Gillibrand. Thank you, Senator.
    Interestingly, we have heard incidents where the special 
victims' counsels have been put in very difficult positions for 
that reason. So that is something many of us are going to look 
into for the next NDAA. I have heard of cases where special 
victims' counsels have advised not to seek mental health 
treatment because of the concern it would be used in the 
Article 32 against them or at least advised you need to be 
aware that it could be used against you.
    I have heard of cases where the question of whether one 
would report or not was debated because of fear of how they 
would be treated. I think we have to really look into 
empowerment of that specific person to make sure they can't be 
bullied. They can't be retaliated against themselves.
    So I think that is something Senator McCaskill and other 
Senators and I are going to work on for the next round. I think 
it is really important.
    Senator Ayotte?
    Senator Ayotte. I want to thank you, Madam Chairman, for 
holding this hearing.
    I want to thank both of you for being here and for your 
courage in coming before us. So sorry for everything that you 
have been through, but to come here before us, it is really 
important because this issue is one that we want to work 
together to stop the occurrence sexual assaults in the 
military, but also to make sure the victims get the full 
support that they need.
    I think this issue of special victims' counsel that Senator 
McCaskill and I and Senator Gillibrand and others on the 
committee have worked on is going to be a very important 
reform. One of the things that the reforms have, too, as well 
is making retaliation a crime under the Uniform Code of 
Military Justice (UCMJ). I think, as we go forward with 
implementing the special victims' counsel, this is something we 
should look at to make sure that it is clear that any kind of 
action against a victims' counsel that is helping a sexual 
assault victim should also be actionable.
    I think that is an important thing so that everyone 
understands that retaliation against a victim is a crime under 
the UCMJ because we have just made it so. But also any 
retaliation against someone acting on his or her behalf should 
be as well, and I think that is something we can make sure as 
we look at this going forward.
    The other issue that Senator McCaskill and I have and 
others on the committee have thought is really important is 
this idea of eliminating the good soldier defense. So I am 
hoping we do that this year. We have done a whole host of 
reforms, including the special victims' counsel. But this good 
soldier defense has no place in determining the outcome of 
these cases in the sense that your conduct should determine the 
outcome.
    If you have committed a crime and have committed these 
horrible acts, then just because you were a good soldier 
doesn't mean you shouldn't be held accountable and fully 
accountable and have the appropriate sentence to go with the 
crime that you committed. I think that, in the civilian system, 
we have eliminated a lot of those things, and those reforms now 
I am hoping we will have some agreement on that. I think there 
is a lot of agreement to get that passed this year as well.
    I just wanted to understand that as you talk about the 
overmedication issue and the transitions that you have made 
outside the military, so how do we improve that transition 
process? What can DOD and the VA do to improve that transition 
process from your perspective and to make sure that you have 
the support system in place if you choose to leave the military 
and have been a victim of sexual assault?
    Last week, I was up in New Hampshire visiting one of our 
veterans centers, and one of their charges is to treat victims 
of sexual assault. How do we make sure that that care is there?
    I just wanted to get your thoughts on what we can do better 
on the transition from DOD, those who are leaving to the VA. 
Obviously, I have heard what you said about the overmedication 
issue within the VA system so that we are working, even though 
the Senate Veterans Committee will work on that, we can work on 
this, I think, in this committee, too. So I just wanted to get 
your thoughts on how we could do a better job.
    Mr. Arbogast. Thank you, Senator.
    I worked closely with and do adaptive sports with the 
Wounded Warrior Regiment for the Marine Corps. They have 
district injured support coordinators. I think the Marine Corps 
has made a huge step when it comes to that because not only do 
they follow from the time that they are in the Wounded Warrior 
Regiment there, to the civilian world, these district injured 
support coordinators that are still Active Duty who check in on 
the veterans.
    I think that is crucial, and it is also an awesome concept 
when it comes to that. So that way, the veteran can pick up the 
phone and say, ``Hey, look, this is going on.'' That desk 
officer or enlisted, whatever it may be, can contact their 
resources and make things move along.
    So the Marine Corps has done tremendously when it comes to 
taking care of their wounded.
    Senator Ayotte. So maybe that is a model that we can look 
at also to make sure that is across Services?
    Mr. Arbogast. I believe so, ma'am. Like I said, it has been 
pretty effective.
    Ms. Kenyon. I would say having the ability for the VA to 
talk to the DOD. That is something that is very broken right 
now. The records and the database in which they both work do 
not communicate at all, and that will go a long way to 
something as simple as a records transfer. That will help, as 
well as affording opportunities outside the VA, and I would 
almost even say a grace period in which PTSD sufferers could 
have proper assistance in getting themselves to a state of 
well-being and to navigate that complex system.
    As I said, there is no right way to have PTSD, and so there 
is no real solution, here are my recommendations, and it will 
work for everybody. However, I think catering and having enough 
support, even if it was just a single counselor for one 
individual to help with paperwork to see that he or she 
receives the proper medications, that they are able to make 
appointments with one phone number and not sit on hold for days 
because----
    Senator Ayotte. For days, really?
    Ms. Kenyon. For hours and hours, and most of the time you 
give up, and then you try again tomorrow.
    Senator Ayotte. Wow.
    Ms. Kenyon. So, that does happen quite a bit. If it is 
okay, I would like to make a comment on retaliation?
    Senator Ayotte. Whatever you would like to.
    Ms. Kenyon. You said you want to make retaliation a crime, 
and currently in regulations, it is. However, it is usually the 
command who does it. As it currently stands, it is the command 
who would prosecute themselves.
    So that is a clear conflict of interest. How would you 
pursue that? How are you proposing that, say I was retaliated 
against, who do I go to, and who would handle that case? As 
well as who would be in charge of making that charge and 
deciding what was really retaliation and what might have just 
been a bad night out or any other number of things that the 
command could downplay it as.
    Senator Ayotte. With what we passed in the legislation 
further emphasized that retaliation, in particular for these 
types of crimes, is a clear crime under the UCMJ to further 
give teeth to that crime under the UCMJ. One of the proposals 
that is on the table allows going beyond the chain of command, 
up the chain beyond if there is a conflict at the next level of 
the chain of command.
    So I think that is one way to deal with it, where you are 
taking it up beyond that person and really upping the issue 
within so that there is a huge emphasis on it. But obviously, 
one of the things we want to get with everything we are doing 
is that we continue to have oversight over this.
    I think what you are you hearing from everyone here is that 
whatever we pass and we have passed some incredibly important 
reforms in the defense authorization, and we may pass further 
reforms--that we are going to continue not just to have this be 
the year where we are emphasizing it, but that we have regular 
oversight over this. So I think that is an important aspect, 
too, so that we can further pass whatever needs to be done and 
also hold people publicly accountable, particularly for those 
who are leaders to understand that this is part of their 
responsibility to have a zero tolerance policy and to support 
victims.
    If a leader in our military is found to be retaliating 
against someone who is a victim or someone helping a victim, 
that they are going to have a lot of problems, and we will hold 
them publicly accountable here, too. So I want you both to know 
this isn't you come here once, and we are just going to have 
this year of issues because I think all of us around this table 
are committed to a continuing oversight function next year and 
each month.
    I think that is what in the past we have had this issue 
where we are all focusing on it and then it goes away, but you 
all are dealing with the problem still. So, we are committed to 
remaining continuously engaged on this issue on a bipartisan 
basis.
    So thank you for raising the issue on the retaliation.
    Senator Gillibrand. Thank you.
    Senator King.
    Senator King. Thank you, Madam Chairman.
    Like my colleagues, I want to thank you. I wouldn't want to 
appear before a Senate committee under any circumstances, and 
you are doing it under particularly difficult circumstances. 
You are truly serving your country today and honoring the oath 
that you took when you joined the Service, and I deeply 
appreciate it.
    I want to focus on the issue of command and chain of 
command because that term has been used repeatedly. Ms. Kenyon, 
you said something about it is the command who retaliates. How 
can they prosecute themselves? My commander lied to me.
    I don't need a name, but what rank person are you referring 
to when you say that?
    Ms. Kenyon. I actually had multiple ranks retaliate as well 
as lie to me and make false promises and things of that nature, 
everyone from my squad leader up to my command sergeant major 
and my lieutenant colonel. Everyone in that rank who I came in 
contact with regarding my sexual assault somehow, some more 
severe than others, let me down or made false promises or 
outright made my life a living hell.
    Senator King. I understand that. But I think one of the 
ways that this discussion that we have been having has been 
somewhat confusing is that we are using the term ``chain of 
command'' as if it is multiple people. In reality, as I 
understand it, under DOD policy, nobody below O-6 makes the 
decision whether or not to go forward with a prosecution, and 
those people you just mentioned all are below the O-6 level.
    In other words, when you say your commander, you are not 
talking about a Navy captain or a colonel or above. Is that 
correct?
    Ms. Kenyon. Yes, Senator. That is correct. At the time that 
I served, it was the commander's ability to lessen the charge 
so an O-6 never--it never came across their desk.
    Senator King. Okay. Now that is an issue we have to be sure 
that the facts get to the O-6 level because they are the people 
making the decision. But I think it is important to inform our 
discussion that when people talk about taking the decision out 
of the chain of command, you are not taking away from sergeants 
and majors. You are taking it away from colonels and naval 
captains. That is a higher level.
    Let me change the subject for a moment. You have talked 
eloquently about the deficiencies of the treatment system. 
Would one solution be to allow military personnel to use their 
benefits in a civilian system? In other words, to go outside 
the military system to get the counseling and those, if there 
is more availability in the area you live?
    For example, we have a program in northern Maine under the 
VA. It is a pilot program where veterans are able to get their 
services not by going 4 hours to the VA hospital, but by 
accessing local civilian services. Would that be something that 
might be helpful in this situation by broadening the field of 
available treatment possibilities, Mr. Arbogast?
    Mr. Arbogast. Thank you, Senator.
    Like I stated before, I already use my TRICARE and Medicare 
for that purpose because of where the VA lacks. I think the VA 
veterans would not have a problem traveling for good care.
    I emphasized on how good my spinal cord injury care is in 
Richmond, VA, now. So that is a 4-hour drive for us. I would go 
there every day----
    Senator King. If you were getting adequate care?
    Mr. Arbogast.--if I was getting adequate care there. I get 
superior care there.
    Senator King. But you mentioned the 90-mile drive for 5 
minutes.
    Mr. Arbogast. That would be within my VA medical center, 
which I try to avoid at all costs because they are just out of 
the loop. They don't have the resources. They don't even have a 
doctor that specializes in spinal cord injury care. He is just 
an M.D. who thinks he just knows about it but really doesn't.
    But the thing is, if every VA had the resources to deal 
with every type of injury, illness, whatever, then it wouldn't 
be a problem to use the VA system. It is the problem that each 
VA medical center is different in what their care is, and I 
think it is because they are not being held accountable.
    Senator King. Ms. Kenyon, do you have thoughts about that?
    Ms. Kenyon. I believe there are a lot of benefits 
especially in the ability to test other counselors and 
caregivers to find whom you feel comfortable with, as well as 
being able to better specialize in what is actually affecting 
you, as well as PTSD, the prescription and overprescribing 
problems.
    But then there is also identity issues and other addictions 
that don't fall under narcotics or alcohol, like shopping 
addictions and things like that that are not treated in the VA. 
But if you went and sought outside help, I think there is a lot 
of benefit to getting more specialized treatment.
    I think it is, I would say, almost impossible for every VA 
to have every specialty. With that knowledge, to have the 
ability to go outside of that would benefit them.
    Senator King. But given the rise of this--I don't want to 
imply that it hasn't existed before. I am sure PTSD goes back 
to the beginning of time. But the increasing awareness of it, 
the volume of it that we are seeing in recent years, I suspect 
you would agree that this is something the VA should be gearing 
up for in a very serious way. I am gathering from your 
testimony that you don't believe that they are?
    Ms. Kenyon. I don't believe the VA has the ability to move 
three moves ahead or to see that where the need is coming until 
they have the problem. Then they approach whomever, and then 
the money comes in for the problem. But by then, it is 2 years 
down the road, and the problem is even bigger.
    I don't see that there is an adequate system for the VA to 
apply certain foresight in seeing where they need help and 
being able to justify it effectively to whomever they have to, 
to get the proper funding to get it. I would consider looking 
into that system where you could encourage the individuals, the 
directors to think three moves ahead and look at what's coming.
    Senator King. What is coming.
    Ms. Kenyon. Right. Look what is coming. You don't 
necessarily have to obviously prove it with the numbers in 
regards to you already have these, and this is what you are 
funded for. You don't have to have them on backup to justify 
the need.
    Senator King. The VA isn't within the purview of this 
committee, but clearly, it is a continuum of concern that we 
have about our military people, whether they are in Service or 
veterans.
    Thank you very much for your testimony. Thanks again for 
taking the time.
    Mr. Arbogast. If I may?
    Senator King. Yes, sir.
    Mr. Arbogast. There is a very big problem with the VA's 
retention rate, too, with providers.
    Senator King. Retention rate?
    Mr. Arbogast. They can't keep doctors, especially where I 
am. Their Community-Based Outpatient Clinics (CBOC). I went 
through seeing a doctor who I had seen for years, we are 
talking about a medical doctor. I had seen him for years, and 
then I come back in and find out he quit.
    Then it takes them 6 months to get a new doctor, so I am 
left without care for 6 months. They finally get a new doctor. 
I have to explain everything all over again. I will see you in 
a month or 2 weeks or whatever it may be. Come to find out, he 
quit. So then I am left without care for 8 months.
    Senator King. Now do you have a choice in all this? Do you 
have to go to the VA hospital, or could you use TRICARE to go 
anywhere?
    Mr. Arbogast. I could use TRICARE to go anywhere, but the 
fact is, some civilian providers are just as bad as the VA 
providers.
    Senator King. Are you suggesting our healthcare system in 
this country is screwed up? [Laughter.]
    Mr. Arbogast. It is.
    Senator King. I am shocked. [Laughter.]
    Mr. Arbogast. It is truly. It is, and it is quite 
disturbing that veterans, more or less, have to go around and 
shop for a doctor specialized in this care. What do they know? 
It is a very disturbing problem.
    Senator King. Thank you.
    Thank you, Madam Chairman.
    Senator Gillibrand. Thank you.
    I want to thank this panel for their testimony. This is 
extremely helpful in our deliberation to understanding these 
issues, and we are grateful for your service.
    Thank you very much.
    Ms. Kenyon. Thank you, Senator.
    Senator Gillibrand. We will now welcome the next panel to 
join us. On our second panel will be Dr. Karen S. Guice, M.D., 
M.P.P., Principal Deputy Assistant Secretary of Defense for 
Health Affairs; Ms. Jacqueline Garrick, LCSW-C, BCETS, 
Director, Department of Defense Suicide Prevention; Dr. Nathan 
W. Galbreath, Ph.D., M.F.S., Senior Executive Advisor, 
Department of Defense Sexual Assault Prevention and Response 
Office; Dr. Susan J. McCutcheon, RN, Ed.D., National Mental 
Health Director, Family Services, Women's Mental Health and 
Military Sexual Trauma, Department of Veterans Affairs; and Dr. 
Margret E. Bell, Ph.D., Director for Education and Training, 
National Military Sexual Trauma Support Team, Department of 
Veterans Affairs.
    I have handed out some data that we can have for the 
benefit of the expert panel we are about to have. The first 
chart shows the likelihood of having PTSD as a result of each 
action.
    [The information referred to follows:]
      
    
    
      
    Senator Gillibrand. So, for example, placement in the U.S. 
Army, it is 1 out of 10. It is 10 percent. Enlisted at 1 out of 
10, Active Duty 1 out of 10, multiple deployments slightly 
higher. But if you have MST, your likelihood of PTSD is 4 out 
of 10.
    So that is just the first chart. The second chart shows the 
number of people who screen positive for MST, the incidence of 
PTSD is higher for both men and women. So if you have 
experienced MST, it is 52 percent of the time you are going to 
get PTSD if you are a man, and 51 percent of the time you are 
going to get PTSD if you are a woman.
    Then the last two charts show that if you screen positive 
for MST, you have a higher incidence rate of mental health 
conditions. Meaning if you have been sexually assaulted, you 
are 75 percent more likely to have a mental health condition as 
a man. Slightly higher for a woman. Same for depressive 
disorders, PTSD, and other anxiety disorders.
    Our experts can refer to these charts if they need to. It 
is just the currently available data for veterans from Iraq and 
Afghanistan from April 1, 2002, through October 1, 2008.
    We also have a statement and materials that we are going to 
add to the record from Mr. Brian Lewis of Protect Our 
Defenders. Without objection, I will enter it into the record.
    Is there an objection? Without objection, it is entered 
into the record.
    [The prepared statement of Mr. Lewis follows:]
                 Prepared Statement by Mr. Brian Lewis
    Chairwoman Gillibrand, Ranking Member Graham, and members of the 
subcommittee, thank you for the opportunity to submit a written 
statement for the record. When I testified before the subcommittee 1 
year ago, it was in the hopes that I would see some substantive changes 
in the way the Department of Defense and the Department of Veterans 
Affairs tackle the problem of military sexual trauma. I am sad to say I 
have been disappointed. Both departments are in fundamentally the same 
places they were 1 year ago. This is a travesty that must be addressed 
through congressional oversight to help turn the tide of 22 veteran 
suicides per day.\1\
---------------------------------------------------------------------------
    \1\ Janet Kemp & Robert Bossarte, Department of Veterans Affairs, 
Office of Mental Health Services, Suicide Data Report, 2012 (2013) 
(available at: http://www.va.gov/opa/docs/Suicide-Data-Report-2012-
final.pdf)
---------------------------------------------------------------------------
                         department of defense
    The Department of Defense still has significant ground to cover in 
order to recognize military sexual trauma as a male issue. The 
Department of Defense still does not consult with military sexual 
trauma advocacy organizations such as Protect our Defenders to inform 
their work for all survivors of military sexual trauma. In addition, 
the Department of Defense still does not consult with any credible 
advocacy organizations dedicated solely to male survivors of military 
sexual trauma.
    Statistics and research within the Department of Defense regarding 
male military sexual trauma survivors remain scarce at best. One of the 
most oft-repeated phrases in the 2012 Workforce and Gender Relations 
Survey of Active Duty Members is that ``results for men are not 
reportable'' or that ``results for men by Service and paygrade are not 
reportable.'' \2\ More efforts need to be undertaken by the Department 
of Defense to ensure that detailed information about male survivors is 
included in various reports and studies instead of glossed over as they 
are currently. The Department of Defense still has no training 
materials featuring or depicting male survivors. Failing to include 
male survivors in training materials reinforces the rape myth that men 
cannot be the victims of a sexual trauma. This conduct also serves to 
marginalize men who have been survivors by communicating the message 
that their trauma is not important enough to include. A senior advisor 
to the Air Force Sexual Assault Prevention and Response Office recently 
acknowledged that one of the biggest challenges currently facing the 
Department of Defense is ``getting individuals properly educated on the 
issue.'' \3\ When male survivors are ignored in the production of 
training materials, our servicemembers are not being properly educated 
on the issue.
---------------------------------------------------------------------------
    \2\ Lindsay Rock, Defense Manpower Data Center, 2012 Workforce and 
Gender Relations Survey of Active Duty Members (2013) (available at: 
http://www.sapr.mil/public/docs/research/2012--Workplace--and--Gender--
Relations--Survey--of--Active--Duty--Members-Survey--Note--and--
Briefing.pdf)
    \3\ Kristin Davis, Former Police Officer Brings His Experience to 
SAPRO, Army Times, Feb. 16, 2014, http://www.armytimes.com/article/
20140216/NEWS06/302160007/Former-police-officer-brings-his-law-
enforcement-expertise-SAPRO
---------------------------------------------------------------------------
    The Department of Defense still has very little information 
concerning perpetrators of sexual violence against male victims. In the 
latest survey, a large majority of this information for male survivors 
was listed as non-reportable.\4\ Knowing who is doing the perpetrating 
is an invaluable tool to fighting this crime. As long as the spotlight 
is on the victim nothing can get done ``in a large, meaningful way to 
take down sexual assault.'' \5\
---------------------------------------------------------------------------
    \4\ See Rock at 35.
    \5\ See Davis (Thomas answer to fifth interview question: ``Like 
what?'')
---------------------------------------------------------------------------
    Congress also needs information concerning repeat perpetrators. My 
own perpetrator was a repeat offender. He perpetrated this crime 
against at least one other sailor aboard the same command. I know I am 
not alone. Many survivors I talk with report the same experience. 
Repeat offenders anecdotally appear to be a significant problem the 
Department of Defense has not addressed.
                              retaliation
    Recent efforts to address this crime have been largely focused on 
what happens to victims and offenders after a report has been filed. In 
order to fully address this problem in a meaningful way, solutions have 
to be found to the multitude of problems survivors face before a formal 
report is filed. A Commanding Officer can exert considerable pressure 
on a victim to not file a formal report. In order to address this 
problem, Congress should take the reporting of this crime away from 
immediate commanders regardless of rank or pay grade.
    If a servicemember does decide to report and face the retaliatory 
measures commanding officers and others can employ, it is very unlikely 
that the person retaliating against the survivor will face any punitive 
actions. A Government Accounting Office investigation found that the 
Department of Defense Inspector General process substantiated. a mere 6 
percent of cases filed as retaliation claims from fiscal year 2006 
through fiscal year 2011.\6\
---------------------------------------------------------------------------
    \6\ Dylan Blalock, Government Accountability Project, Senate 
Approves Military Whistleblower Protection Act Makeover, Dec. 20, 2013, 
http://www.whistleblower.org/blog/44-2013/3123-senate-approves-
military-whistleblower-protection-act-makeover
---------------------------------------------------------------------------
    Very often, a retaliatory measure that is taken is to lower the 
type of discharge a servicemember receives after reporting a crime. My 
own discharge was lowered to General (Under Honorable Conditions) after 
reporting the crime. I am not unique in this regard. Many thousands of 
survivors have had their discharges lowered as a result of retaliation, 
thereby restricting their eligibility for benefits such as the GI Bill, 
care at the Veterans Health Administration (VHA), and potentially 
denial of a compensation claim at the VBA. Many of these survivors have 
never had a due process hearing. I know I did not. When such a vital 
liberty interest is implicated such as the nature of a military 
discharge, a due process hearing should be mandatory for all and not 
just those who have 6 or more years of service.
                board for correction of military records
    Another area contributing to a link between suicide and military 
sexual trauma survivors is the almost impossible process to receive 
discharge upgrades. Survivors are still misdiagnosed with ``weaponized 
diagnoses'' \7\ such as Personality Disorders to deny survivors the 
recognition of their trauma and a potential retirement for post-
traumatic stress disorder. The Department of Defense's various Boards 
for Correction of Military Records are still significant barriers to 
helping a survivor heal from the wounds of military sexual trauma by 
refusing to recognize this fact and upgrade erroneous discharges. This 
low chance of success at the Boards for Correction of Military Records 
is widely acknowledged.8,9 I remember being very discouraged 
to the point of attempting suicide when the Board for Correction of 
Naval Records denied my petition. To this day, even after numerous 
media appearances and testimony before this Congress, the Department of 
the Navy still refuses to change my discharge. Imagine what survivors 
who have not been speaking out feel.
---------------------------------------------------------------------------
    \7\ Credit for this term belongs to Patricia Lee Stotter who is a 
fellow Advisory Board Member of Protect our Defenders.
    \8\ See Clinton v. Goldsmith, 526 U.S. 529 n. 12 (1999)
    \9\ Connecticut Veterans Legal Clinic, Veterans Discharge Upgrade 
Manual (2011) (available at: http://ctveteranslegal.org/resources/) 
(discussing rates for BCMR upgrade rates hovering around 10-20 percent)
---------------------------------------------------------------------------
                     department of veterans affairs
    The Department of Veterans Affairs does not perform any better when 
it comes to the topic of military sexual trauma for a variety of 
reasons. The Department of Veterans Affairs also still refuses to fully 
recognize military sexual trauma as a male issue. Both of these issues 
are probably contributing to an unacceptably high suicide rate among 
veterans.
                    veterans benefit administration
    The Veterans Benefit Administration still has significant problems 
with processing and adjudicating claims for military sexual trauma. As 
of Monday, February 11, 2014, the Department of Veterans Affairs has 
686,861 pending claims of which 403,761 or 58.8 percent are considered 
``backlog'' cases meaning they have been pending for over 125 days.\10\ 
The average time to wait for an initial decision on an initial 
compensation claim is 260 days.\11\ These numbers do not include the 
number of claims that have been appealed to the Board for Veterans 
Appeals. In the most recent year for which data is publicly available, 
the Board of Veterans Appeals received 49,611 claims.\12\ The BVA 
estimates that it takes on average approximately 3 years to process an 
application from the time the appellant files the notice appeal to 
final disposition by the Board of Veterans Appeals.\13\ I have talked 
with many survivors who have been given 10 and 30 percent ratings for 
post-traumatic stress disorder and chose to appeal. Imagine trying to 
feed your family or support your necessary expenses while engaging this 
process for almost 4 years. This drawn out process of fighting for 
benefits that we are due could certainly be contributing to the high 
suicide rate.
---------------------------------------------------------------------------
    \10\ Department of Veterans Affairs, Veterans Benefit 
Administration, Monday Morning Workload Report for Feb. 17, 2014 (2014) 
(available at: http://www.vba.va.gov/REPORTS/mmwr/)
    \11\ Board of Veterans' Appeals, U.S. Department of Veterans 
Affairs, Report of the Chairman: Fiscal Year 2012 (Feb. 4, 2013)
    \12\ Board of Veterans' Appeals
    \13\ Id. at 19
---------------------------------------------------------------------------
    Another problem perpetuated by the Veterans Benefits Administration 
is requiring ``stressor statements'' from survivors of military sexual 
trauma and requiring survivors to have independent confirmation of the 
assault. This same practice is not required of veterans claiming post-
traumatic stress disorder as a result of exposure to combat or 
terrorist activity. In these cases, a simple statement from the veteran 
coupled with service records showing combat awards or deployments serve 
as sufficient corroboration for the claim.\14\ The Court of Appeals for 
Veterans Claims has upheld this difference as a rational exercise of 
the agency's authority.\15\ This distinction is not victim friendly. 
Imagine having to write down the most intimate details of a crime for 
anyone to look at and second-guess. I do not know the pain of having to 
do this at the Veterans Benefit Administration. However, I do know the 
pain of having a Navy psychiatrist second guess what happened when he 
was over 6,000 miles from where the crime occurred. It is a truly 
horrible feeling.
---------------------------------------------------------------------------
    \14\ 38 C.F.R. Sec. 3.304(f)(3)
    \15\ Acevedo v. Shinseki. 25 Vet. App. 286 (2012)
---------------------------------------------------------------------------
                     veterans health administration
    The Veterans Health Administration (VHA) has severe deficits 
concerning proper treatment of male survivors of military sexual 
trauma. Combining oversight of this issue with the Director of Family 
Services and Women's Mental Health who is appearing before the 
subcommittee today demonstrates the complete lack of understanding or 
caring the Veterans Health Administration gives to male survivors of 
military sexual trauma. The Veterans Health Administration still does 
not have military sexual trauma peer support groups available at all of 
their medical centers. The current emphasis on evidence-based 
treatments stifles the basic human interactions needed to learn how to 
cope with being a military sexual trauma survivor. I believe this is 
contributing to the suicide rate among military sexual trauma 
survivors. One of the major factors that hindered my recovery for many 
years was the lack of a peer-support environment within the Baltimore 
VA Medical Center. When I recently transferred my care to the 
Minneapolis VA Medical Center 2 months ago, I was rudely informed that 
their facility did not provide support groups for survivors of military 
sexual trauma.
    The VHA has also failed to open residential treatment programs 
designed specifically for male survivors of military sexual trauma. 
Currently the VHA has approximately 12 separate programs designed 
specifically for treating military sexual trauma survivors. 
Unfortunately all but one accepts only women. The only one that accepts 
men is the Center for Sexual Trauma Services at VAMC Bay Pines, FL.\16\ 
This program attempts to treat both male and female survivors in a 
coeducational environment. As a male survivor, I found this program 
very uncomfortable. Male survivors should be treated equally with 
female survivors to include the provision of resources within the 
Veterans Health Administration. Legislation pending in the Senate 
offered by Senator Bernard Sanders (I-VT) that would require the VHA to 
issue ``a report on the treatment and services available from the 
Department of Veterans Affairs for male veterans who experience 
military sexual trauma compared to such treatment and services 
available to female veterans who experience military sexual trauma.'' 
\17\ Male survivors should not need to wait for this bill to be enacted 
and then wait 630 days for VHA to issue a report, and then wait an 
unknown amount of time to receive gender equality in the provision of 
MST services.
---------------------------------------------------------------------------
    \16\ See Appendix A.
    \17\ Comprehensive Veterans Health and Benefits and Military Pay 
Restoration Act of 2014, S. 1982, 113th Cong. Sec. 364(a).
---------------------------------------------------------------------------
    Another way the Veterans Health Administration fails male survivors 
is their failure to conduct research geared at male survivors. Research 
on male survivors of military sexual trauma is exceptionally limited. A 
lot of studies have acknowledged this fact. However, the Veterans 
Health Administration has taken no concrete steps toward fixing this 
lack of knowledge. The only way to give male survivors quality mental 
health care is through research. Unfortunately the Veterans Health 
Administration is unable or unwilling to take this step.
    The Veterans Health Administration also fails to treat survivors as 
whole persons. I endure chronic pain as a result of my sexual trauma, 
yet the Minneapolis VA Medical Center has refused to treat this problem 
in an adequate fashion. This is another area in which I know I am not 
alone. Many survivors disclose being in physical pain yet are unable to 
receive appropriate medical interventions to include appropriate 
medications at their local VA Medical Centers. The constant physical 
reminders of the sexual trauma without appropriate help from the 
Veterans Health Administration could also be increasing the suicide 
problem.
                               conclusion
    Since I testified last year in front of this subcommittee, I have 
moved to Saint Paul, MN. I graduated with a Bachelor of Science in 
Paralegal Studies from Stevenson University in May 2013. I graduated 
with a Master of Science in Forensic Studies degree from Stevenson 
University in December 2013. I authored my thesis on the topic of 
military sexual trauma. I have been accepted to Hamline University 
School of Law as an incoming first year law student. They took a chance 
on me knowing that I might not be able to be admitted to the Bar in 
Minnesota. This committee should commend them for supporting a military 
sexual trauma survivor. All of these degrees I have completed have been 
without the benefit of the Montgomery GI Bill. I lost that benefit as a 
result of the General (Under Honorable Conditions) Discharge I was 
given for attempting to report the trauma and the retaliation by a Navy 
psychiatrist who accused me of fabricating the trauma. I have 
accumulated about $70,000 in student loan debt that will quickly climb 
as I progress through law school. All of these degrees have been 
accomplished without the assistance of any Department of Veterans 
Affairs vocational rehabilitation services.
    In conclusion, I think Representative Raul Ruiz (D-CA, 36) said it 
best at a hearing when he said, ``It's a triple assault that many of 
our veterans face.''\18\ We first become victims of this crime. We are 
then retaliated against by the military. Then we must endure the lack 
of care and respect from the Department of Veterans Affairs. Congress 
needs to act decisively and break up this pattern of abuse before more 
lives are needlessly lost to suicide.
---------------------------------------------------------------------------
    \18\ Safety for Survivors: Care and Treatment for Military Sexual 
Trauma Before the H. Comm. On Vet. Aff, 113th Cong. (2013) (unpub.)

