[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]










    ENSURING ACCESS TO DISABILITY BENEFITS FOR VETERAN SURVIVORS OF 
                         MILITARY SEXUAL TRAUMA

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

                                HEARING

                               before the

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                                 of the

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        THURSDAY, JUNE 20, 2019

                               __________

                           Serial No. 116-20

                               __________


       Printed for the use of the Committee on Veterans' Affairs








[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]





        Available via the World Wide Web: http://www.govinfo.gov 
        
                             _________
                              
                 U.S. GOVERNMENT PUBLISHING OFFICE
                 
40-821                   WASHINGTON : 2021
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DR. PHIL ROE, Tenessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AMATA COLEMAN RADEWAGEN, American 
MIKE LEVIN, California                   Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          DR. NEAL DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DAN MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      GREG STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                   ELAINE LURIA, Virginia, Chairwoman

GIL CISNEROS, California             MIKE BOST, Illinois, Ranking 
GREGORIO KILILI CAMACHO SABLAN,          Member
    Northern Mariana Islands         GUS M. BILIRAKIS, Florida
COLIN ALLRED, Texas                  STEVE WATKINS, Kansas
LAUREN UNDERWOOD, Illinois           GREG STEUBE, Florida

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




















                            C O N T E N T S

                              ----------                              

                        Thursday, June 20, 2019

                                                                   Page

Ensuring Access To Disability Benefits For Veteran Survivors Of 
  Military Sexual Trauma.........................................     1

                           OPENING STATEMENTS

Honorable Elaine Luria, Chairwoman...............................     1
Honorable Mike Bost, Ranking Member..............................     2
Honorable Annie McLane Kuster, U.S. House of Representatives, 
  (NH-02)........................................................     3

                               WITNESSES

Mr. Steve Bracci, Director, Denver Benefits Inspection, Office of 
  Inspector General, U.S. Department of Veterans Affairs.........     5
    Prepared Statement...........................................    37
Mr. Willie Clark, Deputy Under Secretary for Field Operations, 
  Veterans Benefits Administration...............................     7
    Prepared Statement...........................................    42
        Accompanied by:

    Ms. Beth Murphy, Executive Director, Compensation Service, 
        Veterans Benefits Administration

    Dr. Margret Bell, Ph.D., National Deputy Director for 
        Military Sexual Trauma,Veterans Health Administration

The Honorable Chellie Pingree, U.S. House of Representatives, 
  (ME-01)........................................................    12

Ms. Elizabeth Tarloski, Adjunct Professor, Lewis B. Puller Jr. 
  Veteran's Benefits Clinic, William and Mary Law School.........    27
    Prepared Statement...........................................    47
Mr. Shane L. Liermann, Assistant National Legislative 
  Director,Disabled American Veterans............................    29
    Prepared Statement...........................................    49
Dr. Sharyn Potter, PhD, MPH, Executive Director of Research, 
  Prevention Innovations Research Center, University of New 
  Hampshire......................................................    30
    Prepared Statement...........................................    54

                       STATEMENTS FOR THE RECORD

Protect Our Defenders............................................    56
Vietnam Veterans Of America (VVA)................................    57
 
    ENSURING ACCESS TO DISABILITY BENEFITS FOR VETERAN SURVIVORS OF 
                         MILITARY SEXUAL TRAUMA

                              ----------                              


                        Thursday, June 20, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:30 a.m., in 
Room 210, House Visitors Center, Hon. Elaine Luria [Chairwoman 
of the Subcommittee] presiding.
    Present: Representatives Luria, Cisneros, Allred, 
Underwood, Bost, Bilirakis, and Watkins.
    Also Present: Representatives Pingree and Kuster.

         OPENING STATEMENT OF ELAINE LURIA, CHAIRWOMAN

    Ms. Luria. Good morning. I call this legislative hearing to 
order.
    Welcome to the Subcommittee on Disability Assistance and 
Memorial Affairs hearing. Today, we are here to discuss 
legislation granting veteran survivors of military sexual 
trauma easier access to VA benefits, and to discuss VA's 
progress in correcting errors in claims processing for MST-
related claims.
    Survivors of MST are some of the most vulnerable veterans. 
The economic impacts and psychological trauma associated with 
MST make access to VA benefits critical. It is imperative that 
we make sure we have a system in place that works for veterans, 
and also affords these claims the level of sensitivity and 
deference they deserve, and does not re-traumatize and 
discourage veterans in the process.
    Access to benefits is critically important for veterans who 
have suffered from MST. Experience has taught us that MST can 
result in a number of psychological conditions such as anxiety 
and depression, and not just PTSD. We also know that the 
psychological effects of trauma can last a lifetime.
    MST survivors need VA's help. They need access to benefits, 
because many of them struggle financially to support themselves 
as a direct result of their trauma.
    The legislation introduced by Ms. Pingree, H.R. 1092, 
codifies the relaxed evidentiary standard that simplifies the 
process for a veteran to establish the occurrence of MST. It 
also allows the VA to accept lay statements as sufficient 
evidence for MST. Many veterans did not report sexual violence 
while serving and, therefore, this alternative pathway to 
benefits is crucial; it is the difference between the grant of 
a claim or a denial, along with the substantial economic and 
psychological relief that accompanies these benefits.
    This bill also expands the definition of military sexual 
trauma to include technological abuse, recognizing the 
experience of servicemembers who were stalked, sexually 
harassed, and intimidated online. With the increasing presence 
of technology and social media in our culture, recognition of 
cybercrimes is necessary to broaden our understanding of sexual 
abuse.
    While the best strategy to respond to MST is one of 
prevention, this Subcommittee has the opportunity to improve 
the livelihood and well-being of survivors and their loved 
ones. By increasing access to benefits, we provide economic and 
mental relief. Importantly, we also validate the experiences of 
the men and women who survive MST while serving our Nation.
    I want to extend a warm welcome and thanks to our 
witnesses, some of whom have traveled a long way to be with us 
today. From the VA, we have Mr. Willie Clark, Ms. Beth Murphy, 
and Dr. Margret Bell; from the Office of the Inspector General, 
Mr. Steve Bracci.
    From my home district in Virginia, we have Ms. Elizabeth 
Tarloski, a staff attorney and adjunct professor at the Lewis 
B. Puller, Jr. Veteran's Benefits Clinic at the William and 
Mary Law School. I want to take a moment to recognize the 
incredible work of this clinic, whose mission at the school has 
always been first and foremost to help veterans. I applaud the 
fine work that they do.
    Finally, we welcome Mr. Shane Liermann of Disabled American 
Veterans, and Dr. Sharyn Potter of the University of New 
Hampshire.
    Thank you for being here today to address the issue of 
access to benefits for veterans and MST survivors.
    Before I recognize Ranking Member Bost for his opening 
statement, I want to welcome to this dais my colleague, Ms. 
Annie Kuster.
    And we also expect Ms. Chellie Pingree shortly, who 
introduced this legislation, the Servicemembers and Veterans 
Empowerment and Support Act of 2019. It is one of the subjects 
of our hearing today. Representative Pingree has been working 
actively on this legislation for three consecutive Congresses.
    We are also lucky to have Representative Annie Kuster with 
us today, and we appreciate your work to increase access to 
physical and mental health services for MST survivors. We look 
forward to hearing from you today.
    Without objection, Representative Pingree and 
Representative Kuster are permitted to sit at today's dais 
during the hearing.
    I now recognize Ranking Member Bost for his comments.

         OPENING STATEMENT OF MIKE BOST, RANKING MEMBER

    Mr. Bost. Thank you, Chair Luria. And thank all of you for 
being here today to discuss how the Department of Veterans 
Affairs can improve processing of claims based on military 
sexual trauma, or MST. These veterans have gone through an 
unimaginable ordeal and it is important for the VA to handle 
these sensitive cases properly.
    In fiscal year 2019, the Department of Defense estimated 
that over 20,000 men and women servicemembers experience some 
form of MST and of those only 6,000 servicemembers reported the 
incident. Tragically, studies have shown that victims of MST 
may not feel comfortable reporting an assault due to fear of 
retaliation or concerns it may impact their career progression.
    For these reasons, in 2002 the VA changes its regulations 
to be more lenient when verifying evidence of an in-service 
stressor for post-traumatic stress disorder claims based on 
personal trauma. Accordingly, VA determined a marker such as a 
documented change in behavior around the time of the alleged 
incident to prove a servicemember experienced a traumatic event 
during their service. Unfortunately, last August the Office of 
Inspector General, or IG, reported that PTSD claims based on 
MST were assigned to employees who did not have adequate 
training on developing these cases. As a result, the IG 
estimated that about 1300, or almost 50 percent, of the MST 
claims were not properly developed before the VA issued a 
denial. Although this does not mean that all of these cases 
were improperly denied, I am troubled that the VA did not 
ensure that these claims were handled as carefully as they 
should have been. VA owes it to these brave men and women to 
get their decision right the first time, so they can receive 
their benefits necessary to focus on their healing.
    I was encouraged by Inspector General Missal's testimony 
during the November 30th, 2018 DAMA Subcommittee hearing that 
the VA is in the process of executing all of the IG's 
recommendations in the MST report. Today, I would like to 
receive an update on VA's progress in implementing those 
recommendations.
    Additionally, last November DAMA's hearing focused on how 
the problems identified in the IG's MST report were not 
exclusive to MST claims. Instead, there was a systemic problem 
with the VA to design a plan that mitigates problems that may 
arise when implementing new programs. I appreciate the Under 
Secretary for Benefits Lawrence's commitment to changing the 
culture at VA by spending more time thinking about the 
potential risk and unintended consequences of proposed changes. 
I would like to know if there are any additional steps the VA 
can take to ensure that veterans are better served by the VA's 
claims process.
    Lastly, this hearing will focus on Representative Chellie 
Pingree's bill, H.R. 1092, which is intended to help MST 
survivors receive the benefits and health care they deserve. I 
look forward to the discussion how this bill would impact 
veteran survivors of MST.
    We all want the same thing, to ensure veterans who are 
struggling would trust VA and feel empowered to reach out and 
seek treatment for conditions.
    Thank you and I yield back.
    Ms. Luria. Thank you. And now I would like to recognize 
Representative Annie Kuster for 5 minutes.

       OPENING STATEMENT OF HONORABLE ANNIE MCLANE KUSTER

    Ms. Kuster. Thank you, Chairwoman Luria and Vice Chair 
Bost. I very much appreciate you holding this important 
hearing, and thank you for the opportunity to provide testimony 
this morning.
    I want to welcome all the witnesses participating and 
especially I am excited to welcome Sharyn Potter, a doctor from 
the University of New Hampshire who does extensive research in 
this area. I think you will be pleased to hear her testimony 
and I appreciate her making the trip. Thank you.
    Dr. Potter and her colleagues at the University of New 
Hampshire's Prevention Innovation Center perform outstanding 
and groundbreaking work with regard to sexual violence. Their 
collaboration with the Defense Department gives her a unique 
perspective on addressing military sexual trauma, known today 
as MST, and, more importantly, identifying how to prevent it.
    I also want to acknowledge the incredible leadership of my 
colleague and good friend Chellie Pingree, who will be with us 
shortly.
    I am a proud original cosponsor of the Servicemembers and 
Veterans Empowerment and Support Act, introduced by 
Representative Pingree, and I appreciate the Committee's 
interest in advancing this important legislation. It has been 
introduced for several cycles and I am hoping that this year 
will be the year that we get it through the House. As we 
continue working to foster a climate in the military where 
sexual violence and misconduct becomes eradicated, it is 
responsibility to ensure full services are readily available to 
those who suffer the trauma; the servicemembers and veterans 
who have stepped up to serve our Nation deserve nothing less. 
The Servicemembers and Veterans Empowerment Support Act takes 
an important step forward in reaching that goal.
    Two years ago, I founded and continue to co-chair the 
Bipartisan Task Force to End Sexual Violence. Our task force 
takes a holistic approach to addressing sexual violence across 
every facet of our society and we do so in a way that engages 
both sides of the aisle. From that perspective and as a 6-year 
former Member of this Committee, I recognize just how 
groundbreaking Representative Pingree's legislation will be. It 
allows veterans who report their experience after leaving the 
service to still be eligible for VA care. And let me say, as a 
survivor of sexual violence myself who kept my experience 
secret for 40 years, I cannot understate the importance of this 
provision.
    Our understanding of trauma has come so far, and we now 
recognize how difficult it is for survivors to acknowledge what 
happened to them and the risks that they take in reporting. 
That their military careers may be on the line only adds 
pressure and hesitation to this incredibly difficult decision.
    And let me just say, I can guarantee your study of 
consequences will be extensive. I just this week visited a 
prison in my district--I also have a task force on the opioid 
epidemic and what we are now learning is that many people 
suffering from substance use disorder and other mental health 
consequences have trauma related to sexual assault, whether it 
is in the military or in their civilian lives--and I was told 
that 100 percent of the women incarcerated in our women's 
prison in New Hampshire are survivors of sexual trauma, 100 
percent.
    Those who report months or years after their attack need 
the same level of care as those who are able to report 
immediately. On the task force, I have also had the opportunity 
to see the incredible trauma online and or cyber- harassment 
and violence can cause. It destroys careers, self-worth, and 
sometimes people's lives. I commend the inclusion of cyber-
harassment and violence survivors in this legislation.
    As the VA today provides updates on their work to improve 
MST claims processing and outreach, I urge my colleagues to 
remain vigilant on this issue. It is not an understatement to 
say that lives hang in the balance.
    Regarding sexual harassment and violence within the VA 
itself, I am grateful that the Government Accountability Office 
is executing my recommendation to investigate this issue in 
greater depth. This is one of the very first issues that I took 
up when I came to this Committee 6 years ago. They plan to 
complete their study in early 2020. I look forward to working 
with this Committee to examine the study and determine what 
actions Congress should take to address this situation.
    I again want to thank Chairman Luria and thank you, Vice 
Chair Bost, for your attention to this issue. I look forward to 
working with the Committee going forward and thank you for the 
partnership with our task force.
    Ms. Luria. Well, thank you, Representative Kuster, for 
joining us today. And I would like to now invite Panel 2 to the 
witness table.
    Appearing before us are Mr. Steve Bracci, Director of the 
Denver Benefits Inspection at the VA Office of the Inspector 
General; and Mr. Willie Clark, Deputy Under Secretary for Field 
Operations at the Veterans Benefits Administration. Mr. Clark 
is accompanied by Ms. Beth Murphy, Executive Director of the 
Compensation Service at the Veterans Benefits Administration, 
and Dr. Margret Bell, National Deputy Director for Military 
Sexual Trauma at the Veterans Health Administration.
    Thank you all for joining us today.
    We will start with Mr. Bracci. You are recognized for 5 
minutes. Thanks.

                   STATEMENT OF STEVE BRACCI

    Mr. Bracci. Chair Luria, Ranking Member Bost, and Members 
of the Subcommittee, thank you for the opportunity to discuss 
the Office of Inspector General's oversight of VA's processing 
of disability benefits for post-traumatic stress disorder 
related to MST.
    Sexual trauma experienced while in military service affects 
both men and women with serious and long-term consequences. 
Survivors of MST are often reluctant to report incidents and, 
even when they do, face the potential for significant distress 
during the disability claims process.
    According to the Department of Defense, more than 7600 
individuals reported a sexual assault in fiscal year 2018 for 
an incident that occurred during their military service, an 
increase of about 12.6 percent over the previous year. As more 
MST survivors report their assaults, every effort must be made 
to ensure they receive care and services compassionately and 
fairly. Processing their claims accurately the first time 
should minimize additional trauma while furthering VA's mission 
to serve the needs of our Nation's veterans.
    The OIG's August 2018 report examined whether VBA staff 
correctly processed veterans' MST claims. We found that nearly 
half of denied MST claims were not correctly processed 
following VBA policy. We further identified several 
deficiencies that led to these improper denials, such as a lack 
of specialization, inadequate training for processing staff, 
deficient internal controls, and discontinued special focus 
reviews.
    PTSD is a mental health condition that military members can 
develop after experiencing life-threatening events such as 
combat, natural disasters, and personal trauma. VBA defines MST 
as a subset of PTSD personal trauma claims specifically related 
to sexual harassment, sexual assault, or rape that occurred in 
a military setting.
    According to studies, the vast majority of sexual assault 
survivors do not seek immediate care and do not report the 
incidents to authorities. As a result, it is often difficult 
for victims of MST to produce the evidence required to support 
their disability claims. Because of this, VBA provided further 
guidance in 2011 to help ensure consistency, fairness, and a 
liberal approach for MST claims.
    The OIG audit team reviewed a sample of 169 MST claims that 
VBA staff denied during the period April 1st through September 
30th, 2017. We found that VBA staff incorrectly processed 82 of 
the 169 claims and, based on those results, we estimated that 
VBA did not correctly process nearly 50 percent of denied MST 
claims during that same review period.
    We determined there were four main causes for VBA's 
incorrect processing of these claims. First, there was a need 
for VBA staff with specialized knowledge and experience to 
process these sensitive claims. Second, VBA needed to improve 
the training provided to its employees. Third, VBA needed to 
establish an additional level of review for MST claims to 
ensure accuracy and consistency. And, fourth, VBA needed to 
reinstate special focus quality improvement reviews for MST 
claims, which VBA discontinued in December 2015.
    We made six recommendations to the Under Secretary for 
Benefits, who agreed to implement the recommendations and make 
necessary changes to help ensure the accurate processing of MST 
claims. Some progress has been made. Since the report's 
publication, VBA has provided documentation to close two of the 
six recommendations and has provided acceptable actions plans 
for the remaining four open recommendations.
    VBA provided the OIG their most recent status updates this 
week, which stated that implementation of the four open 
recommendations is still in progress. We will carefully review 
this update, as well as supporting documentation, and assess 
VBA's continued actions.
    VBA has expressed a strong commitment to fixing 
deficiencies identified by the OIG, which should help alleviate 
victims' stress and could also encourage more eligible veterans 
to step forward.
    The significant number of errors in denying MST claims, as 
detailed in our report, also highlights the need for continued 
vigilance even after all the recommendations are closed. We 
will continue to provide oversight on this, as well as other 
benefits and services needed by the most vulnerable population 
of veterans.
    Chair Luria, this concludes my statement, and I would be 
pleased to answer any questions you or other Members of the 
Subcommittee may have.