    [Additonal materials provided by Mr. Lewis follow:]
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    Senator Gillibrand. Thank you to each of you who have 
joined us on our second panel. I appreciate your expertise that 
you are going to bring to this discussion. I invite you each to 
give a personal statement of up to 7 minutes, and your full 
statement will be submitted for the record.
    Dr. Bell, if you would like to start?

STATEMENT OF MARGRET E. BELL, Ph.D., DIRECTOR FOR EDUCATION AND 
    TRAINING, NATIONAL MILITARY SEXUAL TRAUMA SUPPORT TEAM, 
                 DEPARTMENT OF VETERANS AFFAIRS

    Dr. Bell. Good morning, Chairman Gillibrand, Ranking Member 
Graham, and members of the subcommittee.
    Thank you for the opportunity to discuss the intersection 
of two very important issues involving our servicemembers and 
veterans, namely MST and suicide.
    We just heard the incredibly moving stories of the two 
veterans that testified who have struggled very much with the 
issues that we are discussing today. I very much appreciate 
their willingness to come today and really bring some of the 
data that I am about to speak about to life and make it more 
real for us today.
    The stories they have shared really underscore the 
importance of the issues I would like to review in my comments, 
which is what research and empirical literature tell us about 
the health impact of MST, as well as the relationship between 
trauma, MST, and suicide specifically.
    MST is an experience, not a diagnosis or a mental health 
condition. As with other forms of trauma, there are a variety 
of reactions that veterans can have after experiencing MST. The 
type, severity, and duration of a veteran's difficulties will 
all vary based on factors like the nature of the MST 
experienced, the reactions of others at the time and 
afterwards, and whether the veteran had a prior history of 
trauma.
    Although the struggles that men and women have after MST 
are similar and may overlap in some ways, there can also be 
gender-specific issues that they may deal with. The impact of 
MST can also be affected by race, ethnicity, religion, sexual 
orientation, and other cultural variables.
    Our veterans are remarkably resilient after experiencing 
trauma. But unfortunately, some do go on to experience long-
term difficulties after experiencing MST. VA medical record 
data indicate that in fiscal year 2012, PTSD and depressive 
disorders were the mental health diagnoses most commonly 
associated with MST.
    Other common diagnoses were other anxiety disorders, 
bipolar disorders, substance use disorders, and schizophrenia 
and psychotic disorders. Veterans who experienced MST often 
also struggle with physical health conditions and other 
problems, such as homelessness.
    With regard to suicide, research has shown that trauma in 
general is associated with suicide and suicidal behavior. This 
is true for both civilian and military populations. But if we 
focus on sexual trauma specifically, data from civilian studies 
have found an association between sexual victimization and 
suicidal ideation, attempted suicide, and death by suicide. 
These relationships remain even after you control for mental 
health conditions like depression or PTSD.
    Although less work has been done examining the link between 
sexual trauma and suicide among veterans specifically, the data 
that exist show a pattern similar to the studies of civilians 
that I just reviewed. That is, studies and VA administrative 
data show that sexual trauma during military service is 
associated with suicide attempts as well as death by suicide, 
and this association also holds even after accounting for 
mental health symptomatology.
    Treatment approaches always need to be tailored to the 
specific needs of the individual veteran and take into account 
not only comorbid health conditions, but also the veteran's 
treatment and broader psychosocial history, his or her current 
life context, and his or her individual preferences.
    Regarding treatment for veterans with PTSD specifically, a 
significant research base has accumulated identifying exposure-
based cognitive behavioral therapies, such as cognitive 
processing therapy and prolonged exposure, as effective 
treatments for PTSD. Cognitive processing therapy and prolonged 
exposure in particular were originally developed for the 
treatment of sexual assault survivors with PTSD, and they have 
a particularly strong evidence base in this area.
    Although these therapies should be considered a first-
choice approach to treatment of sexual assault survivors with 
PTSD, some veterans may benefit from an initial focus on coping 
skills development before beginning these emotionally demanding 
treatments. This sort of phase-based approach can help augment 
their strategies for managing the emotional distress that may 
be brought up during completion of the cognitive behavioral 
treatment.
    Psychoeducation about PTSD and the impact of sexual assault 
can also be an important component of treatment.
    Madam Chairman, the VA is committed to ensuring that our 
veterans get the help that they need to recover from 
experiences of MST. I really appreciate having the opportunity 
to speak about some of the research in this area today, as well 
as thank you for your support of these important issues. I am 
prepared to respond to any questions you may have.
    [The prepared joint statement of Dr. Bell and Dr. 
McCutcheon follows:]
 Prepared Joint Statement by Dr. Margret Bell and Dr. Susan McCutcheon
    Good morning, Madam Chairman, Ranking Member Graham, and members of 
the subcommittee. Thank you for the opportunity to discuss Department 
of Veterans Affairs' (VA) efforts regarding suicide and military sexual 
trauma (MST).
    The Department is committed to assisting veterans who have 
experienced MST with their recovery. It can take great courage for a 
veteran to seek help after experiencing MST. However, there are caring 
and competent staff and effective programs at VA to assist male and 
female veterans who have experienced MST.
    Veterans Health Administration (VHA) data show continually 
increasing rates of veterans seeking care. In fiscal year 2013, 93,439 
veterans received MST-related care at VHA. This is an increase of 9.3 
percent (from 85,474) from fiscal year 2012. The amount of care 
provided by VHA is also increasing: these veterans had a total of 
1,027,810 MST-related visits in fiscal year 2013, which represents an 
increase of 14.6 percent (from 896,947) from fiscal year 2012.
    Suicide prevention is a key priority for VHA, and these efforts are 
complemented by initiatives specific to veterans who experienced MST. 
To provide context for these efforts, we first review the existing 
research on the health impact of MST, with a particular focus on the 
relationship between MST and suicide. We then review VHA's specialized 
services to meet the range of difficulties that MST survivors might 
experience. VA also ensures that providers and key staff receive 
appropriate training on MST.
              the health impact of military sexual trauma
    MST is an experience, not a diagnosis, and veterans will vary in 
their reactions to MST. Our veterans are remarkably resilient after 
experiencing trauma, but some do go on to experience long-term 
difficulties following MST. Specifically, research has found that both 
women and men are at increased risk for developing post-traumatic 
stress disorder (PTSD) after experiencing MST. In fact, MST is an equal 
or stronger predictor of PTSD than other military-related stressor 
(such as combat) or sexual assault during childhood or civilian life. 
fiscal year 2012 VA medical record data indicate that PTSD and 
depressive disorders were the mental health diagnoses most frequently 
associated with MST among users of VA health care. Other common mental 
health diagnoses include other anxiety disorders, bipolar disorders, 
substance use disorders, and schizophrenia and psychotic disorders.
             research on military sexual trauma and suicide
    Between both civilian and military populations, research has shown 
that experiences of trauma are associated with suicidal behavior. With 
regard to sexual trauma specifically, data from civilian samples have 
shown an association between sexual victimization and suicidal 
ideation, attempted suicide, and death by suicide. These relationships 
remain even after controlling for comorbid mental health conditions 
like depression and PTSD.
    Studies of suicide among veterans who experienced MST show similar 
findings. For example, among both Canadian and U.S. military forces, 
experiences of sexual trauma during military service are associated 
with suicide attempts and death by suicide. A study of veterans of 
Operation Enduring Freedom and Operation Iraqi Freedom similarly showed 
that experiences of sexual harassment and assault are associated with 
suicidal ideation. Consistent with studies of civilians, the 
association between sexual harassment/assault and suicidal ideation 
remained even after controlling for mental health symptomatology. VHA 
administrative data sources show a similar pattern of findings in that 
MST is significantly associated with risk for suicide for both women 
and men, and that this relationship remains even after controlling for 
age, medical and psychiatric conditions, and place of residence.
      military sexual trauma-related care in the veterans health 
                             administration
    Fortunately, recovery is possible after experiences of MST, and VHA 
has services spanning the full continuum of care to assist veterans in 
these efforts.
    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 are screened for experiences of MST. 
Veterans who screen positive are offered a referral for mental health 
services. In fiscal year 2013, among the 77,681 female veterans who 
screened positive for experiences of MST, 58.7 percent received 
outpatient MST-related mental health care. Among the 57,856 male 
veterans who screened positive for experiences of MST, 44.3 percent 
received outpatient MST-related mental health care.
    All VA health care for physical and mental health conditions 
related to MST is provided free of charge. Receipt of these free MST-
related services is entirely separate from the disability compensation 
process through the Veterans Benefits Administration (VBA), and service 
connection (upon which VA disability compensation is based) is not 
required. Veterans are able to receive free MST-related care even if 
they are not eligible for other VA health care.
    Every VA medical center provides MST-related care for both mental 
and physical health conditions. Outpatient MST-related mental health 
services include formal psychological assessment and evaluation, 
psychiatry, and individual and group psychotherapy. Specialty services 
are also available to target problems such as PTSD, substance use, 
depression, and homelessness. Many community-based Vet Centers also 
have specially-trained, sexual trauma counselors. Complementing these 
outpatient services, VA has mental health residential rehabilitation 
and treatment programs and inpatient mental health programs to assist 
veterans who need more intense treatment or support. Some of these 
programs focus specifically on MST or have specialized MST tracks.
    MST Coordinators are available at every VA medical center to assist 
veterans in accessing these services.
   education and training for va staff on mst and suicide prevention
    Ensuring staff have the training they need to work sensitively and 
effectively with veterans who experienced MST is a priority for VA. All 
VA mental health and primary care providers are required to complete 
mandatory training on MST. VA's national MST Support Team hosts monthly 
teleconference training calls on topics related to MST. These calls are 
open to all staff and are available for later review on the VA 
intranet. Content on suicide and sexual trauma has been included in 
these and other MST-specific training efforts.
    In addition, as part of its strong commitment to provide high 
quality mental health care, VHA has nationally disseminated and 
implemented specific, evidence-based psychotherapies for PTSD and other 
mental and behavioral health conditions. Because PTSD, depression, and 
anxiety are commonly associated with MST, these national initiatives 
are important means of expanding MST survivors' access to treatments. 
Furthermore, several of these treatments were originally developed to 
treat sexual assault survivors and have a particularly strong research 
base with this population.
    Recognizing the strong link between sexual trauma and risk for 
suicide, VHA's national MST Support Team has an ongoing collaboration 
with VA's Veterans Crisis Line (VCL). Some current efforts include the 
development of specialized materials to further enhance VCL staff's 
understanding of issues specific to MST and facilitate sensitive and 
effective handling of calls from veterans who experienced MST. The MST 
Support Team and the VCL are also working to train and identify staff 
on the VCL with particular expertise in sexual trauma who can provide 
consultation to other staff members on issues specific to MST.
    Complementing these efforts, MST coordinators, at VA facilities, 
have been encouraged to develop close working relationships with 
facility Suicide Prevention Coordinators. These relationships will 
allow MST Coordinators to ensure local suicide prevention initiatives 
incorporate information about MST and target the unique needs of MST 
survivors. They also will facilitate close collaboration in addressing 
the treatment needs of specific veterans who experienced MST.
            va collaboration with the department of defense
    Complementing VA collaborations with the Department of Defense 
(DOD), VHA's Office of Mental Health Services and its national MST 
Support Team have a longstanding relationship with DOD's overarching 
Sexual Assault Prevention and Response Office (SAPRO). SAPRO and the 
MST Support Team have provided trainings to staff in each Department to 
ensure that each are aware of the other's services and are able to pass 
this information along to servicemembers with whom they work. SAPRO and 
the MST Support Team also communicate, as needed, to help connect 
individual veterans and servicemembers to services that match their 
treatment needs.
    A top priority has been outreach to newly-discharged veterans and 
servicemembers transitioning off active duty to ensure they are aware 
of MST-related services available through VHA. Collaborations between 
DOD and other VA program offices have led to key accomplishments such 
as ensuring MST-specific content is part of mandatory outprocessing 
(i.e., Transition Assistance Program) completed by all servicemembers. 
Sexual Assault Prevention and Response programs, in each of DOD's 
Services have been provided with information about VA's services for 
distribution to DOD Sexual Assault Response Coordinators, other staff, 
and servicemembers, and information about VA's MST-related services and 
benefits has been included in DOD Sexual Assault Forensic Examination 
(SAFE) Helpline, staff trainings, and on the SAFEHelpline Web site.
    VHA staff have also been pivotal members of a joint VA-DOD 
workgroup formed in relation to DOD/VA Integrated Mental Health 
Strategy Strategic Action #28, which focuses on VA and DOD research and 
mental health services for servicemembers and veterans who have 
experienced MST (both male and female).
                               conclusion
    Madam Chairman, VA is committed to providing the highest quality 
care our veterans have earned and deserve. Our work to effectively 
treat veterans who experienced MST and ensure eligible veterans have 
access to the counseling and care they need to recover from MST 
continues to be a top priority.
    We appreciate Congress' support and are prepared to respond to any 
questions you may have.

    Senator Gillibrand. Thank you.
    Dr. McCutcheon?

 STATEMENT OF SUSAN J. McCUTCHEON, RN, Ed.D., NATIONAL MENTAL 
 HEALTH DIRECTOR, FAMILY SERVICES, WOMEN'S MENTAL HEALTH, AND 
     MILITARY SEXUAL TRAUMA, DEPARTMENT OF VETERANS AFFAIRS

    Dr. McCutcheon. Good morning, Chairman Gillibrand, Ranking 
Member Graham, and members of the subcommittee.
    Thank you for the opportunity to discuss the VA healthcare 
services for veterans who have experienced sexual trauma while 
serving on Active Duty or Active Duty for training, which is 
known as MST.
    I would also like to thank the veteran panel for their 
detailed testimony of their struggles and the courage to share 
their stories with us today.
    VA is committed to ensuring that eligible veterans have 
access to the healthcare services that they need to recover 
from MST. To this end, VA has been developing and executing 
initiatives to provide counseling and care to veterans who have 
experienced MST, monitor MST-related screening and treatment, 
provide VA staff with training, and inform veterans about our 
available services.
    Fortunately, recovery is possible after experiences of MST, 
and the Veterans Health Administration (VHA) has services 
spanning the full continuum of care to assist veterans in these 
efforts. Recognizing that many survivors of sexual trauma do 
not disclose their experiences unless asked directly, it is VA 
policy that all veterans seen for healthcare are screened for 
experiences of MST.
    Veterans who screen positive are offered a referral for 
mental health services. All VHA healthcare for physical and 
mental health conditions related to MST is provided free of 
charge. Receipt of free MST-related services is entirely 
separate from the disability compensation process through the 
Veterans Benefit Administration (VBA), and service connection 
is not required for this free treatment.
    Every VA medical center provides MST-related outpatient 
care for both mental and physical health conditions. 
Complementing these outpatient services, VA has mental health 
residential rehabilitation and treatment programs and inpatient 
mental health programs to assist our veterans who need more 
intense treatment or support.
    We have MST coordinators at every VA medical center, who 
will assist veterans in accessing these services. It can take 
tremendous courage for veterans to seek out help after 
experiencing MST. Fortunately, VHA data shows continually 
increasing rates of veterans seeking care.
    Ensuring staff have the training they need to work 
sensitively and effectively with veterans who have experienced 
MST is a priority for VA. All VA mental health and primary care 
providers are required to complete a mandatory training on MST.
    The VA's National MST Support Team hosts monthly 
teleconference training calls open to all VA staff on topics 
related to MST. Content on suicide and sexual trauma has also 
been included in other MST-specific training efforts.
    In addition, as part of its strong commitment to provide 
high-quality mental healthcare, VA has nationally disseminated 
and implemented specific evidence-based psychotherapies for 
PTSD and other mental health conditions. Because PTSD, 
depression, and anxiety are commonly associated with MST, these 
initiatives are very important means of expanding MST 
survivors' access to evidence-based treatments.
    Recognizing the strong link between sexual trauma and risk 
for suicide, VA's National MST Support Team has an ongoing 
collaboration with the VA's Veterans Crisis Line. Current 
efforts include the development of specialized materials to 
further enhance all Veterans Crisis Line staff's knowledge of 
MST-specific issues and facilitate sensitive and effective 
handling of calls from veterans who have experienced MST.
    Complementing these efforts at the local level, MST 
coordinators have been encouraged to develop working 
relationships with the facilities' suicide prevention 
coordinators. These relationships will allow MST coordinators 
to ensure local suicide prevention initiatives incorporate 
information about MST and target the unique needs of these 
survivors. This close collaboration will also facilitate 
addressing the treatment needs of specific veterans at their 
facilities who have experienced MST.
    Madam Chairman, the VA is committed to providing the 
highest quality care that our veterans have earned and deserve. 
Our work to effectively treat veterans who have experienced MST 
and ensure eligible veterans have access to the counseling and 
care they need to recover from MST continues to be a top 
priority.
    I appreciate your support and am prepared to respond to any 
questions you may have.
    Thank you.
    Senator Gillibrand. Thank you.
    Dr. Galbreath?
    Dr. Galbreath. Dr. Guice is going to be presenting for us.
    Senator Gillibrand. Dr. Guice?

  STATEMENT OF KAREN S. GUICE, M.D., M.P.P., PRINCIPAL DEPUTY 
 ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS; NATHAN W. 
GALBREATH, Ph.D., M.F.S., SENIOR EXECUTIVE ADVISOR, DEPARTMENT 
 OF DEFENSE SEXUAL ASSAULT PREVENTION AND RESPONSE OFFICE; AND 
  JACQUELINE GARRICK, LCSW-C, BCETS, DIRECTOR, DEPARTMENT OF 
               DEFENSE SUICIDE PREVENTION OFFICE