    [The prepared statement of Steve Bracci appears in the 
Appendix]

    Ms. Luria. Thank you, Mr. Bracci, and great job. I 
understand it is your first time testifying before a Committee, 
so I thank you for being here.
    And I would now like to recognize Mr. Clark.

                   STATEMENT OF WILLIE CLARK

    Mr. Clark. Good morning, Chair Luria, Ranking Member Bost, 
and Members of the Committee. Thank you for the invitation to 
speak today on VA disability benefits based upon military 
sexual trauma and H.R. 1092, the Servicemembers and Veterans 
Empowerment Support Act of 2019.
    With me is Beth Murphy, Executive Director of the 
Compensation Service, and Dr. Margret Bell, National Deputy 
Director for Military Sexual Trauma.
    Today, I will provide an update on our actions to improve 
MST claims processing, as well as provide the Department's 
views on the proposed legislation.
    The VA OIG completed a review of MST-related claims in 
August 2018. We acknowledge and have concurred on OIG's 
findings and the six recommendations provided. As of today, we 
have fully implemented two and are actively working on the 
remaining four.
    OIG's first recommendation was to review denied MST claims 
since 2017, which we implemented last year. As of yesterday, 
more than 92 percent of those reviews have been completed. We 
are continuing to track the cases that require corrective 
action.
    In response to the second recommendation, in lieu of 
specialized teams, we have mandated that each regional office 
maintain a requisite number of highly skilled employees to 
process MST-related claims. These employees are initially 
placed on second-signature review until they reach a high level 
of accuracy. Using this protocol also ensures our employees 
stay proficient in processing other disabilities that 
oftentimes accompany MST claims.
    OIG's final three recommendations relate to training and 
quality. We have significantly updated the training for 
processing MST-related claims, and will conduct a special-focus 
quality review and a targeted consistency study later this year 
to determine the effectiveness of those updates.
    Beyond these specific recommendations, we are dedicated to 
improving outreach to all veterans affected by MST. We maintain 
two trained MST coordinators, one female and one male, in every 
regional office. I am committed to ensuring that MST remains a 
primary topic for our field leaders.
    Last week, I discussed MST with all our assistant 
directors, and next week we are working with VHA to provide 
training and guidance to all of our Veterans Service Center 
managers at their annual conference. Ms. Beth Murphy leads that 
effort.
    Starting next month, we will institute monthly coordinator 
calls, and in the first quarter of next year we are bringing 
all MST coordinators together for our inaugural annual 
conference.
    We are committed to a robust outreach program for MST 
survivors. In the first 6 months of this fiscal year, we have 
provided over 2,000 veterans, family members, and other 
stakeholders with MST-related information at targeted outreach 
events. We collaborate with VHA on MST counseling and ensure a 
warm handoff.
    VBA is also working actively with DoD to provide 
information and resources to transitioning servicemembers. 
Information regarding MST-related services is included in the 
Transition Assistance Program participant guide, emphasizing 
that veterans and servicemembers are eligible for MST-related 
health care.
    I will now move on to providing the Department's views on 
H.R. 1092.
    VA appreciates the intent of the Committee to support 
veterans who may have experienced MST during service; however, 
we oppose some provisions of the bill. VA has acknowledged a 
challenge of corroborating a veteran's account of MST, which is 
why we allow decision makers to consider alternate sources of 
evidence, including behavioral changes and statements from 
other servicemembers or family when deciding claims. It is not 
necessary--I wanted to make this comment--it is not necessary 
for survivors of MST to have reported the incident in service 
in order to be service-connected for PTSD due to military 
sexual trauma, it is not necessary to report it while you are 
in service; if it happens after you leave service, we develop 
for those claims, and those members are provided the treatment 
and benefits accordingly.
    VA opposes the proposed amendment to Section 1154 of the 
bill; however, we have no objections to provisions in the bill 
that would reasonably expand the definition of ``covered mental 
health condition.''
    The number one priority of VBA is to provide veterans with 
the benefits they have earned in a manner that honors their 
service. This statement is one of the three principles that our 
Under Secretary, Dr. Paul Lawrence, regularly speaks to our 
agency about. In fact, he set the initial tone about our need 
for a compassionate and competent approach to MST claims by 
posting a video on YouTube. VBA must provide veterans affected 
by MST compassionate assistance in completing their claims. To 
that end, we have ensured these claims are processed by highly 
skilled and experienced employees engaged in comprehensive 
action and improved outreach, and committed to sustaining and 
enhancing these developments moving forward.
    This concludes my testimony. I will be happy to address any 
questions from Members of the Committee.

    [The prepared statement of Willie Clark appears in the 
Appendix]

    Ms. Luria. Well, thank you, Mr. Clark.
    I now recognize myself for 5 minutes. I will start out by 
questioning Mr. Clark and Ms. Murphy about a comment that you 
made. You quickly mentioned that you are opposed to Section 3, 
but during your remarks, maybe in the interest of time, you 
didn't amplify what that particular provision was and so I will 
call that out for other people who are participating in the 
hearing. That is the provision that allows for the VA to 
provide counseling and treatment for trauma resulting from 
sexual harassment using social media and cyber-bullying.
    In your more thorough written statement, you cite that your 
contact with field staff over the years, that, quote-unquote, 
``many clinicians would include this definition.''
    Why do you resist removing the ambiguity of what many 
clinicians might recognize and codifying that this in fact a 
means by which sexual harassment and bullying happen, and 
therefore should be clear for the veterans who might wish to 
file a claim, as well as the processors to understand that it 
is within the realm of the evidence that can be provided.
    Mr. Clark. Thank you. I would like to allow my VHA 
counterpart, Dr. Margret Bell, to speak to this topic.
    Dr. Bell. I believe actually Section 3 may speak to 
expanding the definition used by VHA to provide MST-related 
care and, as noted in our written testimony, we certainly don't 
oppose the expansion to include the technological abuse. I 
think, at a practical level, VHA is already operating in a way 
that encompasses much of what is included in that definition.
    Ms. Luria. You say you think. Is it perfectly clear? Is it 
in writing? Why should we leave the ambiguity?
    Dr. Bell. I think it would be perfectly fine to put it in 
writing and to include that in the formal definition in 
1720(d).
    I know, as a national office, if asked for guidance on that 
issue, our response to the field would certainly be that 
technological abuse would be kind of the means or the forums by 
which sexual harassment might be occurring and our 
authorization already includes the ability to provide care for 
sexual harassment, kind of the substance of it. And so, 
regardless of the means by that is occurring--
    Ms. Luria. No, but at this point we are talking about 
evidence. So I think that, you know, digital media, social 
media, records of that are certainly evidence that we should 
allow people to present if that is the means by which the abuse 
occurred.
    So, in the interest of time, I will move on to another 
question for you, Dr. Bell. H.R. 1092 expands the list of MST-
related psychological diagnoses beyond just PTSD. Can you speak 
briefly to the ways that MST can manifest psychologically and 
why it is necessary to recognize any related clinical diagnosis 
such as anxiety and depression also as diagnoses that would 
then qualify for a disability related to MST?
    Dr. Bell. Absolutely. The mental health impact that MST can 
have on our veterans can be very broad-ranging. I do think it 
is important to honor and acknowledge that many of our veterans 
show incredible resilience after MST, but, unfortunately, a 
good number do struggle in profound ways afterwards.
    In VHA, the top diagnoses that we see among the veterans 
that we are providing MST-related care for are post-traumatic 
stress disorder and depressive disorder, those are by far the 
top two, but then also rounding out the top five are anxiety 
disorders, bipolar disorders, and alcohol and substance use 
disorders.
    Ms. Luria. Thank you.
    And I will switch to Mr. Bracci now. Out of the errors that 
you identified in the MST-related claims processing during your 
additional review, was there one or a couple that stood out as 
most common?
    Mr. Bracci. Yeah, the top two categories of errors were--
the first one is that there was evidence that was sufficient to 
request a medical exam, but staff did not do that. That 
accounted for about 28 percent of the errors. And then the 
second one was evidence-gathering issues. And an example of 
that is staff not requesting veterans' private treatment 
records or their full military personnel file, and that 
accounted for about 13 percent.
    Ms. Luria. Thank you.
    And switching back to Mr. Clark or one of the people 
accompanying you. I know that one of the recommendations was to 
establish a checklist, that was recommendation number 6 and 
that has been complete. I would assume that--does the checklist 
encompass those things that were the common errors in order to 
prevent that in future instances?
    Mr. Clark. Yes, Chair Luria, it does. And that checklist we 
effectuated several months ago, and it is being used by all of 
our individuals processing these claims.
    Ms. Luria. Well, thank you. And I know that there is a 
period of time where it was identified that a lot of these 
errors occurred, and then it was required on the OIG to look 
back between October 1st, 2016 and June 30th, 2018. Yet, 
between June 30th, 2018 and the present, just based off of 
historical evidence and the amount of time that, you know, it 
has taken to implement some of these suggestions, would you 
recommend that between June 30th and present, essentially until 
we accomplish all of the recommendations of the OIG report, 
should we continue to evaluate that period, just to make sure 
that no veterans have fallen through the cracks during this 
transition period?
    Mr. Clark. Yes, I do, Chair Luria. And we are actually 
doing that, performing those. We continue to re-look; the 
reviews are ongoing. Once the reviews are finished, we are 92 
percent through those reviews, then we are going to look at all 
of these on the aggregate. We are updating our training 
programs as we speak. My colleague here is in charge of 
training and quality and we have--
    Ms. Luria. I'm sorry to cut you off--
    Mr. Clark. Yes.
    Ms. Luria [continued]. --I am sure we will have an 
opportunity to talk about training--
    Mr. Clark. Yes.
    Ms. Luria [continued]. --but I am out of time and I want to 
make sure that I give other Members--
    Mr. Clark. Thanks.
    Ms. Luria [continued]. --ample time to ask questions.
    So I now recognize Mr. Bost for 5 minutes.
    Mr. Bost. Thank you, Madam Chair.
    I know that all of us are wanting to make sure whatever we 
implement actually allows for the opportunity of these victims 
to make sure that they are processed correctly.
    Mr. Clark, either you or your colleagues, can you please 
describe the VA's concern that they have with H.R. 1092 where 
it may impact the integrity of the claims process due to the 
changes it would make to evidence accepted as proof of MST? And 
I don't think it is the sponsor's intent or anyone on this 
Committee to change it to where it would make it worse, we want 
to make it better. So what do you see as a danger there?
    Ms. Murphy. So thank you, Ranking Member Bost. I think the 
concern that we have is that we have liberalized since 2002 the 
manner that we go about trying to connect the dots through the 
markers and indicators if somebody doesn't claim it during 
service. We have that for the PTSD, and we do support the 
portion of expanding to other conditions such as depressive 
disorder.
    The concern for liberalizing almost to a combat level is 
that the tenets of combat are such that it is not, you know, 
documenting and record keeping that is going on at that time. 
It is a serious situation with people ducking and trying to 
just execute the mission. So to compare combat and military 
sexual trauma, we have concerns about going that far.
    Mr. Bost. Then I am going to ask to try to work with the 
sponsor to figure that out. As I said--
    Ms. Murphy. Absolutely.
    Mr. Bost [continued]. --right off the start, we want to 
make it that the process is as easy and as less stressful, 
because of the trauma itself at the level that we are dealing 
with, to make sure that those who truly are deserving of the 
benefits receive it.
    Let me switch right quick, if I can. Mr. Bracci, your 
testimony mentioned that in 2010 the IG reported and in 2014 
the GAO reported both recommendations that the VA improve 
training and enhance quality controls for MST-related claims. 
Are you confident that the VA responds in August 2018 will the 
IG report will provide the long-term solution that ensures the 
claims processors can handle MST claims properly?
    Mr. Bracci. Yes, we are cautiously optimistic that VBA can 
achieve this. They have a renewed focus on MST claims, that is 
evident, and the Under Secretary for Benefits agreed with our 
recommendations; they have implemented two of them already and 
we have closed them, and the remaining four they have provided 
acceptable action plans and they are making progress on those.
    Mr. Bost. Okay, good.
    Mr. Clark, I want to come back to you and your colleagues. 
On November 30th, 2018 at the DAMA hearing, USB Lawrence 
discussed how he planned to adjust the way the VBA will 
approach changes in the future to avoid the challenges the IG 
identified with the MST reporting. Can you kind of explain or 
provide examples of how the VA has used recommendations from 
the MST reporting to improve other aspects of the VA's claim 
process?
    Ms. Murphy. So I think we moved from an individual regional 
office working in a paper form on only its own state's claims 
to a national work queue, an electronic claims processing 
system, electronic national workload distribution system. So we 
went from each state, each regional office working its own 
state's claims, to moving the work around broadly.
    We did gain efficiencies there, but I think that we have 
learned in the process is that swinging the pendulum over to 
move the work everywhere, we lost some of the specialization 
that we had with individuals focusing on important cases such 
as military sexual trauma, ALS, Lou Gehrig's disease, traumatic 
brain injury. So we have learned from this, returned to 
specialized, specially-trained individuals processing these 
claims.
    Mr. Bost. Yeah, as you worked on the national queue--I am 
going off script here, okay?
    Ms. Murphy. Sure.
    Mr. Bost. And this is the concern I had when we actually 
received that testimony. Quite often, as the VA has learned, to 
try to--and thank you for trying to speed up the process, but 
if you don't have specialists on those fields and getting them 
in the hand of the specialist, all you have done is got them in 
the hand of somebody to take care of it, and then when you deal 
with these particular ones, I hope that you have realized that 
that is not the best way. Without proper training--everybody 
doesn't have an expertise in this field--
    Ms. Murphy. Yes, and--
    Mr. Bost [continued]. --I guarantee you, I wouldn't.
    Ms. Murphy [continued]. --I agree with you, sir. And I 
think the other piece of that is making sure that these 
specialized individuals see these cases often enough to 
maintain their proficiency. That we train them, we continue to 
check in with them, do quality assurance reviews, and 
additional measures that Mr. Clark described, having a 
conference, a training event in the fall.
    Mr. Bost. Thank you, Madam Chair. I yield back.
    Ms. Luria. Well, thank you, Ranking Member Bost.
    And we have now been joined by our colleague Representative 
Chellie Pingree. She was on the House floor, working on some 
other legislation. But, as a reminder, she has introduced H.R. 
1092, the Servicemembers and Veterans Empowerment Support Act, 
and I would like to yield 5 minutes to Ms. Pingree to discuss 
her bill.

             STATEMENT OF HONORABLE CHELLIE PINGREE

    Ms. Pingree. Well, thank you very much, Madam Chair and 
Ranking Member Bost. I apologize for being late. It is hard to 
be in two places at once and it is a busy week, as we all know, 
but thank you so much for the opportunity to participate in the 
hearing. And, most importantly, thank you for focusing 
attention on proper compensation for those who have suffered 
sexual trauma during their military service.
    I want to go back a little bit and talk about how I got to 
the point of submitting this particular piece of legislation. 
My experience on this issue goes back to my first years in 
Congress. Women and men who had experienced military sexual 
trauma came to my office seeking help as a desperate last 
resort, because many of them found that someone refused to 
believe their story or because the case was buried to protect 
the service's reputation, or because benefits were denied 
because the law, frankly, hasn't kept up with the science.
    Through hundreds of contacts from MST survivors from all 
over the country, we have been haunted and humbled by the 
stories that we have heard, and let me just read one from 
someone who contacted us who said, ``Since being raped at my 
first Reserve duty station, I have lived off the grid. I have 
not been able to work around people, cannot sustain any 
relationships. I don't really go anywhere or have any friends, 
and I am filled with anxiety. Despite receiving VA counseling 
for PTSD, I was told by an examiner that I did not have PTSD, 
so could not use my markers for service-connection with the VA. 
I have waited over 20 years to tell anyone and I don't know if 
I can go on.''
    For this and many stories that we have heard, we have had 
the desire to finally pass some legislation that would update 
VA policy.
    Seven years ago--I have been here ten years--I sat with 
this very Committee in a hearing on my bill related to MST. 
Studies had already found that PTSD claims following MST were 
granted at much lower rates than PTSD claims resulting from 
combat trauma--we have heard a little bit about that since I 
was able to come in--but with lower rates for men than for 
women. Plus, there was a different standard of evidence for 
PTSD claims based on combat versus sexual assault.
    As a result, the VA then agreed to create a dedicated, 
specialized MST claims processing team within each VA regional 
office for exclusive handling of MST-related PTSD claims with 
specific training.
    Further, at my request then, and after conceding that they 
had inappropriately denied many claims, the VBA agreed to 
review denied MST claims for possible errors. But here we are, 
7 years later, the Inspector General has reported that the VA 
has failed once again after abandoning specialized--claims 
specialization training and oversight. Nearly half of the 
veterans--and I know you have already heard this this morning--
who had submitted claims following MST had not been even 
provided the opportunity for exam or they were inappropriately 
denied.
    We should feel a lot of anger and disappointment about not 
being able to fix this problem.
    I understand the pressure to reduce the claims backlog, but 
abandoning a long-awaited, more effective process for 
adjudicating claims following MST was unbelievably 
shortsighted. Many survivors have waited decades to tell the 
stories of their sexual assault while serving. They interpret 
denials as a, quote, ``the VA thinks I'm a liar.'' Of course, 
not every denial is in error, but these denials are 
traumatizing. Given the concern about veteran's suicide, we 
must resolve the problem of inappropriate denials.
    I am lucky enough to be a member of the MilCon VA 
Subcommittee of Appropriations and at our hearing in March I 
asked Secretary Wilkie what he was doing to ensure the VA 
didn't repeat that mistake. He said all the right things, but 
top officials come and go, and so I think this falls on all of 
you, the career people.
    I know you have acknowledged dropping the ball and I want 
to hear more about how you are implementing the IG 
recommendations, and how you will foster cultural change at the 
VBA.
    Following a lawsuit almost two decades ago, the VA conceded 
that most survivors of sexual trauma would not have specific 
evidence in their military records. As a result, they created a 
relaxed evidentiary standard for PTSD claims following MST. 
That was a big leap forward, but it wasn't sufficient.
    As the regulations were written, the relaxed standard does 
not apply to veterans diagnosed with other mental disorders. 
Not every survivor develops PTSD. Today, we better understand 
the range of mental health disorders that sexual trauma can 
cause, including major depressive disorders or anxiety 
disorders, as well as newly recognized trauma disorders as 
defined by the American Psychological Association DSM-5. But 
despite the advancements in diagnosis and treating of mental 
health problems following sexual trauma, only survivors with 
PTSD can use evidence not in their personnel file for service-
connection. The VA has conceded that most veterans don't tell, 
so won't have the evidence in their files, and this is the case 
regardless of their eventual diagnosis.
    At that hearing in March, VBA Under Secretary Lawrence 
agreed on the need for a uniform standard. He said the VA 
couldn't do it; it would take a change in the law.
    We have known this was a problem for a very long time, this 
is why I reintroduced 1092, the Servicemembers and Veterans 
Empowerment Support Act. This bill would add anxiety, 
depression, and other mental health diagnoses in addition to 
PTSD as connections eligible to utilize secondary markers as 
evidence for service-connection as a result of sexual trauma 
while serving.
    I am out of time. So I will stop there, but I know I have 
covered the ground, you know very well what I am talking about 
and addressing, and we can't let this stand the way it is.
    So, thank you so much, Madam Chair.
    Ms. Luria. I will now recognize one of our other colleagues 
for 5 minutes, Representative Underwood.
    Ms. Underwood. Thank you, Madam Chair, and thank you to all 
of our witnesses joining us today.
    I appreciate how seriously the Department of Veterans 
Affairs has taken the recommendations laid out in the Office of 
Inspector General's report, which will help identify and 
overcome the barriers that survivors of military sexual trauma 
face while applying for service-connected disability benefits. 
It is essential that the VA confront these barriers head-on, 
because the epidemic of sexual abuse in the military is a 
critical moral and national security failure and, by some 
metrics, it is getting worse.
    A recent Pentagon study highlighted that cases of sexual 
assault in the military increased by 38 percent from 2016 to 
2018, even as reporting of assaults has gone down. The sexual 
assault rate for women servicemembers is at its highest level 
since 2006.
    So, Ms. Murphy, many of those women will eventually seek 
care and benefits from the VA. Ms. Murphy, right now is the VA 
sufficiently prepared and equipped to handle the anticipated 
rise in applications for disability compensation related to 
their military sexual trauma as these servicemembers transition 
into the veteran's population?
    Ms. Murphy. Certainly we are equipped as far as our 
training and the quality reviews, making sure that they are 
doing the right job, gathering the right evidence, and making 
sure they don't miss any of the steps along the way in the 
claims process. And we do applaud the IG for helping us to look 
into that and to illuminate some of these things with us.
    As far as the number of claims we receive, we have made 
some projections and we have some cost analysis regarding the 
additional amount of resources it would take to process those 
claims.
    Ms. Underwood. So in addition to the projections and the 
cost analysis, can you detail any other specific steps that the 
VA is taking to prepare for the increase in benefits claims 
that we are expecting to come to the VA related to MST?
    Ms. Murphy. So we work closely with the Office of Field 
Operations, who runs our 56 regional offices. Certainly we 
would be looking at the IT support equipment, IT support 
systems for that, where to put the folks, how to get them 
through our challenge training for newly hired and newly 
promoted individuals that my office runs, and just continuing 
to bring the focus to this.
    And I can't agree more with what everyone has said today 
that this is an evolving issue and it is something that we 
continue to learn more about. I have learned some things, 
particularly about the 100-percent rate in prison, that I 
didn't know before this morning. So I think as we all learn 
more and can bring additional focus to this important issue, 
that is what we need to continue to do.
    Ms. Underwood. And are there any additional resources that 
the VA needs in order to ensure the timely processing of all 
these benefits claimed?
    Ms. Murphy. We would be able to give you some information 
about that. We have done the cost analysis to figure out how 
many more claims processors it would take both for claims and 
appeals.
    Ms. Underwood. Great, please do.
    Ms. Murphy. Sure.
    Ms. Underwood. The number of women veterans using the 
Veterans Health Administration has more than tripled and 
currently 30 percent of new users of VA health care are female. 
In a previous hearing in this Committee with Secretary Wilkie, 
I raised my concerns regarding the lack of data on issues 
facing women veterans.
    Dr. Bell, given that military sexual trauma 
disproportionately affects women servicemembers, what steps are 
being taken to ensure that the VA maintains accurate, gender-
specific data on the effects of military sexual trauma on 
veterans?
    Dr. Bell. That is an incredibly important issue. As you 
noted, the issue of MST is one that disproportionately affects 
women. It is certainly an issue that is exceptionally difficult 
for both men and women, but there can be particular issues that 
women may struggle with differentially because of some of the 
gender-specific issues.
    We do maintain all our data separately for men and women, 
so that we are able to look at that information. Currently, 
about 29--so we have a universal screening program in VHA 
wherever veteran seen for health care is asked whether they 
experienced MST, that is an important way that we make sure to 
connect them with services, if those are appropriate or needed 
for them. And in those data, we see that about 29 percent of 
women respond yes, that they did experience MST during their 
service, about 1 percent of men respond yes.
    Ms. Underwood. Yeah.
    Dr. Bell. So we do maintain that data separately and our 
treatment data, and all of that is--we are able to disaggregate 
that by gender as well.
    Ms. Underwood. Yeah, that is consistent with what we have 
heard from other sources as well.
    So, Dr. Bell, male survivors of a military sexual trauma 
can face unique barriers and stigmas, what steps is the VA 
taking to help them navigate these unique challenges?
    Dr. Bell. Well, as noted, it is very important to be paying 
attention to the gender-specific issues that both men and women 
are facing.
    Ms. Underwood. Right.
    Dr. Bell. We do in our screening program screen all of our 
veterans, both men and women, all of our treatment services are 
available to men and women, make sure that in the 
implementation of those services that they are sensitive to 
gender concerns. So we don't ask men to meet in a women's 
clinic or need to meet with a women's health provider, make 
sure that there is a space in a clinic where they are able to 
get that care in a way that doesn't aggravate some of the 
stigma or the gender-specific concerns they might struggle 
with.
    Our outreach materials make a concerted effort to make sure 
that we are using gender-neutral pronouns, both he and she, 
include photos of men and women, and generally be conveying 
that our services are available to men and women, and that we 
want to make sure that everyone who comes through our doors is 
going to be comfortable and able to access the care they need.
    Ms. Underwood. Awesome. Well, thank you so much for being 
here and providing the Committee this information today.
    And, Madam Chair, I yield back.
    Ms. Luria. Thank you.
    I now recognize Mr. Bilirakis for 5 minutes.
    Mr. Bilirakis. Thank you, Madam Chair, I appreciate it very 
much. And thank you all for your testimony this morning.
    Mr. Clark, I understand that VA did a review of denied PTSD 
claims based on MST and found that about 20 percent of the 
denied claims had errors that required additional work. It 
doesn't surprise me that the OIG had recommended that all MST 
claims go specifically to specialized, well-trained veterans 
service center representatives when the error rate is that 
high. And I would hope that a full reexamination of the 
training process would be done, of course, in order to ensure 
VA is avoiding unnecessary new work for yourselves.
    Have you taken in any feedback from employees on how to 
tweak the training documents and guidance further on MST 
claims, or are you sticking primarily with the top-down 
approach?
    Mr. Clark. Thank you for that question. We are 
collaborating with DoD, we are collaborating with the VHA, we 
are collaborating with the VSOs, and also our employees. We are 
taking a top-down approach. I had mentioned earlier that our 
Under Secretary, Dr. Paul Lawrence, developed a video and 
posted it. We need to get the word out to everyone about this 
military sexual trauma and the difficulties that our claimants 
are dealing with, and we need to do a better job in processing 
these claims.
    So, to your specific question as well, bottom-up, if our 
employees come in and they say that here are some suggestions 
for processing these claims, we incorporate those into our 
process as well. Ms. Murphy is in charge of training and she 
handles that aspect of our training very well.
    I want to make it clear that while we don't have 
specialized teams like we used to have, we do have specific 
individuals at each RO, we have to maintain a requisite amount 
of individuals to make sure that we are processing these claims 
timely. Now, we certainly want to get a highly accurate claim, 
but when we ensure that we have certain individuals doing this 
work and make sure that they get enough repetition so they can 
maintain that quality, that is how we provide better service.
    Mr. Bilirakis. All right, thank you.
    Next question, again for Mr. Clark. One of the action items 
VA had committed to was conducting a consistency study to 
determine whether training is effective. I fully agree that we 
need to ensure that processing of MST claims occur consistently 
across the board and that coordinators all know how to look for 
the necessary signs. Can you please provide us with an update 
as to where you are in that consistency study or some specific 
plans as to how you are going to administer the study on MST-
related claims? I think it is so very important that it be, of 
course, accurate, quality--timely is so important, but quality 
even more, and accuracy and consistency. I mean, our veterans 
are entitled to that.
    So, please.
    Ms. Murphy. So if I could answer that, sir.
    Mr. Bilirakis. Yeah, that's fine.
    Ms. Murphy. The consistency studies and the special-focus 
reviews that we agreed to in the IG report are run by my 
office. First, we are looking at the consistency study. So we 
will run a test across all of our folks who do MST claims 
processing and they will have a pretest, some training, if 
necessary, and a post-test. A secondary piece of that will be 
this special-focus review that we are doing. We just started 
the pulls now.
    We wanted to make sure we conducted the training, let some 
of the feedback from the case reviews trickle down to the 
field. And then we are at the point now we are just starting to 
do the random pulls and then do the review in this last 
quarter, so that we can see what the impact of the additional 
training and the revamped training is that we have provided. So 
we are doing that now and we are on track to finish that by the 
end of this fiscal year.
    Mr. Bilirakis. Very good. Follow-up, and whoever wants to 
take it is fine. Is VA using other approaches such as the 
results of second-signature reviews to assess the effectiveness 
of its new training, or how are you planning on measuring the 
outcomes of the changes you have made to new training 
requirements? I know you have touched on it, but if you could 
elaborate, I would appreciate it.
    Mr. Clark. As part of any good, quality program, there is a 
continuous improvement aspect in that, as you review the work 
that you have done and you see errors, that you have to 
incorporate that back into the process. So one of the things, 
Ms. Murphy had talked about these focused reviews that we will 
be doing, but in reviewing the cases, we have gotten through 92 
percent of them right now, we are finding things we need to, 
and we are incorporating back into the process.
    And I want to just point out that 20 percent is too high 
and we are going to get better at that, but that 20 percent 
means that one or more issues we found that we should have 
done, it doesn't necessarily mean that would have resulted in a 
denial and, as we go through, we are finding that some of those 
will not change the result. Still, we need to make sure that we 
go through, develop a case properly. If an examine is needed or 
if we need to contact the veteran, and to be less caustic and 
to prevent them from reliving this situation over and over the 
fewer times that we must, and then deliver a quality product, 
that is our goal.
    Mr. Bilirakis. All right, thank you very much.
    I yield back, Madam Chair.
    Ms. Luria. Thank you.
    I would now like to recognize Mr. Cisneros for 5 minutes.
    Mr. Cisneros. Thank you, Madam Chair.
    I just want to follow up on the training. I know you have 
already taken a lot of questions on that already, but I just 
want to talk also, go through the process.
    If an individual is going to report, a veteran, one of our 
veterans is going to report an MST, who is the first person 
that they report that to?
    Mr. Clark. We get it a myriad of ways. It could be a VSO 
that they claim could have come in, they could call in through 
our 1-800 number, they could walk in through one of our public 
contact areas. We work in concert with VHA, Dr. Bell runs our 
national office, and they may be seeking treatment and it comes 
in that way. And we have some reciprocity in that if someone is 
seeking medical treatment and there is a claims question or 
benefits, they contact us and--
    Mr. Cisneros. So there is a variety of individuals--
    Mr. Clark. There is a variety.
    Mr. Cisneros [continued]. --that they can report this to. 
Have all those individuals been trained on how to respond and 
how to take the response, the proper response when somebody 
comes to them with that MST claim?
    Mr. Clark. Yes, sir. Now, not all individuals are tasked to 
know how to develop the claim, but certainly to acknowledge and 
receive a claim--
    Mr. Cisneros. Receive and who to refer it to?
    Mr. Clark. And to whom to refer it, that is correct. We 
have to provide a warm handoff to the individuals that are 
responsible, up to and including Beth and myself. If something 
comes in, we know the steps to take and, obviously, Dr. Bell. 
So, yes, sir.
    Mr. Cisneros. Once that referral is made, how long does it 
take for the veteran to get a response back?
    Mr. Clark. A response back about the claim being completed 
or--
    Mr. Cisneros. Right, to let them know--
    Mr. Clark [continued]. --just to acknowledge that--
    Mr. Cisneros [continued]. --that it has been handed off and 
it has been acknowledged, and now somebody is calling them to 
deal with their claim?
    Mr. Clark. Well, I would have to get back with you on a 
time, but we as expeditiously as possible, if someone comes 
into our office, if they walk into the office, then we call the 
MST coordinator down right then that day. If they call in, the 
person, there is a protocol for the individual that is 
receiving calls, and they are to provide a warm handoff to VHA 
and to our office in how to produce that claim, and they should 
get a callback within a few days.
    Mr. Cisneros. So the MST coordinator, where are they 
located? Are they located at VHAs or are they located--?
    Mr. Clark. Yes, sir.
    Mr. Cisneros. So every veteran's hospital has an MST 
coordinator?
    Mr. Clark. Mr. Cisneros, I will allow Dr. Bell to speak to 
that, but in every regional office we have a male and a female 
MST coordinator. Additionally, nationally, we have a male and a 
female coordinator that coordinates with VHA about getting 
training materials out nationally. We are a learning 
organization and we need to do better. But if someone comes to 
our agency and they file a claim, we will get back with them, 
we will undertake the proper development and, when we find that 
we haven't, we will get it right.
    And, Dr. Bell, if you want to speak to VHA?
    Dr. Bell. I was just going to point out, so there are MST 
coordinators on both sides of the VA. So that VHA has its own 
MST coordinators that can assist veterans with seeking 
treatment or making sure the system, the VHA part of the system 
is doing what it should be doing to assist them, and then VBA 
has its own MST coordinators and they have close relationships 
across the two sites and make sure they talk to each other.
    Mr. Cisneros. Are they receiving the same training?
    Dr. Bell. The VHA coordinators would receive training 
specific to VHA. So clinical care issues, we have a mandatory 
training that all of our mental health and primary care 
providers need to complete on MST. Our MST coordinators are 
typically mental health professionals, so they would complete 
that mental health training.
    Mr. Cisneros. Okay. So, once somebody reports an MST, are 
they dealing with the VBA or are they dealing with the VHA?
    Dr. Bell. So if they are interested in care, they would be 
on the VHA side, and the--typically, the way VHA would learn 
about an experience of MST would be in a clinical context. So 
someone would be seeking mental health treatment or some other 
treatment, we would ask them if they had these experiences 
during their service and, if they said, yes, they did, then we 
would talk to them about the services that VHA could provide 
them and also, as needed, refer them to VBA to file a 
disability compensation claim, if they were interested in that.
    Mr. Cisneros. Okay, last question. And, Mr. Clark, you 
stated in your opening statement, 18,000 MST claims each year 
that people are reporting; are we sharing this information with 