    Dr. Guice. Madam Chairman, members of the subcommittee, 
thank you for the opportunity to assess DOD's support for 
sexual assault survivors and the relationship between sexual 
assault, the subsequent development of PTSD, and suicide.
    Sexual assault survivors are at an increased risk for 
developing sexually transmitted infections, depression, 
anxiety, and PTSD, conditions that can have a long-lasting 
effect on well-being and future functioning and can precipitate 
suicidal thought.
    To address these and other potential risks, and regardless 
of whether the survivor is male or female, whether the sexual 
assault occurred prior to joining the military or during 
service, or whether the manifestations are physical or 
emotional, DOD has policy, guidelines, and procedures in place 
to provide access to a structured, competent, and coordinated 
continuum of care and support for survivors of sexual trauma. 
This continuum begins when the individual seeks care and 
extends through their transition from military service to the 
VA or care in their communities.
    DOD has issued comprehensive guidance on medical management 
for survivors of sexual assault for all military treatment 
facilities and service personnel who provide or coordinate 
medical care for sexual assault survivors. Included in this 
guidance is the requirement that the care is gender responsive, 
culturally competent, and recovery oriented.
    Any sexual assault survivor who presents to one of our 
military treatment facilities is treated as a medical 
emergency. Treatment of any and all immediate life-threatening 
conditions takes priority. Survivors are offered testing and 
prophylactic treatment options for sexually transmitted 
illnesses. Women are advised of the risk for pregnancy and 
counseled with regards to emergency contraception.
    Prior to release from the emergency department, survivors 
are provided with referrals for additional medical services, 
behavioral health evaluation, and counseling in keeping with 
the patient's preferences for care. In locations where DOD does 
not have the needed specialized care, including emergency care 
within a given military treatment facility, patients are 
referred to providers in the local community.
    Last spring, the Assistant Secretary of Defense for Health 
Affairs issued a memorandum to the Services regarding reporting 
compliance with these standards. The Services returned detailed 
implementation plans, and the first of a yearly reporting 
requirement is due this summer from each of them.
    The long-term needs of the survivors of sexual assault 
often extend beyond the period which a servicemember remains on 
Active Duty. To support individuals with mental healthcare 
needs, DOD provides the inTransition program. This program 
assigns servicemembers to a support coach to bridge between 
healthcare systems and providers.
    You asked about the relationship between suicide, PTSD, and 
sexual abuse. We know from civilian population research that 
sexual assault is associated with an increased risk of suicidal 
ideation, attempts, and completions. Furthermore, this 
association appears to be independent of gender.
    Sexual assault is also associated with mental health 
conditions such as depression, anxiety, and PTSD. Likewise, 
these mental health conditions are associated with suicidal 
ideation, attempts, and completions.
    For military populations, the evidence associating sexual 
assault and subsequent suicidal ideation, attempt, or 
completion is less well-defined for that of the civilian 
population. Between 2008 and 2011, the number of individuals 
who attempted or completed suicide and reported either sexual 
abuse or harassment in DOD ranged from 6 to 14 per year, or 45 
in total. Only nine of those individuals also had a diagnosis 
of PTSD.
    These data show an association that is similar with 
clinical experience and prior studies in civilians. The data do 
not, however, describe causation, the nature of the 
association, its directionality, or potential influence of 
additional comorbidity factors.
    DOD has a variety of research initiatives directed to 
better understand the variety of issues associated with 
suicide, including risk factors, the impact of deployment, and 
possible precursors.
    Madam Chairman, members of the subcommittee, thank you for 
the opportunity to discuss these very important issues. Our 
policies within DOD are designed to ensure that all trauma 
survivors, and particularly those subjected to sexual assault, 
have access to a full range of medical and behavioral health 
programs to optimize recovery and that their transition from 
military service back to civilian life is supported.
    I also would like to add my thanks to the witnesses today. 
It is compelling testimony that makes us see ourselves in a 
better light.
    Thank you.
    [The prepared statement of Dr. Guice, Dr. Galbreath, and 
Ms. Garrick follows:]
Joint Prepared Statement by Dr. Karen Guice, Dr. Nathan Galbreath, and 
                         Ms. Jacqueline Garrick
    Madam Chairman, members of the subcommittee, thank you for the 
opportunity to discuss with you the Department of Defense's (DOD) 
support for sexual assault survivors and the relationship between 
sexual assault, the subsequent development of post-traumatic stress 
disorder (PTSD) and suicide. The Department is committed to ensuring 
that all servicemembers and DOD beneficiaries receive access to timely, 
evidence-based health care delivered by competent and compassionate 
providers. The Department is also committed to a strong prevention 
strategy for sexual assault and suicide in the military.
      post-traumatic stress disorder, sexual assault, and suicide
    One of the signature injuries from the Operation Enduring Freedom, 
Operation Iraqi Freedom, and Operation New Dawn conflicts is PTSD, a 
treatable psychological condition commonly associated with a traumatic 
event. The Department Armed Forces Health Surveillance Center has 
tracked a continuously rising prevalence of PTSD in the force, which 
has doubled from approximately 1 percent of servicemembers to 
approximately 2 percent in the last decade of war. Unfortunately, not 
everyone who develops PTSD symptoms seeks care and, for some, PTSD 
symptoms may not develop until months or years following the traumatic 
event. DOD routinely screens servicemembers, both pre- and post-
deployment, for PTSD symptoms. For those who screen positive, we 
provide a number of treatment options and are monitoring the outcomes 
of those therapies. We also have integrated behavioral health providers 
into the primary care clinics to deliver timely interventions for those 
who need this type of help and support.
    Trauma associated with sexual assault--a term that encompasses a 
range of penetrating and non-penetrating crimes--is also a treatable 
psychological condition. In fact, many of the treatments developed for 
PTSD were designed specifically for sexual assault survivors. Recovery 
from any form of sexual assault can be very challenging for the 
survivor and the people that support them. Given the stigma and shame 
that many survivors experience following the crime, it is often 
difficult for victims to engage care or even report. Civilian and 
military research both show that less than a third of sexual assaults 
are ever reported to law enforcement, with the vast majority of 
reporters being women; men rarely report these crimes. This is 
unfortunate because Department of Justice research finds that reporting 
of sexual assault makes it much more likely that victims will engage 
care and treatment. Consequently, the Department took the advice of 
civilian experts and instituted two reporting options in 2005--
Unrestricted and Restricted Reporting--to facilitate reporting and help 
victims to get needed care and services they deserve. Over time, this 
approach has worked. In 2004, before the Sexual Assault Prevention and 
Response Program was instituted, the Department received only 1,700 
reports of sexual assault. In fiscal year 2013, preliminary data 
indicates that were about 5,400 reports of sexual assault--more than 
three times the number received in 2004. While any report of sexual 
assault is troubling, this increase in reporting of the crime has 
allowed us to offer many more survivors the assistance and care they 
need to help restore their lives. Care helps survivors better cope with 
not only the symptoms of PTSD, but also with other conditions known to 
impact survivors, such as substance dependence, anxiety disorders, and 
depressive disorders--which for some may bring about thoughts of 
suicide.
    We know from civilian population research that experiencing sexual 
assault, especially childhood sexual assault, are associated with 
increased risks of suicidal ideation, attempts and completions. 
Furthermore, this association appears to be independent of gender. As I 
previously stated, the experience of sexual assault is also associated 
with increased risk for a number of mental health conditions. Some of 
these mental health conditions may also be associated with suicidal 
ideation, attempts, and completions.
    Overall, suicide deaths among members of the U.S. Armed Forces 
increased between 2001 and 2012, peaking in 2012 with a rate of 23.3 
per 100,000. For 2013, preliminary data shows that this trend is 
reversing. While there was an increase in female suicides from 2011 to 
2012, the majority of suicides are among males, reflective of the 
overall military population. DOD collects information about suicides, 
both completed and attempts. This includes information about reported 
sexual abuse or sexual harassment before and since joining the 
military, as well as medical conditions, such as PTSD.
    Between 2008 and 2011, the total number of individuals who 
attempted or completed suicide and reported either sexual abuse or 
harassment ranged from 6 to 14 individuals. During that same time 
period, only nine individuals who completed suicide also had a 
diagnosis of PTSD.
    For military populations, the evidence associating sexual assault 
and subsequent suicidal ideation, attempt or completion is less well 
defined. More work certainly needs to be done in clinical and research 
spectra. Until we have more conclusive data, we assume that our 
military community would have the same risks as those in the civilian 
community following sexual assault.
    In order to address a need for more information, Defense Suicide 
Prevention Office and Sexual Assault Prevention and Response Office 
(SAPRO) are jointly sponsoring a study to better understand the 
prevalence of suicide risk among sexual assault victims. Using data 
from the Survey of Health-Related Behavior of Active Duty members, the 
study will assess the existence of statistically significant 
relationships between self-reported instances of sexual assault and 
suicidal ideation and attempts. In addition, the study will analyze the 
extent to which risk factors for sexual assault overlap with risk 
factors for suicidal ideation and attempts.
    DOD will also include a behavioral health-related question in the 
Defense Equal Opportunity Management Institute's Organizational Climate 
Survey (DEOCS) for the first time in 2014. The DEOCS questionnaire 
measures climate factors associated with equal opportunity and 
employment programs, organizational effectiveness, discrimination/
sexual harassment, and sexual assault prevention and response.
    In addition to these research efforts, the Department is focusing 
on reducing stigma, increasing education, and building resilience. Each 
of the Services offers comprehensive suicide awareness training that 
teaches servicemembers to recognize the warning signs and symptoms of 
self-harming behavior, resilience building skills, and to intervene 
when necessary. A key feature to the training and outreach being done 
by the Services promotes the use of the Veterans/Military Crisis Line 
(V/MCL) that is a collaborative effort with the Department of Veterans 
Affairs (VA), which staffs the call center. The V/MCL is a 24/7/365 
confidential crisis line that is available to all servicemembers and 
their families throughout the United States, Europe, and Japan and 
online worldwide. For those not in immediate crisis, but seeking 
solutions, Vets4Warriors provides 24/7/365 confidential peer support 
and resilience case management for Active and Reserve component members 
and their families. Using the Reciprocal Peer Support Model, the 
program assists servicemembers who are facing personal challenges with 
tools to manage their stress and build their resilience. Vets4Warriors 
will continue to provide resilience case management and transition 
assistance to its sister programs at VA throughout the callers military 
career life-cycle.
                     department of defense efforts
    Because sexual assault and harassment, PTSD and suicide are issues 
of great concern, DOD has invested in a variety of prevention and 
treatment strategies, as well as policies and protocols to ensure that 
appropriate care and support is provided. Sexual assault survivors are 
at increased risk for developing sexually transmitted infections, 
depression, anxiety, and PTSD; conditions that can have a long-lasting 
effect on well-being and future functioning, and can precipitate 
suicidal thinking.
    To address these and other potential risks, and regardless of 
whether a survivor is male or female, whether the sexual assault 
occurred prior to joining the military or during service, or whether 
manifestations are physical or emotional, DOD has policies, guidelines 
and procedures in place to provide access to a structured, competent 
and coordinated continuum of care and support for survivors of sexual 
trauma. This continuum of care begins when individuals seek care and 
extends through their transition from military service to the VA or to 
care in their communities.
    Department of Defense instructions provide comprehensive guidance 
on medical management for survivors of sexual assault for all Military 
Health Service personnel who provide or coordinate medical care for 
sexual assault survivors. These detailed instructions mandate that the 
Military Medical Departments meet specific standards of care, including 
standards for sexual assault forensic exams, health care provider 
training, and the provision of comprehensive and timely care and 
support to survivors. DOD requires that care is gender-responsive, 
culturally competent and recovery oriented. Moreover, healthcare 
professionals providing care to sexual assault survivors are also 
required to recognize the potential for pre-existing trauma and the 
perils of re-traumatization.
    According to the Department's instructions, the case of any sexual 
assault survivor who presents to one of our military treatment 
facilities is treated as a medical emergency. In the emergency 
department, survivors receive a comprehensive evaluation that includes 
a detailed history and physical examination. Treatment of any and all 
immediate life-threatening injuries takes priority. Once an individual 
is stabilized, he or she is provided with the services of a Sexual 
Assault Response Coordinator (SARC) or Sexual Assault Prevention and 
Response Victim Advocate (VA), and offered a sexual assault forensic 
examination (SAFE). In addition, survivors are offered testing and 
prophylactic treatment options for human immunodeficiency virus and 
other sexually transmitted illnesses. Women are advised of their risk 
for pregnancy and counseled regarding options for emergency 
contraception. Prior to release from the emergency department, health 
care providers ensure all survivors receive instructions for the 
treatment provided, as well as referrals for additional medical 
services and behavioral health evaluation and counseling.
    DOD policy requires that standardized forensic examinations are 
offered to all sexual assault survivors who present for care. The 
Standardized SAFEs follow the U.S. Department of Justice Protocol, ``A 
National Protocol for Sexual Assault Medical Forensic Examinations, 
Adults/Adolescents.'' Military Treatment Facilities (MTFs) must have 
either SAFE trained healthcare providers at the MTF or agreements with 
local civilian providers to conduct these exams. SAFE kits are 
available at all Medical Treatment Facilities (MTFs) and providers 
document their findings using the most current edition of Department of 
Defense Form 2911 (DD 2911), ``DOD Sexual Assault Forensic Examination 
Report.'' Furthermore, DOD requires that all collected specimens are 
appropriately labelled and that the evidentiary chain of custody is 
maintained.
    SARCs and Advocates serve as a single 24/7 point of contact for 
sexual assault survivors and help coordinate all services provided to 
survivors including follow-up health care. SARCs are responsible for 
counseling survivors on the choice between unrestricted and restricted 
reports, and for coordinating subsequent actions following the 
survivor's decision on reporting. The DD Form 2911, mentioned above, 
documents the reporting preference (restricted or unrestricted) of the 
sexual assault survivor. When a survivor elects to pursue an 
unrestricted report, SARCs facilitate the initial interaction with a 
Service's Military Criminal Investigative Organization (MCIO--Army 
Criminal Investigative Division, Naval Criminal Investigative Service, 
and the Air Force Office of Special Investigations). SARCS also ensure 
that SAFE Kits and associated evidence are provided to the appropriate 
Military Criminal Investigative Organization when unrestricted 
reporting is selected. Restricted reports are kept confidential and, 
consistent with the survivor's wishes, criminal investigators and 
commanders are not notified.
    When a survivor requests a SAFE yet elects restricted reporting, a 
restricted reporting control number is generated for specimen labeling 
purposes. This approach provides survivors the ability to recover at 
their own pace, with a degree of desired control and privacy, while 
preserving the option to convert a case to an unrestricted report at a 
later date.
    DOD provides a wide range of medical treatment for both the 
physical and emotional injuries that may result following any traumatic 
event, including sexual assault. Identification of a patient's needs 
begins when they first seek medical care or with the assistance of a 
SARC--whether the event was immediate, recent or if it occurred in 
years past. Individuals are offered evidence-based behavioral health 
services or a referral for follow-up medical services as clinical 
conditions and patient preference dictate. Access to both needed 
evidence-based medical care and behavioral health services is widely 
available across DOD to address the specific physical and emotional 
needs of traumatized individuals. In locations where DOD does not have 
a particular form of specialized care within a given Military Treatment 
Facility, patients are referred to specialty providers in the local 
community.
    Patient preference and involvement drive the type of approach used 
in order to achieve maximal recovery. This includes the type of therapy 
selected, whether or not medication is prescribed, or both. Patient 
preference for the gender and/or duty-status of the therapist are 
respected and accommodated. Delivery of medical and mental health care 
is responsive and sensitive to the patient's gender, sexual 
orientation, age, and other issues of personal identity.
    Patient preference has also motivated us to provide multiple 
methods of entry into care. Given the stigma, fear, and shame 
associated with this horrible crime, the Department created DOD SAFE 
Helpline--a crisis support service for adult servicemembers of the DOD 
community who are survivors of sexual assault. SAFE Helpline is owned 
by the Department of Defense and is operated by the non-profit Rape, 
Abuse and Incest National Network, the Nation's largest anti-sexual 
violence organization. This service is independent of DOD and all 
information shared by visitors is anonymous and confidential. SAPRO has 
also expanded the SAFE Helpline by adding content which specifically 
addresses concerns and questions asked by male survivors in the 
military. Based on SAFE Helpline staff interactions with callers, it 
appears that sometimes men find it easier to first tell an anonymous 
SAFE Helpline staffer rather than a loved one about their sexual 
assault. This allows the survivor to speak to someone who is trained to 
listen and help. Many men find that talking to staff first makes it 
easier to tell friends and family later.
    Survivors of sexual assault may also access care through Military 
OneSource. While OneSource is not anonymous, survivors may engage a 
variety of care options through this confidential Department of 
Defense-funded program that provides comprehensive information on every 
aspect of military life at no cost to Active Duty, Guard, and Reserve 
component members, and their families. Confidential services are 
available 24-hours-a-day by telephone and online. In addition to the 
website support, Military OneSource offers confidential call center and 
online support for consultations on a number of issues. Military 
OneSource also offers confidential non-medical counseling services 
online, via telephone, or face-to-face. Survivors may receive 
confidential non-medical counseling addressing issues requiring short-
term attention. However, should survivors require more intensive 
support, civilian OneSource providers provide referrals back to the 
military healthcare system.
    We recognize that the long-term needs of survivors of sexual 
assault often extend beyond the period in which a servicemember remains 
on active duty. When sexual assault survivors are still actively 
receiving behavioral health care at the time of separation from the 
Service, they are linked to the DOD inTransition Program to help ensure 
that continuity of care is maintained. The inTransition program assigns 
servicemembers a support coach to bridge support between health care 
systems and providers. The coach does not deliver behavioral health 
care or perform case management, but is an added resource to patients, 
health care providers and case managers to help ensure transition of 
care is seamless. SAFE Helpline also provides information for sexual 
assault survivors that may be transitioning from military to civilian 
life.
    Madam Chairman, members of the subcommittee, we want to again thank 
you for the opportunity to appear before you today to discuss these 
very important issues. The Department's policies are designed to ensure 
that all trauma survivors, and particularly those subjected to sexual 
assault, have access to a full range of health treatments and support 
programs to optimize recovery. We look forward to any questions you may 
have.

    Senator Gillibrand. Thank you all for being here today.
    For the DOD witnesses, I don't know who is appropriate, but 
I think it is perhaps Dr. Galbreath. I have heard from 
survivors and others that some are stopping therapy because 
they are afraid that their mental health records will be used 
against them during the court martial.
    For example, the alleged victim in the Naval Academy case 
stopped going to therapy once she learned her records could be 
reviewed by a military judge and possibly provided to the 
accused and his attorneys. I understand that this comes under 
the constitutional exception to the psychotherapist-patient 
privilege. But I am concerned about the negative impact on 
survivors' mental health if they feel like there is no 
confidentiality for their treatments.
    As practitioners, what might be the impact on survivors if 
they choose not to seek care because they are worried about 
therapy being made public? Are you seeing this happening? What 
do you think the risk is?
    Related, when a victim and a survivor doesn't report the 
case, they might not have access to those mental health 
services because they have not been willing to come forward. 
So, again, the risk of PTSD or suicide may be higher than it 
should. I would like your thoughts on that.
    Dr. Galbreath. Thank you, ma'am.
    Just to start out, as a psychologist, I am required to 
inform all patients seeking care with me that there are 
limitations to privacy and confidentiality in the military. 
That is part of the informed consent document that everybody 
that wants to come to see me as a provider has to understand.
    Not only do I work through them with those limitations to 
privacy, and one of those issues is if an administrative or a 
court proceedings, there might be a situation where those 
records might become available. I also give them a verbal 
counseling as well to document that.
    That is a concern that I think all therapy providers in DOD 
have. I haven't seen it happen very often, but it does happen. 
I am concerned. I have never had anyone quit treatment with me 
because of that concern, but I have seen other situations where 
that occurs.
    So one of the things that I do, given my law enforcement 
background, is I am very careful about how I document care, and 
I also teach others at the Center for Deployment Psychology at 
the Uniformed Services University. About every 2 months, I 
teach anywhere from 60 to 70 different providers, and we talk 
about these issues and how to best protect our patients' care.
    So that is something that we are very concerned about. You 
asked about what the chances are of a person's condition 
worsening if they don't get care, and that is definitely a 
possibility. Most people do tend to get better. I think what 
our research shows is that what we can do for most people is 
help them get better sooner with our therapy and our care.
    However, for some people, they don't get better without 
care, and we do want to have a number of different ways to 
provide them treatment. So given those concerns, DOD has looked 
at a number of different ways to help people sample what is 
right for them.
    Any victim of sexual assault has had a number of different 
things taken away--their health, their privacy, their sense of 
being. We want them to be able to sample at the rate that they 
would like to. The most anonymous way of doing that is through 
our DOD Sexual Assault Forensic Examination (SAFE) Helpline.
    That is run for us by the Rape, Abuse, and Incest National 
Network (RAINN). It is completely anonymous. Victims can call 
in from any area, and they can get care and services that they 
need through there.
    Senator Gillibrand. Thank you, Dr. Galbreath.
    We have some information. I think this is for Dr. Guice. 
SAPRO gave us some new numbers, and we have raw numbers about 
restricted and unrestricted reports that have been made. We 
have a number, about 5,400 reports. Do we have the number of 
incidents so we can assess whether reporting has gone up or 
not?
    Because when we compared the earlier reports when we had 
the benefit of looking at 2012 and 2011, the number of reported 
rapes went up, but the incidence rate went up higher. So, 
actually, there was a decrease in reporting from 13 percent to 
9 percent. Do we know if there is higher incident rate or if we 
really have a higher reporting rate?
    Dr. Guice. I believe that is Dr. Galbreath.
    Dr. Galbreath. Okay. Ma'am, we don't have a survey this 
year for that. What I would offer to you is we know that even 
in 2006, when we had the highest rates of unwanted sexual 
contact reported, we only got about 2,900 servicemembers coming 
forward to make a report.
    This year, with 5,400, we really do assess that this is due 
to increased victim confidence and more people hearing our 
message and understanding that we are going to take care of 
them. One piece of that that I would offer to you to consider 
is there are a portion of reports every year that come to us 
that occurred prior to military service. This year, that 
percentage increased from 4 percent in 2012 to 11.5 percent in 
2013.
    All the offenders in those cases are outside the military 
justice system. So the only real reason for our survivors to 
come forward in that situation is to get care and services that 
we offer through the Sexual Assault Prevention and Response 
Program. We feel that that is a real----
    Senator Gillibrand. So we have seen an uptick in reporting 
prior to service?
    Dr. Galbreath. Yes, ma'am.
    Senator Gillibrand. Is that the difference between the two 
numbers?
    Dr. Galbreath. It is not the entire difference. Last year, 
we had a total of about 132 reports that were for incidents 
that occurred prior to service. This year, the number is 621.
    Senator Gillibrand. So that is a huge increase for people 
who were assaulted before they joined the military.
    Dr. Galbreath. Yes, ma'am.
    Senator Gillibrand. They are eligible for mental health----
    Dr. Galbreath. Care and services.
    Senator Gillibrand. A related question. We have heard from 
survivors that after they report the assault and they attempt 
to seek mental health treatment, they were diagnosed with a 
personality disorder and are medically discharged. So this 
diagnosis is labeled as a preexisting condition and, therefore, 
effectively cuts off services for the survivor.
    Many of these same survivors have said that after the 
assault, they still wanted to stay in the military and were 
planning on doing so. But because of the diagnosis of 
personality disorder, they were kicked out. What has your 
experience been with that issue, and what is the best way to 
address it?
    I don't know if VA wants to address that or Dr. Galbreath.
    Dr. Galbreath. Do you want to----
    Dr. Guice. What we have done is that no one can leave the 
military, be separated for a personality disorder without a 
complete medical review so that we make sure that there is no 
underlying TBI that is causing the action or the behavior or 
psychological health issue that needs to be addressed. I think 
we have actually put a mechanism in place to make sure that we 
have safeguarded and that people are not leaving without a 
second look by medical professionals.
    Dr. Galbreath. If I could add to that, ma'am? Section 578 
of the NDAA for Fiscal Year 2013, you helped us out with that, 
and we took your advice and we expanded on it a little bit. For 
any separation due to retaliation, within a year of the report, 
it had to be reviewed by a general officer. That was the nature 
of the law.
    I checked in our military instructions, and that has been 
incorporated into the administrative separation instruction. 
But we have expanded it just a little. Instead of just a year 
from the date of report, we took it from a year from the date 
that the case disposition was made. So it is a much longer 
period.
    Instead of just retaliation, admin separation, we have any 
separation administratively can be heard in this process and be 
reviewed. In addition to that, instead of the first general 
officer, flag officer in the chain, we took it to the first 
general officer, flag officer in the chain of that 
administrative separation authority's chain of command. So it 
goes beyond that one person.
    So we took your good idea and put it into our instructions.
    Senator Gillibrand. Thank you.
    Senator Graham.
    Senator Graham. A follow up on that. A personality disorder 
would make one subject to involuntary discharge. Is that right, 
Dr. Galbreath?
    Dr. Galbreath. Yes, sir.
    Senator Graham. The point we are trying to make is if you 
are a victim of an assault, one of the consequences, obviously, 
would be people would be disturbed, and it would show. That we 
don't want to cut off treatment. We don't want it to be 
anything other than an honorable discharge. We want to make 
sure that the person may no longer be able to serve in the 
military, but they are not denied treatment for what happened 
to them in the military. Is that correct?
    Dr. Galbreath. That is correct.
    Senator Graham. Okay. Now having said that, personality 
disorder is often used as a way to separate, and we want to 
make sure that we don't deny people treatment but, at the same 
time, not deny the military the ability to separate somebody 
from a unit for a cause.
    As to this chart, it makes perfect sense to me that a 
person who has experienced sexual assault would have a higher 
propensity to have PTSD simply because of the nature of the 
attack, compared to anything else. The one category that we 
left out is combat-related action.
    Most of the PTSD cases that I am familiar with come from 
people who have been involved in a combat-related experience. I 
would argue that a sexual assault is every bit as traumatic, if 
not more. So that makes perfect sense to me that that would 
occur.
    Now about two things. The military system is being 
scrutinized, and that is fair. That is appropriate. We have a 
problem. You have to admit your problem before you can fix it. 
The question is how to fix it. That is what the whole debate is 
about.
    I want to also highlight some of the things about the 
military that are worth noting. I asked the question if one of 
our staff members were assaulted at work, would they be 
entitled to medical disability as a result of that assault? I 
have been told that is not the case.
    I just want people to understand that in the workplace in 
the civilian world, sexual assaults occur. Most employers are 
not going to be held liable for worker compensation claims 
based on the criminal acts of a third party. That is a general 
proposition of law.
    In the military, when the assault occurs during employment, 
you are treated quite differently. I think that is a positive 
thing. Just realize that if somebody in your own office were 
assaulted, they are a Federal employee, under the law that 
exists now, all the things available to a military member would 
not be available to your staff. That is probably true in the 
civilian population.
    So let us focus on the fact that if you get assaulted in 
the military sexually, there is an array of benefits and 
counseling available to you unlike anything that I know of in 
the private sector, and I think that is very much appropriate 
because of your willingness to serve your country.
    So how we make that better is the subject of the 
discussion, but we need to realize that our military members 
have access to healthcare, to treatment not available to the 
average person who goes through the similar experience in the 
workplace. We want to make it better, but we should be proud of 
the fact, quite frankly, that occurs in our military. We want 
to make it better.
    Now about expanding treatment options. Both witnesses 
testified that they believe that services available in the 
civilian sector could supplement or greatly increase the 
likelihood of a better outcome. The one gentleman, the lance 
corporal, is TRICARE eligible. The other lady is not.
    How do we deal with that dilemma? What do we do as a 
Congress to make sure that someone who goes through the 
disability evaluation process--you make a claim. ``This 
happened to me in the military. I was sexually assaulted. As a 
result, I am having these problems.'' Once the medical board 
evaluates in the VA or DOD, you are eligible for compensation 
based on your evaluation.
    This gentleman is eligible for TRICARE because of his 
disability rating. The lady was not. How do we correct that 
problem?
    Dr. McCutcheon. Senator, I certainly can't speak to the 
compensation process because that falls under the VBA. But for 
our veterans who screen positive for MST, and every veteran who 
comes to the VA is screened for these experiences, these are 
two questions. One question addresses sexual assault that 
occurred while you were on Active Duty or Active Duty for 
training, and the second question is sexual harassment.
    If you answer yes to one or both of the questions, you are 
considered to have screened positive for MST.
    Senator Graham. Are you eligible then for civilian 
treatment outside the VA?
    Dr. McCutcheon. Non-VA care is always an option.
    Senator Graham. So these two witnesses, has anyone ever 
told them that? She is shaking her head no. How can that be?
    Dr. McCutcheon. What we do do, Senator, is that we have an 
MST coordinator at every VA facility, and we----
    Senator Graham. Is part of the screening process making you 
aware that you are available for treatment outside the VA?
    Dr. McCutcheon. If you screen positive, you are given a 
referral to mental health. We can always connect you with the 
MST coordinator, and that person can explore options for you 
if, for some reason, there is an access issue for you, like the 
gentleman spoke, as far as like 90 miles to get to treatment or 
various things.
    Senator Graham. Both of the witnesses seem to indicate that 
while they appreciate the services, they were limited and I 
understand overmedication. Every problem you have in the 
military, you have in the civilian world when you deal with 
these issues. People afraid to report, intimidated. The defense 
attorneys have to do their job. The rape shield law exists in 
the military, and exists in the civilian community.
    Some of these problems we are never going to solve because 
somebody accused of a crime has a right to defend themselves, 
and where that right starts and stops is always subject to 
debate. But both witnesses seem to be very much unaware that 
they had access to healthcare outside of the traditional VA 
system.
    Do you agree with that statement by me? If so, how can we 
improve that?
    Dr. McCutcheon. I think, Senator, in all of our outreach 
materials, we encourage veterans to contact the MST coordinator 
at the facility, and that person is in a perfect position to 
help them as far as coordinating care within the facility or 
applying for non-VA care.
    What we are finding, Senator, is that every year we have 
been tracking MST-related treatment is our numbers are 
increasing. We are seeing more and more veterans, after they 
have screened positive, coming to the VA for services.
    Senator Graham. I would just conclude, I want to end on a 
positive note, I appreciate the gains made and the focus and 
the attention. This is a very real problem for the military, 
and I think we are on the right track, but we can learn from 
these experiences. This has been a good hearing in that regard.
    I really appreciate the additional scrutiny and Congress' 
interest. But for the two witnesses, I do think there is a gap. 
I think the average--at least these two, if they are 
representative, there seems to be a disconnect between what is 
actually available to them and what they perceive to be 
available to them. So let us try to fix that.
    Thank you.
    Senator Gillibrand. Dr. McCutcheon, I just want to follow 
up on Senator Graham's question.
    Dr. McCutcheon. Yes.
    Senator Gillibrand. When did the MST coordinators get 
placed in every VA in the country? Was that in the last year, 
last 6 months?
    Dr. McCutcheon. In 2000, ma'am.
    Senator Gillibrand. So there has been a MST coordinator at 
every VA in the United States since then?
    Dr. McCutcheon. Yes.
    Senator Gillibrand. Is that person busy? [Laughter.]
    Dr. McCutcheon. Yes, ma'am. It is a position where there is 
a great focus on looking at our screening data, our treatment 
data, educating staff.
    Senator Gillibrand. Do they meet with trauma survivors?
    Dr. McCutcheon. As part of their clinical work, yes. A 
majority of them do also provide treatment. The MST 
coordinators are predominantly either a psychologist or a 
social worker, and so as part of their clinical workload, they 
would be giving therapy, administering therapy as well as 
looking and monitoring their screening, treatment rates, other 
rates of the reports we provide.
    Senator Gillibrand. Okay. I am going to make a formal 
request afterwards to get data on all the MST coordinators in 
every VA, how many patients they see a year, what their 
workload is. Because maybe they are not even known that they 
exist.
    I would like to know what they actually do. So we can work 
on that later.
    Dr. McCutcheon. Thank you, ma'am.
    Senator Kaine.
    Senator Kaine. Thank you, Madam Chairman.
    Thank you all for the work that you do on this important 
area.
    I want to start with a concern that was raised by Corporal 
Arbogast and directing it to the VA, and that was the concern 
that he raised about as a man being told, we don't really have 
a group for men and feeling like the Services weren't at the 
same level.
    I was just curious, Dr. McCutcheon, as I was looking at 
your title, you are the National Mental Health Director, and it 
says family services, women's mental health, and MST. Is that 
the name of a department or division or program? Family 
services, women's mental health, and MST.
    Dr. McCutcheon. Senator, that is a good question. It is 
actually three areas of responsibility I hold in my position.
    Senator Kaine. I see.
    Dr. McCutcheon. I have a colleague who is the National 
Director for Evidence-Based Treatment and Psychogeriatrics.
    Senator Kaine. Okay.
    Dr. McCutcheon. It just happened to be that those were the 
special areas. But my title in no way implies that we see MST 
as a women's issue. We have worked very hard to show it as a 
gender neutral disorder, and actually, the program 
responsibility for MST was removed from women's health services 
to be placed in mental health services in 2006.
    Senator Kaine. Good. That is helpful.
    Let me ask your reactions, each from the VA and the DOD 
side, about the discussion in both of our earlier witnesses, 
their concerns about this overmedication phenomenon. What could 
you tell me about that?
    Dr. McCutcheon. Senator, I will start from the VA. I really 
can't speak to that because I have no firsthand knowledge of 
what the VA is doing as far as analyzing the use of medication. 
So I would need to take that for the record. I am sorry.
    Dr. Guice. I don't know with the degree of specificity that 
I think really you need to have for this answer. So we would 
like to take it for the record, too.
    Senator Kaine. Then what I will do is we will try to submit 
a precise question in writing rather than have you have to 
guess what we mean. That might be a little bit easier, and we 
will just take that one under advisement.
    One concern, just to share a concern that I have heard and 
I don't know whether it is regionally or more general, is in 
the suicide prevention area. I think you guys do a good job of 
trying to publicize to Active Duty and veterans suicide 
prevention hotlines within DOD and VA.
    I had an experience in the last year in the Hampton Roads 
area of Virginia, where there are a lot of veterans, of 
somebody saying they were doing a great job of putting out 
there is a suicide prevention hotline and there will always be 
somebody there to take your question and deal with you. He 
said, ``But they didn't deal with me right away.'' I said, 
``Why not?'' He said, ``I contacted them right away.''
    We dug into it, and it was an individual who had emailed 
the email address. It turned out that the hotline really was a 
24-hour hotline if you called on the phone. But if you emailed, 
it was a cold line, and he made the point to me that if you are 
in extremis in a mental health area, it might--even the act of 
talking to someone can be a little bit tough, and it can be a 
little bit easier just to write an email and send that ``I need 
help.''
    He felt like his cry for help was ignored, and as we got to 
the bottom of it, it turned out that maybe it was treated 
differently because it was an email. I would just recommend 
that to your attention that might be fixed or might have been 
an aberration, might have just been one VA hospital. But I can 
see why somebody in an extreme situation might feel more 
comfortable reaching out for help via an email than a phone 
call.
    Ms. Garrick. Senator, you raise a good point in that we 
know suicide is complex, and so we like to think that the way 
in which we deal with suicide also takes a multifaceted 
approach. So that when somebody reaches out for help that there 
are options in how they even initiate that contact.
    What the VA has as the Veterans Crisis Line, the DOD uses 
it as well, and we brand it as the ``military crisis line.'' It 
is the same crisis line.
    We also have a Vets4Warriors program that we have funded in 
DOD that is a peer support program. So it gives you an option 
of if you just want to talk to a peer and do some problem 
solving, get a referral, and the peers also provide what we 
call resilience case management so that they can track and stay 
with you over the course of your military career.
    The goal, though, is to make sure that regardless of 
whether you do a phone call, an email, a text, a chat, that 
when you look for help, there are different options and ways 
for you to find that help.
    Dr. Galbreath. Sir, I would offer that at the DOD SAFE 
Helpline as well, you can click, call, or text 24/7, and there 
is somebody there live to answer any kind of a reach-out from 
the individual.
    Senator Kaine. Finally, I would like to go back to Ms. 
Kenyon's testimony. When I asked her that question about her 
analogy between incest and military sexual assault because of 
the betrayal factor, I was curious. In some full hearings 
before the Armed Services Committee, we have tackled, to some 
degree, the issue of suicide of Active Duty and veterans. 
Senator Donnelly on our committee has been really focused on 
this.
    I recall some testimony that while it is a complex 
phenomenon, a number of military witnesses in the past talking 
about and enlightening me a little bit about it, that it is 
less people have come back, seen horrible things and the 
horrible things are weighing on them and driving them to 
suicide, and more that people were involved in such a close 
support network and then came back, and that network, that band 
of brothers and sisters was no more. Even if they had networks 
of people around them, they didn't understand what they had 
been through.
    That experience of going from a close support network of 
colleagues to a feeling of disconnection, that that has been a 
factor in testimony earlier before the full committee that has 
been suggested that there is some research that really ties 
that into this problem of military suicide.
    Am I remembering it or basically describing it correctly? 
Is that one of the factors?
    Ms. Garrick. Again, the causes and associated factors with 
suicide do tend to be very complex. We know that the primary 
factors associated with suicide are relationship issues, 
financial issues, and legal issues.
    When we look at relationship issues, I think what you are 
describing is the loss of a relationship issue. We tend to 
think about that as an intimate relationship issue, but that 
does certainly extend beyond, and we know that this is--on the 
Active Duty side, this is mostly young white males who have 
died by or attempted suicide.
    When they come and go from Active Duty or change units, we 
have seen the majority of our suicides are among those that in 
their first year of enlistment and who have never deployed and 
have not been in combat, and 89 percent have not seen combat.
    There are some serious issues that we feel we try to look 
at, and that is why, again, the peer support and providing 
community-based care is so important is because we really see 
that those relationship issues are such a driving factor in 
relationship to suicide and self-harm.
    Senator Kaine. Madam Chairman, just to close the loop with 
one last question that would then loop back to Ms. Kenyon's 
point about the betrayal phenomenon.
    In a sexual assault within the military, if there is a 
close connection between colleagues, your superior, a sexual 
assault within your unit is the sundering of a relationship 
that you had an expectation that was a relationship based on 
trust. That suggests a little bit of the connection between 
sexual trauma in the military and this risk of suicide.
    Ms. Garrick. The Defense Suicide Prevention Office and Dr. 
Galbreath's office are working on a study right now looking at 
some of those intersections between suicide prevention and 
sexual assault response so that we can get a better 
understanding of how we can move forward on providing support 
and services to this population.
    Senator Kaine. Thank you. Oh, do you want to say something?
    Dr. Galbreath. I was just going to say I couldn't agree 
more with Ms. Kenyon. It really is tantamount to an incest type 
of situation, and I think that is a very adequate description.
    Senator Kaine. Thank you.
    Thank you, Madam Chairman.
    Senator Gillibrand. But to follow on, isn't the betrayal 
also that they have to tell their dad, or their dad is the 
decisionmaker. It is not just the betrayal that you are being 
raped by your brother. It is that second betrayal that makes it 
intense.
    Dr. Galbreath. It is depending on who the perpetrator is, 
ma'am, yes.
    Senator Gillibrand. No. What I am saying is the second 
thing about reporting. The decisionmaker is, I have just heard 
one victim say it is like being raped by your brother, and your 
father decides the case. So the reference to incest goes beyond 
who the rapist is. It is also that it is decided as a family 
matter, and the person deciding has to decide between two 
children that they both deeply love.
    That lack of objectivity to just look at the facts, look at 
the record, knowing the victim, knowing the perpetrator, 
according to this one victim, that was the second betrayal. It 
is not just one betrayal.
    Dr. Galbreath. It is so important now to have so many 
different ways to report so we can get it outside of that 
system that you can report to a sexual assault response 
coordinator----
    Senator Gillibrand. We are just talking about the 
decisionmaker. Your dad decides. There is no question. I was 
just trying to clarify the----
    Dr. Galbreath. Oh, okay.
    Senator Gillibrand. No question.
    Dr. Galbreath. I am waiting, ma'am.
    Senator Gillibrand. I was just clarifying what I understood 
the testimony to be, based on other conversations I have had 
with survivors and how they perceived it. That the incestuous 
reference is not just about who rapes you, it is also about who 
decides your future, your fate.
    Dr. Galbreath. That is not one that I had heard from my 
victims, but I understand what she said.
    Senator Gillibrand. Senator Ayotte?
    Senator Ayotte. Thank you very much.
    I want to thank the witnesses for being here.
    I wanted to follow up, Dr. McCutcheon, just to clarify one 
point that I think it is important for people listening at home 
to understand is that in terms of sheer numbers, there are 
actually more male victims in the military of sexual assault 
than female victims. Isn't that right, just in terms of sheer 
numbers?
    Dr. McCutcheon. Senator, that was correct maybe about 3 or 
4 years ago, but what we are seeing right now is there is 
actually more women who screen positive for MST who choose to 
come to the VA, who are part of our VA healthcare system. But 
the numbers are pretty close.
    Senator Ayotte. So we now have more women victims, with the 
recent numbers, that have come forward?
    Dr. McCutcheon. In our last fiscal year, ma'am, we have 
within our system about a little over 77,000 women who have 
screened positive for MST, and for the men, it is over 57,000.
    Senator Ayotte. Because the one point I wanted to make is 
that this isn't a male or a female victim situation. As this 
issue has come up in our committee and people talk to me about 
it, they make it an issue of this is an issue of women, and 
certainly women, there are fewer women in the military, and 
thankfully, they are taking on greater roles, which is a 
wonderful thing. I just want people to understand that are home 
right now that there are a lot of men who are victims as well 
and who are watching this.
    This isn't a male or a female crime. This is a crime 
committed against anyone could be the victim of this in the 
military. I think that is important because people need to 
understand that as we get at this issue that it needs to be 
addressed for everyone.
    One of the questions that I wanted to follow up with you, 
how long on average does it take for once the referral is 
entered, for someone actually to see a mental health provider?
    Dr. McCutcheon. I am sorry, ma'am. I don't have that data 
with me as far as from screen to treatment. So I will have to 
take that for the record.
    [The information referred to follows:]