the DoD and letting them know that, you know, this is what we 
are seeing? Or is there any coordination to work with DoD to 
try and--well, to keep them informed and let them know what is 
going on?
    Mr. Clark. We do coordinate with DoD. In fact, Ms. 
Underwood spoke to this 38 percent increase that was in USA 
Today a few weeks ago, we provided that training to all of our 
senior leaders going forward, we are having conferences of our 
MST coordinators. Ms. Murphy and I regularly talk to DoD 
personnel about that and other things as well. But, yes, the 
answer is, we do coordinate with DoD. And usually, of course, 
they come up with metrics that tell us there is an increase 
and, accordingly, an increase of individuals claiming MST, and 
that gears us up to say, hey, that we have got a potential 
increase in claims coming. But we are resourced, and we are 
trained to handle those claims and, when we find that we are 
not, we take efforts to improve upon that process.
    Mr. Cisneros. All right. Thank you very much. My time has 
expired.
    Ms. Luria. Thank you. I now recognize Mr. Allred for 5 
minutes.
    Mr. Allred. Thank you, Madam Chair, and thank you for 
holding this important hearing.
    As my colleagues have noted we are of course experiencing a 
crisis of military sexual assault with claims likely to 
increase on VBA and VHA going forward.
    I have the honor of representing the Great State of Texas. 
We are home to the most women veterans of any state, and I am 
very proud of our 181,000 women veterans who have served us. 
And I want to make sure that we do everything we can to serve 
them. I know you do as well. And I want to thank you for that.
    I want to begin with you, Mr. Clark, though and ask you, 
because I have spoken with a lot of our women veterans service 
organizations that have mentioned that we need to do a better 
job of tailoring both our VHA and VBA services and benefits and 
outreach to women veterans.
    And I just want to begin by asking what we are doing and 
what you are doing to target your outreach to women veterans 
about the VBA services here?
    Mr. Clark. Thank you, Mr. Allred.
    We have a robust outreach program. Again, we need to do 
more. But working with our VSOs, working with the VHA, working 
with DoD, we are holding events, claims clinics, town
    halls and working with all of those entities that I spoke 
of to get the word out. And just so far this year we have had 
roughly 155 events. We have reached a little over 2,000 
veterans and their families and the like.
    We need to get the word out, and we ask all of our leaders 
top down that they are to know about MST processing and as they 
go out and do outreach throughout the state and throughout this 
great country of ours, then we need to get the word out that we 
are here to serve individuals that make it possible for us to 
live in this great country.
    And all of our senior leaders are aware of this. But it is 
a continual process. You can't do a one and done and think you 
have got it. We embrace the OIG to take a look at us to help us 
get this right.
    And so when we get these--they tell us that we have 
challenges we take that upon ourselves as a way to try to 
improve rather than just being in denial.
    Mr. Allred. To you and to the IG as well, do you anticipate 
that you need more resources to better access and reach out to 
our women veterans?
    Mr. Clark. I think we have got the resources we need. You 
know, the easiest thing to do is always ask for more resources. 
The hard thing to do is to look within and to get more 
efficient. Our boss is about efficiency and done. So thanks to 
Congress we get the resources that we need to do this work.
    Mr. Allred. Mr. Bracci.
    Mr. Bracci. Yeah. As far as resources go, I know there is a 
budget process. I think the question of whether or not we have 
sufficient resources is probably better answered by our 
inspector general, Mr. Missal.
    Mr. Allred. Okay. Well --
    Ms. Murphy. I'm sorry. Could I add--
    Mr. Allred. Go ahead.
    Ms. Murphy [continued]. --that I think also to your 
question earlier, also there is no wrong door here and we are 
all in this together. And I do want to applaud Ms. Pingree's 
office. We work closely with her staff. And she has referred 
several cases after she gets the privacy release, several cases 
that our national star team looks at. And we have been able to 
take a few of those and do a little extra or look a little 
deeper.
    And I would offer that to anybody. If anybody has a case in 
their jurisdiction or that comes to their attention and you 
want us to take a deeper look, we are happy to do that. Just 
reach out to myself, Mr. Clark, and we will get our national 
level quality reviewers to take a second look.
    Mr. Allred. Yeah. Well, I would encourage you to reach out 
to my office as well and see if we can be helpful in Texas.
    Ms. Murphy, I want to in my last minute here ask you a 
question about your opposition to Memo 2, Section 1164 that 
mimics the combat presumption because the circumstances of MST 
are not similar to the circumstances of combat. But with both 
combat and MST related injuries we see chronic underreporting. 
Should we not ease the strict standard for proving in-service 
assaults by accepting satisfactory lay statements?
    Ms. Murphy. So I would say that we do that now. We look for 
markers. We take lay statements. We take all the evidence that 
we can gather, and we weigh it and we look deeper.
    So I think the concern that we have is that within a combat 
situation there is a reason that we don't--sometimes we don't 
have that record-keeping is because of the nature of the combat 
environment. We--I certainly understand why folks would not 
want to come forward and report. That is an individualized 
decision as to whether you want to come forward with that.
    Our concern is making the situation so that if it is a mere 
statement and there is any mental health professional who says, 
yes, I think that this happened because of this, in private 
sector sometimes they don't get a chance to look at the full 
claims folder. Our concern is mainly that we would be 
defaulting to the fact that this happened without an 
appropriate level of corroboration that we have in the current 
way we process claims.
    Mr. Allred. And--
    Mr. Clark. And, sir--
    Mr. Allred. Go ahead.
    Mr. Clark [continued]. --can I add to that, please?
    Mr. Allred. Sure.
    Mr. Clark. I'm sorry for interrupting you.
    The onus, though, falls upon the VA to make sure that our 
folks are properly trained to help corroborate that story. When 
someone just--the only thing they have is the statement that 
they made. So that is where we need to get better at. And we 
have done some great things with accepting markers, lay 
statements, behavioral changes, these things that lend itself 
to something happened and we need to help to flush that out.
    Mr. Allred. Yeah. One overall concern with underreporting 
and that is what we are trying to address here. So thank you so 
much.
    Ms. Luria. Well, thank you. And just based off the 
responses to the last two lines of questioning I wanted to 
follow up from the VHA and give an example.
    Say you have a patient who comes in for other treatment. 
They have routine headaches or a broken arm or whatever it is, 
but in the course of their care they happen to mention to the 
medical provider that this happened.
    My first question is does the medical provider themselves 
just providing primary care, for example, know whether the 
person has a claim or has a rating for disability for a 
particular instance? I mean, would that primary care provider 
already know that this person had been approved for, you know, 
the MST?
    Dr. Bell. So just to provide a little context that can help 
me answer that question, one of the wonderful things on the VHA 
side is that veterans do not need to be service-connected, have 
a disability claim in order to receive free MST-related care 
through VHA.
    Ms. Luria. Right. But that's really not my question.
    Dr. Bell. Right.
    Ms. Luria. Like the person just come sin because they have 
a broken arm. But during the course of that, this is very 
traumatizing so that brings up memories and now they start 
talking about an issue related to MST. Does the provider 
treating them for the broken arm know what conditions they are 
covered for as service related disabilities? Just a general 
question, does every--
    Dr. Bell. If--
    Ms. Luria [continued]. --provider know the scope of 
what's--
    Dr. Bell. If it has been adjudicated, then, yes, that would 
be--
    Ms. Luria. It is in their record.
    Dr. Bell [continued]. --in the system. Yes.
    Ms. Luria. Okay. And so then that provider hears this, and 
this person has never been adjudicated, never put in a claim 
for this, you know, has no background of it. Is that provider 
obligated in any way to counsel that patient and say, you know, 
thank you for sharing this sensitive information with you. Are 
you aware that the, you know, VA can help you with this issue 
and I would recommend that you would now warm handoff to the 
VBA to talk about whether you want to put in a claim about 
this? Is there any obligation on the part of the provider to 
make a next step with the information that they are given?
    Dr. Bell. There would not be an obligation. They--again, 
because the care on the VHA side related to MST would be 
provided regardless. They certainly could provide the care.
    In terms of the claim--
    Ms. Luria. Oh, so would they not even need a claim? Like if 
the primary care provider--
    Dr. Bell. Correct.
    Ms. Luria [continued]. --learned about this issue could 
they then give them a referral to mental health services?
    Dr. Bell. Absolutely.
    Ms. Luria. Already, without ever--
    Dr. Bell. Without a claim, without filing a claim, without 
an approved claim.
    Ms. Luria. So say in this scenario then the person did say 
that is a great idea. I would love to speak to a counselor and 
then they go speak to a counselor, at what point in the process 
would they--would it be brought to their attention that, you 
know, this could actually also be a service-related disability 
and you should follow up with this claims process?
    Dr. Bell. Yeah. Certainly, our VHA outreach materials refer 
to the potential for seeking disability compensation related to 
experiences of MST. As a mental health provider I know that is 
often one of the issues that comes up early in treatment just 
as something we will explore with someone or they may already 
be involved in the process and we will be checking in with them 
about how that is going.
    So certainly in a mental health context it will often come 
up and be discussed at that point.
    Ms. Luria. Okay. And just to clarify, so any primary 
medical condition, the broken arm example, that someone brings 
up an issue, MST related or not, but that the primary care 
provider thinks that they might also need to be referred for 
mental health services, they are always referred even if that 
is not a service-related or service-connected disability that 
has already been recognized?
    Dr. Bell. If the veteran is interested in mental health 
treatment or, you know, evidences some need for that, of course 
we would connect them with the appropriate care.
    I assume because they are being seen in the system, they 
are eligible for care in general. And so absolutely they would 
then be eligible for mental health care regardless of whether 
it was MST related or not.
    But certainly, again, if the care was MST-related, again, 
that does not require disability compensation. It does not 
require any evidence or documentation that the MST occurred. 
There are some veterans that can get free MST related care from 
VHA even if they are not eligible for other VHA care.
    Ms. Luria. Okay. Thank you for clarifying.
    And I--and, Mr. Bost, do you have any further comments on 
that topic?
    Okay. I would now like to recognize Ms. Kuster for 5 
minutes.
    Ms. Kuster. Thank you very much. And I very much appreciate 
your testimony. But I share the concern of my colleagues, 
especially Representative Pingree who has been working on this 
for a long time.
    And in particular I just wanted to explore with you in 
terms of the training, it seems to me the added trauma of 
having the claim denied will exacerbate the underlying 
condition and the response to the military sexual trauma.
    I can just say for myself, I mentioned in my opening 
statement that I was a victim of sexual assault in a college 
experience and actually once here working on Capitol Hill, and 
I didn't tell anyone for 40 years.
    And what I didn't even understand until much, much later 
when I finally told the story was when I was a Member of 
Congress and this--there was a great deal of press attention 
during the last presidential election. And I was in the midst 
of a press interview and a reporter asked me, what are the 
ramifications of this. And I started to say, oh, I am fine, and 
then I realized I didn't even understand the connection. I 
said, well, I can't actually be alone in my home and sometimes 
I wake up in the night screaming.
    Now I have never told anybody this. So I am telling you 
this to say, do you have survivors as part of your training 
because I think it is very important that your people--and I 
appreciate Mr. Bost. We all want to try to get past this. And, 
clearly, we have more work to do as Members of Congress with 
the Armed Services, with the DoD, in HASC. I am shocked. I am 
stunned actually to hear the statistic that our colleague 
Representative Underwood has shared today.
    This is a national tragedy that the people in uniform that 
are serving our country, 1 in 3 women are experiencing sexual 
assault and military violence, a 38 percent increase. So I am 
not blaming any of you for that. But I hope you will work with 
us and the VA so that not a single person is ever traumatized 
further.
    But I would just ask the question, are survivors' part of 
your training and would you consider that going forward?
    Mr. Clark. I will allow Ms. Murphy to also speak to this, 
but we will be having our first annual conference on MST 
training the first quarter of fiscal year 2020. And to be 
honest I hadn't thought of that, not for MST because one of the 
things in my limited knowledge is that you try to not allow 
individuals to relive that.
    We use that modality of training when we are talking about 
prisoners of war and things like that. We have used that. And, 
again, that is traumatic as well. But for MST we hadn't, but I 
am--
    Ms. Kuster. I would love to have you consider it and--
    Mr. Clark. Yes, ma'am.
    Ms. Kuster [continued]. --and I think Dr. Potter from the 
University of New Hampshire who is on the next panel could help 
you with those resources because it is something that needs to 
be described from the perspective of somebody who has 
experienced it.
    The whole notion of why people don't come forward, they 
don't come forward because they are not believed. In the case 
of 50 percent of the claims being denied, why would you come 
forward? I mean, it is not like people don't know this 
information, because their privacy is breached, because, you 
know, it impacts their career.
    I mean, trust me. It is not easy for me as a Member of 
Congress to go talking about it.
    Mr. Clark. Yes. Yes, ma'am. Thank you for sharing and I 
appreciate that. Again, we will take that under consult and 
certainly Dr. Bell, you know, working with the VHA, that is 
who--with whom we collaborate. And certainly if it is felt, you 
know, taken what you say, if that is the course of action, you 
know, we are benefits, not experts, and clinical issues. So 
certainly we will take their consult and act appropriately.
    But, again, thank you--
    Ms. Kuster. Thank you.
    Mr. Clark [continued]. --for sharing.
    Ms. Kuster. I appreciate it. We are all learning and thank 
you for all the work you do. And I yield back. And thank you 
again for allowing me to appear today.
    Ms. Luria. Well, thank you for joining us. And I now 
recognize Representative Pingree for 5 minutes.
    Ms. Pingree. I thank you again for having this hearing, my 
colleague from New Hampshire for sharing her own experience, 
and just reminding us all that it sort of doesn't matter what 
position you take on in life. These are--these things stay with 
you for a very long time and are incredibly difficult to 
discuss. So thank you so much for doing that.
    I guess what troubles me, and I had the chance to, you 
know, read my testimony earlier about the bill and recount that 
I have been here before in this Committee and also served on 
the Armed Services Committee and, you know, been through a lot 
of the shock at how deep this goes. And, you know, 7 years ago 
we had some very positive conversation about moving forward. 
And the fact that we thought we did and then perhaps because of 
a reorganization and, you know, a hurry to get through claims, 
you know, what good had been done was already lost and now we 
have a promise of doing that again.
    But it is just unthinkable that in this day and age we ask 
people to serve in the military. They have these horrendous 
experiences, and then--so, a, that's an Armed Services 
Committee issue and we need to continue to address that.
    But then people present themselves for claims and many of 
them going back, you know, an incredibly long period of time 
and then hit these brick walls. So I know there is some 
opposition to this bill. And I think what troubles me most 
deeply is 7 years ago and then today we are being told that 
part of the problem is that it is just going to cost money, you 
know, the more claims that we process and the more we recognize 
that people have real issues.
    And one of the--I think in one of the written testimony the 
estimated cost is nearly $10 billion over 10 years. But a large 
portion of this legislation, the use of secondary marketers to 
establish services already exists in the VA regulations. So why 
in the world are we saying it is going to cost $10 billion? 
And, even if it was, it is our obligation to make sure we make 
people whole again. We do everything we possibly can. But that 
just seems to me a completely disproportionate cost.
    And can you address--I just think that is unreasonable and 
I just think it is what we use all the time to not move 
forward.
    Ms. Murphy. I would say one piece of that is we have made 
reference earlier; we get an average of about 18,000 claims a 
year for military sexual trauma. Off the top of my head I think 
the first couple of years we are expecting it would be about 30 
or 35,000 claims if we implemented the bill. And I think a 
piece of that is some folks don't come forward if they aren't 
diagnosed with PTSD. And the fact that we are opening this up 
to other related mental health concerns would make more people 
eligible. So if you have a depressive disorder and it has been 
several years since you were in service, maybe you wouldn't be 
coming forward.
    So I think a big--a piece of the cost is that more folks 
would be eligible to pursue a claim and be paid because we 
would be expanding the types of conditions apart from just 
PTSD.
    Ms. Pingree. And I--look, I am on the appropriations side 
of this so I shouldn't be arguing about the finances here 
today, but I just think that that often gets used. And then 
what perversely happens is they get used to limit the amount of 
eligibility, just as you said. We say, well, then that disorder 
shouldn't be allowed, or those particular markers, or you 
didn't come forward in time, or all these road blocks that have 
been set up along the way are in a sense the byproduct of the 
fact that we say, well, it will cost us money if we allow that 
to be claim instead of saying, we recognize this is a serious 
problem and we need to make sure that we do everything we can 
to understand how people are going to present, which way they 
are going to deliver their claim, what mental conditions that 
people might experience and mental health issues that people 
might experience should be covered.
    And so I am just appalled that I have to keep facing this 
argument every time we come before trying to change the public 
policy about something that I think in a very bipartisan way we 
agree shouldn't be going on. And then we agree that people can 
be left with the ramifications of this trauma for years and 
years and years deeply impacting their life, their family life, 
their ability to make a living, just a whole variety of things.
    And I guess I would add that, you know, and I have seen it 
some of the testimony and you have talked a little bit about, 
you know, trying to make the distinction between the combat 
claims. And I understand this is a different situation, but 
much of it is exactly the same. You know, when you have PTSD 
you can't always define exactly when in combat that happened. 
You can't report immediately because you are in the thick of a 
war or you are in the thick of a battle. And for so many people 
they are in the same situation.
    I am out of time and I mostly lectured you. I am sorry. 
But, you know, I have just been around this too long. And one 
of the reasons we have very proactively in the bill talked 
about these teams and these specialized claim--you know, what 
to do is because we were told it was all going to happen and 
then the VA decided to reorganize and said, oh, we gave that up 
because we were rushing through too many claims. And now you 
guys say, okay, we are going to go back and do that. But it has 
got to get done.
    Thank you, Madam Chair.
    Ms. Luria. Well, thank you. And just to offer if anyone on 
the panel has any additional questions for this set of 
witnesses before we move on.
    Okay. Well, thank you very much. I really appreciate your 
taking the time to be here today and to work so diligently on 
these issues. So thank you for appearing today. And we will 
give a few minutes to shift over to the next panel of 
witnesses.
    While we do that, I will introduce the third panel. On this 
panel we will have Ms. Elizabeth Tarloski, Adjunct Professor at 
the Lewis B. Puller Jr. Veteran's Benefits Clinic at William 
and Mary Law School; Mr. Shane Liermann, Assistant National 
Legislative Director at the Disabled American Veterans; and Dr. 
Sharyn Potter, Executive Director of Research at the Prevention 
Innovations Research Center at the University of New Hampshire.
    So we will give you a few minutes to get situated and then 
we will move on to the next portion of our hearing.
    [Pause]
    Ms. Luria. Okay. Well, thank you again for being here and 
thank you again to Ms. Tarloski for traveling here from William 
and Mary in Virginia, and also for Dr. Sharyn Potter for 
visiting us from New Hampshire to bring your experience.
    And we will start by giving Ms. Tarloski 5 minutes for your 
opening statement.