    It is important to note that Military Sexual Trauma (MST) is an 
experience, not a diagnosis or mental health condition in and of 
itself. Not every MST survivor will have long-term difficulties 
following the experience, and thus not every veteran who screens 
positive for MST will be interested in receiving MST-related treatment. 
At this time, data are not available on time to access mental health 
care among the subset of MST survivors who desire these services. VA is 
addressing this need through a revision to the MST screening 
procedures. All veterans are screened for MST via a Clinical Reminder 
in the electronic medical record that alerts providers of the need to 
screen the veteran, provides language to use in asking the veteran 
about MST, and documents the veteran's response to the screen. 
Currently, all veterans seen in VHA who screen positive for MST are 
offered a referral for further assessment and/or treatment of health 
concerns. The forthcoming revision to the MST Clinical Reminder will 
standardize this automatic referral process system-wide, via an option 
in the Reminder itself to initiate a referral for services. 
Incorporating the referral option into the Reminder will provide 
critical additional data for national monitoring efforts including data 
on whether veterans who request MST-related mental health services are 
able to access those services in a timely manner.
    MST is associated with a wide range of mental conditions, and MST 
survivors receive care in a variety of mental health clinical settings. 
As such, VA policy for all mental health care generally is also 
relevant to MST survivors who request mental health services. It is VA 
policy that all new patients requesting or referred for mental health 
services must receive an initial evaluation within 24 hours, and a more 
comprehensive diagnostic and treatment planning evaluation within 14 
days.
    At this time, data are not available on time to access mental 
health care among the subset of veterans who have experienced MST. 
Steps are being taken to address the need for these data, as described 
in the previous response.

    Senator Ayotte. I would appreciate that because I think 
that is an important question because immediacy is really 
important, that people are waiting too long to see mental 
health providers. I hear this from people at home, and I can 
only imagine that this could be even exacerbated for someone 
who is a victim of sexual assault.
    I would also like for you to take for the record, is that 
period getting shorter or longer? I think the other challenge 
we face is what is the situation in terms of providers? Are we 
facing a shortage of providers?
    One of the things I was certainly glad to hear the report 
of is that more people are coming forward. That is what we 
wanted. We wanted to feel that people would be able to come 
forward, and we want more to come forward. Also that will mean 
that we will need to make sure that we have the providers to 
give treatment and to give support.
    I wanted to get your answer on that one, too. What is our 
situation on having enough providers in the mental health area? 
Because my experience has been that even at my State, for 
example, taking it outside of the military context, we have a 
shortage of mental health providers within our State. So I 
would imagine that you may have similar challenges. I wanted to 
get your thoughts of whether we needed to put more of an 
emphasis on that.
    Dr. McCutcheon. Senator, we are required to produce a 
report on capacity to provide MST-related mental healthcare, 
and virtually all medical centers within the VA system do have 
that capacity. So that is something that we do track.
    Senator Ayotte. Okay. If on the follow-up if you can let me 
know how long does an average person wait once the referral is 
made? Also, if you can answer to me what you think the provider 
challenges are in terms of going forward, as we are going to 
have more people report, to make sure that we have adequacy of 
support system there. I would appreciate an answer to that as 
well.
    [The information referred to follows:]

    To fulfill the reporting requirements of title 38, U.S.C., section 
1720D(e), VA's national Military Sexual Trauma (MST) Support Team 
completes an annual report to determine whether each Department of 
Veterans Affairs (VA) health care system has adequate capacity to 
provide MST-related care. Adequate capacity is assessed by comparing 
each facility to a benchmark staffing-to-population size ratio. The 
target benchmark ratio was established by examining facilities that 
provide a high volume of MST-related mental health care. Facilities 
that fall within two standard deviations of the staffing-to-population 
size ratios of these ``high volume'' VA health care systems are 
considered to have adequate capacity to provide MST-related care.
    The most recent report found that for the analyzed fiscal year 
2012, 99 percent of VA health care systems were at or above the 
established benchmark for MST-related mental health staffing capacity. 
During the year, over 64,000 veterans received MST-related mental 
health care from a VA health care facility. These veterans received a 
total of over 693,000 MST-related mental health care visits from over 
17,950 individual providers.
    Only one VA health care system was found to be below the target 
level for MST-related mental health staffing capacity. The MST Support 
Team and the Veterans Health Administration Office of Mental Health 
Operations partnered with mental health stakeholders at the health care 
system and healthcare network levels to develop and implement an action 
plan to increase documented staffing levels. The MST Support Team in 
collaboration with Office of Mental Health Operations regularly provide 
technical assistance and consultation to all VA health care systems to 
ensure the highest capacity for and quality of mental health care for 
veterans who have experienced MST.

    Senator Ayotte. Dr. Galbreath, I wanted to follow up on 
where we are with regard to the reports and the increase that 
we have seen in the reports. What do you think that that says 
in terms of you have talked, I think, fairly positively about 
that as an indicator that we are certainly glad that more 
people are feeling that they can come forward.
    What do you think in terms of the role of the commander? 
Here, one of the pieces of legislation that we are going to be 
looking at is, within the system, who keeps the decision in 
terms of whether the charge will go forward?
    The proposal that Senator McCaskill and I have is one that, 
if there is a difference of opinion between the Judge Advocate 
General lawyer and the commander, it would go up all the way to 
the civilian secretary in instances where the decision is not 
to bring a case. In instances where both are in line that a 
case should not be brought, then it still goes up for another 
level of review.
    What effect do you see or what role do you believe the 
commander should have in terms of involvement in addressing 
this issue, if you have thoughts on this?
    Dr. Galbreath. I will offer, ma'am, I am a clinical 
psychologist. Clearly, my perspective would come from treating 
victims. So I know that any----
    Senator Ayotte. Yes, and I am only asking you from your own 
background and perspective.
    Dr. Galbreath. You bet. I would offer to you that we 
believe that commanders really do need to be more involved, not 
less involved in this process because we know that they are 
going to be critical to setting that climate of dignity and 
respect in a unit. That is a kind of unit environment where we 
know that victims can heal and flourish.
    Every single victim who comes forward is influencing, their 
experience influences other victims that are deciding whether 
or not to report. Until we get this right and we make sure that 
commanders are held appropriately accountable to set that 
climate of dignity and respect and have those tools with them 
that would allow them to enforce that climate, we really do 
believe that that is going to allow us to move forward on this 
and increase even more reports of sexual assault every year.
    Senator Ayotte. Thank you. I appreciate that.
    Could you also give us an update, my time is almost gone 
here. We have talked a lot about the special victims' counsel 
today, and I think all of us are very supportive of this. This 
has been legislation that I worked on also with Senator Patty 
Murray, who was the chair of the Senate Veterans' Affairs 
Committee, now the chair of the Senate Budget Committee, but 
very involved in these issues.
    Just how are things going? I know this is a very important 
and large undertaking. So, just as an initial report of what 
your thoughts are of implementing this important initiative 
that is going to give every victim counsel that is their 
counsel, that is there to advocate for them and no one else.
    Dr. Galbreath. Yes, ma'am. Very briefly, all the Services 
were supposed to have initial operating capability last 
October. They all stood up their full capability in January.
    The Air Force has the greatest number. They had this 
program going for about a year now.
    Senator Ayotte. They started it as a pilot, and we extended 
it.
    Dr. Galbreath. They did.
    Senator Ayotte. Yes, that is right.
    Dr. Galbreath. Absolutely. Yes, ma'am.
    The information that we have gotten back from the survivors 
that have used the special counsel is overwhelmingly favorable. 
I do believe that this is a deal-changer for victims of sexual 
assault in the military. Having that person to represent you 
increases their confidence. It allows them to understand what 
their options are even more from a legal perspective.
    Although it is a small number, I would offer to you that 
what we have heard is of the restricted reporters that have 
engaged a special victim counsel, their conversion rate from 
restricted to unrestricted cases that would then bring them 
into the justice system and participate in a prosecution, their 
conversion rate is at about 50 percent, 5-0.
    Senator Ayotte. Wow.
    Dr. Galbreath. On average across DOD, we are about 14 to 15 
percent conversion rate. Now once again, small numbers, but 
initial data. But we do think that this is very promising, and 
from a psychologist's perspective, I think it is great because 
it builds victim confidence and boosts their abilities and 
gives them a greater understanding of the legal system.
    Senator Ayotte. Thank you. I think one of the things we 
will be watching carefully is just making sure that we are 
updated on how it is being implemented so that every victim can 
have access to a special victims' counsel.
    Dr. Galbreath. Thank you, ma'am.
    Senator Gillibrand. Senator King?
    Senator King. Madam Chairman, I am going to be very brief. 
First, I want to associate myself with your request for the 
data on the backlog. That is really important, and don't 
sugarcoat it. We want the straight data on from the day 
somebody on the average applies to the time they get accepted. 
Because treatment delayed is treatment denied in many of these 
cases. That is number one.
    Number two, Madam Chairman, I think there is a gap here in 
coverage in the sense that TRICARE is only available to 
retirees 20 years or more. So if you can't get service at the 
VA for your service-related trauma, you don't have any other 
choices. So I think that is something we need to be thinking 
about that is not like they can turn around and to go to 
TRICARE and use their local provider.
    Finally, Dr. Galbreath, this isn't really a question. I 
just want to make a statement. I don't understand why anybody 
would go to you for counseling if they understand that that 
record of that counseling can be made available in a later 
proceeding.
    That just makes no sense whatsoever, and I want to revisit 
that one, Madam Chairman.
    Senator Gillibrand. Absolutely.
    Senator King. Thank you.
    Senator Gillibrand. Thank you, Senator.
    Dr. Galbreath, I just want to go back over a little bit of 
your testimony. I agree that we have to set a climate of 
dignity and be more involved, not less involved for commanders. 
I agree that commanders need to actually be taking 
responsibility for setting command climate, making sure there 
is no retaliation, making sure the victim feels safe to come 
forward and report the crime, making sure he or she gets the 
mental health services and the support they need.
    No one is actually suggesting commanders become less 
involved, and, in fact, when they do so, they actually distort 
the debate because the only commanders today who have the 
authority to be the convening authority to make a decision 
about whether to go to trial are very senior-level commanders. 
It is less than 3 percent of commanders.
    So the 97 percent of commanders are as involved as they 
have ever been involved, and what we have been trying to do in 
the underlying bill is to make them more responsible by 
actually reviewing their record on creating a command climate 
that is consistent with no rape, no assault, that is conducive 
for victims to come forward.
    Those commanders will never have the right to make the 
legal decision. So whether or not we take that right away from 
that 3 percent of top-level commanders, the purpose is to 
instill confidence by the victims.
    If you listen to our victims panel and you listened to what 
they said, one of our victims was retaliated against by all 
these junior-level commanders. So, her hope that a senior-level 
commander would have her back doesn't exist because her 
perception is that all the other in the chain of command are 
going to retaliate against me so they will believe those 
commanders over me every time.
    I really want you to focus on that because when you say I 
don't think they should be less involved, I don't think they 
should be less responsible, no one is arguing them to be less 
involved or less responsible. In fact, everything we have done 
in the NDAA is making them more responsible and more involved.
    I just want to remove that appearance, and the VA's Web 
site specifically says that the current system is undermining 
recovery and is actually creating greater PTSD and undermining 
the patients. I read it when I did my opening statement. I 
don't know if you heard it, if you were all here, but it says 
here, ``Many victims are reluctant to report sexual trauma, and 
many victims say that there were no available methods for 
reporting their experiences to those in authority.'' That is a 
perfect example of what our first witness, Ms. Kenyon, said. 
She didn't feel like she could tell anybody because everyone in 
her chain was retaliating against her.
    ``Many victims are reluctant to report sexual trauma, and 
many victims say that there were no available methods for 
reporting their experiences to those in authority. Many 
indicate that if they did report the harassment, they were not 
believed--'' perfect example with Ms. Kenyon ``--or encouraged 
to keep silent about the experience. They may have had their 
reports ignored or, even worse, have been themselves blamed for 
the experience. Having this type of invalidating experience 
following a sexual trauma is likely to have a significant 
negative impact on the victim's post-trauma adjustment.''
    How do you review that VA Web site's analysis?
    Dr. Galbreath. Ma'am, I would offer to you that the system 
that we have in place today is not the system that we had in 
place even a few years ago. When Mr. Panetta took the stand in 
January 2012 and he said we have a problem and he cited numbers 
associated with that, he put a chain of events in motion that I 
would offer to you have really substantively changed the 
landscape of the current military system.
    What you see in our numbers this year, this is the system 
that we have now. This is the system that we have today. I 
believe that the increase in the number of reports have come 
from people that believe what our commanders are doing is 
correct and supporting them.
    Senator Gillibrand. Dr. Galbreath?
    Dr. Galbreath. Yes, ma'am.
    Senator Gillibrand. Two out of 10 rape victims are 
reporting today. I would not pat yourself on the back for 2 out 
of 10. Granted, according to your number, we know that there 
are more reports.
    Dr. Galbreath. Yes, ma'am.
    Senator Gillibrand. But we don't have the base number. We 
don't know if it is the same thing that happened between 2011 
and 2012 where total reports are up, but the incident rate 
skyrocketed. So, in fact, reporting by a percentage went down.
    So please, before we have the evidence and data, we should 
not be patting ourselves on the back----
    Dr. Galbreath. Ma'am, I----
    Senator Gillibrand.--on any level. Having 2 out of 10 
report is insufficient and is still a significant failure. So 
please do not say we are succeeding. Because if 8 out of 10 
victims stay mum because they don't believe justice is possible 
or they fear retaliation, we are failing 8 out of 10, clearly.
    Dr. Galbreath. We have a long way to go. You are absolutely 
correct. But I would offer to you is that this is evidence of 
change in the system, and----
    Senator Gillibrand. We don't know that. If we don't have 
the raw numbers, we don't know. We know that if you have been 
raped before you get in the military, there has been an 
increase in reporting. We don't know what the raw numbers of 
total rapes within the military were this year. We just know 
the number of brave individuals who came forward and actually 
signed their name to a real report.
    But if the number of actual rapes went up, well, we are not 
doing any better. If it is still 1 out of 10 cases, we are 
still where we were last year.
    Dr. Galbreath. I don't see the data that way, ma'am.
    Senator Gillibrand. You don't know the raw numbers. You 
can't see the data any way.
    Dr. Galbreath. We have had very consistent reporting of 
unwanted sexual contact since 2006. It is somewhere between 4 
percent and 7 percent for women. For men, it is between 1 and 2 
percent.
    In that historical context, I judge that this increase in 
reporting is progress.
    Senator Gillibrand. Unless there is an increase in rape, 
like what we saw between 2011 and 2012.
    Dr. Galbreath. Even so, ma'am, that was just in two 
instances in two Services. That wasn't across the board.
    Senator Gillibrand. That is the DOD's report.
    Dr. Galbreath. Yes, ma'am. I was involved in that.
    Senator Gillibrand. So----
    Dr. Galbreath. I would offer to you, ma'am, that you are 
exactly right. Next year, when we have a prevalence survey that 
we are able to judge in better context what this increase in 
reporting means, we will have a better picture. But given 
historical data and confirmation from other independent surveys 
that we have that have been conducted in the last 5 years, that 
this increase in reporting is a positive sign.
    We are not done by any means. We are very cognizant that we 
have a lot more work to do, and it is not a pat on the back by 
any means. But I just want to make you understand that we do 
take this very seriously, and we are doing everything we can to 
bring more victims forward so they can get the help and care 
that they need so that they can restore their lives.
    Senator Gillibrand. So can we go back to the issue of the 
VA's Web site? What is your impression of that?
    Dr. Galbreath. Ma'am, I would offer to you that was 
probably a snapshot of time of things in the past history. I 
don't know this article. I don't know what they are talking 
about as far as the time aspect goes.
    But like I said, since 2012, we have had a number of 
reforms helped by you and the members of this body, as well as 
a number of other things that we have done to bring more 
victims forward.
    Senator Gillibrand. Dr. Bell?
    Dr. Bell. I am really best positioned to speak to research, 
but it looks like this is coming from the National Center for 
PTSD's Web site, which is, of course, a VA entity.
    What I would turn to, thinking research-wise, is we 
certainly know that the types of support, the types of 
reactions that people get after experiences of sexual assault 
are really pivotal in their recovery. In fact, we know that it 
is the biggest and strongest predictor of their recovery 
afterwards and the biggest and strongest predictor of 
developing PTSD.
    I think the systemic responses, I think the support from 
family and friends, I think the societal response more 
generally is really going to strongly shape the course of 
someone's recovery after an experience like this.
    Senator Gillibrand. Thank you all for testifying. I am 
extremely grateful for the hard work you are doing. I am 
extremely grateful that you have taken it upon yourself with 
both the DOD and the VA to meet the needs of these survivors.
    I know this is a very, very, hard, hard, and difficult road 
ahead of us. But I trust your commitment, and I am grateful for 
that commitment because you are the difference between men and 
women receiving the care they need and not.
    Thank you so much for your service, and thank you for being 
here today.
    Dr. Galbreath. Thank you, ma'am.
    [Whereupon, at 12:33 p.m., the subcommittee adjourned.]

    [Questions for the record with answers supplied follow:]
          Questions Submitted by Senator Kirsten E. Gillibrand
                         military sexual trauma
    1. Senator Gillibrand. Dr. McCutcheon, you stated in your testimony 
that: (1) recovery is possible for those who have been diagnosed with 
Military Sexual Trauma (MST); (2) MST services are provided free of 
charge at the Department of Veterans Affairs (VA); and (3) there are 
MST coordinators at every VA Medical Center. Please provide information 
on the total number of MST coordinators nationwide and the description 
of their responsibilities.
    Dr. McCutcheon. Veterans Health Administration (VHA) Directive 
2010-033, MST Programming, provides information about the MST 
coordinator role and specifies that every VA health care system must 
appoint an MST coordinator. Some health care systems choose to split 
the MST coordinator duties among multiple appointees. For example, some 
health care systems may have one MST coordinator for the VA Medical 
Center but another for the community-based outpatient clinics 
associated with the health care system. In March 2014, there were 163 
staff members serving in MST coordinator roles across the VA health 
care system.
    MST coordinators have five primary areas of responsibility:

    1.  Implementation of national, Veterans Integrated Service Network 
(VISN), and local-level screening and treatment policies. MST 
coordinators help ensure that veterans being seen for care at the 
facility are screened for experiences of MST, that veterans have access 
to needed MST-related services, and that the care is provided free of 
charge. Coordinators monitor local MST-related programming and make 
efforts as needed to expand the scope of available services.
    2.  Implementation of national, VISN, and local-level staff 
education policies. MST coordinators help ensure that local staff 
members receive mandated MST education and training and provide 
training as needed in clinics throughout the health care system to 
ensure that staff members have the needed knowledge and skills to work 
effectively with MST survivors.
    3.  Implementation of national, VISN, and local-level informational 
outreach policies. MST coordinators engage in outreach to veterans to 
raise awareness of the availability of MST-related services and to 
facilitate engagement in care.
    4.  Serving as local point person for MST-related issues. MST 
coordinators serve as local points of contact, sources of information, 
and problemsolvers regarding MST-related issues for both veterans and 
VA staff. They engage in consultation with local offices and services, 
serve as advocates for veterans in working with the system, and address 
systems issues that may create barriers to care.
    5.  Communicating with national, VISN, and facility-level 
leadership. MST coordinators stay in regular contact with leadership, 
stakeholders, their VISN-level points of contact, and other MST 
coordinators in their VISN, in order to stay apprised of polices and 
trends related to MST. MST coordinators also respond to requests for 
information about local MST programming from VA Central Office.

    2. Senator Gillibrand. Dr. McCutcheon, you stated that these MST 
coordinators are the single point of contact for every veteran who 
screens positive for MST. What is the average workload for each of 
these coordinators? Please include the number of veterans seen annually 
by these coordinators.
    Dr. McCutcheon. To clarify, MST coordinators serve as point people 
for MST-related issues within their facility. They serve as sources of 
information and problemsolvers both for veterans and for staff. When 
needed on a case-by-case basis, MST coordinators consult on care-
related issues for particular veterans or serve as advocates to assist 
particular veterans with navigating the system. Although individual 
facilities may choose to set up a process wherein the MST coordinator 
has personal contact with every veteran who screens positive for MST, 
this is not a model required by national policy.
    With respect to MST coordinator workload, VHA Directive 2010-033 
permits facilities to designate the MST coordinator as a collateral 
position, performed in addition to other roles. It is an administrative 
position in that direct clinical care and case management 
responsibilities are not part of the role. However, most staff in the 
MST coordinator position do provide clinical care to MST survivors as 
part of other roles. The Directive requires facility leadership to 
ensure that MST coordinators have adequate protected administrative 
time to fulfill the responsibilities of the position. Currently, no 
specific amount of protected time is required, as facilities vary 
widely in their size, complexity, number of veterans seeking MST-
related care, and other factors relevant to the MST coordinator role. 
Facility leadership is encouraged to consider these factors when 
determining how much protected time is needed.
    VA has recent survey data that provide some information about how 
much protected time MST coordinators are allocated. As part of the 
Department of Defense (DOD)/VA Integrated Mental Health Strategy (IMHS) 
Strategic Action #28, a survey of practice was disseminated to VA 
health care facilities. Among other areas, facility leadership were 
asked to indicate whether the local MST coordinator had been given 
protected time for the duties of that role. The majority of facilities 
(82 percent) reported that the MST coordinator has protected time to 
devote to MST-related training and administrative activities, although 
there was wide variability in the amount of protected time per week. 
Among facilities who provided data, the mean number of hours of 
protected time per week was 6.2 hours.

    3. Senator Gillibrand. Dr. McCutcheon, during your testimony you 
indicated there is mandatory training for VA mental health providers 
and other health care personnel which includes the MST coordinators. 
What does that training entail?
    Dr. McCutcheon. VHA Directive 2012-004, Mandatory Training of VHA 
Mental Health and Primary Care Providers on Provision of Care to 
Veterans Who Experienced MST, established an MST-mandatory training 
requirement for all VA mental health and primary care providers. This 
one-time training requirement was established to ensure that all 
clinicians receive a consistent baseline level of training on MST. 
Mental health providers fulfill the requirement by completing a 
comprehensive web-based independent study course that focuses on the 
treatment of mental health sequelae associated with MST, including an 
overview of empirically-based treatments for post-traumatic stress 
disorder (PTSD), depression, and substance use. Mental health providers 
also have the option to ``test-out'' of the course by passing an MST 
knowledge assessment test that demonstrates significant pre-existing 
expertise in mental health issues related to MST.
    Primary care providers must complete the mandatory training 
requirement by completing a web-based training on ``MST for Medical 
Providers.'' This training covers information about health conditions 
associated with MST; issues related to screening for MST; how MST can 
affect a veteran's experience of health care; how to appropriately 
adapt care to address the needs of MST survivors; and VA documentation 
requirements.
    Additionally, trainees in health professions which provide clinical 
services at VA facilities are required to complete the web-based course 
Mandatory Training for Trainees in their first year and a refresher 
version of the course each year thereafter. VHA's Office of Academic 
Affiliations has included information on MST in both the initial and 
refresher courses to ensure that all trainees have a baseline level of 
knowledge about MST. In addition, regular close supervision that 
trainees receive from licensed, VA-credentialed clinicians ensures that 
all trainees receive training and consultation about MST and veterans' 
clinical needs on an ongoing basis.
    For many years, VHA has also offered a range of voluntary MST-
related training programs for continuing education. These allow both 
providers and trainees the opportunity to develop MST-related knowledge 
and skills above the baseline provided by the mandatory training 
described above. Continuing education courses include a monthly 
teleconference training series on MST-related topics and an annual 
training conference designed primarily for MST coordinators.