                STATEMENT OF ELIZABETH TARLOSKI

    Ms. Tarloski. Thank you.
    Good morning, Madam Chairwoman Luria, Ranking Member Bost, 
and Members of the Subcommittee. Thank you for the invitation 
to speak here today on an important and pressing issue.
    Along with law students, I assist veterans in filing and 
appealing complex disability claims involving PTSD, TBI as well 
as mental health claims based on military sexual trauma.
    I have witnesses firsthand the uphill battle MST survivors 
face in submitting and appealing PTSD claims. It is no secret 
that the VA claims process can be long and confusing, and when 
a veteran has experienced trauma this process is that much more 
daunting.
    One of the requirements for establishing service-connection 
for PTSD is to produce credible evidence of the occurrence of 
an in-service stressor. When the in-service stressor involves 
combat or fear of hostile military or terrorist activity, a lay 
statement is enough to establish the stressor occurred, if 
consistent with the circumstances of one's service.
    This, however, is not enough for a PTSD claim when the in-
service stressor is sexual assault or harassment because the VA 
requires additional evidence in the form of markers.
    I support House Bill 1092 because it would recognize the 
unique nature of MST claims by extending the standard applied 
to combat and fear of hostile military or terrorist activity to 
those who file mental health claims not just for PTSD, and 
would be sending a clear message to our Nation's veterans that 
they will be believed and supported.
    As noted on the VA's own website, sexual assault is 
actually more likely to result in symptoms of post-traumatic 
stress disorder than other types of trauma including combat.
    Also, the experience of MST can differ from the experience 
of other traumas and even from the experience of sexual trauma 
in the civilian world. The VA has acknowledged that sexual 
assaults and harassment are underreported in the military, but 
at the same time ignoring the shame, embarrassment and stigma 
that leads to the silence of veterans after service.
    Studies have shown that there are multiple barriers faced 
by veterans to disclosing MST or even seeking out mental health 
treatment after they leave service. This makes it difficult for 
a veteran to submit evidence even in the form of markers to 
indicate the in-service stressor event occurred if that 
evidence does not exist, is hard to find, destroyed or never 
documented in the first place.
    Gathering evidence for these claims is also burdensome and 
confusing. As pointed out in the 2014 government accountability 
office report regarding MST, 2 VA claims adjudicators could 
look at the same marker and come to different conclusions, and 
both would be right according to the VA's own regulations. My 
own experience assisting veterans and reviewing VA decision 
letters denying benefits reflects this finding.
    The current standard is not practical given the length of 
time it may take for a veteran to come forward to file a claim. 
Many veterans wait years, if not decades, before deciding to 
tell their story, let alone submit a disability claim, and some 
will never do either.
    Many veterans applied once years ago before the standard 
was relaxed to include markers and never reapplied after being 
denied. It is not uncommon for veterans and their advocates to 
wait over a year just to receive military personnel and medical 
records, and sometimes they are incomplete and hard to read.
    Private medical records are usually destroyed after 5 to 10 
years, and the absence of records is important because many of 
the examples of markers, such as episodes of depression or 
anxiety, visits to medical centers, substance abuse, et cetera 
can be best shown by these medical records.
    The stigma of MST while it is now lessening is still 
salient, especially for older generations. Requiring those who 
may have never before disclosed trauma to provide documentation 
of markers is unreasonable and infeasible for many, especially 
because the documentation may no longer exist.
    Male veterans are also negatively affected by the current 
standard. Men are less likely to report sexual assaults and 
harassment in the military, and they are generally less likely 
to talk about MST or seek mental health treatment after 
service, meaning they are less likely to be able to depend on 
in-service reports or even evidence that could serve as 
markers.
    In Section 4 of the proposed bill a claim for MST still 
must be supported by a diagnosis as well as an opinion by a 
mental health professional that a mental health condition is 
related to MST. Even so, evidence can be rebutted by clear and 
convincing evidence to the contrary.
    I do believe H.R. 1092 would streamline the processing of 
these claims and reduce the number of appeals, which at this 
point can take up to 4 years to decide, if not longer if they 
continue to be appealed.
    The wounds associated with PTSD and MST are not always 
visible, and many veterans will go decades without disclosing 
the MST to anyone, including mental health professionals. The 
reforms contained in H.R. 1092 would put veterans who have 
experienced MST on equal footing with other veterans who submit 
claims for PTSD and would ease the burden survivors of MST 
currently face.
    Thank you. That concludes my statement, and I am happy to 
answer any questions.

    [The prepared statement of Elizabeth Tarloski appears in 
the Appendix]

    Ms. Luria. Well, thank you.
    And I will now recognize Mr. Liermann for 5 minutes.

                  STATEMENT OF SHANE LIERMANN

    Mr. Liermann. Thank you.
    Chairman Luria, Ranking Member Bost, and Members of the 
Subcommittee, on behalf of DAV's more than 1 million members we 
thank you for the opportunity to testify at today's hearing on 
ensuring access to disability benefits for veteran survivors of 
military sexual trauma.
    For nearly 21 years I have represented thousands of 
veterans in claims and appeals before 4 different VA regional 
offices and the Board of Veterans' Appeals. So I personally 
understand the challenges facing veteran survivors of MST and 
the issues navigating the VA claims system.
    Madam Chair, military sexual trauma has become an all too 
common experience for women and men who serve in our armed 
forces. According to DoD's 2018 annual report, sexual assault 
was experienced by 6 percent of women and 0.7 percent of men. 
However, that actual number is nearly equal. Rates of reporting 
MST are growing from 1 out of 14 in 2006 to 1 out of 3 in 2017.
    Sexual harassment occurs even more frequently than assault, 
with 24 percent of women and 6 percent of men indicating they 
have experienced.
    First, we need to find a way to end MST in the Armed 
Forces.
    Second, DoD needs to make it easier for survivors to report 
these assaults. When MST incidents are not reported to military 
authorities, it complicates VA's current claims process for 
establishing service-connection for PTSD related to that 
assault.
    PTSD claims based on MST do not require survivors to have 
absolute verification of the incident, only corroboration. And 
as noted, this threshold differs from other PTSD related claims 
due to the lack of documentation of such incidents.
    However, VA has demonstrated persistently a systemic 
problem in implementing this regulation. VA has shown its 
inability to properly train, develop and adjudicate claims for 
PTSD based on MST as evidenced by the numerous reports of the 
OIG and GAO.
    In the 2010 OIG report VA denied 50 percent of female 
veterans for PTSD claims versus 38 percent of male veterans. In 
the 2011 OIG report it was noted that VA staff did not 
correctly process PTSD claims which was due to the staff 
lacking sufficient experience and training to process these 
claims accurately.
    In 2014 GOA report it found confusion among adjudicators 
and examiners in how to evaluate a claim and recommended 5 
actions to include expanding training on MST related claims, 
develop a more comprehensive quality review of MST claims, and 
to expand their outreach.
    In the 2018 report OIG estimated that VA staff incorrectly 
processed approximately 49 percent, almost 50 percent of MST 
related claims. The reasons were due to a lack of previous 
specialization, lack of additional level of review, 
discontinued special focus reviews and inadequate training. The 
report concluded with 6 recommendations, but to date VA has 
completed 2 of the 6.
    In order to ensure VA's compliance and accountability with 
MST related claims, DAV believes it is time for Congress to 
enact H.R. 1092, the Service Members and veterans Empowerment 
and Support Act of 2019. This legislation would essentially 
codify several parts of the regulation and also add other 
mental health conditions in addition to PTSD as being related 
to MST.
    H.R. 1092 would add electronic media as a source of 
harassment and abuse as well as require VA to reestablish 
specially trained teams to adjudicate MST related claims for 
mental health conditions.
    Finally, the bill would require VA to report MST claims 
annually to Congress to help ensure that these claims are 
adjudicated equitably. DAV strongly supports H.R. 1092 and we 
urge Congress to pass this legislation.
    Madam Chair, since the inclusion of personal assault 
provisions in 2002, veteran survivors of MST have faced 
countless challenges in obtaining their earned benefits. For 9 
years VA has struggled to properly train, develop and 
adjudicate all claims for PTSD based on MST.
    We want to thank you, Madam Chair, and the Committee for 
holding this oversight hearing today. And the DAV looks forward 
to working with you and the community in the future to ensure 
all MST veteran survivors receive fair and equitable access to 
their earned benefits.
    This concludes my testimony, and I would be pleased to 
answer any questions you or any of the other Members may have.

    [The prepared statement of Shane Liermann appears in the 
Appendix]

    Ms. Luria. Well, thank you.
    And now I recognize Dr. Potter for 5 minutes.

                   STATEMENT OF SHARYN POTTER

    Dr. Potter. Chair Luria, Ranking Member Bost, and 
Congressmen Kuster and Pingree, I am honored to testify today.
    I have spent the better part of 20 years developing, 
administering and evaluating sexual violence prevention and 
response strategies. My recent research focuses on the economic 
impact of sexual assault. My research shows the devastating 
cost of sexual violence and its impact on victims' health, 
education and career trajectories.
    One participant we interviewed described the sexual assault 
perpetrated against her as the bomb that shattered everything 
as no part of her life was left intact.
    H.B. 1092 will provide an easier path for veterans to prove 
they suffered MST making them eligible to receive disability 
benefits.
    Additionally, the proposed bill's inclusion of 
technological abuse is critical for addressing the increasing 
prevalence of technology as a tool for perpetrators.
    While I have developed a technology application that 
assists victims, I have also seen how technology that we use 
every day is used by perpetrators to isolate, control, scare 
and intimidate victims.
    The Department of Defense report on sexual assault in the 
military indicates that 7,500 active duty military men and 
13,000 women were sexually assaulted in 2018. Only one-third of 
these military people reported to a Department of Defense 
authority. The low reporting rates are consistent with research 
on colleges and workplaces, and there are many sound reasons 
why victims do not come forward, including fear of jeopardizing 
their career, retaliation and shame.
    In addition to the mental and physical health consequences 
of MST, victims face substantial impediments to completing 
their education and attaining their career goals further 
undermining their economic success. My study of campus sexual 
assault victims ages 24 to 65 at the time of the study 
highlights some economic losses. One-third never finished 
college and many recounted serial low wage positions with 
limited health care coverage.
    In my research I have interviewed both veterans and 
civilians who were sexually assaulted as they pursued their 
military careers or education. Many describe how the health 
problems caused by sexual trauma hinder their ability to 
maintain stable employment. Sexual trauma victims are often 
triggered or re-traumatized by workplace incidents, including 
being left alone in an office or dealing with an 
inappropriately behaving boss or customer.
    When people transition in and out of the workplace, they 
face economic instability, posing challenges in their ability 
to obtain food, housing, transportation and health care. Access 
to disability benefits will reduce the veteran's MST burden, 
allowing them to attain medical assistance and financially 
support themselves and their families.
    Victims of MST suffer unimaginable personal and financial 
loss. The significant societal costs of not treating MST 
include drug addiction, homelessness and incarceration.
    Providing help for male MST victims poses unique challenges 
as the military culture expects men to be hyper-masculine and 
physically strong. The stigma of MST makes male veterans less 
likely than female veterans to report and seek treatment, 
exacerbating the impact of the MST in all areas of the 
veteran's life.
    Veterans who suffered active duty injuries from an 
explosion or a vehicle crash during active duty are eligible 
for disability benefits. However, the shame of MST prevents the 
majority of active duty men and women from coming forward. Yet 
we know when MST victims receive help, even belatedly, their 
lives and the lives of their families and our societies are 
improved.
    Amending the evidentiary standards and claims for 
compensation for MST induced psychological trauma is critical 
in supporting our servicemembers who have suffered sexual 
assault while serving their country.
    This concludes my testimony.
    Thank you.

    [The prepared statement of Dr. Sharyn Potter appears in the 
Appendix]

    Ms. Luria. Well, thank you.
    And I now yield 5 minutes to myself for some questions.
    I would like to start with Ms. Tarloski, and I want to in 
the process of this, you know, bring out a quote that I am 
going to highlight in the VA's statement and some of the 
statements that you made.
    So, basically, I will read this first. It says: ``The VA 
strongly opposes the amendment to Section 1154 because the VA 
is concerned that the bill's language would functionally 
require VA to accept all allegations of an MST stressor and 
potentially award service-connection based on a single lay 
statement from the veteran without even minimal supporting the 
existence of an in-service stressor.''
    And it goes on to say that, ``In essence, the bill would 
require the VA to award service-connection as long as there is 
a current diagnosis of a covered mental health condition and a 
mental health professional that would corroborate that.''
    So basically what they are saying is that, you know, this 
particular proposed legislation is too liberal and that someone 
might just make a statement in order to gain the system or the 
way I read it without particularly sound evidentiary standards.
    So in your experience of dealing with lots of these cases 
and lots of veterans, in your professional opinion do you ever 
see people who just try to gain the system? I mean, this seems 
like a very painful thing to put yourself through in reporting. 
And so just from your experience on a legal side is that 
something that you would be concerned about in this 
legislation?
    Ms. Tarloski. No, not at all. The veterans that I do see as 
clients are extremely hesitant to open up to us at all. It 
takes sometimes multiple meetings building trust. A lot of them 
feel like they are not deserving of the benefits and it usually 
takes them, like I said, decades to even come forward at all. I 
don't think this is an experience people want to share readily, 
let alone make up.
    And I am concerned that the differing standards kind of 
puts our PTSD survivors who are veterans in 2 different 
categories that we should believe those who are in combat that 
can't document them or document what happened, but we need 
additional evidence from those who suffer from MST. And to me 
that is troubling. I do believe the standard should be the same 
for those who are in combat as well as those who experience 
MST.
    Ms. Luria. Well, thank you.
    And I will shift to Dr. Potter. From your experience, what 
portions of the process of applying for these benefits, either 
in your experience or anecdotally from your expertise in the 
field, what portions of this process would be re-traumatizing 
for a victim and how could that be improved just to be able to 
provide your experience and expertise, you know, back to the 
VBA as far as how they handle these claims?
    Dr. Potter. So I can't speak to the experience of seeking 
these benefits, but what we do know is that when victims come 
forward, how they are responded to can actually be re-
traumatizing, especially if they feel like they are not being 
believed or they are being shut down.
    And by the time a victim comes forward, it has taken so 
much courage for them to disclose what has happened to them to 
an authority that to be treated as if they are not telling the 
truth would shut them down and would probably put them further 
into the pain that they are already in.
    Ms. Luria. Well, thank you.
    And just, I would like to share from my experience in the 
limited time since I have been here, I have had a group of 
female veterans come to my office to talk to me about this 
issue. And it was very frequently the case that they having 
been denied or having peers who had been denied just really 
felt the re-traumatization and sort of, that were kind of 
thrown to the wayside because they weren't believed.
    And so I do think that the expanded types of evidentiary 
standards will be helpful in making sure that people's stories 
are believed and that all evidence available is used to 
adjudicate a claim.
    I will shift last to Mr. Liermann.
    So if an MST survivor is separated with a bad paper 
discharge other than honorable or some type of discharge that 
would otherwise make them not eligible for care under the VA, 
do you find that it is less likely that they could eventually 
be treated for things related to MST? And is there anything 
that we can do about that because we have frequently talked 
about some of the mental health issues, some of the things that 
have been leading to increases in veteran suicide and making 
sure that everyone can be seen in a crisis.
    And do you see, you know, direct correlations with MST 
cases similar to some of the other areas where we have talked 
about this issue?
    Mr. Liermann. Absolutely. DAV issued 2 women veteran 
studies in 2014 and 2018, and one of the things that we did 
highlight is when there is a discharge and it is due to 
something that would preclude maybe health care or even 
service-connection, a lot of times they are going to remain 
untreated for years, whether in some cases it is true or not, 
they just may hear that they are not entitled. So a lot of 
times they won't even file a claim or seek health care.
    So one of the things we are trying to establish is ways 
around those types of situations because I believe within the 
last year or so they did state that VA will now treat those 
with certain types of discharge, especially if it is due to 
MST, TBI and PTSD and other type issues for health care. And 
that is encouraging because once we can establish the health 
care, then essentially maybe we can establish a claim, because 
if there is no diagnosis and no mental health treatment up 
front it will complicate the entire process.
    Ms. Luria. Thank you.
    And I now give Mr. Bost 5 minutes for questions.
    Mr. Bost. Thank you.
    Ms. Tarloski, and understand that all of us involved with 
the panel and everyone with the VA, we want to make sure that 
we get this right. We have to get it right. But as we move 
forward, we have the obligation to the veteran. We have an 
obligation to a taxpayer. But our first obligation is to the 
veteran. Okay. We all know that.
    So do you know in your studies and what you have witnessed, 
is there people who have received, who have MST that do not 
have some form of the markers that the VA have out there? I 
mean, is there a case where, okay, they don't show any of that?
    Ms. Tarloski. I would say most cases, at least in the cases 
I have handled where there is markers in decision letters that 
have denied those veterans benefits, those markers are either 
attributed to another trauma, which I see quite often. They are 
ignored. I mean, they are acknowledged in the letter and then 
ignored.
    I have seen a case where the VA honed in on a discrepancy 
of 2 days when the veteran says the assault happened in 2 
different letters that this person submitted, and they said, 
well, you know, obviously this isn't a credible lay statement 
because you are changing your story in an assault that happened 
41 years ago.
    So where there are markers, I think they are not being 
interpreted correctly or they are just not being adjudicated 
correctly. I have seen some claims with no markers at all where 
the veteran is coming forward for the first time. However, if a 
marker could be interpreted as a medical record because they 
have said something to a VA health care professional, then it 
should be weighed, but I don't find that it usually is.
    Mr. Bost. Dr. Potter, would you agree with that, that--and 
I'm just trying to figure out, okay, I know that there is 
people that I know in my family that have experienced this. And 
I know certain things and certain actions that have changed in 
their life after the experience.
    So are there those that have no identifying markers?
    Dr. Potter. I doubt it. When I was read the proposed bill, 
I thought the 4 secondary markers really encompassed all of, or 
most of, all of the victims I have spoken to and all of the 
research.
    These markers are well documented in the research and I was 
really impressed that they were going to be used as proxies 
because there are so many good reasons, as we have talked 
about, why people can't come forward in the aftermath of the 
assault. And they are great reasons and we have to respect 
those individual decisions.
    So I think those markers are spot on.
    Mr. Bost. Okay. Mr. Liermann, what are you suggesting or 
what suggestions might the DAV have for how to better train or 
are we moving in the right direction with the VA on the 
training that is given to those people because you have seen a 
lot of these claims? You have also seen other combat claims and 
post-traumatic stress in many ways. Are we training right and 
are we training enough to deal with the situations as they 
occur?
    Mr. Liermann. Well, as the OIG report noted that previously 
a lot of the MST claims and the training was one time. I don't 
believe training somebody once on how to handle these issues is 
ever going to be enough.
    For example, within DAV and our national service officers 
around the country we provide annual training on MST 
sensitivity claims, the entire process, to make sure it is 
always fresh, we understand, plus if something new comes out we 
can always train or alter or tailor that training just to make 
it one of those issues that we fully understand.
    As far as VA's new training or what they are doing now, I 
really can't comment because I haven't seen any of the new 
training as of yet. DAV would love to be a part of it and 
partner with VA in developing some of the training.
    And I love the point that was made earlier, that something 
from a survivor's point of view really is, I think, needed in 
the training because if you haven't experienced it yourself, it 
is hard to always have enough empathy for somebody.
    Mr. Bost. Sure.
    Mr. Liermann. And unless you can really put a face with it 
and emotion with it and truly understand the impact it has on 
people.
    Mr. Bost. All right. Well, my time is expired, and I want 
to thank you for being here. But I will turn it over--I will 
yield back.
    Ms. Luria. Thank you.
    Would you like more time for any additional questions?
    Mr. Bost. Just a comment, if I could.
    Ms. Luria. Of course.
    Mr. Bost. Let me say this, and for all of the panel of us 
here. As I said, this is vitally important. We have kept our 
head in the sand for a very, very long time on these issues. 
The military today has got to be a tremendous, tremendously 
different than when I went in because it was strictly a case 
that if something like this occurred, you just didn't report 
it. You just didn't, at all. It could ruin your career. It was 
embarrassing. The list goes on and on. And the worst thing 
about it was back then your superiors knew it.
    It is my hope the DoD has been very, very clear in making 
sure that as you mentioned earlier that we have got to stop it 
on that end. But we still have to deal with its aftermath and 
that is the VA's job. Unfortunately, quite often the VA's job 
is to clean up the mistakes and mess that the DoD does. And I 
don't mean to bad mouth the DoD here. I am just saying that 
that is military life. But a lot of it that happens is not 
acceptable, and we have got to do our job on this side of the 
dais to make sure that you are doing that--give you all the 
tools you can on that side to make sure that we deal with those 
that are dealing with this.
    So thank you.
    Ms. Luria. Well, thank you.
    And I wanted to wrap up and conclude by thanking all of you 
again for agreeing to come today and participate in this very 
important discussion.
    And I also wanted to thank the representatives from VA and 
OIG for staying to hear the additional testimony because I 
think the ongoing dialogue between experts in the legal field, 
the medical field and then the Veterans Service Organizations 
is a very important part of solving these problems and how we 
can attack this and other issues that are important for our 
veterans receiving the benefits that they have earned and 
deserve.
    So I would like to thank you again and give one more 
opportunity if Mr. Bost would like to make any more closing 
remarks. And I would like to remind all Members that they have 
5 legislative days to revise and extend their remarks and 
include any extraneous material.
    So thank you and the hearing is adjourned.

    [Whereupon, at 12:24 p.m., the Subcommittee was adjourned.]




                            A P P E N D I X

                              ----------                              

                   Prepared Statement of Steve Bracci
    Chairwoman Luria, Ranking Member Bost, and members of the 
Subcommittee, thank you for the opportunity to discuss the Office of 
Inspector General's (OIG's) oversight of the Department of Veterans 
Affairs' (VA's) processing of disability benefits for posttraumatic 
stress disorder related to military sexual trauma (MST). Sexual trauma 
experienced while in military service affects both men and women-with 
serious and long-term consequences. According to the Department of 
Defense, more than 7,600 individuals reported a sexual assault in 
fiscal year (FY) 2018 for an incident that occurred during their 
military service, an increase of about 12.6 percent from the previous 
year. \1\ Understandably, many survivors are reluctant to report the 
sexual assault either at the time of its occurrence or even much later. 
It is, therefore, imperative that VA reviews each MST-related claim for 
benefits expeditiously, thoroughly, and with sensitivity by engaging a 
group of specialized staff to ensure eligible veterans receive the 
benefits to which they are due. Accurate and efficient claims 
management and decision-making can help minimize additional trauma 
while furthering VA's mission to serve the needs of the nation's 
veterans.
---------------------------------------------------------------------------
    \1\ Department of Defense Annual Report on Sexual Assault in the 
Military, Fiscal Year 2018.
---------------------------------------------------------------------------
    In August 2018, the OIG published the report, Denied Posttraumatic 
Stress Disorder Claims Related to Military Sexual Trauma. The OIG's 
audit team examined whether responsible staff correctly processed 
veterans' MST-related claims in accordance with Veterans Benefits 
Administration (VBA) procedures. \2\ Based on the review, the OIG found 
that nearly half of denied MST-related claims were not properly 
processed following VBA policy. The potential impact on veterans 
seeking benefits related to MST is considerable given VBA's estimate of 
about 12,000 MST overall claims being processed per year and the 
growing number of reports to the Department of Defense. The audit team 
identified several deficiencies that led to the improper denial of 
benefits such as lack of specialization, inadequate MST-related claim 
training for processing staff, deficient internal controls, and 
discontinued special focus reviews.
---------------------------------------------------------------------------
    \2\ Denied Posttraumatic Stress Disorder Claims Related to Military 
Sexual Trauma, August 21, 2018.

---------------------------------------------------------------------------
BACKGROUND

    In October 2017, the OIG implemented a new national inspection 
model for VBA oversight. Under this new approach, the OIG conducts 
nationwide audits and reviews of high-impact programs and operations 
within VBA. The purpose of these types of audits and reviews is to 
identify systemic issues within VBA that affect veterans' benefits and 
services, determine the root causes of identified problems, and make 
useful recommendations to drive positive change across VBA. Previously, 
the OIG largely conducted its oversight through routine inspections of 
VBA's 56 regional offices. The OIG's August 2018 MST report was one of 
the first reports that the OIG published under the new national 
inspection model. \3\
---------------------------------------------------------------------------
    \3\ Other reports published under the new national inspection model 
include Unwarranted Medical Reexaminations for Disability Benefits, 
July 17, 2018; Processing Inaccuracies Involving Veterans' Intent to 
File Submissions for Benefits, August 21, 2018; Accuracy of Claims 
Involving Service-Connected Amyotrophic Lateral Sclerosis, November 20, 
2018; Deferrals in the Veterans Benefits Management System, May 15, 
2019; Decision Ready Claims Programs Hindered by Ineffective Planning, 
May 21, 2019; Inadequate Oversight of Contracted Disability Exam 
Cancellations, June 10, 2019.

---------------------------------------------------------------------------
PTSD

    Posttraumatic Stress Disorder (PTSD) is a mental health condition 
that military members can develop after experiencing or witnessing 
life-threatening events such as combat, natural disasters, personal 
trauma, or other significant stressors. \4\ According to VBA, a veteran 
must have a current diagnosis of PTSD, credible evidence that the 
stressor occurred during military service, and a link between the 
current PTSD symptoms and the in-service stressor for VBA to establish 
service-connection for PTSD.
---------------------------------------------------------------------------
    \4\ 38 Code of Federal Register 3.304(f), Posttraumatic 
stress disorder.

---------------------------------------------------------------------------
MST

    VBA defines MST as a subset of PTSD personal trauma claims, 
specifically related to sexual harassment, sexual assault, or rape that 
occurred in a military setting. \5\ According to a 2013 report by the 
RAND Corporation National Defense Research Institute, the vast majority 
of sexual assault survivors do not seek immediate care and the 
incidents are not reported to authorities. \6\ Reasons for not 
reporting, which are particularly relevant to the military, include 
reluctance to submit a report when the perpetrator is a superior 
officer, concerns about negative implications for performance reports, 
worries about punishment for collateral misconduct that may be related 
to the trauma, and the perception of an unresponsive military chain of 
command.
---------------------------------------------------------------------------
    \5\ M21-1 Adjudication Procedures Manual, Part III, Subpart iv, 
Chapter 4, Section H, Topic 4, General Information on Personal Trauma. 
(Historical)
    \6\ Coreen Farris, Terry L. Schell, and Terri Tanielian, Physical 
and Psychological Health Following Military Sexual Assault, 
Recommendations for Care, Research, and Policy, RAND, 2013.
---------------------------------------------------------------------------
    It is often difficult for victims of MST to produce the required 
evidence to support the occurrence of the sexual harassment, sexual 
assault, or rape. Because of this difficulty with obtaining evidence of 
stressors, VBA provided further guidance in 2011 to ensure consistency, 
fairness, and a ``liberal approach'' for MST-related claims. \7\ These 
guidelines eased the requirements for the types of supporting evidence 
VBA could accept to support and identify an in-service stressor for 
MST.
---------------------------------------------------------------------------
    \7\ VBA Training Letter, Adjudicating PTSD Claims Based on MST. 
(Historical)

---------------------------------------------------------------------------
The MST-Related Claims Process

    Each VA Regional Office (VARO) has two MST coordinators-one male 
and one female. They are designated as the local points of contact for 
veterans with MST-related claims. These employees typically also have 
other claims processing responsibilities. Upon receipt of an MST-
related claim, the coordinator must attempt to contact the veteran by 
telephone. The purpose of this telephone call is to determine whether 
the veteran reported the claimed traumatic event in service, and if so, 
determine how they reported it and identify how to obtain this 
evidence. If the assault was reported, the veteran is urged to supply 
the report or provide the name of the military base where the report 
was filed. If the MST coordinator is unable to reach the veteran by 
telephone, a Veterans Service Representative (VSR) must send a letter 
to the veteran requesting information about the reporting of the sexual 
assault.
    VSRs are VARO employees whose duties include determining what 
evidence is necessary to decide an MST-related claim, undertaking 
development action to obtain necessary evidence, and determining when a 
claim is ready for decision. Once obtained, VSRs must thoroughly review 
all evidence to confirm the stressor or identify behavior markers for 
MST. A marker is an indicator of the effect or consequences of the 
personal trauma on the veteran. If the evidence shows possible PTSD 
symptoms or a current diagnosis, credible evidence of the stressor, or 
a single marker for MST, the VSR must request a medical examination. 
The purpose of this examination is to provide a report that includes a 
medical diagnosis, if warranted, and an opinion about whether the 
diagnosis is related to the claimed sexual assault to establish the 
required nexus.
    The claim evidence and exam results are then sent to a Rating 
Veterans Service Representative (RVSR), who are also VARO employees, 
with the authority to make formal decisions on veterans' claims. Before 
RVSRs can decide a veteran's MST-related claim, they must ensure that 
all required steps were completed. These steps include executing the 
procedures for obtaining the veteran's complete military personnel 
file; thoroughly reviewing all evidence, including military personnel 
files and service medical records for potential behavioral markers; and 
requesting a medical examination when appropriate. Once RVSRs determine 
that all appropriate procedures were completed, they evaluate the 
evidence and make a decision on the veteran's claim. RVSRs may deny an 
MST-related claim without requiring a medical examination only if there 
is no ``credible evidence'' of a stressor, no evidence of a behavioral 
marker, or no evidence of symptoms of a mental disorder.

PREVIOUS OIG AND GAO REPORTS IDENTIFIED ISSUES WITH MST-RELATED CLAIMS 
    PROCESSING

    In December 2010, the OIG published a report, Review of Combat 
Stress in Women Veterans Receiving VA Health Care and Disability 
Benefits. \8\ The report assessed whether VBA developed and 
disseminated MST training and policies to claims processors. The OIG 
identified deficiencies in evaluating and processing MST claims and 
recommended that VBA conduct specialized training and an analysis of 
the consistency in which MST claims were processed. As a result, VBA 
implemented special focus quality improvement reviews of MST-related 
claims and directed VAROs to designate MST specialists beginning in 
2011.
---------------------------------------------------------------------------
    \8\ Review of Combat Stress in Women Veterans Receiving VA Health 
Care and Disability Benefits, December 16, 2010.
---------------------------------------------------------------------------
    In June 2014, the Government Accountability Office (GAO) published 
a report, Military Sexual Trauma Improvements Made, but VA Can Do More 
to Track and Improve the Consistency of Disability Claim Decisions and 
identified similar deficiencies. \9\ GAO noted that VBA began assigning 
MST-related claims to specialized claims processors and required them 
to receive MST-specific training; however, quality reviews and analyses 
of claim decisions had shortcomings. They recommended improved training 
and enhanced MST-related quality reviews and outreach.
---------------------------------------------------------------------------
    \9\ Military Sexual Trauma Improvements Made, but VA Can Do More to 
Track and Improve the Consistency of Disability Claim Decisions, June 
2014.

OIG FINDS ALMOST HALF OF VETERANS' DENIED MST-RELATED CLAIMS WERE 
---------------------------------------------------------------------------
    PROCESSED INCORRECTLY

    At the time of the OIG review, VBA reported to the OIG that over 
the last three years it had been processing approximately 12,000 
veterans' claims per year for PTSD related to MST. In FY 2017, VBA 
denied about 5,500 of those claims (46 percent). The OIG review covered 
a population of 2,851 MST-related claims that VBA staff denied and 
completed from April 1, 2017, through September 30, 2017, of which 169 
MST-related claims were sampled.

Incorrectly Processed Claims

    The OIG audit team found that VBA staff incorrectly processed 
veterans' denied MST-related claims in 82 of 169 cases during the 
review period. The team provided VBA with details on the 82 veterans' 
claims that staff incorrectly processed. VBA reviewed the cases and 
agreed with the OIG audit team's conclusions. Based on this review, the 
OIG estimates that VBA did not properly process approximately 1,300 of 
2,700 denied MST-related claims (49 percent).
    The following table summarizes the projected errors based on the 
results of the OIG's claims review. \10\
---------------------------------------------------------------------------
    \10\ The OIG team estimated that in about 300 cases (11 percent), 
multiple errors contributed to the incorrect processing of the denials. 
Therefore, the numbers and percentages do not sum.

                 Table 1. Incorrectly Processed Denial Error Projections for MST-Related Claims
----------------------------------------------------------------------------------------------------------------
                                                                  Projected Number of    Projected Percentage of
                        Error Category                                   Errors                   Errors
----------------------------------------------------------------------------------------------------------------
Evidence was sufficient to request a medical exam and opinion,             740 cases                      28%
                               but staff did not request one
----------------------------------------------------------------------------------------------------------------
     Evidence-gathering issues, such as VSRs not requesting                340 cases                      13%
                         veterans' private treatment records
----------------------------------------------------------------------------------------------------------------
MST Coordinator did not make the required telephone call, or               300 cases                      11%
 VSRs did not use required language regarding the reporting of
                   the assault in letter sent to the veteran
----------------------------------------------------------------------------------------------------------------
      RVSRs made a decision on the veteran's claim based on                270 cases                      10%
    contradictory or otherwise insufficient medical opinions
----------------------------------------------------------------------------------------------------------------
                                                      Total              1,300 cases                      49%
----------------------------------------------------------------------------------------------------------------
Source: VA OIG analysis of statistically sampled MST related claims completed from April 1, 2017, through
  September 30, 2017.


Impact of Incorrectly Processed Claims

    The OIG team found that VBA staff did not follow required 
procedures for processing these claims, which potentially resulted in 
undue stress to veterans as well as a denial of compensation benefits 
for survivors of MST who could have been entitled to receive them. One 
mental health provider confirmed for the OIG audit team that it can be 
traumatizing for individuals claiming MST benefits to relay their 
stories during examinations. Another mental health provider noted that 
veterans are confused and upset when VBA denies their claims, and this 
undue stress can interfere with the treatment process. As a result, the 
OIG audit team concluded that the trauma of restating or reliving 
stressful events could cause psychological harm to individuals 
experiencing MST and prevent them from further pursuing their claims. 
Additionally, incomplete processing may lead to inaccurate claims 
decisions and a significant amount of rework for VBA employees.