    4. Senator Gillibrand. Dr. McCutcheon, as we heard from the two 
survivors at the hearing, they did not appear to be aware of their 
mental health options available through the VA. What information is 
supposed to be provided to each veteran who screens positive for MST or 
who meets with an MST coordinator?
    Dr. McCutcheon. VA screens all veterans seen for health care for 
experiences of MST via a clinical reminder in the electronic medical 
record. The MST Clinical Reminder alerts providers of the need to 
screen the veteran, provides language to use in asking the veteran 
about MST, and documents the veteran's response to the screening. 
Upcoming revisions to the MST Clinical Reminder will capitalize on 
screening as an opportunity to provide all veterans with information 
about VHA's MST-related services, regardless of whether or not they 
disclose having experienced MST. This will be achieved by the addition 
of an introductory script that notifies all veterans that VHA provides 
free MST-related care. Revisions will also provide additional 
information to those who disclose having experienced MST. Providers 
will be instructed to offer every veteran who reports experiencing MST 
a fact sheet which reviews the definition and prevalence of MST, the 
impact of MST, VA's services for MST, and how to access care. The 
revised MST Clinical Reminder will also include a mental health 
services referral question, which will streamline access to care for 
veterans who express interest in MST-related treatment. It will also 
facilitate national monitoring of referrals for this care. Individual 
facilities will decide how this referral will operate locally. Some 
facilities may decide to route all referrals through the MST 
coordinator, but many will route referrals to their general mental 
health service and consult with the MST coordinator, as needed.
    In addition, MST coordinators conduct outreach activities year 
round to help ensure that information about VA's MST services is 
readily available. For example, MST coordinators arrange for outreach 
posters to be displayed in visible locations and for outreach brochures 
to be available in clinic waiting rooms. These materials discuss the 
availability of MST-related services and provide contact information 
for the MST coordinator. MST coordinators also often work with local 
veterans Service Organizations and other community groups to make 
information available to the veterans they serve. MST coordinators also 
engage in staff educational activities to help ensure that providers 
and frontline staff who work with veterans are aware of local MST 
services, know how to contact the MST coordinator, and are able to make 
appropriate referrals for care when needed. Facilities often capitalize 
on Sexual Assault Awareness Month (every April) to host a range of 
informational and awareness-raising events. These local efforts 
complement the National MST Support Team's initiatives to disseminate 
information about VA's MST-related services, some of which are 
described later in this series of questions and answers.

    5. Senator Gillibrand. Dr. McCutcheon, what mechanisms are in place 
to ensure MST coordinators are providing all required information to 
the veterans they meet with?
    Dr. McCutcheon. MST coordinators represent one important source of 
information for veterans interested in MST-related services, but VA 
disseminates information about its services broadly to ensure that even 
veterans who do not come in contact with the MST coordinator are aware 
of available services. For example, as noted in the previous question, 
upcoming revisions to the MST Clinical Reminder will standardize the 
information provided to all veterans during the screening process. For 
veterans and family members looking for information on the Internet, VA 
has a Web site on MST (http://www.mentalhealth.va.gov/msthome.asp) with 
basic information about MST, descriptions of programs and services, and 
links to other online resources. Also, as described in question 18 
below, VA has disseminated information about MST services to key DOD 
staff members who work with sexual assault survivors, as well as DOD 
online resources like the Sexual Assault Forensic Examination (SAFE) 
Helpline, in order to provide additional avenues for servicemembers to 
access this information.
    Not all veterans interested in MST-related services will 
necessarily have contact with the facility MST coordinator. However, 
MST coordinators are well-prepared to address the MST-specific needs of 
veterans with whom they do meet. VHA Directive 2010-033 requires that 
the MST coordinator be a professional who is knowledgeable about trauma 
and mental health and who possesses expertise in issues specific to 
MST. The MST coordinator role is almost always fulfilled by a mental 
health provider who is very familiar with local services important for 
MST survivors and readily able to describe these services. To 
facilitate provision of information about VA's services more broadly, 
the National MST Support Team has developed outreach and educational 
materials for MST coordinators to distribute. In addition to this 
standardized information, as mental health providers, MST coordinators 
are skilled at assessing difficulties related to MST and thus readily 
able to provide information tailored to each veteran's specific 
treatment needs.

                                 gender
    6. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, the VA has 
sponsored significant research on the links between sexual assault and 
harassment, PTSD, and suicide. Based on your research, what can you 
tell me about the differences in male and female survivors in terms of 
these links?
    Dr. McCutcheon and Dr. Bell. As noted in Dr. Bell's testimony, 
research has identified a relationship between sexual trauma and PTSD, 
between PTSD and suicide, and between sexual trauma and suicide. 
Studies have shown that the association between sexual trauma and 
suicide holds even after controlling for mental health conditions like 
depression and PTSD.
    With regard to how gender impacts these relationships, research to 
date has relatively and consistently shown that both men and women have 
an increased risk for suicide after experiencing sexual trauma. This 
appears to be true for both civilian and veteran samples. Although some 
studies have identified some potential differences in the strength or 
nature of this relationship, it would be premature to make definitive 
statements about gender differences in this area. However, this is a 
very active area of research and as the field's knowledge continues to 
grow, more definitive conclusions about gender differences may be 
possible in the future.

    7. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, do female and 
male survivors of military sexual assault or harassment present with 
symptoms differently? If so, how do treatment protocols accommodate and 
respond to these differences?
    Dr. McCutcheon and Dr. Bell. It is crucial for VA and others to 
continue expanding the research base on how gender shapes reactions to 
and recovery from MST. The literature on gender differences in response 
to civilian sexual trauma is similarly small but growing.
    Generally, studies have shown that men and women experience similar 
types of mental health difficulties after experiencing MST, with the 
most common mental health conditions for both being PTSD, depression, 
anxiety disorders, and substance use disorders (SUD). There is also 
often considerable overlap in the specific difficulties with which men 
and women present after experiences of sexual trauma, including 
struggles with self-blame, difficulties trusting others, and lack of 
social support.
    Some recent work has suggested, however, that the strength of 
association between MST and negative mental health outcomes may be 
larger for men than for women. Clinically, it is common for men to 
present with struggles related to gender role socialization, including 
questions about their masculinity and/or sexual orientation, 
particularly if the perpetrator of the MST was male. Men may also be 
particularly reluctant to disclose experiences of MST for fear of 
encountering negative reactions from others, given widespread 
misinformation and stigma related to sexual trauma among men.
    Women may also face unique issues in their recovery, such as the 
possibility that MST may intensify pre-existing concerns about safety, 
given significant rates of violence against women in U.S. society more 
generally. There may be factors related to their experience as a woman 
in the military that affect recovery from MST as well. For example, 
women are often numerically a minority in their unit, and it is 
possible that stressors associated with minority status may amplify the 
impact of MST or create additional challenges for recovery.
    Treatment always needs to be tailored to the specific difficulties 
of each individual veteran. Best practices would include discussing 
with the veteran how his or her gender and sense of self might be 
affected by the experiences of MST. Treatment often includes providing 
psychoeducation to counter rape myths, having discussions about the 
impact of gender socialization and societal inequalities related to 
gender, and addressing any gender-specific issues with which the 
veteran might present. Research examining whether different evidence-
based treatment approaches are differentially effective based on 
patient characteristics is in the early stages but will provide crucial 
information to allow VA and others to be more targeted in treatment 
planning. Early data show no substantial gender differences in the 
efficacy of some of the most commonly used evidence-based 
psychotherapies, but gender is a key variable for consideration as this 
literature continues to expand.

    8. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, do you believe 
there should be different treatment programs for male and female 
survivors?
    Dr. McCutcheon and Dr. Bell. Limited research exists on the 
relative effectiveness of single-gender and mixed-gender programming 
for male and female sexual trauma survivors. This is true both for 
civilian and military/veteran populations. Both single-gender and 
mixed-gender treatment environments have advantages and may be 
clinically indicated at different points in a veteran's recovery. For 
example, single-gender environments may facilitate addressing safety 
and gender-specific concerns, while mixed-gender environments may help 
veterans challenge assumptions and confront fears about those of a 
different gender. Veterans themselves also vary with respect to their 
preferences about single-gender versus mixed-gender programming. For 
example, a man who experienced MST perpetrated by another man may 
prefer participation in a mixed-gender treatment program. Others may 
feel that a single-gender environment will best facilitate their 
recovery. Given these considerations, VHA does not promote one model as 
universally appropriate for all veterans. The needs and preferences of 
a specific veteran dictate which model is clinically most appropriate. 
As such, VHA makes a range of treatment options available to enable 
veterans to decide, in collaboration with treatment providers, which 
option will best address their specific difficulties.

    9. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, are there 
differences between findings in the civilian world and the military?
    Dr. McCutcheon and Dr. Bell. Information about differences in 
civilian and military/veteran research findings related to gender and 
treatment is integrated into responses to questions 6, 7, and 8.

                            stigma and care
    10. Senator Gillibrand. Dr. Guice and Dr. Galbreath, although much 
is known about PTSD in male veterans and in those who fought in earlier 
conflicts, less is known about PTSD in female veterans. Several studies 
have found that MST plays a larger role in explaining PTSD among women 
veterans than does combat exposure or other wartime stressors. Sexual 
harassment is also associated with many later mental health symptoms, 
including PTSD and other anxiety. DOD has spent a lot of time working 
to reduce the stigma of combat-related PTSD and encouraging 
servicemembers to get help. What is DOD doing to reduce the stigma of 
sexual assault and the resultant mental health injuries like PTSD, 
depression, and suicidal ideation?
    Dr. Guice and Dr. Galbreath. The potential development of mental 
health sequel (pathological condition resulting from a disease, injury, 
therapy, or other trauma) associated with sexual assault, and the 
victim's potential fear of seeking help, are both of great concern to 
DOD. Providing multiple points of access to a structured, competent, 
and coordinated continuum of care for survivors of sexual trauma--
regardless of gender or time of the sexual assault--is imperative to 
reducing the potential long-term mental and physical risks associated 
with sexual trauma. DOD has implemented policies, guidelines, 
procedures, programs, and support delivery systems to ensure that care 
is available and executed in a manner which fosters stigma reduction. 
This continuum of care extends as long as needed including through 
assignment or duty status transitions.
    DOD's prioritization of the importance of provider education, 
awareness, and sensitivity has led to the implementation of multiple 
policies and initiatives to assure that providers are educated to 
deliver care that is gender-responsive, culturally competent, recovery-
oriented and alert to the potential for mental health issues that may 
develop over time, or be the result of sexual trauma. Health care 
providers who care for survivors of sexual assault are trained in the 
concept of trauma-informed care and must recognize the high prevalence 
of pre-existing trauma. Additionally, they receive training in the 
broad range of physical and emotional responses that they may observe. 
Every servicemember and civilian employee throughout DOD is required to 
take training about sexual assault, sexual harassment, and trafficking 
in persons upon entry and annually thereafter. Servicemembers receive 
instruction on military core values from the moment recruit training 
starts, and training continues over a member's time in the Service.
    A victim's preference for how to access help the type of therapy 
and services they want to receive are cornerstone precepts for both 
mitigating the potential fear of stigma associated with reporting the 
incident and in achieving maximal recovery. To increase and leverage 
these protective factors, DOD has created multiple options and points 
of access for obtaining assistance, including private reporting, 
anonymous points of entry to assistive resources, and available one-to-
one support and coaching personnel. This respect for the victim's 
autonomy and needs extends to accommodating patient preference for the 
gender and duty-status of the therapist.

    11. Senator Gillibrand. Dr. Guice and Dr. Galbreath, in 2013, the 
Government Accountability Office (GAO) found that military health care 
providers did not have a consistent understanding of their 
responsibilities in caring for sexual assault survivors because DOD has 
not established guidance for the treatment of injuries stemming from 
sexual assault--which requires that specific steps are taken while 
providing care to help ensure the victim's right to confidentiality. 
Additionally, while the Services provide required training to first 
responders, GAO found that some of these responders were not always 
aware of the health care services available to sexual assault 
survivors. Has DOD developed Department-level guidance on the provision 
of care to survivors of sexual assault?
    Dr. Guice and Dr. Galbreath. Yes, DOD released DODI 6495.02 
``Sexual Assault Prevention and Response (SAPR) Program Procedures'' on 
March 28, 2013. Enclosures 7, 8, and 10 outline a comprehensive, 
standardized policy for compassionate medical response to survivors of 
sexual assault, including a requirement that health care personnel 
receive appropriate training. This policy includes guidance for both 
restricted and unrestricted reporting and treating all sexual assault 
victims as priority emergencies.
    The Assistant Secretary of Defense for Health Affairs (ASD(HA)) 
issued a memorandum to the Services on April 15, 2013, to notify the 
Services about the publication of the revised DOD Instruction (DODI). 
The memorandum noted the enhancements to guidelines for provision of 
health care support for survivors of sexual assault, including the 
restricted reporting process. The memorandum noted the minimum 
standards for health care and training requirements for health care 
personnel who manage both acute and long-term care needs for victims of 
sexual assault and for providers who would conduct SAFEs. In that 
memorandum, the ASD(HA) also requested submission of an annual report 
to include information on the capability of each military treatment 
facility (MTF) to provide SAFEs, and information on agreements with 
local civilian providers in cases where there was not SAFE availability 
within the MTF. Finally, the ASD(HA) requested that the Services submit 
written plans with target dates for implementation to meet the 
requirements of the revised DODI.
    DOD received and reviewed the responses from the Services and 
determined that Service implementation plans already meet the basic 
requirements of the DODI and also include enhancements to their 
training programs for Service certification to perform SAFEs. The 
Services report that their training assures that all health care 
personnel are aware of restricted reporting requirements. These 
training programs also include Service-specific criteria for 
certification to perform SAFEs that are consistent with the guidelines 
set forth in the U.S. Department of Justice-National Protocol for 
Sexual Assault Medical Examinations for Adults and Adolescents. The 
Services also noted that they are enhancing their training programs to 
include a wider variety of experiences in both care of the victim and 
courtroom testimony. This includes live examination experiences with 
standardized patients or volunteers and observation of mock trials.
    In an effort to provide the highest quality of care, the Services 
are continuously evaluating and updating training in this area. Each 
Service has either already updated its operational policies or will 
complete their current updates by the end of fiscal year 2014.
    The Office of ASD(HA) is monitoring completion of Service program 
implementation and issued an additional memorandum on March 27, 2014, 
that outlines all elements of the oversight plan and sets dates for 
submission of reports. This plan requires an annual update of SAFE 
provider coverage, training enhancements, and policy and procedure 
changes. Additionally, OASD(HA) monitors program performance on an 
ongoing basis throughout the year at the SAPR Integrated Program Team 
and Health Affairs Women's Health Issues Working Group meetings, both 
of which address health care related to the response to sexual assault.

    12. Senator Gillibrand. Dr. Guice and Dr. Galbreath, what has DOD 
done to improve first responder compliance with DOD requirements for 
annual refresher training?
    Dr. Guice and Dr. Galbreath. The goal of DOD is to deliver 
consistent and effective prevention methods and programs. It is 
critical that our entire military community work together to prevent 
criminal behavior from occurring, when possible, and respond 
appropriately to incidents when they occur. Sustained leadership 
attention by commanders and first line supervisors is critical to this 
effort, as they are central in establishing the climate of dignity, 
respect, sensitivity, and environmental expectations for conduct at the 
unit level that can reduce and eliminate these crimes.
    In March 2013 (updated 14 February 2014), the Department published 
guidance to require that all DOD sexual assault responders receive 
consistent baseline training. DODI 6405.02 ``Sexual Assault Prevention 
and Response Program Procedures,'' (pages 66-72) outlines who must 
receive training as well as the topical areas to be presented. Further, 
this has been followed by the development of core competencies and 
learning objectives for all SAPR training, starting with pre-command 
and senior enlisted groups, to ensure consistent learning and 
standardization across the Services. DOD has worked collaboratively 
with pre-command and senior enlisted groups to deploy innovation and 
assessment teams across the Nation to identify promising prevention 
strategies and techniques.
    In addition to the basic first responder training, health care 
personnel must receive additional training (outlined on pages 72-73 of 
DODI 6495.02). There are two tiers of training. The first tier provides 
additional information regarding encounters in MTFs. The training 
standards and topical areas are set based upon the skill-level and 
duties of the health care personnel. Therefore, clerks, assistants, and 
non-skilled personnel receive information at their level of training 
and health care providers who will assess, interview, and treat sexual 
assault survivors receive an additional level of basic information. All 
personnel who will perform SAFEs must take a second tier of training. 
This training provides detailed information on the conduct of a SAFE, 
including the specific history taking, physical examination, and 
handling of evidence. Personnel who take this training are Service-
certified to conduct SAFEs. Planned enhancements to SAFE training will 
expand the variety of experiences and teaching methods, adding 
additional supervised experiences with live volunteer or standardized 
patients and mock courtroom experiences by the end of fiscal year 2014.

    13. Senator Gillibrand. Dr. Guice, I know that the Army has worked 
to create specialized training for sexual assault investigators to 
ensure they are not traumatizing victims during interviews. The 
Services have also created additional trainings for Judge Advocate 
General (JAG) lawyers working on special victims cases. Finally, we 
have created a Special Victims Counsel for survivors to access during 
the process. These are all important steps in supporting our survivors 
post-attack. What else should the military do to mitigate the follow-on 
trauma from sexual assaults?
    Dr. Guice. All of the Services have fielded a Special Victims 
Capability, composed of specially trained and certified criminal 
investigators, attorneys, paralegals, and Victim/Witness Assistance 
Program personnel. All of these investigative and legal personnel who 
are working cases of sexual assault, serious domestic violence, and 
child abuse are trained and certified in interviewing techniques that 
minimize re-traumatization and consider the special needs of 
individuals with trauma-impacted memory. Given the Special Victims 
Capability, the Special Victims Counsel, the updated specialized 
training for all criminal investigators, attorneys, Sexual Assault 
Response Coordinators (SARC), victim advocates, and medical/mental 
health providers, I believe we are taking great steps to mitigate 
follow-on trauma. However, as these programs are new, we are 
continually evaluating how they are working in the field. As we 
identify additional steps we can take to minimize a victim's 
retraumatization, we will update our policy and programs to best 
support the victims.

    14. Senator Gillibrand. Dr. Guice, is there additional training 
that could be given to investigators and JAGs to ensure that victims 
are not revictimized during the investigative process?
    Dr. Guice. Yes, there is. As part of the Special Victims Capability 
training, the Department fielded last year, The Military Criminal 
Investigative Organizations and the Service Judge Advocates, their 
paralegals, and Victim/Witness Assistance Program personnel are 
currently receiving additional training. All investigative and legal 
personnel working cases of sexual assault, serious domestic violence, 
and child abuse are trained in interviewing techniques that minimize 
re-traumatization consider the special needs of individuals with 
trauma-impacted memory.

                                suicide
    15. Senator Gillibrand. Ms. Garrick, suicide is a very complicated 
issue--every incident of suicide has its own causes. I believe DOD goes 
through every case to try to understand what happened and what could 
have been done to prevent each suicide. When DOD assesses cases of 
suicide in the Services, are you finding that there are cases that are 
related to sexual assault?
    Ms. Garrick. For DOD, the loss of a single servicemember is one too 
many; as such, the Department endeavors to examine thoroughly any 
potential issue that may lead to a servicemember's suicide. Through the 
DOD Suicide Event Report (DODSER), DOD collects data about military 
suicide decedents and attempters. The DODSER tracks demographic 
information such as the cause and manner of death or attempts, 
substance abuse and psychological health history, and deployment and 
combat experiences.
    In addition, the DODSER tracks servicemembers who had reported 
cases of sexual abuse and harassment along with cases of sexual abuse 
and harassment perpetration. Reported cases may include sexual abuse 
before and since joining the military. Additionally, not all survivors 
of sexual assaults disclose their histories; therefore, the data 
contained in the DODSER may not provide a full picture of the 
prevalence of a sexual abuse history in those who died by suicide. 
However, based on the available DODSER data, DOD cannot conclude that 
there is a causal relationship between military sexual assaults and 
suicides at this time.
    In 2012, 10 servicemembers who had reported a history of sexual 
abuse and 3 servicemembers who had reported a history of sexual 
harassment had died by suicide. These servicemembers accounted for 3.1 
percent and 0.9 percent of all suicides in 2012.

    16. Senator Gillibrand. Ms. Garrick, what more can you tell me 
about the study being jointly sponsored by the Defense Suicide 
Prevention Office (DSPO) and the Sexual Assault Prevention and Response 
Office (SAPRO) to better understand the prevalence of suicide risk 
among sexual assault victims?
    Ms. Garrick. The DSPO and the SAPRO are jointly sponsoring a study 
using data from the Survey of Health-Related Behavior of Active Duty 
Members. The study will assess whether statistically significant 
relationships between self-reported instances of sexual assault and 
suicidal ideation and attempts exist. In addition, the study will 
analyze the extent to which risk factors for sexual assault overlap 
with risk factors for suicidal ideation and attempts. DSPO will use the 
data to assess whether there is a need to modify existing suicide 
prevention and resilience programs to address any unique risks 
associated with sexual assault victims. However, it should be noted 
that those who assist in sexual assault responses are already being 
trained on suicide prevention.

    17. Senator Gillibrand. Ms. Garrick, once that study is done, will 
you come back and update us on its findings?
    Ms. Garrick. DOD will be glad to brief the results of the joint 
DSPO and SAPRO's analysis of the relationships between self-reported 
instances of sexual assault incidents and suicidal ideation/attempts 
from the 2011 Survey on Health-Related Behaviors of Active Duty 
Servicemembers.

                        transition difficulties
    18. Senator Gillibrand. Dr. Guice and Dr. McCutcheon, how do DOD 
and VA currently transition servicemembers who have been sexually 
assaulted?
    Dr. Guice. DOD has policies and programs in place to ensure 
transition of care for servicemembers with mental health and medical 
care issues, including those who are survivors of sexual assault. These 
policies are not diagnosis specific because DOD views all of our 
wounded, ill, and injured, either medically or physically or both, 
regardless of cause, as equally warranting seamless transition of care 
between time of discharge from the Active component to continuation of 
care outside of the Military Health System (MHS).
    One of the Strategic Actions in the joint DOD/VA IMHS includes 
enhancing continuity of care for servicemembers relocating within or 
across departments who are receiving ongoing mental health care by 
implementing the inTransition program. The Joint DOD/VA inTransition 
program ensures continuity of mental health care, including survivors 
of sexual assault engaged in treatment, for servicemembers as they move 
between DOD and VA health care systems or providers. Personal coaches, 
working with a multitude of resources and tools, provide psychological 
health care support and connect the newly separated servicemember to a 
new provider. Coaches locate community resources, support groups, and 
crisis intervention services, and monitor individuals to ensure a 
seamless transition of care.
    Additionally, servicemembers who have been sexually assaulted may 
utilize transition services offered as part of the SAFE Helpline. The 
SAFE Helpline is operated by Rape, Abuse, and Incest, National Network, 
the Nation's largest anti-sexual violence organization, which also runs 
the National Sexual Assault Hotline. This helpline provides live, one-
on-one crisis support across the enterprise, offers intervention 
services, emotional support, information, and ``warm hand-off'' 
transfers to SARCs, Military OneSource, and the National Suicide 
Prevention Lifeline. For transitioning servicemembers, SAFE Helpline 
has a full database of VA and civilian resources to include Veteran's 
Benefits Coordinators and civilian sexual assault service providers. 
SAFE Helpline staff provide these resources based on a servicemember's 
location and include the nearest medical or legal personnel, chaplain, 
veterans services, and civilian sexual assault service providers.
    Dr. McCutcheon. VA has an extensive range of initiatives to 
facilitate all servicemembers' seamless transition from DOD to VA, in 
general. To ensure the unique needs of MST survivors are addressed, MST 
coordinators work closely with their facility Operation Enduring 
Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) 
Program Manager and Care Management Teams, the facility-level staff 
most closely involved with facilitating transitions between DOD and VA. 
In addition, MST coordinators provide assistance and consultation on 
specific cases as needed. MST coordinators are also encouraged to 
establish working relationships with DOD SARCs associated with local 
military installations, to help facilitate seamless access to VA 
services.
    A number of outreach and training initiatives complement these 
efforts. For example, information about VA's MST-related services is 
included in the mandatory outprocessing (i.e., Transition Assistance 
Program) completed by all servicemembers.
    In addition, VA's national MST Support Team has an established 
relationship with DOD's overarching SAPRO. SAPRO and the MST Support 
Team have provided trainings to staff in each Department to ensure that 
each are aware of each others' services and are able to pass this 
information along to the servicemembers with whom they work. 
Information about VA's MST-related health care services is included in 
DOD's SAFE Helpline, and VA's MST outreach brochure is posted on 
SAPRO's myduty.mil Web site. SAPRO and the MST Support Team also 
communicate as needed to help connect individual veterans and 
servicemembers to services that match their treatment needs.
    The MST Support Team has also engaged in conversations with each 
Department's SAPR programs about how to ensure that transitioning 
servicemembers and newly-discharged veterans, specifically, are aware 
of VA's MST-related services. This has resulted in several 
presentations to SAPR program staff and other DOD program offices, in 
order to encourage inclusion of information about VA services in 
outreach and training efforts. One particular area of discussion has 
been the inclusion of information about VA's MST-related services in 
SAPR orientation and other training materials for DOD SARCs. To support 
this effort, VA has provided informational materials about VA's MST-
related services to SAPRO and individual SAPR programs for distribution 
to SARCs, other DOD staff, and servicemembers.

    19. Senator Gillibrand. Dr. Guice and Dr. McCutcheon, are there 
gaps in the hand-off between DOD and VA?
    Dr. Guice. There are programs in place to facilitate transition of 
care and provide warm hand-offs between DOD and VA; however, there is 
not a mandate specific to the transition of survivors of sexual assault 
to the VA. While a servicemember who is a survivor of sexual assault is 
not required to obtain ongoing or follow-up care within the VA care 
system, one of the DOD/VA IMHS actions is reviewing mental health 
services for females and males who have experienced sexual assault and 
identifying opportunities to improve continuity of care and information 
sharing during transition between DOD and VA. Also, a Sexual Assault 
Advisory Group (SAAG) was commissioned under the DOD's Psychological 
Health Council in November 2013. The SAAG has provided a forum to 
regularly advise DOD Health Affairs and Personnel and Readiness 
leadership on issues related to sexual assault and prevention and 
ensure continuous improvement in coordination between DOD SARCs and 
health care providers. The Defense Centers of Excellence for 
Psychological Health and Traumatic Brain Injury (TBI) are developing a 
clinical recommendation tool for providers to guide them in how to ask 
about sexual assault and sexual harassment and take the appropriate 
actions when reported. This tool will prompt providers to ask 
servicemembers about possible transitions in and out of DOD and will 
recommend a warm handoff to VA for those who are transitioning out of 
military service.
    Dr. McCutcheon. VHA believes that the comprehensive efforts 
coordinated by its national Care Management and Social Work program 
office and facility OEF/OIF/OND Program Managers and Care Management 
Teams provide a solid foundation to ensure seamless transitions for 
veterans who experienced MST. As noted above, the MST Support Team and 
the Care Management and Social Work program office have collaborated to 
ensure that the MST-specific needs of veterans are addressed as part of 
these existing efforts.

    20. Senator Gillibrand. Dr. Guice and Dr. McCutcheon, are there 
gaps in the hand-off between DOD and VA for those who are diagnosed 
with personality disorders (PD) and discharged from Service?
    Dr. Guice. There is not a mandate specific to the transition of 
those diagnosed with PDs to the VA. Rather the DOD has policies and 
programs in place to ensure transition of care and a hand-off for 
servicemembers with all types of mental health and medical care issues 
inclusive of a PD. These policies are not specific to one diagnosis 
such as a PD because the DOD views all of our wounded, ill, and 
injured, either medically or physically or both, regardless of cause, 
as equally warranting seamless transition of care between time of 
discharge from the Active component to continuation of care outside of 
the MHS.
    Dr. McCutcheon. A diagnosis of a PD would not affect a 
servicemember's transition to VA or eligibility for VA services, 
provided he or she is eligible under title 38, U.S.C., for VA benefits.

    21. Senator Gillibrand. Dr. Guice, you said in your written 
testimony that ``When sexual assault survivors are still actively 
receiving behavioral health care at the time of separation from the 
Service, they are linked to the DOD inTransition Program to help ensure 
that continuity of care is maintained. The inTransition program assigns 
servicemembers a support coach to bridge support between health care 
systems and providers. The coach does not deliver behavioral health 
care or perform case management, but is an added resource to patients, 
health care providers, and case managers to help ensure transition of 
care is seamless. SAFE Helpline also provides information for sexual 
assault survivors that may be transitioning from military to civilian 
life.'' Can you tell me approximately how many victims are part of this 
program?
    Dr. Guice. The inTransition program publishes monthly statistics 
related to the number of new cases, closed cases, and active cases per 
month and from inception of the program. InTransition does not track 
information regarding how many clients who used inTransition were 
victims of sexual assault. The March 2014 report of the program shows 
program growth from its time of inception, February 2010 through March 
2014:

         The inTransition program has opened 5,039 cases since 
        its inception in February 2010. In March, 93 new cases were 
        opened, 46 percent of the referrals were made by 
        servicemembers.
         98 percent of servicemembers referred to the program 
        accepted services, 88.2 percent were Active Duty, 6.3 percent 
        were discharged, 2.4 percent were retirees, 0.5 percent Active 
        Guard/Reserves.
         The majority 63 percent of cases was from the Army; 15 
        percent of cases were from the Air Force; remaining cases 
        spread between the Marine Corps, Navy, and National Guard.
         Providers who refer to the inTransition program report 
        that 100 percent stated that the program met their needs with 
        4.85 out of 5 would refer this program to another provider.