Causes for Incorrectly Processed Claims

    The OIG determined there were several root causes for VBA's failure 
to properly process MST-related claims.
    Need for Specialization. In 2016, the VBA Office of Field 
Operations implemented the National Work Queue to manage and distribute 
the national claims inventory and improve VBA's overall production 
capacity. The distribution of daily workload is based on VARO capacity, 
national claims processing priorities, and special missions. Prior to 
implementation of the National Work Queue, VBA had VAROs use the 
Segmented Lanes Organizational Model, which required VSRs and RVSRs on 
Special Operations teams to process claims VBA designated as requiring 
special handling, which included MST-related claims. The OIG team found 
these staff developed special expertise on these highly sensitive 
claims due to focused training and repetition. The National Work Queue 
model allowed these sensitive claims to be directed to any VSR or RVSR, 
regardless of their experience and expertise. VARO staff suggested that 
VBA reestablish specialized processing to help employees redevelop the 
expertise needed for more consistent and accurate MST-related claims 
outcomes.
    Inadequate Training. The goal of VBA's MST training is to improve 
employee awareness of the characteristics and impacts of MST and ensure 
claims processors correctly apply the relevant regulations and 
policies. At the time of OIG's review, VBA had not updated the MST 
training modules since 2014, despite multiple changes to the 
Adjudication Procedures Manual. The OIG audit team reviewed the MST 
training modules and identified several deficiencies including the 
following:

      Consistently referred to a development checklist that was 
outdated and inaccurate
      Included erroneous development procedures, such as 
instructing claims processors to use incorrect medical opinion language
      Misstated the MST Coordinator's role and responsibilities
      Did not address how to rate claims where a diagnosis 
other than PTSD was provided
      Included incomplete information regarding what 
constitutes an insufficient or inadequate examination

    Furthermore, MST training was provided as one-time only, with no 
requirement for annual refresher training. The OIG team, therefore, 
recommended improvements to VBA's training for MST-related claims.
    Lack of an Additional Level of Review. At the time of the OIG's 
work, VBA required a second level of review for some complex claims, 
such as traumatic brain injury cases, but not for MST-related claims. 
An additional level of review would serve as an internal control to 
help ensure VBA staff process claims properly. VBA staff generally 
thought that an additional level of review would be helpful and could 
improve accuracy. Compensation Service management indicated this second 
review would have to be weighed against the cost of the requirement, as 
well as the delay in claims processing. Still, given the sensitive and 
time-consuming nature of MST-related claims, the OIG team determined 
that this added internal control would be appropriate and would help 
improve the quality of claims decisions.
    Discontinued Special Focus Reviews. The Systematic Technical 
Accuracy Review (STAR) team conducts reviews of claims at each VARO as 
part of the Compensation Service national quality assurance review 
program. STAR staff completed special focus quality improvement reviews 
of MST-related claims beginning in 2011. These reviews, designed to 
correct deficiencies identified during the claims process, occurred in 
response to the previously mentioned 2010 OIG report related to 
``combat stress'' experienced by women veterans, and continued, in 
part, because of the 2014 GAO report on MST-related claims. Staff 
performed the reviews twice a year and identified errors similar to 
those identified by the OIG team, such as missed evidence or markers 
and failure to request necessary medical exams. In December 2015, the 
STAR office stopped completing reviews of MST-related claims because 
the error rate for these claims improved from 2011 to 2015. Given the 
resurgence of a high error rate, the OIG team determined that the STAR 
team should reinstate special focus quality improvement reviews for 
MST-related claims.

RECOMMENDATIONS

    The OIG made six recommendations to the Under Secretary for 
Benefits, who agreed to implement the recommendations and make 
necessary changes to ensure the accurate processing of MST-related 
claims. Since the report's publication on August 21, 2018, VBA has 
provided documentation to close recommendations two and six listed 
below and has provided acceptable action plans for implementing the 
remaining four open recommendations.
    The following list presents additional information on the status 
for each OIG recommendation based on a March 2019 VBA status update on 
the implementation of the recommendations:

    1.Review all denied MST-related claims since the beginning of FY 
2017, determine whether all required procedures were followed, take 
corrective action based on the results of the review, and render new 
decisions as appropriate. Status: Open.
    Status of VBA's Action Plan: VBA reported that it has implemented a 
plan to conduct a review of the denied MST-related claims decided 
between October 1, 2016, through June 30, 2018, and take corrective 
actions based on the review if an incorrect decision was made. From 
December 2018 through the March update, VBA has reviewed 25 denied 
claims at the Columbia VARO. These claims were reviewed as part of 
VBA's first phase review plan to validate the established review 
process. This first phase ensured the effectiveness of the policies, 
procedures, and guidance related to the review. In March 2019, VBA 
began its second and final phase of the review which has been expanded 
to Muskogee, Cleveland, Huntington, and Portland VAROs. These VAROs 
will be reviewing approximately 9,700 remaining MST claims with a 
target completion date of September 30, 2019. Targeted Completion Date: 
September 30, 2019.

    2.Focus processing of MST-related claims to a specialized group of 
VSRs and RVSRs. Status: Closed.
    Status of VBA's Action Plan: VBA advised that on November 20, 2018, 
the Office of Field Operations issued guidance for designating a 
specialized group of trained VSRs and RVSRs at each regional office to 
process MST-related, amyotrophic lateral sclerosis, and traumatic brain 
injury-related claims. Completion Date: April 2, 2019.

    3.Require an additional level of review for all denied MST-related 
claims and hold the second-level reviewers accountable for accuracy. 
Status: Open.
    Status of VBA's Action Plan: VBA reported it has instituted a 
process to conduct second-level reviews of MST-related claims. The OIG 
is awaiting additional evidence from VBA that a sufficient number of 
denied claims will be reviewed as part of this process. Targeted 
Completion Date: November 30, 2019.

    4.Conduct special focus quality improvement reviews of denied MST-
related claims and take corrective action as needed. Status: Open.
    Status of VBA's Action Plan: VBA stated that STAR staff will 
conduct a special focus review of denied MST claims in the fourth 
quarter of FY 2019. Targeted Completion Date: September 30, 2019.

    5.Update the current training for processing MST-related claims and 
monitor the effectiveness of the training. Status: Open.
    Status of VBA's Action Plan: VBA stated that it is finalizing the 
``PTSD Due to MST'' training course and would mandate all VSRs and 
RVSRs training be completed by May 31, 2019. By September 30, 2019, VBA 
will administer a targeted consistency study to assess the 
effectiveness of the training. Targeted Completion Date: October 31, 
2019.

    6.Update the development checklist for MST-related claims and 
require claims processors to certify that they completed all required 
actions. Status: Closed.
    Status of VBA's Action Plan: VBA reported that on October 1, 2018, 
it released the updated development checklist for MST-related claims. 
VBA developed a training module to complement the checklist. When RVSRs 
sign the rating decision for any disability compensation claim, they 
are certifying all required development actions have been taken 
regardless of claim type. Completion Date: January 8, 2019.
    The OIG anticipates receiving an additional status update from VBA 
by June 21, 2019, and will monitor VBA's progress until all proposed 
actions are completed. The OIG website provides information on the 
real-time implementation status of all OIG recommendations.

CONCLUSION

    Survivors of MST are often reluctant to report incidents and, even 
when they do, face the potential for significant distress during the 
claims process for related benefits. Every effort must be made to 
minimize that from happening. VBA has expressed a strong commitment to 
fixing deficiencies identified by the OIG that should help alleviate 
that stress and could also encourage more eligible veterans to step 
forward. Sustainable progress in reducing the large number of errors 
associated with denied MST claims can only be made by trained 
specialists who have the expertise and experience to routinely manage 
these claims in a sensitive and timely manner. Prior OIG and other 
oversight reports detailed some of the same problems that were 
identified in the OIG's most recent report. The significant number of 
errors in denying MST claims, as detailed in the OIG's 2018 report, and 
the recurrence of prior problems should indicate the need for vigilance 
in ensuring that after all OIG recommendations are closed, VBA needs to 
take measures to sustain that progress. The OIG will continue to 
provide oversight on these and other processes that have a significant 
impact on veterans who have suffered harm during their military 
service.
    Chairwoman Luria, Ranking Member Bost, and members of the 
Subcommittee, this concludes my statement. I would be happy to answer 
any questions.
                                 
               Prepared Statement of Willie C. Clark, Sr.
    Good morning Chairwoman Luria, Ranking Member Bost, and Members of 
the Committee. Thank you for the invitation to speak today on the 
important topic of VA disability compensation benefits based on 
military sexual trauma (MST) and H.R. 1092, the Servicemembers and 
Veterans Empowerment Support Act of 2019. With me is Beth Murphy, 
Executive Director of Compensation Service, and Margret Bell, National 
Deputy Director for Military Sexual Trauma, Veterans Health 
Administration (VHA). In this statement, I will provide an update on 
VA's actions to review and improve MST claims processing and outreach, 
as well as provide the Department's views on the proposed legislation.

Office of the Inspector General (OIG) Report & Veterans Benefits 
    Administration Actions

    Over the past five years, VA has processed approximately 18,000 
MST-related claims each year, on average. The VA OIG completed a review 
in August 2018 to determine if claims adjudicators correctly processed 
MST-related claims in accordance with VBA policy. VA strives to provide 
accurate and timely benefits to our Veterans and appreciates the 
efforts of the OIG to assist us in this regard. As a result of this 
review, the OIG made six recommendations. VBA acknowledges and concurs 
with OIG's findings and took immediate steps to ensure MST-related 
claims are processed accurately. As of today, VBA has fully implemented 
two of the six recommendations and these have been closed by OIG. One 
recommendation is fully implemented but pending closure by OIG. VBA is 
actively working on the remaining three recommendations.

Review of Previously Denied Claims

    OIG's first recommendation was to review all previously denied 
claims since the beginning of fiscal year (FY) 2017, which consisted of 
a universe of 9,724 claims. Last year, VBA implemented that review of 
denied MST-related claims decided between October 1, 2016, through June 
30, 2018, and is taking corrective actions as necessary. On November 
14, 2018, VBA began the first phase of this review This initial review 
allowed VBA to ensure the effectiveness of the policies, procedures, 
and guidance related to the review. In March 2019, VBA began the second 
and final phase to review the approximately 9,700 remaining claims. As 
of May 29, 2019, more than 75 percent of reviews have been completed. 
VBA is finding that approximately 20 percent of claims reviewed have an 
error that requires additional development. VBA is taking necessary 
actions on these claims and all affected Veterans will be notified. 
Once the additional development actions are complete, each of those 
claims will be re-adjudicated to determine whether the decision to the 
Veteran changes. The most common development errors that have been 
identified from this review are:

      The Development Letter did not have the appropriate 
Department of Defense (DoD) report notification language;
      The MST Coordinator did not attempt to contact the 
Veteran for any additional reports; and
      The Veteran was not asked whether DoD Forms 2910 or 2911 
were completed, nor whether the report was restricted or unrestricted.

    Together, these development errors account for over 70 percent of 
the issues discovered in this review, and many of VBA's actions in 
providing additional training and guidance to claims processors and 
outreach personnel are aimed at preventing these errors of inadequate 
development. The target completion date for this recommendation is 
September 2019.

Specialized MST Processing

    The second recommendation was to focus the processing of MST claims 
to specialized employees, as would also be required in H.R. 1092, the 
Servicemembers and Veterans Empowerment Support Act of 2019. VBA 
completed this recommendation, which OIG has now closed, and has 
designated specialized teams of trained Veterans Service 
Representatives (VSRs) and Rating Veterans Service Representatives 
(RVSRs) at every RO to process MST-related claims. These specially 
trained employees will maintain proficiency by working MST claims on a 
regular basis. Leveraging this best practice, VBA has proactively 
designated specialized teams for two other high-priority and often 
complex claims: amyotrophic lateral sclerosis and traumatic brain 
injury.

Additional Level of Review

    The third recommendation required an additional level of review for 
all denied MST-related claims. In conjunction with establishing the 
specialized teams, VA instituted a requirement for 90 percent accuracy 
on at least 10 cases per employee, with all cases subject to a second-
signature review until that accuracy rate is achieved. Single-signature 
authority is granted for this specialized group of claims processors 
once the required accuracy rate has been accomplished. These claims are 
also subject to VBA's standard quality review process. VBA has 
requested closure of this recommendation.

Special Focus Review

    OIG's fourth recommendation is to conduct a special focus quality 
improvement review of denied MST-related claims. As such, in the fourth 
Quarter of FY19 VBA will conduct a special focused review of MST claims 
that were denied between May 1, 2019 and June 30, 2019. The purpose of 
this initiative is to assess the impact of the updated guidance and 
training to improve the overall quality of MST decisions.

Training

    With regard to OIG's fifth recommendation to update and monitor the 
effectiveness of training, VBA has significantly updated and improved 
the VSR and RVSR training for processing MST-related claims. VBA has 
updated courses on MST markers and claims development, as well as the 
overall ``PTSD due to MST'' course and has mandated this training for 
all VSRs and RVSRs who handle MST claims. Additionally, VBA will 
administer a targeted consistency study to assess the effectiveness of 
the training; this is on track for completion in September 2019.

Development Checklist

    VBA fully implemented OIG's sixth recommendation to update the 
development checklist for MST-related claims in December 2018, and OIG 
closed this recommendation in January 2019. The updated checklist 
includes the specific steps claims processors must take in evaluating 
MST claims.

MST Outreach

    Beyond the specific recommendations from the OIG, VBA is dedicated 
to improving outreach to Veterans affected by MST. VBA maintains two 
trained MST coordinators in every RO (one male and one female) whose 
names are posted on VBA's public facing website at https://
benefits.va.gov/benefits/mstcoordinators.asp. The coordinators case-
manage MST claims and personally reach out to Veterans to ensure they 
understand the types of information needed to process the claim. MST 
Coordinators serve as the primary point of contact for all claims 
related to MST and are expected to be subject matter experts for all 
Veteran and/or VBA staff questions regarding MST. MST coordinators can 
assist Veterans during the claims process and connect Veterans to MST-
related resources available within the Veterans Health Administration 
and the local community. Also, two MST program managers in VBA central 
office provide guidance to the field on MST-related outreach. I have 
personally engaged MST coordinators and claims processors in the field 
and am committed to ensuring that MST remains a priority topic for our 
field leaders.
    While it can be challenging to complete outreach for MST due to the 
sensitivity of the trauma, VBA ensures that all public contact 
representatives receive training to help them identify indicators of 
stressors that result from MST and signs of possible MST. VBA conducts 
routine targeted outreach that includes briefings on MST to inform, 
educate, and empower Veterans on access to the benefits and resources 
available to them. This includes information on how to file an MST 
claim and how to contact an MST coordinator. As of the second quarter 
in FY 2019, VBA completed 155 hours of MST-related outreach at over 49 
events, reaching 2,067 Veterans, family members, beneficiaries, and 
other stakeholders.
    Additionally, VBA collaborates with VHA on MST counseling and 
treatment to ensure a warm hand-off and has provided MST-related 
training to DoD personnel.
    Finally, VBA publishes MST-related information across its public-
facing web and social media channels, and in November 2018, VA's Under 
Secretary for Benefits, Dr. Paul R. Lawrence, released a video 
emphasizing VBA's commitment to supporting those who have experienced 
MST, providing treatment to help the healing process, and ensuring 
compensation for those disabled by MST. This video can be viewed at 
https://www.youtube.com/watch?v=-b6NdB6cMwo.