    The inTransition coach provides support and assistance to the 
transitioning servicemember though regular telephonic contact until he 
or she engages in behavioral health treatment with a follow-on 
provider, whether that is in the VA health care system, the MHS, 
TRICARE, or the community. The coaches assist servicemembers during the 
transition period, empower them to make healthy life choices globally, 
and are available 24/7. Calls are toll-free.

    22. Senator Gillibrand. Dr. Guice, is connecting the survivors to 
VA services part of the mandate of this program? If so, how? If not, 
why?
    Dr. Guice. There is not a mandate specific to the transition of 
survivors of sexual assault to the VA. DOD has policies and programs in 
place to ensure transition of care for servicemembers with mental 
health and medical care issues inclusive of those who are survivors of 
sexual assault. These policies are not diagnosis specific because the 
DOD views all of our wounded, ill, and injured, either medically or 
physically or both, regardless of cause, as equally warranting seamless 
transition of care between time of discharge from the Active component 
to continuation of care outside of the MHS. A servicemember who is a 
survivor of sexual assault, just as survivors of combat war injuries or 
other military associated injuries, is not required to obtain ongoing 
or follow-up care within the VA care system. Should they choose to 
avail themselves of these services, there are policies such as DODI 
6490.10, ``Continuity of Behavioral Health Care for Transferring and 
Transitioning Servicemembers'', case management procedures (e.g. 
Clinical Case Management, (DTM) 08-033--Interim Guidance for Clinical 
Case Management for the Wounded, Ill, and Injured Servicemember in the 
MHS and programs such as the inTransition program to facilitate 
transition to the VA.

    23. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, VA granted 
disability benefit claims for PTSD related to MST at a significantly 
lower rate than claims for PTSD unrelated to MST every year from 2008 
to 2012. Because female veterans' PTSD claims are more often based on 
MST-related PTSD than male veterans' PTSD claims, female veterans 
overall are disparately impacted by the lower claims rates for MST-
related PTSD. For every year between 2008 and 2011, a gap of nearly 10 
percentage points separated the overall claims rate for PTSD claims 
brought by women and those brought by men. Among those who file MST-
related PTSD claims, male veterans face particularly low claims rates, 
when compared to female veterans who file MST-related PTSD claims. What 
have you done to reform VA regulations on disability claims based on 
PTSD related to in-service assault?
    Dr. McCutcheon and Dr. Bell. Following the direction of Under 
Secretary for Benefits Hickey, the Veterans Benefits Administration 
(VBA) began an aggressive program to address the sensitive issues 
related to MST and PTSD. This involved a nationwide focus beginning in 
2011. Less than 6 months after an enhanced nationwide training agenda 
and deployment of specially trained claims processors and health 
professionals throughout the country, the percentage of disability 
claims granted for MST/PTSD increased from 34 percent to about 55 
percent. At that time, the grant rate for all PTSD claims was 
approximately 60 percent. Since then, the grant rates for MST/PTSD 
claims, as well as all PTSD claims, has fluctuated. For fiscal year 
2013, the average grant rate for MST/PTSD claims was 49 percent, 
compared to 55 percent for all PTSD claims. The higher grant rates for 
all PTSD claims is likely due to the numerous combat-related claims 
that are the result of U.S. military operations in Southwest Asia. 
Regarding gender variations, the grant rate for male veterans claiming 
MST/PTSD rose to within 7 points of the grant rate for female veterans 
making the same claim. These rising MST/PTSD numbers show the benefits 
of the training initiative and special handling.
    Additionally, VBA recognized that some veterans' MST/PTSD claims 
were decided prior to the increased nationwide training and special 
emphasis on handling these claims. To provide those veterans with the 
same evidentiary considerations as veterans who file claims today, VBA 
notified those veterans we could identify through our tracking system 
of the opportunity to request a review of their previously denied MST/
PTSD claims.
    VBA efforts have emphasized the liberal evidentiary approach 
available under current PTSD regulations, which provides for a VHA 
mental health examination if any circumstantial evidence of a behavior 
change or MST event is found in the record. The examiner's opinion 
regarding the occurrence of the MST stressor can then lead to PTSD 
service connection. These efforts, within the scope of current PTSD 
regulations, have produced a significant rise in the MST/PTSD grant 
rate. As a result, VBA does not see the need to alter current 
regulations.

    24. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, treatment of 
MST-related PTSD claims varies widely from one VA regional office 
(VARO) to another. The VAROs that discriminated most egregiously in 
2012 include those in St. Paul, MN; Detroit, MI; and St. Louis, MO. 
What have you done to improve training and oversight of VA offices with 
poor records in granting MST claims?
    Dr. McCutcheon and Dr. Bell. VBA's Office of Quality Review, within 
Compensation Service, has obtained data regarding the adjudication of 
MST/PTSD claims from all VA regional offices. Variations in grant rates 
have been noted. In order to promote nationwide accuracy and 
consistency in adjudication of MST/PTSD claims, VBA's Quality Review 
staff will call in a percentage of cases from each regional office with 
a low grant rate and thoroughly review the decisions. If needed, 
additional training will be provided to these regional offices. This 
review is scheduled for April 2014.

                         personality disorders
    25. Senator Gillibrand. Dr. Guice, a PD is a mental health disorder 
that usually surfaces in pre-adolescence, adolescence, or early 
adulthood, is stable over time, and involves an enduring pattern of 
inner experience and behavior that deviates from the expectations of an 
individual's culture. The Services define PD as a condition pre-
existing military service. Yet for many survivors, the PD is only 
diagnosed after they have reported a sexual assault. What prescreening 
is done prior to joining a Service to ensure a servicemember does not 
have a PD?
    Dr. Guice. PD diagnoses cannot be discovered reliably with 
screening measures during recruit or accession processing. These 
disorders stem from biological, psychological, or social deficits that 
manifest early in a person's life, and are characterized by a recurrent 
pattern of maladaptive behavior in the face of stressors. A PD is 
always considered to be a pre-existing condition.
    All applicants for military service go through a multi-step medical 
screening process. An essential part of that screening is a medical 
exam. With respect to PD or other mental disorders, applicants are 
required to complete a medical pre-screening before reporting. Medical 
evaluation by a physician includes a review of any history of 
psychological disorders and current emotional status. All positive 
responses are addressed by the examining physician at the time of the 
physical examination. Through the course of interactions with military 
and medical professionals, any presenting symptoms may result in 
further examinations. With regard to mental health, if an applicant 
fails to reveal a history of mental health problems and no symptoms of 
PD are detected, the applicant would be cleared for enlistment.
    The Services typically separate 2 to 3 percent of servicemembers 
for PD during initial accession and recruit training. Entry level 
discharges are mandated for individuals who are unable to adapt to the 
rigors of military training. It is uncommon for a servicemember to be 
separated for a PD after the initial years of service associated with a 
first enlistment. DOD currently separates only approximately 300 
persons/year (out of 1.4 million servicemembers, or 0.02 percent) due 
to PDs.
    The existence of a PD is not necessarily incompatible with military 
service and the ability to perform one's duties. Individuals with some 
types of PD may be able to function well. However, those with other 
types of PD may not be able to interact or perform successfully in a 
military environment. If a servicemember has a PD but is able to 
accomplish the requirements of military training and subsequent duty 
assignments--with no evidence of aberrant, maladaptive, or disruptive 
behavior--they would not be likely to be referred for mental health 
care, or subsequently be diagnosed as having this disorder within the 
Military Healthcare System.

    26. Senator Gillibrand. Dr. Guice, how are servicemembers allowed 
to join without the PDs being detected and remain able to perform their 
duties for some years?
    Dr. Guice. PD diagnoses cannot be discovered reliably with 
screening measures during recruit or accession processing. These 
disorders stem from biological, psychological, or social deficits that 
manifest early in a person's life, and are characterized by a recurrent 
pattern of maladaptive behavior in the face of stressors. A PD is 
always considered to be a pre-existing condition.
    All applicants for military service go through a multi-step medical 
screening process. An essential part of that screening is a medical 
exam. With respect to PD or other mental disorders, applicants are 
required to complete a medical pre-screening before reporting. Medical 
evaluation by a physician includes a review of any history of 
psychological disorders and current emotional status. All positive 
responses are addressed by the examining physician at the time of the 
physical examination. Through the course of interactions with military 
and medical professionals, any presenting symptoms may result in 
further examinations. With regard to mental health, if an applicant 
fails to reveal a history of mental health problems and no symptoms of 
PD are detected, the applicant would be cleared for enlistment.
    The Services typically separate 2 to 3 percent of servicemembers 
for PD during initial accession and recruit training. Entry level 
discharges are mandated for individuals who are unable to adapt to the 
rigors of military training. It is uncommon for a servicemember to be 
separated for a PD after the initial years of service associated with a 
first enlistment. DOD currently separates only approximately 300 
persons/year (out of 1.4 million servicemembers, or 0.02 percent) due 
to PDs.
    The existence of a PD is not necessarily incompatible with military 
service and the ability to perform one's duties. Individuals with some 
types of PD may be able to function well. However, those with other 
types of PD may not be able to interact or perform successfully in a 
military environment. If a servicemember has a PD but is able to 
accomplish the requirements of military training and subsequent duty 
assignments--with no evidence of aberrant, maladaptive, or disruptive 
behavior--they would not be likely to be referred for mental health 
care, or subsequently be diagnosed as having this disorder within the 
Military Healthcare System.

    27. Senator Gillibrand. Dr. Guice and Dr. Galbreath, an October 
2008 GAO report found that DOD could not be sure that its key PD 
separation requirements were being followed. A follow-on report 
conducted in September 2010 also found the military Services had not 
demonstrated full compliance with DOD's PD separation requirements. The 
2008 report recommended, and the 2010 report reiterated, that DOD 
should: (1) ensure that the Services' PD separations comply with 
established DOD requirements; and (2) monitor the Services' compliance. 
Since the GAO reports came out, what has DOD done to determine whether 
commanders with separation authority are ensuring that DOD's key 
separation requirements are met?
    Dr. Guice and Dr. Galbreath. DOD is confident that the requirements 
as set forth by the GAO report, ``Additional Efforts Needed to Ensure 
Compliance with Personality Disorder Separation Requirements'', October 
2008 are being met. In January 2009, the Under Secretary of Defense for 
Personnel and Readiness (USD(P&R)) directed the Military Departments to 
report fiscal year 2008 and fiscal year 2009 compliance with DOD PD 
separation requirements. In September 2010, the USD(P&R) extended the 
requirement for PD separation compliance reporting through fiscal year 
2012, and directed the Military Departments to provide status on their 
efforts to contact veterans who had deployed to combat areas and were 
later separated for PD without enhanced screening for PTSD.
    There were eight separation requirements stipulated by the GAO. Of 
these, by 2012, the Military Departments have achieved 100 percent 
compliance in all but two areas:

         ``Member was advised that the diagnosis of a PD does 
        not qualify as a disability.''--The Army and Navy were 100 
        percent compliant; the Marine Corps was 78 percent compliant 
        and the Air Force was 87 percent compliant.
         ``Member's PD diagnosis was endorsed by The Surgeon 
        General of the Military Department concerned prior to 
        discharge.'' The Army, Navy, and Marine Corps were 100 percent 
        compliant; the Air Force was 75 percent compliant.

    The Marine Corps and the Air Force are committed to remediation of 
the areas for which 100 percent compliance was not achieved, and have 
issued supplemental guidance to their field commands. A new requirement 
from the National Defense Authorization Act (NDAA) for Fiscal Year 2014 
requires the Comptroller General to also report the extent to which the 
Military Departments comply with regulatory requirements in separating 
members on the basis of a PD. Thus, although the Military Departments' 
reported compliance for fiscal years 2008 through 2012, as required, 
this new report will follow up on these requirements for continued 
monitoring and notification of achieving 100 percent compliance.

    28. Senator Gillibrand. Dr. Guice and Dr. Galbreath, does DOD have 
reasonable confidence that its requirements are being followed?
    Dr. Guice and Dr. Galbreath. DOD is confident that the requirements 
as set forth by the GAO report, ``Additional Efforts Needed to Ensure 
Compliance with Personality Disorder Separation Requirements'', October 
2008 are being met. In January 2009, the USD(P&R) directed the Military 
Departments to report fiscal year 2008 and fiscal year 2009 compliance 
with DOD PD separation requirements. In September 2010, the USD(P&R) 
extended the requirement for PD separation compliance reporting through 
fiscal year 2012, and directed the Military Departments to provide 
status on their efforts to contact veterans who had deployed to combat 
areas and were later separated for PD without enhanced screening for 
PTSD.
    There were eight separation requirements stipulated by the GAO. Of 
these, by 2012, the Military Departments have achieved 100 percent 
compliance in all but two areas:

         ``Member was advised that the diagnosis of a PD does 
        not qualify as a disability.''--The Army and Navy were 100 
        percent compliant; the Marine Corps was 78 percent compliant 
        and the Air Force was 87 percent compliant.
         ``Member's PD diagnosis was endorsed by The Surgeon 
        General of the Military Department concerned prior to 
        discharge.'' The Army, Navy, and Marine Corps were 100 percent 
        compliant; the Air Force was 75 percent compliant.

    The Marine Corps and the Air Force are committed to remediation of 
the areas for which 100 percent compliance was not achieved, and have 
issued supplemental guidance to their field commands.

    29. Senator Gillibrand. Dr. Guice and Dr. Galbreath, I am 
interested in the comparison between those suffering from combat-
related PTSD and from sexual assault-related PTSD. Can you tell me how 
many servicemembers have been discharged with a PD that emerged as a 
result of combat-related trauma versus the number of sexual assault 
survivors who have been discharged with a PD that is actually PTSD?
    Dr. Guice and Dr. Galbreath. Empirical research on military 
populations is smaller than civilian studies but evidence does suggest 
that sexual assault victims are at higher risk for PTSD than other 
populations. Both conditions are underreported which increases the 
difficulty of obtaining these exact numbers. While DOD does not have 
statistical data on sexual assault survivors being discharged with PDs, 
policy protection as detailed in DODI, 1332.14, are in place to ensure 
individuals with PDs are not discharged inappropriately. Owing to the 
implementation of this policy and direction issued by the USD(P&R) in 
2009 for the Military Departments to report fiscal year 2008 and fiscal 
year 2009 compliance with DOD PD separation requirements, PD 
separations have decreased from 4,000 per year (1 in 3,000 members) in 
2007 to 300 per year currently (1 in 50,000 members).

                              demographics
    30. Senator Gillibrand. Dr. Bell, during your testimony, you 
specified that MST can be affected by demographics. The VA reported 
some 600,090 veterans are seeking care for MST. What is the demographic 
breakdown by era of service, gender, and age?
    Dr. Bell. Below is a demographic breakdown by gender, age, and era 
of service for the 93,439 veterans who received outpatient care from VA 
for either a mental or physical health condition related to MST in 
fiscal year 2013.
Gender:
    Among the 93,439 veterans who received MST-related care in fiscal 
year 2013, 58,061 (62.1 percent) were female, and 35,378 (37.9 percent) 
were male.
Age:
    Among the 58,061 female veterans who received MST-related care in 
fiscal year 2013, 24,095 (41.5 percent) were between 18 and 44 years, 
31,179 (53.7 percent) were between 45 and 64 years, and 2,787 (4.8 
percent) were 65 years or older.
    Among the 35,378 male veterans who received MST-related care in 
fiscal year 2013, 5,837 (16.5 percent) were between 18 and 44 years, 
20,802 (58.8 percent) were between 45 and 64 years, and 8,738 (24.7 
percent) were 65 years or older.
Era of Service:
    Although VA cannot generally provide MST data aggregated by period 
of service, data is available specific to the cohort of veterans who 
have been deployed in service of OEF/OIF/OND.
    Among the 58,061 female veterans who received MST-related care in 
fiscal year 2013, 10,451 (18 percent) served in OEF/OIF/OND.
    Among the 35,378 male veterans who received MST-related care in 
fiscal year 2013, 2,830 (8 percent) served in OEF/OIF/OND.

  VETERANS RECEIVING VA OUTPATIENT CARE RELATED TO MST FISCAL YEAR 2013
                                [Percent]
------------------------------------------------------------------------
                                                     Women        Men
                                                  (N=58,061)  (N=35,378)
------------------------------------------------------------------------
Gender..........................................        62.1        37.9
Age range:
 
  18-44.........................................        41.5        16.5
  45-64.........................................        53.7        58.8
  65 or older...................................         4.8        24.7
 
OEF/OIF/OND.....................................        18.0         8.0
------------------------------------------------------------------------

                                 ______
                                 
                Questions Submitted by Senator Tim Kaine
                             overmedication
    31. Senator Kaine. Dr. Guice, Ms. Garrick, and Dr. Galbreath, 
overmedication of Active Duty servicemembers has directly led to 
suicides in recent years. At a Senate Veterans Affairs Committee 
hearing in Atlanta, GA, in 2013, a caregiver recalled a soldier in the 
Warrior Transition Unit at Fort Stewart, GA, who was struggling with 
PTSD and overdosed. After 2 months of inpatient rehabilitation 
elsewhere, he returned to Fort Stewart. Soon after, his squad leader 
took him to the hospital because he was complaining of severe pain. The 
hospital prescribed codeine and sent him back to the barracks. That 
night he took the codeine pills, crushed them up, and injected them. He 
died as a result. What is DOD doing to monitor the multiple and various 
prescription drugs that are given to servicemembers suffering from 
PTSD?
    Dr. Guice, Ms. Garrick, and Dr. Galbreath. DOD has developed 
several programs to monitor patients who are on multiple prescription 
medications that pose a risk because of high addiction or lethality 
potential. The programs listed below provide prescription monitoring 
for patients on high risk medications that are used for multiple 
diagnoses, to include complex PTSD with comorbid chronic pain.

         Each MTF's Prescription Restriction Program, available 
        in the electronic Pharmacy Data Transaction Service (PDTS), can 
        set restrictions on prescriptions for patients on high risk 
        medications (those with high dependency and/or lethality 
        potential). PDTS automatically checks new prescriptions against 
        the patient's medical/prescription history before a new drug is 
        dispensed. Drug dispensing histories from MTF pharmacies, 
        retail, and mail-order pharmacy are integrated. This 
        information helps providers to know when to restrict controlled 
        and psychotropic/central nervous system prescriptions.
         The Services' Wounded Warrior Programs provide 
        assistance and advocacy for severely wounded, ill, and injured 
        servicemembers, veterans, and their families.
         The MHS also offers Case Management services to ``high 
        utilizer'' patients (those with 10 or more emergency department 
        visits in 1 year) and ``at-risk'' patients, defined as those 
        patients with multiple conditions or diagnoses, or catastrophic 
        conditions such as serious brain injury, spinal cord injury, 
        traumatic amputation, cancer and/or those needing extensive 
        coordination of resources and services.
         The Services' SUD programs provide frequent substance 
        use monitoring through random alcohol and drug testing. 
        Concerns over substance misuse and relapse are communicated to 
        prescribing providers.

    32. Senator Kaine. Dr. Guice, Ms. Garrick, and Dr. Galbreath, one 
of the concerns that I've expressed to the VA Secretary is reducing the 
wait time for a veteran to schedule an appointment, particularly those 
veterans with symptoms of PTSD. For servicemembers with PTSD, what is 
DOD doing to reduce wait times between initial appointments and follow-
up at MTFs?
    Dr. Guice, Ms. Garrick, and Dr. Galbreath. DOD has been diligently 
working to increase the availability of care, the number of mental 
health providers, and to develop multiple portals of entry (not all of 
them medical) making it easier to obtain care, advice, or assistance. 
DOD beneficiaries are using mental health services at the highest rate 
ever. The amount of clocked wait time for a routine follow-up 
appointment is determined by two primary factors: the servicemember's 
schedule preference for the day and time of an appointment and the 
availability of a sufficient number of mental health providers to 
deliver follow-on care.
    DOD policy mandates specific access standards regarding wait times 
for the different circumstances requiring care which are the same as 
the standard followed for medical primary care services. Emergency care 
is provided immediately. Urgent care appointments are provided within 
24 hours. A follow-up appointment is categorized as ``routine care'' 
and should be scheduled within 7 days of the servicemember's request 
for an appointment. A vast expansion of mental health providers into 
primary care clinics and into line units (for Active Duty 
servicemembers) allows most patients to be seen same day, even if the 
need is not urgent. We are at virtually 100 percent compliance for 
meeting the appointment time requirements for emergency and urgent 
care. The overall average number of days for receiving follow-on care 
appointments of any kind for those servicemembers on Active status is 
less than 10 days. While this is slightly over the 7-day policy 
requirement, this is often related to servicemember scheduling 
requirements and preferences. DOD is continuously monitoring 
appointment wait times, and working to improve access to timely 
appointments.

    33. Senator Kaine. Dr. McCutcheon and Dr. Bell, similar to Active 
Duty members, overmedication of veterans has been a recent concern. At 
a hearing for the House Committee of Veterans' Affairs in October 2013, 
a physician who formerly worked at the VA hospital in Hampton, VA, 
commented, ``There are multiple instances when I have been coerced or 
even ordered to write [prescriptions] for Schedule II narcotics when it 
was against my medical judgment.'' How is the VA looking into 
situations where doctors may feel pressure to prescribe narcotics 
against their medical judgment?
    Dr. McCutcheon and Dr. Bell. We cannot comment on individual cases. 
However, individual care plans are developed by clinicians. Currently, 
VA medical centers are working to provide education for providers to 
help them develop opioid treatment plans and address their concerns.

    34. Senator Kaine. Dr. McCutcheon and Dr. Bell, what is the VA 
doing to monitor the multiple and various prescription drugs that are 
given to veterans to minimize the possibility of suicidal behavior?
    Dr. McCutcheon and Dr. Bell. VA's duty is to minimize the risk of 
suicidal behavior no matter what method a patient may be considering. 
In fact, overdoses represent the most common method for suicide 
attempts, but not deaths, among VA patients. VA monitors prescribed 
medications in many contexts.
    The first opportunity to monitor medication use to minimize the 
possibility of suicidal behavior is at the time a VA provider initiates 
or modifies a patient's medication regimen. During this encounter, the 
provider reviews all medication prescribed by VA providers, medications 
the patient reports receiving from non-VA providers, and non-
prescription, over-the-counter medications the patient reports using. 
The information on medications is used in conjunction with other 
clinical information to maximize the effectiveness of treatment and to 
minimize the potential for drug-drug and drug-disease interactions as 
well as the risk of suicide.
    There are a number of additional safeguards that occur after this 
step. First, there are routine reviews of prescriptions by pharmacists 
during the process of filling and dispensing a prescription to identify 
prescribing errors. Second, during care transitions there are 
comprehensive reviews of medications, known as medication 
reconciliation, where medications prescribed by VA and outside 
providers are compared with those actually taken by the patient. Third, 
providers ask about whether patients have accumulated stores of 
medications or other potential means for completing suicide as part of 
the safety planning process whenever they identify patients at high 
risk for suicide.
    In recent years, VA identified a number of medications, including 
anticonvulsants and antidepressants, which had the potential of 
contributing to the causes of suicide-related behaviors and outcomes. 
Whenever these effects were observed, VA systematically sent 
information to providers notifying them about the findings and provided 
guidance about the need for providing increased monitoring, while 
ensuring patients with conditions such as seizure disorders and 
depression received effective treatment.
    At present, VA is augmenting these ongoing strategies with two 
programs. One is the Opioid Safety Initiative, designed to enhance 
monitoring for all patients receiving opioids for pain management. The 
other is the Psychopharmacology Effectiveness and Safety Initiative, 
designed to improve the quality of psychopharmacological treatment as a 
key component of overall mental health treatment. This program has 
provided feedback to VISNs and facilities about prescribing patterns 
and is working to ensure that facilities have the knowledge and 
evidence-based pharmacology tools to support clinical judgment.

    35. Senator Kaine. Dr. McCutcheon and Dr. Bell, one of my concerns 
that I've expressed to the VA Secretary is reducing the wait time for a 
veteran to schedule an appointment, particularly those veterans with 
symptoms of PTSD. For servicemembers with PTSD, what is the VA doing to 
reduce wait times between initial appointments and follow-up at MTFs?
    Dr. McCutcheon and Dr. Bell. The Department is addressing the 
current and growing demand for mental health services through a 
summarized strategy covering four major themes: (1) Development of 
policies that explicitly establish access standards and centralized 
oversight to track compliance with those standards; (2) Leveraging 
telehealth and other technologies that extend the reach of brick and 
mortar facilities into rural communities and digital phone technologies 
that provide ``on demand'' veteran access to behavioral health support; 
(3) Staffing recruitment; and (4) Leveraging community partnerships.
Policies and Standards
    First, VHA has redefined access to mental health as a veteran's 
ability to schedule an appointment within 14 days of his or her desired 
date for new or established mental health appointments. Fiscal year 
2014 data demonstrate that 95.5 percent of established patients are 
seen within that standard.
Telehealth
    In order to reach veterans in rural communities, telemental health 
efforts have resulted in telehealth psychotherapy mental health 
encounters tripling between fiscal years 2011 and 2013. In addition, 
digital phone applications that support the treatment of PTSD (i.e., 
PTSD Coach) have been developed and downloaded 126,000 times for 
iPhones and Android smartphones in 75 countries.
Staffing
    To meet this growing demand, VA has hired an additional 1,600 
mental health clinicians and expanded its mental health workforce to 
include more than 800 Peer Specialists who are also veterans.
Community Partnerships
    VA also recognizes that coordinated, collaborative care is 
effective care, and in fiscal year 2013, VA hosted local mental health 
summits at each of our medical centers to broaden the community 
dialogue. Preliminary data from these summits suggest that they 
fostered an improved understanding and relationship between VA 
facilities and the communities in which they are located.
                                 ______
                                 
           Questions Submitted by Senator Angus S. King, Jr.
                            confidentiality
    36. Senator King. Dr. Galbreath, you spoke briefly about mental 
health providers being bound by law to inform servicemembers of the 
potential that their psychotherapy records may be required to be 
released for potential use in criminal proceedings against their 
assailant. Please describe the psychotherapist-patient privilege in the 
military. Does a similar privilege exist in non-military Federal 
criminal courts? If so, how do they differ?
    Dr. Galbreath. [Answer provided by the Office of General Counsel]:
    Because this question poses purely legal issues, it has been 
referred to the DOD Office of General Counsel for a response.
A. The military and Federal civilian courts' approaches to privilege 
        rules
    The Military Rules of Evidence were modeled after the Federal Rules 
of Evidence, which apply to the Federal district courts. Most of the 
Military Rules of Evidence are identical to their Federal Rules 
counterparts with the exception of using military-specific terminology 
where it differs from Federal civilian nomenclature. One of the key 
areas where the Military Rules of Evidence and the Federal Rules of 
Evidence diverge, however, concerns privileges.
    When the Supreme Court proposed the Federal Rules of Evidence in 
1972, they included nine rules codifying the law of privileges. One of 
those proposed rules--Rule 504--would have established a 
psychotherapist-patient privilege subject to three exceptions. Congress 
ultimately rejected the Supreme Court's proposed privilege rules. In 
their place, in 1975 Congress adopted a rule providing that privileges 
``shall be governed by the principles of the common law as they may be 
interpreted by the courts of the United States in light of reason and 
experience.'' Fed. R. Evid. 501.
    When the President promulgated the Military Rules of Evidence in 
1980, he took a different approach, opting to codify privilege rules. 
As the Military Rules of Evidence's drafters explained, the military 
justice system vests considerable authority in non-lawyers. For 
example, the non-lawyer commanders who impose nonjudicial punishment 
and the non-lawyer military officers who often conduct summary courts-
martial must apply the law of privileges in those proceedings. 
Accordingly, the rules' drafters believed that it was important to 
provide specific rules of privilege. However, to allow for further 
development of the rules governing privileges, Military Rule of 
Evidence 501 provides that privileges generally recognized in civilian 
criminal trials in United States district courts will be applied in 
court-martial proceedings to the extent that they are not inconsistent 
with the prescribed privilege rules.
    The Military Rules of Evidence as originally drafted and adopted 
did not include a psychotherapist-patient privilege. Then, and now, the 
rules specifically reject a physician-patient privilege. Mil. R. Evid. 
501(d).
B. The Supreme Court's recognition of a psychotherapist-patient 
        privilege
    In 1996, in the case of Jaffee v. Redmond, the Supreme Court held 
that ``confidential communications between a licensed psychotherapist 
and her patients in the course of diagnosis or treatment are protected 
from compelled disclosure under Rule 501 of the Federal Rules of 
Evidence.'' 518 U.S. 1, 15 (1996). That case involved a civil action 
arising from a police officer shooting and killing a suspect. The 
Supreme Court held that a psychotherapist-patient privilege existed and 
protected police officers' statements made during counseling sessions 
with a licensed clinical social worker. The Supreme Court indicated 
that the privilege was not absolute and ``that there are situations in 
which the privilege must give way,'' such as ``if a serious threat of 
harm to the patient or to others could be averted only by means of a 
disclosure by the therapist.'' Id. at 18 n.2. But the Court declined to 
define the privilege's specific scope, indicating that future cases 
would determine the privilege's ``full contours.'' Id. at 18.
C. Military Rule of Evidence 513
    In 1999, the President adopted Military Rule of Evidence 513, which 
provides a psychotherapist-patient privilege. The rule was amended in 
2012 to delete a spousal abuse exception and in 2013 to allow a 
military judge greater discretion to decline to examine the evidence or 
a proffer in camera. As amended, the rule provides:
    Rule 513. Psychotherapist-Patient Privilege
    (a)  General Rule. A patient has a privilege to refuse to disclose 
and to prevent any other person from disclosing a confidential 
communication made between the patient and a psychotherapist or an 
assistant to the psychotherapist, in a case arising under the Uniform 
Code of Military Justice, if such communication was made for the 
purpose of facilitating diagnosis or treatment of the patient's mental 
or emotional condition.
    (b)  Definitions. As used in this rule:

        (1)  ``Patient'' means a person who consults with or is 
examined or interviewed by a psychotherapist for purposes of advice, 
diagnosis, or treatment of a mental or emotional condition.
        (2)  ``Psychotherapist'' means a psychiatrist, clinical 
psychologist, or clinical social worker who is licensed in any State, 
territory, possession, the District of Columbia, or Puerto Rico to 
perform professional services as such, or who holds credentials to 
provide such services from any military health care facility, or is a 
person reasonably believed by the patient to have such license or 
credentials.
        (3)  ``Assistant to a psychotherapist'' means a person directed 
or assigned to assist a psychotherapist in providing professional 
services, or is reasonably believed by the patient to be such.
        (4)  A communication is ``confidential'' if not intended to be 
disclosed to third persons other than those to whom disclosure is in 
furtherance of the rendition of professional services to the patient or 
those reasonably necessary for such transmission of the communication.
        (5)  ``Evidence of a patient's records or communications'' 
means testimony of a psychotherapist, or assistant to the same, or 
patient records that pertain to communications by a patient to a 
psychotherapist, or assistant to the same, for the purpose of diagnosis 
or treatment of the patient's mental or emotional condition.

    (c)  Who May Claim the Privilege. The privilege may be claimed by 
the patient or the guardian or conservator of the patient. A person who 
may claim the privilege may authorize trial counsel or defense counsel 
to claim the privilege on his or her behalf. The psychotherapist or 
assistant to the psychotherapist who received the communication may 
claim the privilege on behalf of the patient. The authority of such a 
psychotherapist, assistant, guardian, or conservator to so assert the 
privilege is presumed in the absence of evidence to the contrary.
    (d)  Exceptions. There is no privilege under this rule:

        (1)  when the patient is dead;
        (2)  when the communication is evidence of child abuse or of 
neglect, or in a proceeding in which one spouse is charged with a crime 
against a child of either spouse;
        (3)  when Federal law, State law, or Service regulation imposes 
a duty to report information contained in a communication;
        (4)  when a psychotherapist or assistant to a psychotherapist 
believes that a patient's mental or emotional condition makes the 
patient a danger to any person, including the patient;
        (5)  if the communication clearly contemplated the future 
commission of a fraud or crime or if the services of the 
psychotherapist are sought or obtained to enable or aid anyone to 
commit or plan to commit what the patient knew or reasonably should 
have known to be a crime or fraud;
        (6)  when necessary to ensure the safety and security of 
military personnel, military dependents, military property, classified 
information, or the accomplishment of a military mission;
        (7)  when an accused offers statements or other evidence 
concerning his mental condition in defense, extenuation, or mitigation, 
under circumstances not covered by R.C.M. 706 or Mil. R. Evid. 302. In 
such situations, the military judge may, upon motion, order disclosure 
of any statement made by the accused to a psychotherapist as may be 
necessary in the interests of justice; or
        (8)  when admission or disclosure of a communication is 
constitutionally required.

    (e)  Procedure to Determine Admissibility of Patient Records or 
Communications.

        (1)  In any case in which the production or admission of 
records or communications of a patient other than the accused is a 
matter in dispute, a party may seek an interlocutory ruling by the 
military judge. In order to obtain such a ruling, a party must:

            (A)  file a written motion at least 5 days prior to entry 
of pleas, specifically describing the evidence and stating the purpose 
for which it is sought or offered, or objected to, unless the military 
judge, for good cause shown, requires a different time for filing or 
permits filing during trial; and
            (B)  serve the motion on the opposing party, the military 
judge and, if practical, notify the patient or the patient's guardian, 
conservator, or representative that the motion has been filed and that 
the patient has an opportunity to be heard as set forth in subdivision 
(e)(2).

        (2)  Before ordering the production or admission of evidence of 
a patient's records or communication, the military judge must conduct a 
hearing. Upon the motion of counsel for either party and upon good 
cause shown, the military judge may order the hearing closed. At the 
hearing, the parties may call witnesses, including the patient, and 
offer other relevant evidence. The patient must be afforded a 
reasonable opportunity to attend the hearing and be heard at the 
patient's own expense unless the patient has been otherwise subpoenaed 
or ordered to appear at the hearing. However, the proceedings may not 
be unduly delayed for this purpose. In a case before a court-martial 
composed of a military judge and members, the military judge must 
conduct the hearing outside the presence of the members.
        (3)  The military judge may examine the evidence or a proffer 
therefore in camera, if such examination is necessary to rule on the 
motion.
        (4)  To prevent unnecessary disclosure of evidence of a 
patient's records or communications, the military judge may issue 
protective orders or may admit only portions of the evidence.
        (5)  The motion, related papers, and the record of the hearing 
must be sealed in accordance with R.C.M. 1103A and must remain under 
seal unless the military judge or an appellate court orders otherwise.

D. Psychotherapist-patient privilege exception in Federal civilian 
        courts
    As previously noted, the Supreme Court left the task of developing 
the contours of the psychotherapist-patient privilege to the lower 
Federal courts. The resulting case law has been far from uniform; the 
privilege is applied in different manners--and different exceptions 
have been recognized--in various Federal courts.
    A comparison of the exceptions recognized under Military Rule of 
Evidence 513 and in Federal practice follows:

    (1)  Deceased patient exception

    Federal case law on whether the psychotherapist-patient privilege 
survives the patient's death is sparse. As one Federal district court 
recently observed, ``Whether the psychotherapist-patient privilege 
survives the death of the patient, or is otherwise affected by the 
patient's death, is a matter that has not been conclusively decided.'' 
Awalt v. Marketti, 287 F.R.D. 409, 414 (N.D. Ill. 2012). The few courts 
that have substantively addressed the issue concluded that the 
privilege survives the patient's death. See id. at 414-15; Richardson 
v. Sexual Assault/Spouse Abuse Resource Center, Inc., 764 F. Supp. 2d 
736, 741 (D. Md. 2011). In United States v. Hansen, 955 F. Supp. 1225, 
1226 (D. Mont. 1997), the court did not hold that the privilege is 
unavailable where the patient is dead, but indicated that ``[t]he 
holder of the privilege has little private interest in preventing 
disclosure, because he is dead.'' That ruling, however, preceded the 
Supreme Court's holding in Swidler & Berlin v. United States, 524 U.S. 
399 (1998), that the attorney-client privilege generally survives the 
client's death.
    Military Rule of Evidence 513(d)(1) expressly excludes dead 
patients from the protection of the privilege.

    (2)  Child abuse or neglect exception

    There do not appear to be any reported post-Jaffee decisions 
addressing whether there is a child abuse or neglect exception to the 
Federal psychotherapist-patient privilege. There are cases, however, in 
which Federal courts have applied State law child abuse or neglect 
exceptions. See, e.g., Bassine v. Hill, 450 F. Supp. 2d 1182 (D. Or. 
2006) (applying Oregon's statutory exception to psychotherapist-patient 
privilege for child abuse cases); United States v. Mathis, 377 F. Supp. 
2d 640, 646 (M.D. Tenn. 2005) (applying Tennessee's statutory exception 
to psychotherapist-patient privilege for child abuse cases).

    (3)  Duty to report exception

    Federal courts are split as to whether the psychotherapist-patient 
privilege is abrogated where the psychotherapist is under a legal duty 
to report a statement, such as a threat to another. The United States 
Courts of Appeals for the Sixth and Ninth Circuits hold that such 
statements may not be admitted into evidence. United States v. Chase, 
340 F.3d 978 (9th Cir. 2003) (en banc); United States v. Hayes, 227 
F.3d 578 (6th Cir. 2000). The United States Courts of Appeal for the 
Fifth Circuit will not apply a privilege in such situations. United 
States v. Auster, 517 F.3d 312 (5th Cir. 2008). Military Rule of 
Evidence 513 is consistent with practice in the Fifth Circuit. Military 
Rule of Evidence 513(d)(3) provides an exception ``when Federal law, 
State law, or Service regulation imposes a duty to report information 
contained in a communication.''

    (4)  Dangerous-patient exception

    In Jaffee, the Supreme Court observed that ``we do not doubt that 
there are situations in which the privilege must give way, for example, 
if a serious threat of harm to the patient or to others can be averted 
only by means of a disclosure by the therapist.'' Jaffee, 518 U.S. at 
18 n.19. Federal courts, however, have split over what is called the 
``dangerous-patient exception'' to the psychotherapist-patient 
privilege. The Sixth, Eighth, and Ninth Circuits have rejected such an 
exception. Chase, 340 F.3d 978; United States v. Ghane, 673 F.3d 771 
(8th Cir. 2012); Hayes, 227 F.3d 578. Tenth Circuit case law supports 
such an exception. United States v. Glass, 133 F.3d 1356 (10th Cir. 
1998); see also United States v. Robinson, 583 F.3d 1265, 1279 (10th 
Cir. 2009) (noting that Glass created a narrow exception to the 
psychotherapist-patient privilege ``where `disclosure [is] the only 
means of averting [imminent] harm' ''). Military Rule of Evidence 513 
is consistent with the Tenth Circuit's application of Jaffee.

    (5)  Crime/fraud exception

    The United States Court of Appeals for the First Circuit has held 
that a crime/fraud exception applies to the psychotherapist-patient 
privilege. In re Grand Jury Proceedings (Gregory P. Violette), 183 F.3d 
71, 77 (1st Cir. 1999). A Federal district court decision from Virginia 
agrees. In re Sealed Grand Jury Subpoenas, 810 F. Supp. 2d 788, 794 
(W.D. Va. 2011). There do not appear to be any reported post-Jaffee 
Federal decisions to the contrary. Military Rule of Evidence 513 is 
consistent with the First Circuit's approach.

    (6)  Military necessity exception

    Military Rule of Evidence 513's exception for ensuring the safety 
and security of military personnel, military dependents, military 
property, classified information, or the accomplishment of a military 
mission is military-specific and has no analog in Federal civilian 
practice.

    (7)  Waiver by placing the patient's mental condition in issue

    In Jaffee, the Supreme Court recognized that a patient may waive 
the psychotherapist-patient privilege. Jaffee, 518 U.S. at 15 n.14. 
Federal courts have generally held that a patient waives the privilege 
when the patient puts his or her mental health at issue in a court 
case. See, e.g., Doe v. Dairy, 456 F.3d 704, 718 (7th Cir. 2006); 
Schoffstall v. Henderson, 223 F.3d 818, 823 (8th Cir. 2000). Federal 
courts have, however, differed over the precision with which a patient 
must place a psychotherapist-patient communication in issue to waive 
the privilege, though those differing approaches arise in a civil, 
rather than criminal, litigation context. See generally Koch v. Cox, 
489 F.3d 384, 390 (DC Cir. 2007); see also St. John v. Napolitano, 274 
F.R.D. 12, 17-21 (D.D.C. 2011).
    Military Rule of Evidence 513's exception 7 removes the privilege 
only from certain psychotherapist-patient communications by an accused; 
it does not remove the privilege from any psychotherapist-patient 
communications by a victim or witness.

    (8)  Constitutionally required exception

    Some Federal courts have held that the psychotherapist-patient 
privilege recognized in Jaffee, which was a civil case, does not apply 
against the defense in criminal cases. For example, a United States 
District Court for the District of Oregon decision held that a criminal 
defendant's rights of confrontation and due process overcome the 
psychotherapist-patient privilege. Bassine v. Hill, 450 F. Supp. 2d 
1182, 1185 (D. Or. 2006). The U.S. District Court for the District of 
Massachusetts reached a similar result. United States v. Mazzola, 217 
F.R.D. 84, 88 (D. Mass. 2003). Other Federal district court decisions 
have used a balancing test to determine whether the privilege applies 
in a particular criminal case. See, e.g., United States v. Alperin, 128 
F. Supp. 2d 1251, 1253-54 (N.D. Cal 2001); United States v. Hansen, 955 
F. Supp. 1225, 1226 (D. Mont. 1997). Still other Federal district court 
decisions have held that the psychotherapist-patient privilege does not 
yield to a criminal defendant's constitutional rights. See, e.g., 
United States v. Shrader, 716 F. Supp. 2d 464, 471-72 (S.D. W. Va. 
2010); United States v. Doyle, 1 F. Supp. 2d 1187, 1189-90 (D. Or. 
1998). Following a detailed analysis of competing precedent, a Federal 
district judge in West Virginia held, ``The psychotherapist-patient 
privilege contemplates an exception where necessary to vindicate a 
criminal defendant's constitutional rights.'' United States v. White, 
No. 2:12-cr-00221, 2013 WL 1404877, at *13 (S.D. W. Va. April 5, 2013). 
The court elaborated that ``where a requesting party establishes that 
the guarantees of due process may be implicated by the withholding of 
evidentiary information, confidential documents otherwise subject to 
the psychotherapist-patient privilege may be disclosed if they are 
material, either because they may be exculpatory or because they 
adversely affect the credibility of the government's witnesses.'' Id. 
at #15. In White, the judge ordered the release of certain mental 
health documents concerning a witness to the defense. Id. at *17.
    The United States Court of Appeals for the Tenth Circuit, whose 
precedent is particularly important for the military justice system 
because it reviews habeas corpus decisions in cases arising from the 
United States Disciplinary Barracks, has held that absent an absolute 
evidentiary privilege, a prosecutor must disclose information to the 
defense, even if it falls under a psychotherapist-patient privilege, if 
it is favorable to the defense and material to the defendant's guilt or 
punishment. Browning v. Trammell, 717 F.3d 1092, 1094 (10th Cir. 2013). 
Evidence is favorable to the defense if it is exculpatory or 
impeaching. Id. (citing Banks v. Dretke, 540 U.S. 668, 691 (2004)). The 
10th Circuit noted that the Supreme Court has reserved judgment on a 
prosecutor's duty to disclose potentially exculpatory evidence where an 
absolute privilege exists. Id. at 1102 n.8 (citing Pennsylvania v. 
Ritchie, 480 U.S. 39, 58 n.14 (1987)).
    Military practice, in which the psychotherapist-patient privilege 
applies but may be overcome by the accused's constitutional rights in a 
given case, is more protective of the patient than in some Federal 
civilian jurisdictions and less protective than in others. It is 
consistent with the middle, contextual approach followed by, among 
other Federal courts, the United States District Court for the Southern 
District of West Virginia in White.
E. In camera review of documents to resolve privilege issues
    Federal judges considering a party's request for a defendant's or 
witness's mental health records have often reviewed the records in 
camera. See, e.g., United States v. Blake, No. 13-80054-CR, 2014 WL 
1764679, at *7 (S.D. Fla. 2014); United States v. White, No. 2:12-cr-
00221, 2013 WL 1404877 (S.D. W. Va. April 5, 2013); United States v. 
Loughner, 782 F. Supp. 2d 829, 833 (D. Ariz. 2011); United States v. 
Robinson, 583 F.3d 1265 (10th Cir. 2009); United States v. Mazzola, 217 
F.R.D. 84, 86-87 (D. Mass. 2003); United States v. Alperin, 128 F. 
Supp. 2d 1251, 1255 (N.D. Cal. 2001); United States v. Haworth, 168 
F.R.D. 660 (D.N.M. 1996); United States v. Lowe, 948 F. Supp. 97 (D. 
Mass. 1996). But see United States v. Stone, No. CR. 05-30049, 2005 WL 
1845153, at *3 (D.S.D. 2005); Doyle, 1 F. Supp. 2d at 1191. The United 
States Court of Appeals for the 10th Circuit has held that in camera 
reviews are appropriate to determine whether the Constitution requires 
that evidence falling within the psychotherapist-patient privilege be 
turned over to the defense. Browning, 717 F.3d at 1095.
    In military practice, the Navy-Marine Corps Court of Criminal 
Appeals has identified a three-part inquiry based on Wisconsin case law 
to determine whether a military judge will conduct an in camera review:

    (1)  did the moving party set forth a specific factual basis 
demonstrating a reasonable likelihood that the requested privileged 
records would yield evidence admissible under an exception to Mil. R. 
Evid. 513; (2) is the information sought merely cumulative of other 
information available; and (3) did the moving party make reasonable 
efforts to obtain the same or substantially similar information through 
non-privileged sources?

    United States v. Klemick, 65 M.J. 576, 580 (N-M. Ct. Crim. App. 
2006) (citing Wisconsin v. Green, 648 N.W.2d 298 (Wis. 2002)).
    The procedural approach to resolving psychotherapist-patient 
privilege issues under Military Rule of Evidence 513 appears to be 
similar to that applied in most Federal district courts.

    37. Senator King. Dr. Galbreath, please provide your views on 
legislation that would require the following: If a victim of sexual 
assault or MST provides details to a therapist about the effect that 
episode has had on their lives or details of the incident in question, 
that information should be bound by confidentiality and not subject to 
subpoena for potential use in military justice proceedings.
    Dr. Galbreath. This question asks for views on hypothetical 
legislation. It would be inappropriate to comment on such hypothetical 
legislation. Having actual or draft legislation to review would 
facilitate an informed assessment.
                                 ______
                                 
             Questions Submitted by Senator Lindsey Graham
       commander's role in medical care of sexual trauma victims
    38. Senator Graham. Dr. Guice, what responsibility does a commander 
have to ensure a servicemember under his/her command gets appropriate 
medical care, including mental health care, following a sexual assault?
    Dr. Guice. The Surgeons General of the Military Departments provide 
guidance on the medical management of victims of sexual assault to 
ensure there is standardized, timely, accessible, and comprehensive 
care for every patient. To emphasize the importance, every sexual 
assault victim is treated as an emergency and given priority treatment. 
In addition, subordinate commanders have specific responsibilities to 
ensure servicemembers get appropriate medical care. This information is 
detailed in the DODI 6495.02, March 28, 2013.
    Unit commanders, supervisors, and managers at all levels are 
responsible for the effective implementation of the SAPR program and 
policy. Military and DOD civilian officials at each management level 
shall advocate a strong SAPR program and provide education and training 
that shall enable them to prevent and appropriately respond to 
incidents of sexual assault.
    Each installation commander develops guidelines to establish a 24-
hour, 7-day-per-week sexual assault response capability for their 
locations, including deployed areas. For SARCs that operate within 
deployable commands that are not attached to an installation, senior 
commanders of the deployable commands shall ensure that equivalent SAPR 
standards are met. In addition, the Installation Commander chairs the 
Case Management Group (CMG) and can request a high-risk safety 
assessment be conducted by trained personnel of each sexual assault 
victim at each CMG meeting. If victim is assessed to be in a high-risk 
situation, the CMG chair will immediately stand up a multi-disciplinary 
high-risk response team to continually monitor the victim's safety, by 
assessing danger and developing a plan to manage the situation.
    SARCs must be notified of every incident of sexual assault 
involving servicemembers or persons covered in the policy, in or 
outside of the military installation when reported to DOD personnel. 
Upon notification, the SARC or SAPR VA shall respond to offer the 
victim SAPR services. All SARCs shall be authorized to perform victim 
advocate duties in accordance with Service regulations, and will be 
acting in the performance of those duties. In the instance of 
Restricted Reports, the SARC shall be notified by the healthcare 
personnel or the SAPR VA and in Unrestricted Reports, the SARC shall be 
notified by the DOD responders. The SARC shall serve as the single 
point of contact to coordinate sexual assault response when a sexual 
assault is reported.

                         sexual trauma and ptsd
    39. Senator Graham. Dr. Bell, what is the prevalence of PTSD in 
veterans who are victims of sexual trauma?
    Dr. Bell. Among the subset of veterans who use VHA care and who 
received MST-related mental health care in fiscal year 2012, 57 percent 
of women and 54 percent of men had a diagnosis of PTSD. It is important 
to note that these data are for only those veterans currently receiving 
MST-related mental health care and not all veterans who have 
experienced MST. As such, these data likely represent an overestimate 
of prevalence of PTSD among all veterans who experienced MST.

    40. Senator Graham. Dr. Bell, is history of sexual trauma a major 
risk factor for PTSD?
    Dr. Bell. Research has consistently found that both men and women 
are at increased risk for developing PTSD after experiencing sexual 
trauma, whether in civilian or military contexts. Sexual trauma is, in 
fact, more likely to result in symptoms of PTSD than are most other 
forms of trauma, including combat. Data suggest this finding holds for 
sexual assault in the military context as well, with MST being more 
strongly associated with PTSD and other health consequences than most 
other types of trauma.

                                suicide
    41. Senator Graham. Ms. Garrick, what is the prevalence of PTSD in 
servicemembers who are victims of suicide?
    Ms. Garrick. Through the DODSER, the Department collects data about 
military suicide decedents and attempters. The DODSER tracks 
demographic information such as the cause and manner of death or 
attempts, substance abuse and psychological health history, and 
deployment and combat experiences. The DODSER also tracks the 
prevalence of PTSD amongst those servicemembers who died by suicide. In 
2012, 17 servicemembers or 5.3 percent of those who died by suicide 
were diagnosed with PTSD. The range in previous years has been 14 
servicemembers in 2010 and 19 servicemembers in 2009.

    42. Senator Graham. Ms. Garrick, in DOD's experience, is history of 
sexual trauma a major risk factor for suicide?
    Ms. Garrick. Empirical research from civilian populations suggests 
that sexual assault victims are at an increased risk for suicidal 
ideation, attempts, and deaths. The few research studies that have been 
conducted on the military population also suggest that military sexual 
assault and harassment victims may be subject to similar risks. 
However, to date, we do not have enough data to state conclusively what 
the linkages between military suicides and military sexual assaults are 
and if there is any correlation.
    The DSPO and the SAPRO jointly sponsoring a study to better 
understand the prevalence of suicide risk among sexual assault victims. 
Using data from the Survey of Health-Related Behavior of Active Duty 
Members, the study will assess whether statistically significant 
relationships between self-reported instances of sexual assault and 
suicidal ideation and attempts exist. In addition, the study will 
analyze the extent to which risk factors for sexual assault overlap 
with risk factors for suicidal ideation and attempts. DSPO will use the 
data to assess whether there is a need to modify existing suicide 
prevention and resilience programs to address any unique risks 
associated with sexual assault victims.

            appropriate therapies for sexual assault victims
    43. Senator Graham. Dr. Guice and Dr. McCutcheon, are DOD and VA 
providing the most appropriate medical and behavioral health therapies 
for sexual assault victims? Please explain.
    Dr. Guice. Yes we are. Medical care for survivors of sexual assault 
is mandated by DODI 6495.02 ``Sexual Assault Prevention and Response 
Program Procedures'' and describes the four key comprehensive elements 
of care provided to survivors of sexual assault.

    (1)  Timely and standardized health care across the Services

         It is DOD policy that sexual assault victims 
        presenting to a medical facility must be seen and assessed 
        immediately regardless of evidence of physical injury, be 
        gender-responsive, culturally competent, and recovery-oriented.

    (2)  Comprehensive acute and follow-up medical care

         All survivors receive a comprehensive assessment 
        including a history and physical exam;
         Once victims are medically stable, they are offered a 
        SAFE;
         Offered the services of a SARC;
         Offered testing and prophylactic treatment options for 
        sexually transmitted diseases;
         Offered assessment of pregnancy risk with options for 
        emergency contraception;
         Offered counseling on any necessary or recommended 
        follow-up care and referral services; and
         When feasible, and with the victim's consent, medical 
        management is linked to the patient's primary care manager for 
        follow-up treatment to facilitate continuity of care and 
        support.

    (3)  Standardized DOD and Service forensic examination procedures 
requires:

         Standardized SAFE kits at all MTFs;
         Medical providers are trained to follow the ``National 
        Protocol'' Standard;
         SARC services are offered to the survivors (The SARC 
        or a Sexual Assault Response Victim Advocate is available to 
        respond and speak to victims at any time requested);
         Communication and coordination of care between the 
        SARC responders and healthcare personnel;
         Mechanisms exist to assure confidentiality in cases 
        where the survivor has elected restricted reporting;
         After a SAFE has been conducted, the chain of custody 
        is maintained and handed off to the military Service-designated 
        law enforcement agency (in the case of unrestricted reporting) 
        or Military Criminal Investigative Organization for restricted 
        reports; and
         There is a mechanism for the SARC to generate a 
        restricted reporting control number for labeling in cases of 
        restricted reports to preserve confidentiality of the survivor 
        while ensuring that the chain of custody for evidence will be 
        retrievable if the survivor chooses to proceed with 
        unrestricted reporting at a later date.

    (4)  Comprehensive behavioral health services

         Survivors are assessed and offered immediate 
        behavioral health services or a referral for follow-up 
        services, as the survivor requests or as clinically indicated.
         The most appropriate medical and behavioral health 
        therapies are based on a thorough clinical assessment and take 
        into account patient centered preferences for treatment if they 
        request treatment. Behavioral health care is guided by the 2010 
        VA/DOD Post-Traumatic Stress Clinical Practice Guideline that 
        states survivors of trauma (including sexual assault) must be 
        assessed for trauma related symptoms, medical and functional 
        status, pre-existing medical and psychiatric problems, and risk 
        for developing PTSD and other conditions in the aftermath of a 
        trauma. While survivors of sexual assault may develop no 
        symptoms of a disorder, evidence-based treatments are 
        recommended and provided for disorders (e.g., depression, 
        insomnia, and PTSD) when they occur. These treatments include 
        pharmacotherapy and exposure-based psychotherapies, such as 
        Prolonged Exposure and Cognitive Processing Therapy for PTSD.

    Dr. McCutcheon. MST is associated with a range of mental health 
conditions and appropriate treatment will depend on a given veteran's 
specific difficulties. Over the past decade, VA has made a significant 
commitment to ensuring that all veterans have access to cutting-edge, 
evidence-based psychotherapies. For example, VA national policy 
requires every VA health care facility to provide evidence-based 
psychotherapies. VA Mental Health Services has also conducted national 
rollouts of evidence-based psychotherapies such as Cognitive Processing 
Therapy, Prolonged Exposure, Acceptance and Commitment Therapy, and 
Cognitive Behavioral Therapy to train VA mental health providers in 
these evidence-based approaches. Practice guidelines developed outside 
VA and DOD, such as the guidelines issued by the International Society 
for Traumatic Stress Studies and the American Psychiatric Association, 
concur with the VA/DOD guideline in recommending these treatments and 
similar cognitive-behavioral approaches for treating sexual assault 
survivors. These rollouts of evidence-based psychotherapies have 
particular significance for veterans who experienced MST, as they 
target mental health conditions that are strongly associated with MST. 
Also, several were originally tested and developed with sexual trauma 
survivors. The rollouts are an important means of providing veterans 
with access to state-of-the-art treatment to assist them in their 
recovery from MST.

                  civilian approaches to ptsd therapy
    44. Senator Graham. Dr. Guice and Dr. McCutcheon, DOD and VA both 
use evidence-based therapies--like prolonged exposure therapy and 
cognitive processing therapy--to treat PTSD. What do civilian experts 
recommend as the most effective treatment approaches for PTSD?
    Dr. Guice. Both military and civilian mental health providers rely 
on the VA/DOD Clinical Practice Guideline for PTSD for recommendations 
on the most effective psychological treatments currently available. The 
PTSD Clinical Practice Guideline workgroup brought together DOD, VA, 
and civilian subject matters experts to develop these guidelines based 
on military, VA, and academic research. The exposure-based 
psychotherapies recommended in the PTSD Clinical Practice Guideline--
Prolonged Exposure and Cognitive Processing Therapy--were originally 
developed by civilian psychotherapy researchers specifically to treat 
PTSD among rape victims, and these treatment approaches are currently 
considered the state-of-the-art for treatment of PTSD due to various 
forms of trauma (to include combat as well as sexual assault) for 
civilians and military personnel alike.
    Dr. McCutcheon. Treatment approaches always need to be tailored to 
the specific needs of individual veterans and take into account not 
only comorbid health conditions but also the veteran's treatment and 
broader psychosocial history, his or her current life context, and his 
or her individual preferences. Psychoeducation about PTSD and the 
impact of sexual assault can also be an important component of 
treatment. Regarding treatment for veterans with PTSD specifically, a 
significant research base has accumulated identifying trauma-focused 
Cognitive Behavioral Therapy, such as Cognitive Processing Therapy and 
Prolonged Exposure, as effective treatments for PTSD. Cognitive 
Processing Therapy and Prolonged Exposure in particular were originally 
developed to treat sexual assault survivors and have a particularly 
strong evidence base in this area. Practice guidelines developed 
outside VA and DOD, such as the guidelines issued by the International 
Society for Traumatic Stress Studies and the American Psychiatric 
Association, concur with the VA/DOD guideline in recommending these 
treatments and similar cognitive-behavioral approaches for treating 
sexual assault survivors.

                           continuity of care
    45. Senator Graham. Dr. Guice and Dr. McCutcheon, how do DOD and VA 
ensure continuity of medical care, including mental health care, as 
victims of MST transition from Active service to veteran status?
    Dr. Guice. DOD ensures continuity of care to the VA through: (a) 
care coordination and case management activities; and (b) electronic 
health record information-sharing initiatives for all patients, to 
include victims of sexual trauma who receive health care services 
within the Mental Health Services. Military retirement circumstances 
determine the type of care coordination Services offered. Four care 
coordination/case management pathways are presented below to 
illustrate:

    1.  An Active Duty servicemember receiving mental health service 
care is eligible and chooses to retire from Service. This Active Duty 
servicemember is assigned a SARC and Sexual Assault Prevention and 
Response Victim Advocate (SARP VA). The SARC is the single point of 
contact for coordinating care but the SARP VA, therapist, and case 
manager may also assists with referrals.
    2.  The Active Duty servicemember is in the Warrior Transition Unit 
(WTU) and the Integrated Disability Evaluation System (IDES) process 
with a medical discharge from Military Service. The Active Duty 
servicemember is assigned a physician Primary Care Manager (PCM) and a 
WTU Nurse Case Manager (NCM) who coordinates transition of care to the 
VA. This Active Duty servicemember may have already received care at a 
VA Polytrauma Center and would already be a shared DOD/VA patient. The 
SARC and SARP VA can also assist to set up transfer to the VA.
    3.  An Active Duty servicemember in the IDES process is being 
medically discharged from the Service but not in a WTU. The PCM and the 
NCM in the Patient Centered Medical Home would arrange VA care. The 
SARC and SARP VA can also assist in the transfer.
    4.  An Active Duty servicemember survivor of sexual assault from a 
spouse would receive counseling from the Service's Family Advocacy 
Program. The Family Advocacy Program counselor, the SARC or SARP VA 
could assist the patient to transfer to VA if the patient is retiring 
from Service or being medically discharged and not in a WTU.

    Recent DOD and VA Integrated Electronic Health Record clinical 
data-sharing initiatives makes it possible for DOD and VA providers to 
view medical record information from both departments electronically, 
which facilitates continuity of care:

    1.  The Bidirectional Health Information Exchange which offers two-
way data sharing for patients who receive care in both DOD and VA. Real 
time data include: allergies, outpatient pharmacy, lab and radiology 
reports, demographics, diagnoses, vital signs, problem lists, family 
history, social history, questionnaires, and theater clinical data.
    2.  The Clinical Data Repository/Health Data Repository is a two-
way (DOD to VA and VA to DOD) repository for patients who receive care 
in both DOD and VA facilities (shared patients). The Clinical Data 
Repository/Health Data Repository provides pharmacy and drug allergy 
data in real time and is computable, which means that data elements can 
be pulled and sorted. The use of these shared data programs promotes 
continuity of medical care, including mental health treatment between 
DOD and VA.
    3.  The Federal Health Information Exchange provides monthly 
transfer of data from DOD to VA (one way) on servicemembers separated 
from Active Duty service. Data include patient demographics, lab and 
radiology results, outpatient pharmacy, allergies, and hospital 
admission information.

    Dr. McCutcheon. Please see the response to Question 18.

            sexual assaults before entering military service
    46. Senator Graham. Dr. Galbreath, we understand that 
servicemembers are coming forward to report sexual assaults that 
occurred to them prior to coming into the military. Does DOD report 
those cases to civilian law enforcement authorities for investigation?
    Dr. Galbreath. Yes. At the victim's request, each of the Military 
Criminal Investigative Organizations (Army Criminal Investigations 
Division, Naval Criminal Investigative Service, Air Force Office of 
Special Investigations) can and do connect a servicemember with the 
civilian law enforcement agency that would have responsibility for 
investigating a report of sexual assault that occurred prior to his or 
her joining the military.

                    polypharmacy and substance abuse
    47. Senator Graham. Dr. Guice and Dr. McCutcheon, sexual trauma 
victims can sometimes experience devastating physical injuries and 
mental health disorders. Often, medical providers will prescribe 
multiple medications, including drugs with abuse potential. Some 
servicemembers will also self-medicate with alcohol or other drugs. 
What are DOD and VA doing to identify and implement best practices to 
prevent substance abuse among sexual assault victims?
    Dr. Guice. Current policy, screening programs, and collaboration 
across agencies target the identification and prevention of substance 
misuse among sexual assault victims, as well as among all 
servicemembers. DODI 1010.04 ``Problematic Substance Use by DOD 
Personnel,'' signed February 20, 2014, addresses prevention, screening, 
and intervention for SUDs. This policy requires regular and systematic 
medical screening for substance use/early intervention and increased 
training for healthcare personnel on screening and prevention of SUDs.
    For example, DOD is currently implementing Screening, Brief 
Intervention, and Referral to Treatment (SBIRT) in primary care. SBIRT 
is an approach endorsed by the Office of National Drug Control Policy, 
the Substance and Mental Health Services Administration, and the VA. 
SBIRT includes the routine screening of patients for SUDs using 
empirically-validated measures along with prescribing interventions 
stemming from identified risks. Widespread implementation of SBIRT 
within primary care settings provides an opportunity for early 
identification of substance misuse, which allows for timely 
intervention. Finally, to prevent misuse of prescription medication, 
the dispensing and tracking of prescription medications in a manner 
that best monitors therapeutic use is a nationwide and DOD priority. 
The DOD PDTS matches real-time prospective drug utilization with a 
patient's medication history for each new or refilled prescription 
before it can be dispensed to the patient. PDTS flags beneficiaries 
whose cases reveal an excessive number of: controlled substance claims, 
pharmacies used to obtain controlled drugs, and/or prescribing 
providers.
    Dr. McCutcheon. Substance use is a key concern in the treatment of 
veterans who experienced MST, as SUDs are one of the top five 
conditions associated with MST among veterans seen in VA for MST-
related mental health care. Facility MST coordinators are encouraged to 
develop collaborative relationships with other clinical program 
coordinators, including VA's SUD-PTSD Specialists at each facility, to 
integrate MST-specific materials into their training for staff and 
outreach to veterans. MST coordinators are also available to provide 
consultation to staff on cases involving MST, when needed.
    It is VHA policy that veterans treated in VA receive an annual 
screening for unhealthy alcohol use in Primary Care, Mental Health, or 
other Specialty Care Clinics. Those veterans who indicate at-risk 
alcohol consumption receive brief counseling and either a 
recommendation to reduce their consumption to within recommended limits 
or to abstain from alcohol, as clinically indicated. Providers of 
patients with screening results that show the highest risk for alcohol 
use disorders are prompted to discuss referral to specialty addiction 
treatment providers for comprehensive evaluation or additional 
treatment.
    VA/DOD Clinical Practice Guidelines for Management of PTSD and 
Acute Stress Reaction (published in 2010) and the accompanying Pocket 
Guide (published in 2013) specifically recommend against prescribing 
benzodiazepines for either acute stress reaction or PTSD, citing 
evidence of harm from use of benzodiazepines in patients with PTSD. VHA 
provides training in evidence-based treatment of acute stress reaction 
and PTSD emphasizing psychotherapy and medications without addictive 
potential.
    Since fiscal year 2013, VHA has implemented a national Opioid 
Safety Initiative that identifies patients on high doses of opioid 
medications for pain or patients who are receiving benzodiazepines and 
opioids concurrently. Consistent with the VA/DOD Clinical Practice 
Guideline on Management of Opioid Therapy for Chronic Pain, multiple 
efforts are underway to support more effective pain management 
strategies, including the availability of alternatives to opioid 
medications and urine drug testing to monitor those for whom long-term 
opioid therapy is clinically indicated.

    48. Senator Graham. Dr. Guice and Dr. McCutcheon, as sexual assault 
victims transition from DOD to VA health care, how do the two 
Departments transfer pharmacy data so healthcare providers have real-
time data available to prevent harmful drug interactions and to avert 
over-prescribing psychoactive and/or narcotic drugs?
    Dr. Guice. DOD and the VA transfer pharmacy data through two 
Integrated Electronic Health Record clinical data-sharing initiatives, 
which make it possible for both DOD and VA to view each other's medical 
record information in real time.

    1.  The Bidirectional Health Information Exchange offers two-way 
(DOD to VA and VA to DOD) data-sharing on patients who receive care in 
both DOD and VA. Real time data includes: allergies, outpatient 
pharmacy, lab and radiology reports, demographics, diagnoses, vital 
signs, problem lists, family history, social history, questionnaires, 
and theater clinical data.
    2.  The Clinical Data Repository/Health Data Repository is a two-
way (DOD to VA and VA to DOD) repository for patients who receive care 
in both DOD and VA facilities (shared patients). The Clinical Data 
Repository/Health Data Repository provides pharmacy and drug allergy 
data in real time and is computable, which means that data elements can 
be pulled and sorted. The use of these shared data programs promotes 
continuity of medical care, including mental health, between DOD and 
VA.

    To prevent harmful drug interactions and to avert over-prescribing 
psychoactive and/or narcotic drugs, the DOD Pharmaco-Economic Center 
has a MTF Prescription Restriction Program available in the electronic 
PDTS that can set restrictions on prescriptions for patients on high 
risk medications (those with high dependency and/or lethality 
potential). PDTS automatically checks new prescriptions against the 
patient's medical/prescription history before a new drug is dispensed. 
Drug dispensing histories from MTF pharmacies, retail, and mail-order 
pharmacy are integrated. This information helps providers know when to 
restrict controlled and psychotropic/central nervous system 
prescriptions. This information is available to VA through 
Bidirectional Health Information Exchange and Clinical Data Repository/
Health Data Repository for sexual assault victims transitioning to VA 
care.
    Dr. McCutcheon. Providers and pharmacists can view a patient's 
prescription records by viewing information in a variety of locations, 
such as Janus Legacy Viewer, VistAWeb, and Remote Data View. Each of 
these simply provides a `view only' option (allowing users to see 
information entered at other sites), but they do not provide medication 
alerts.
    Limited DOD pharmacy data elements are available through the 
Clinical Data Repository/Health Data Repository application. Clinical 
Data Repository/Health Data Repository is a combined effort between DOD 
and VA. Clinical Data Repository/Health Data Repository is used to 
exchange clinical data between VA's Health Data Repository and DOD's 
Clinical Data Repository for Active Dual Consumer patients.
    A Dual Consumer is a patient who is eligible for health care under 
both DOD and VA health plans or a patient who has been assigned to a 
joint venture site and meets the requirements under a DOD/VA sharing 
agreement for coverage of specified clinical services. An Active Dual 
Consumer patient is a dual consumer who has actually been treated by 
both DOD and VA facilities. Active Dual Consumer patients can have 
their Active Dual Consumer status set to active or inactive. When an 
Active Dual Consumer patient's status is set as Active, the sharing of 
DOD and VA records is initiated. In order to comply with laws and 
policies that are designed to protect the privacy of patient medical 
records, Active Dual Consumer patients have their status set to 
inactive status by default.
    Detailed prescription data is not transferred to VA via Clinical 
Data Repository/Health Data Repository. Even though detailed 
prescription data is not transferred, if a veteran is marked as an 
Active Dual Consumer, then Health Data Repository will display data 
showing all of the drugs the veteran has been prescribed at DOD 
facilities. The record will not specify whether the veteran is still 
prescribed these medications, or if the veteran is still taking these 
medications.
    Medication Order Check Healthcare Application compares VA 
prescriptions against the list of DOD drugs in Health Data Repository. 
With this information, Medication Order Check Healthcare Application 
provides an alert for known adverse drug interactions and possible 
duplicate therapy. This alert prompts the pharmacist or provider to 
check the viewable DOD records in Janus Legacy Viewer, VistAWeb, or 
Remote Data View to determine the point in time that the veteran was 
prescribed the medication and at what dosages.
    In addition to providing mediation alerts, Medication Order Check 
Healthcare Application's duplicate therapy order checks detect over-
prescribing by comparing the drug ordered by the provider against a 
patient's current and past prescription profile using DOD data in 
Health Data Repository. Finally, dosing checks (which are now being 
deployed as part of Medication Order Check Healthcare Application 2.0) 
analyze the dosage of the current order being prescribed in order to 
ensure that the medication is not being overprescribed. Dosing order 
checks only occur at the time a medication is ordered. In other words, 
dosing checks do not occur upon transfer of prescription data from DOD 
to VA, but rather when a new drug order is made.
    At any time, irrespective of whether Medication Order Check 
Healthcare Application has issued an alert for duplicative therapy or 
for questionable dosage, the pharmacist or provider can view DOD 
prescription data using Janus Legacy Viewer, VistAWeb, or Remote Data 
View. The pharmacist or provider can then use this information to check 
for duplicate therapy, drug-drug interactions, or allergy concerns.

    49. Senator Graham. Dr. Guice, Dr. McCutcheon, and Dr. Galbreath, 
how do benefits, support, and medical care for victims of sexual 
assault in the military compare to those offered to civilian victims?
    Dr. Guice and Dr. Galbreath. I am aware of the following free 
benefits, support, and medical care for military victims that are not 
available in the civilian community:

         The DOD SAPR policy requires medical care and SAPR 
        advocacy services are gender-responsive, culturally competent, 
        and recovery-oriented;
         Healthcare providers and SARC shall provide a response 
        that recognizes the high prevalence of pre-existing trauma 
        (prior to the present sexual assault incident). Trauma-Informed 
        Care is an approach to engage people with histories of trauma 
        that recognizes the presence of trauma symptoms and 
        acknowledges the role that trauma has played in their lives. 
        Trauma-informed services are based on an understanding of the 
        vulnerabilities or triggers of trauma survivors that 
        traditional service delivery approaches may exacerbate, so that 
        these services and programs can be more supportive and avoid 
        re-traumatization;
         Free medical care (both initially for immediate or 
        acute care and any follow up);
         Free mental health care, for as long as the member 
        desires treatment;
         Free legal representation by military attorneys at all 
        military justice proceedings through the Special Victims 
        Counsel program;
         The opportunity to request an expedited transfer to 
        another location, if they filed an Unrestricted Report;
         A Military Protective Order that can be issued by a 
        military officer that does not require a court appearance or 
        open court-testimony by the victim; and
         A multi-disciplinary safety evaluation that involves 
        command, law enforcement, the SARC, legal personnel, mental 
        health professionals, and others as required.

    Dr. McCutcheon. It would be difficult to provide a concise 
comparison of VA and civilian services for sexual assault survivors, as 
there is no comparable equivalent to VA's single-source system of care 
in the civilian setting; the benefits, support, and medical care 
accessible to civilian survivors depends greatly on their particular 
circumstances. VA can, however, summarize aspects of VA health care 
that are unlikely to be duplicated, at least to the same degree, in 
civilian systems.
    First, it is VHA policy that all veterans seen for health care are 
screened for MST. This recognizes, importantly, that many survivors of 
sexual trauma do not disclose their experiences unless asked directly, 
may not be aware of available MST-related services, and may also not be 
aware of the extent to which their health conditions are related to 
sexual trauma. VA uses screening as an opportunity to make all patients 
aware of care that is available to them and to streamline access for 
those interested in this care.
    Second, individuals who have experienced sexual trauma, both 
veterans and civilians, may have a range of mental and physical health 
needs and seek treatment from a variety of clinics and medical 
settings. As a single umbrella provider, VA is well-positioned to 
provide coordinated, tailored care that ensures the veteran's history 
of MST is considered in all treatment provided. VA providers are 
familiar with internal resources available to address new or emergent 
treatment needs and can provide timely referrals, as needed. This 
includes the ability to refer for non-VA care from a private provider, 
if necessary. VA has a single system to document all MST-related care, 
regardless of type or setting, in the electronic medical record, which 
helps ensure that patients are not billed for the MST-related care they 
receive.
    Third, VA has taken extensive steps to ensure that MST-related 
treatment is available in every VA health care facility. Every facility 
has providers knowledgeable about mental health treatment of MST, and 
every facility provides MST-related mental health outpatient services 
including formal psychological assessment and evaluation, psychiatry, 
and individual and group psychotherapy. Specialty services are also 
available to target problems such as PTSD, substance abuse, depression, 
and homelessness. Outpatient counseling is also available at community-
based Vet Centers. For veterans who need more intensive treatment, VA 
has inpatient programs available for acute care needs, and many VA 
facilities have Mental Health Residential Rehabilitation and Treatment 
Programs. Some of these programs focus specifically on MST or have 
specialized MST tracks. As noted, every VA health care facility has a 
designated MST coordinator who serves as a point of contact on MST-
related issues and can assist veterans with accessing needed services.
    Finally, VA provides all medical, mental health, and pharmaceutical 
care for MST-related conditions free of charge. There are no external 
payers or insurance plan involvement for this care; no co-pays are 
required, and there are no time limits on the extent of this care, nor 
any exclusions for any health conditions.

    50. Senator Graham. Dr. Guice and Dr. McCutcheon, we heard 
testimony about medication being the initial therapy option while 
sexual assault victims wait a long time to see a counselor for 
treatment. Is it a common practice in both the civilian and Mental 
Health Services to offer medications soon after a sexual trauma event?
    Dr. Guice. It is a common practice in both the civilian and Mental 
Health Services to make clinical decisions based on a thorough 
assessment, taking into account patient-centered preferences for 
medication and/or psychotherapy. Based on these individual factors, 
medication may be indicated to best manage the symptoms associated with 
the early aftermath of sexual assault.
    DOD promotes evidence-based practices. Medication management is 
included as an evidence-based therapy for PTSD and the common comorbid 
conditions such as depression, bipolar disorder, substance use 
disorders, and chronic pain. The 2010 VA/DOD Clinical Practice 
Guideline for PTSD indicates victims must be assessed for trauma 
related symptoms, medical and functional status, pre-existing medical 
and psychiatric problems, and risk for developing PTSD or other 
comorbid conditions in the aftermath of a trauma. While the Clinical 
Practice Guideline states that there is no evidence to recommend 
pharmacotherapy to prevent PTSD, the guideline recommends that symptom-
specific treatment should be provided and basic needs addressed in the 
immediate period following a trauma. A short medication course for 
specific comorbid symptoms may be needed to address sleep disturbance, 
management of pain, irritation, and excessive arousal and anger. 
Patient preferences for treatment are also important considerations, 
and all patients are reassessed and monitored during clinical follow-
up.
    DHA evaluates the appropriateness of prescribing practices through: 
(1) electronic pharmacy surveillance programs; and (2) the peer review 
process required as part of the credentialing process for individual 
providers in the direct care system. Electronic surveillance programs 
include the PDTS which has a MTF Prescription Restriction Program that 
can set restrictions on prescriptions for patients on high risk 
medications (those with high dependency and/or lethality potential). 
The appropriateness of high risk medications are evaluated through use 
of the pharmacy information alert systems. The credentialing process 
for individual providers in the MTFs contains safeguards to ensure that 
individual prescribing practices meet the standard of care for safe and 
effective medical care. MTFs are accredited by The Joint Commission 
which requires peer review as part of the credentialing process for 
individual privileged providers with an independent practice scope of 
practice. Peer review involves the routine clinical quality monitoring 
performed by a peer in the same profession and clinical area of 
expertise as the provider under review. Peer review ensures that each 
privileged provider meets the standard of care. Results of peer review 
are summarized in the credentials package submitted every 24 months as 
part of periodic review for renewal of privileges for individual 
providers. Any concerns identified about a provider's prescribing 
practices are addressed as part of the peer review process.
    Dr. McCutcheon. The VA/DOD Clinical Practice Guideline for PTSD and 
other mental health disorders describe evidence-based prescribing of 
psychotropic medication. The Guideline may be accessed on the Internet 
at www.healthquality.va.gov. Good clinical practice would typically 
involve consideration of whether medication might be useful in the 
management and treatment of any mental health symptoms resulting from 
sexual trauma, either in the immediate aftermath of the experience or 
in the long-term. Research has shown that the best mental health 
treatment outcomes often occur when a combination of psychotherapy and 
medications are used. Treatment planning in the case of an individual 
veteran is always a veteran-centric endeavor, with the veteran and 
health care provider collaboratively determining what will be the best 
approach to address his or her specific needs. In VA, survivors of MST 
typically are not coming for care soon after the event (because the 
event occurred in the military, prior to separation), so VA cannot 
comment on the use of medications soon after a sexual trauma event.

    51. Senator Graham. Dr. Galbreath, does DOD have data to show the 
average time a sexual assault victim must wait from the initial report 
to the first counseling session? If so, please explain.
    Dr. Galbreath. DOD does not maintain data to show the average wait 
time a sexual assault victim must wait from the initial report to the 
first counseling session. However, the Surgeons General of the military 
departments provide guidance on the medical management of victims of 
sexual assault to ensure there is standardized, timely, accessible, and 
comprehensive care for every patient. Every sexual assault victim is 
treated as an emergency and given priority treatment. Emergency care is 
provided immediately. Urgent care appointments are provided within 24 
hours. A follow-up appointment is categorized as ``routine care'' and 
should be scheduled within 7 days of the servicemember's request for an 
appointment.
    A vast expansion of mental health providers into primary care 
clinics and into line units (for Active Duty servicemembers) allows 
most patients to be seen same day, even if the need is not urgent. We 
are above 90 percent compliance for meeting the appointment time 
requirements for emergency and urgent care.
    DOD continuously monitors appointment wait times, and works to 
improve access to timely appointments.
                                 ______
                                 
              Questions Submitted by Senator Kelly Ayotte
    early identification of mental health disorders and intervention
    52. Senator Ayotte. Dr. Guice, regarding treatment for 
servicemembers with psychological health problems, the Institute of 
Medicine found that challenges still exist at both DOD and VA. Among 
the areas of concern noted by the Institute of Medicine are 
inconsistencies in the availability of care, as well as a lack of 
systematic evaluation for treatment programs. How can DOD and VA both 
work together, and within their Departments, to ensure that high-
quality care is better coordinated and delivered in an efficient and 
effective manner?
    Dr. Guice. DOD and the VA have been working together to ensure that 
high-quality care is coordinated and delivered in an efficient manner 
via formal collaboration in the Health Executive Council (Health 
Executive Council, co-chaired by the VA Under Secretary for Health and 
the ASD(HA)) and its subcommittees, namely the DOD/VA Psychological 
Health and TBI Work Group, the DOD/VA Pain Management Work Group, and 
others.
    One initiative of the DOD/VA Psychological Health/TBI Work Group is 
the DOD/VA IMHS. This is a joint effort between the two Departments to 
advance an integrated public health model to improve access, quality, 
effectiveness, and efficiency of mental health services for all Active 
Duty servicemembers, National Guard and Reserve members, veterans, and 
their families. The IMHS includes 28 Strategic Actions, and 1 Strategic 
Action specifically addresses standardization of the quality and 
clinical outcome metrics used across both Departments to ensure 
continuous coordination of mental health quality measures.
    DOD and VA also adhere to Clinical Practice Guidelines developed by 
interagency working groups to ensure coordinated high-quality care both 
within and across Departments. Toolkits for providers, patients, and 
family members have been developed for the Clinical Practice Guidelines 
and are available for download at https://www.qmo.amedd.army.mil/
pguide.htm.
    Most recently, the President's Executive Order on ``Improving 
Access to Mental Health Services for Veterans, Servicemembers, and 
Families'' has charged the Interagency Task Force between DOD, VA, and 
Health and Human Servcies to develop coordinated solutions to improve 
access and eliminate barriers to mental health care. Standardization of 
mental health outcome metrics across the three Departments will 
facilitate the systematic evaluation of treatment programs and 
prevention initiatives.

                  sexual assault response coordinator
    53. Senator Ayotte. Dr. Galbreath, section 1724 of the NDAA for 
Fiscal Year 2014 (P.L. 113-66) requires each Service Secretary to 
ensure timely access to a SARC for any member of the National Guard or 
Reserve who is the victim of a sexual assault. Please provide an update 
on how DOD is doing in implementing this provision related to SARCs for 
the Guard and Reserve.
    Dr. Galbreath. The DOD SAPRO provides oversight and guidance to the 
Services as they implement NDAA for Fiscal Year 2014 provisions. Each 
of the Services has addressed providing timely access and support of 
SARC services differently that takes into consideration organizational 
structure and geographic coverage apart from the military unit. A 
summary of the status to providing timely access to SARCs for Reserve 
component servicemembers follows:

         The National Guard has hired one full-time SARC in 
        every State and Territory (54 States and Territories), for 
        servicemembers who are located at the Joint Forces Headquarters 
        and serve in either Title 32 Active Guard Reserve, Technician, 
        or Active Duty Operational Support status. Every SARC is 
        trained to provide service to both Air and Army National 
        guardsmen within the State or Territory. Additionally, the Air 
        National Guard has placed one airman, who serves on full time 
        status to serve in the SARC role as required within each wing. 
        The Army National Guard has one SARC, called the Collateral 
        SARC, at each division down to brigade.
         U.S. Army Reserve policy requires that a servicemember 
        victim be linked to the SARC that is located closest 
        geographically. In addition, the U.S. Army Reserve maintains 5 
        hotlines (1 hotline for each of 4 Regional Support Commands and 
        1 in Puerto Rico) staffed by 35 full-time military technicians 
        and Active Guard and Reserve SARCs. The hotlines are staffed 
        24/7. These SARCs offer support on the phone when a victim 
        calls, and can refer them to local civilian resources in crisis 
        situations. The hotline numbers, along with the DOD SAFE 
        Helpline phone number, are prominently posted in unit/drill 
        areas. The Army Reserve Command publishes an array of products 
        listing all five hotline numbers.
         Each U.S. Navy Reserve unit is required to have a 
        designated Unit SAPR VA who responds to servicemember victims. 
        In addition, the U.S. Navy Reserve provides SAPR response and 
        services through a Navy Operation Support Center which is 
        aligned with a Navy region with the Installation SARC providing 
        services. The contact number for 24/7 SAPR VA and SARC services 
        is posted in the Navy Operation Support Center and is made 
        available via the DOD SAFE Helpline. Audits are conducted 
        monthly to ensure posted telephone contacts are accurate and 
        victims receive immediate support.
         All U.S. Marine Corps Reserve sites have at least one 
        trained and appointed Uniformed Victim Advocate assigned to the 
        site to provide in-person response to victims of sexual 
        violence. All of the sites have memorandums of understanding 
        with other SAPR military and civilian rape crisis centers in 
        their localities. In addition, the U.S. Marine Corps Reserve 
        maintains a 24/7 Sexual Assault Helpline which provides 
        immediate telephonic crisis response to all Active Duty and 
        Reserve component marines/sailors assigned to the 162 Marine 
        Reserve sites throughout the United States including Alaska, 
        Hawaii, and Puerto Rico. The Helpline is staffed by the SAPR 
        Program Manager, three SARCs, and two civilian Victim Advocates 
        located in New Orleans. Once a report is received, a referral 
        will be made to the Uniformed Victim Advocate to provide 
        immediate in-person response. Uniformed Victim Advocates are 
        required to answer all calls within 15 minutes and to respond 
        in person within 1 hour of notification. All Marine Reserve 
        locations are mandated to post the SAPR Helpline as well as the 
        DOD SAFE Helpline throughout common areas of their facilities.
         The U.S. Air Force maintains a civilian SARC at each 
        of the 11 Host Wings. All Wing SARCs report to the Command SARC 
        who is located at Robins Air Force Base. Each of the SARCs is 
        issued a government cell phone and is on call 24/7. These SARC 
        numbers along with the DOD SAFE Helpline are posted in many 
        locations to ensure airmen are aware of the support.