H.R. 1092 - Servicemembers and Veterans Empowerment and Support Act of 
    2019

    I will now move on to providing the Department's views on H.R. 
1092, Servicemembers and Veterans Empowerment and Support Act of 2019.
    H.R. 1092 would amend several sections of title 38, United States 
Code (U.S.C) relating to the administration of health care and benefits 
based on military sexual trauma. VA appreciates the intent of the 
Committee to enhance the processing of disability claims and treatment 
of Veterans who may have experienced MST during service. Provided 
Congress finds corresponding funding offsets, VA does not object to 
certain provisions of the bill but VA opposes others.
    VA does not object to section 2 of the bill, which would add 
``technological abuse'' to the list of definitions provided in 38 
U.S.C.  101. Further, VA does not object to the portion of 
section 4 of the bill, which would amend 38 U.S.C.  1154 to 
include ``technological abuse of a sexual nature'' within the meaning 
of the term ``MST.'' ``Technological abuse'' would include behavior 
such as cyber bullying, stalking, or nonconsensual sharing of 
photographs or videos that may occur via the Internet, social media 
platforms, mobile devices, etc. VA views this addition and expansion of 
terminology as reasonable given the prevalence and access of cellular 
and internet-based communications in society.
    Section 3 of H.R. 1092 would amend 38 U.S.C.  1720D(a)(1) 
to authorize VA to provide a Veteran with counseling and care and 
services needed to overcome psychological trauma determined (in the 
judgment of a VA mental health professional) to have resulted from 
technological abuse of a sexual nature.
    VA does not support section 3, as we believe VA's current authority 
is adequate in this regard. Under section 1720D, VA is authorized to 
provide counseling and treatment for trauma resulting from sexual 
harassment (defined as ``repeated, unsolicited verbal or physical 
contact of a sexual nature which is threatening in character''), and 
this can include sexual harassment that is conducted through cyber 
contact, including the use of Internet social media services. Contacts 
with field staff over the years suggest that many clinicians would 
currently conceptualize experiences similar to those described in 
section 2 as falling within the scope of the existing definition of 
MST, assuming they had a sexual component, and this is consistent with 
the views of VHA's leadership and subject matter experts.
    Section 4 of the bill would amend 38 U.S.C.  1154 to 
specify the standard of proof for service-connection of mental health 
conditions related to MST. VA does not object to the provision that 
would define the term ``covered mental health condition'' to include 
posttraumatic stress disorder (PTSD), anxiety, depression, or other 
mental health diagnoses described in the current version of the 
Diagnostic and Statistical Manual of Mental Disorders that VA 
determines to be related to MST. In doing so, the bill would expand the 
coverage of the lowered evidentiary standard provided in VA regulation 
(38 CFR  3.304(f)(5)), which currently only applies to MST-
based claims for PTSD, to also apply to claims for other mental health 
disorders based on MST.
    VA strongly opposes the amendment to section 1154 in section 4 of 
the bill that would require VA to accept as sufficient proof of 
service-connection a diagnosis of a covered mental health condition by 
a mental health professional together with satisfactory lay or other 
evidence of such trauma and an opinion by the mental health 
professional that such covered mental health condition is related to 
MST in service. VA acknowledges that the circumstances of service make 
the claimed MST stressor more difficult to corroborate, and to that 
end, VA has promulgated regulations in 38 Code of Federal Regulations 
(CFR)  3.303 and 3.304(f)(5), which establish 
equitable standards of proof and provide examples of the type of 
evidence needed to corroborate an in-service injury, disease, or event, 
for purposes of service-connection.
    The amended section 1154, as written, would, however, substantively 
create a new standard for establishing a nexus between a claimed mental 
health condition and a claimed MST stressor, and verification of 
stressful events when adjudicating and determining service-connection 
for MST-related conditions. VA is concerned that the bill's language 
would functionally require VA to accept all allegations of an MST 
stressor and potentially award service-connection based on a single lay 
statement from the Veteran, without even minimal evidence supporting 
the existence of an in-service stressor event (such as the supporting 
evidence and behavioral changes listed in VA regulations). VA views 
this type of evidence as needed to maintain the integrity of the claims 
process. In essence, the bill would require VA to award service-
connection as long as there is a current diagnosis of a covered mental 
health condition, and a mental health professional who is willing to 
speculate that the claimant's symptoms are related to an event in 
military service reported by the Veteran. This would occur despite the 
mental health professional's inability to assess whether the claimed 
in-service stressor or event occurred.
    The current statute, in 38 U.S.C.  1154, emphasizes the 
importance of considering the time, place, and circumstances of service 
when evaluating disability claims. Subsection (b) of section 1154 
specifically refers to consideration of claims based on engagement in 
combat with the enemy. Proposed H.R. 1092 mimics this combat language 
and places MST claims on par with combat related claims. The combat 
provision is based on acknowledgement of the disruptive circumstances 
occurring on a battlefield and the resulting incomplete record keeping. 
This is the reason for a lowered evidentiary standard with acceptance 
of the combat Veteran's lay statement as sufficient evidence of a 
combat stressor. It is not clear how the circumstances of MST events 
are similar enough to those of combat trauma to be placed in the same 
statute or why there is no necessary threshold evidentiary requirement 
beyond a lay statement related to MST, as distinguished from lay 
statements related to combat stressor events. Unlike in-service events 
related to combat, MST is not linked to the ``places, types, and 
circumstances'' of a Veteran's service, but can happen anywhere and at 
any time during service. Even with this lowered standard under current 
section 1154 for combat Veterans, VA must obtain threshold evidence 
that verifies the Veteran engaged in combat before the lay statement 
can be accepted. By contrast, the proposed bill, as drafted, would 
essentially preclude VA from verifying basic information about claimed 
MST stressors.
    Moreover, the proposed amendment would create a conflict with 
proposed section 1164(f)(3) which, when VA obtains conflicting evidence 
related to the substantiation of the claim, would require VA to ``give 
more credence to the evidence that is more beneficial to the 
claimant.'' An unsupported lay assertion is ``evidence'' and would thus 
appear to take precedence over conflicting evidence of any nature. For 
example, if a claimant alleges that an assault occurred on a military 
base in Afghanistan, and VA obtains information reflecting that neither 
the claimant nor the assailant ever served in Afghanistan, VA 
adjudicators arguably would be required to give more credence to the 
claimant's allegation despite the provision in proposed section 
1154(c)(1) that states ``[s]ervice-connection of such covered mental 
health condition may be rebutted by clear and convincing evidence to 
the contrary.'' This conflict may result in disparate treatment of 
similarly situated claimants in VA adjudications.
    Apart from our above-stated concerns regarding section 1164(f)(3), 
the addition of a new section 1164 to title 38, U.S.C., is unnecessary 
because such similar provision already exists in VA's regulations (see 
38 C.F.R.  3.303 and 3.304(f)(5)). VA has 
acknowledged the challenge of corroborating a Veteran's account of an 
MST, which led to the promulgation of regulations that allow decision 
makers to consider alternative sources of evidence (i.e., markers) when 
corroborating the MST stressor. These markers include substantially the 
same evidence listed in the proposed bill such as records from non-
military health professionals, behavioral changes, and statements from 
other Servicemembers or family members. VA regulations also include the 
requirement contained in the bill to provide, prior to any denial of a 
claim based on MST, the proper notice and opportunity for the claimant 
to supply non-military evidence relating to the MST claim, and the 
requirement to solicit an opinion from a medical professional as to 
whether evidence provided by the claimant indicates an MST event 
occurred.
    The proposed section 1164 would also require VA to establish points 
of contact in letters to claimants and establish trained specialized 
teams to process MST claims. These statutory requirements would be 
redundant of requirements that VBA has instituted across all ROs.
    VA opposes the provision of section 4 of the bill that adds a new 
section 1165 to title 38, U.S.C., which would require VA to submit 
annual reports to Congress on several aspects of MST claims processing 
through 2027. VA stands ready and willing to provide Congress with 
available data on MST at any time. However, certain reporting 
requirements from the bill would be untenable, and the proposed 
required data and metrics may not be captured by our current 
information technology/business systems. For example, VA cannot 
accurately identify the numbers of Veterans who fail to report for an 
examination annually. In addition, such reporting requirements would 
not represent a reasonable use of VA full-time equivalent capacity as 
such resources could be used in adjudicating claims. For example, VA 
notes the extensive efforts required to meet the bill's requirement to 
annually report a description of MST-related training, including 
frequency, length, and content of the training. Training across the 56 
regional offices varies depending on the position (i.e., MST 
coordinator, Rating Veterans Service Representative, etc.), employee 
turnover, individual quality review results, etc.
    Section 4 of the bill would also require that VA establish 
specialized teams to process MST claims and to ensure team members are 
trained to identify markers indicating military sexual trauma. As 
mentioned, this requirement would be redundant as VA has already 
implemented specialized teams and ensured robust training for these 
designated claims processors. VA believes this provision is unnecessary 
and it reduces VA's flexibility in managing workload appropriately.
    Section 5 of the bill would require DoD to provide Servicemembers 
with information regarding eligibility of services from VA. The 
Secretary of Defense would be required to ensure that DoD's Sexual 
Assault Response Coordinators advise members of the Armed Forces who 
report instances of sexual trauma about their eligibility for services 
from VA.
    While VA defers to the Secretary of Defense on the specific 
obligations this section would impose, we support this section in 
principle. VA currently provides counseling for MST to Servicemembers 
and is pleased to do so. Informing Servicemembers of the benefits for 
which they are eligible is important to ensuring they receive the care 
and services they need.
    Section 6 of the bill would express the sense of Congress that 
members of the Reserve and the National Guard should be able to access 
all VA health care facilities, not just Vet Centers, to receive 
counseling and treatment relating to MST.
    While VA generally defers to Congress in expressing its sense, we 
note that Active Duty Servicemembers and National Guard and Reserve 
Component Servicemembers on Active Duty can receive care at VA medical 
facilities (VAMC) in emergency situations or upon referral by military 
treatment facilities. Members of the Reserve and National Guard who are 
not on Active Duty have the option to purchase TRICARE Reserve Select, 
which could be a means for them to obtain a TRICARE referral and thus 
access care at a VAMC. For those members of the Reserve or National 
Guard who do not have TRICARE coverage, VA's Vet Centers remain an 
important option for receiving care through VA. Vet Centers are widely 
available and provide MST-related individual and group counseling, 
marital and family counseling, referral for benefits assistance, 
liaison with community agencies, and substance use information and 
referral. Vet Center counselors are fully trained and licensed mental 
health professionals who are clinically experienced in treating 
psychological trauma and associated issues such as anxiety, depression, 
and substance abuse. Vet Center Client Records are maintained 
independent of, and governed by, policies different than VA's medical 
facility records. They are thus completely confidential and unable to 
be shared with DoD without the permission of the Servicemember. This is 
in contrast to VA medical facility records, which are available to DoD 
providers via VA-DoD open record sharing. We further note there are 
some technical concerns with this section, such as the reference to 
section 1720D(a)(1) in section 6(b)(1), and we would be happy to work 
with the Committee to address these concerns.
    Benefit costs associated with section 4 are estimated to be $272.6 
million in 2020, $3.6 billion over five years, and $9.7 billion over 
ten years. In addition, significant administrative costs are associated 
with implementing the benefits proposed in this bill.

Looking Ahead

    VA is grateful for the support of this committee and the ongoing 
efforts of this Congress and OIG in enhancing claims processing, 
treatment, and outreach for Veterans who have experienced MST.
    We will continue to explore other ways to improve and supplement 
training and outreach for MST-related claims. We have internalized the 
actions initiated in response to the VA OIG report recommendations to 
ensure that robust training and quality systems remain in place for 
MST-related claims and the entire claims process. I look forward to 
continuing to work with the committee on initiatives to improve the 
Veteran experience with VA.

Conclusion

    The number one priority of VBA is to provide Veterans with the 
benefits they have earned in a manner that honors their service. Due to 
the sensitive nature of the events that caused conditions related to 
MST, VBA must provide compassionate assistance to affected Veterans in 
gathering evidence necessary to complete their claims. To that end, VBA 
has ensured these claims are processed by highly skilled and 
experienced employees who receive specialized training on MST claims, 
engaged in comprehensive action to improve outreach, and committed to 
sustaining and enhancing these developments moving forward.
    This concludes my testimony. I would be happy to address any 
questions from Members of the Committee.

                                 
           Prepared Statement of Elizabeth A. Tarloski, Esq.
    I would like to begin by thanking the Committee on Veterans' 
Affairs, Subcommittee on Disability Assistance and Memorial Affairs for 
inviting me to speak on this important issue.
    I currently serve as a staff attorney and adjunct professor at the 
Lewis B. Puller, Jr. Veterans Benefits Clinic at William and Mary Law 
School and I am submitting this testimony in my individual capacity. 
The clinic assists veterans in filing and appealing disability claims 
and focuses on complex claims involving Post Traumatic Stress Disorder 
(PTSD), Traumatic Brain Injury (TBI), as well as mental health claims 
based on Military Sexual Trauma (MST). I regularly work with veterans 
to gather evidence in support of MST-related claims, and appeal 
decisions that deny them benefits.
    I support H.R. 1092 because it would put veterans who have 
experienced MST on equal footing with other veterans who have non-
personal trauma PTSD claims. The VA's own internal manual sets forth 
the following: ``If a claimed stressor is not related to combat, 
experience as a former prisoner of war, fear of hostile military or 
terrorist activity, or drone aircraft crew member duties, a claimant's 
lay testimony regarding in-service stressors is not sufficient, by 
itself to establish the occurrence of the stressor, and must be 
corroborated by credible supporting evidence.'' \1\ This creates an 
unfair burden on veteran survivors of MST that many other veterans who 
suffer from PTSD do not bear.
---------------------------------------------------------------------------
    \1\ VA ADJUDICATION PROCEDURE MANUAL M21-1, Pt. III(iv), Ch. 4, 
 O(g), https://www.knowva.ebenefits.va.gov/system/templates/
selfservice/va--ssnew/help/customer/locale/en-US/portal/
554400000001018/content/554400000076270/M21-1,-Part-III,-Subpart-iv,-
Chapter-4,-Section-O---Mental-Disorders#4f (last updated Oct. 19, 2018) 
(emphasis added).
---------------------------------------------------------------------------
    The VA has repeatedly said that it has ``lowered the burden'' of 
evidence required to substantiate a claim for PTSD related to personal 
trauma, which includes MST claims. The current standard allows for the 
submission of ``markers'' to be submitted as supporting evidence that 
the in-service stressor occurred. The VA allowed for the use of 
additional evidence starting in 2002, and it issued a description of 
markers that could be used as evidence in 2012. But the supposed 
lowered burden is not much different from the previous standard because 
documentation is still required. H.R. 1092 would allow a veteran's own 
testimony to be used to establish the occurrence of a stressor and 
would not require the additional burden of markers from records that 
may no longer exist.
    Markers divide into two major categories: (1) alternative sources 
of evidence, and (2) behavioral changes. Alternative sources of 
evidence can include records of visits to medical facilities, police 
reports, or statements from chaplains. Behavioral changes can include 
substance abuse issues, episodes of depression and anxiety, and changes 
in performance while in the military. \2\
---------------------------------------------------------------------------
    \2\ VA ADJUDICATION PROCEDURE MANUAL M21-1, Pt. III(iv), Ch. 4, 
 O(d)-(e), https://www.knowva.ebenefits.va.gov/system/
templates/selfservice/va--ssnew/help/customer/locale/en-US/portal/
554400000001018/content/554400000076270/M21-1,-Part-III,-Subpart-iv,-
Chapter-4,-Section-O---Mental-Disorders#3d (last updated Oct. 19, 
2018).
---------------------------------------------------------------------------
    With the current standard, the VA acknowledges that records of 
assaults and harassment are often unavailable because of barriers 
veterans face in reporting during service. Even so, the VA requires 
veterans to produce other documentation, such as medical records, to 
show proof of behavioral changes that may indicate that an MST event 
occurred. Indeed, multiple studies have shown that there are many 
barriers faced by veterans not only to reporting MST in service, but 
also seeking health-care, or discussing the sexual assault or 
harassment post-service. \3\
---------------------------------------------------------------------------
    \3\ J. A. Turchik, C. McLean, S. Rafie, T. Hoyt, C. S. Rosen, & R. 
Kimerling, Perceived barriers to care and provider gender preferences 
among veteran men who have experienced military sexual trauma: A 
qualitative analysis, 10 PSYCHOLOGICAL SERVICES, 213 (2013) (available 
at http://dx.doi.org/10.1037/a0029959).
---------------------------------------------------------------------------
    In addition to the reluctance of veterans to report or discuss 
sexual assault or harassment, the absence of records and the passage of 
time adds to the difficulty of finding evidence of markers. In my 
practice, it is not uncommon for my veteran clients to wait years, 
sometimes decades before filing MST/PTSD claims. Private medical 
records are usually destroyed after only 5 to 10 years and when 
military records do exist, it can take veterans-or those helping them-
over a year just to receive a copy of those records. Further, those in-
service medical and personnel records often contain thousands of pages 
and can include handwritten, hard to read medical notes. Sifting 
through these records to determine what may be considered a marker is 
difficult, confusing, and time intensive.
    Older veterans, who may not have electronic access to records, are 
additionally burdened. The stigma of military sexual trauma, while it 
is now lessening, is still salient. This is even more true for veterans 
of past eras. Requiring veterans, who may never before have disclosed 
trauma, to provide documentation of markers is unreasonable and 
infeasible for many, especially because that documentation may no 
longer exist. \4\
---------------------------------------------------------------------------
    \4\ U.S. GOV'T ACCOUNTABILITY OFF., GOA-14-477, MILITARY SEXUAL 
TRAUMA: IMPROVEMENTS MADE BUT VA CAN TO BETTER TO TRACK AND IMPROVE THE 
CONSISTENCY OF DISABILITY CLAIM DECISIONS, 22 (2014), https://
www.gao.gov/assets/670/663964.pdf. ("[R]epresentatives from four of 
five veteran advocacy organizations we interviewed expressed concern 
that the requirement to substantiate an MST incident is still difficult 
to meet for many with valid claims. Some of these representatives said 
that even markers can be difficult to find or may not exist, since 
veterans may have initially tried to hide their experience due to fear 
of reprisal or feelings of shame or embarrassment, among other 
reasons.'')
---------------------------------------------------------------------------
    Not only is this a higher burden for older veterans, male veterans 
are also negatively affected by the current standard. Men are less 
likely to report sexual assaults in the military, and they are 
generally less likely to disclose MST and seek mental health treatment 
after service. \5\ The 2018 Department of Defense annual report on 
sexual assaults notes that only 17% of men who have experienced sexual 
assaults report them in the military, compared to 38% of women. \6\ 
Therefore, while the percentage of women who experienced sexual assault 
in the military, compared to men, has recently increased overall, men 
are both more likely to be forced into depending on the markers 
standard and less likely to have documented post-service medical 
evidence that could serve as a marker. \7\
---------------------------------------------------------------------------
    \5\ See Mental Health After Military Sexual Trauma, U.S. DEP'T OF 
VETERANS AFFAIRS, https://www.publichealth.va.gov/exposures/
publications/oef-oif-ond/post-9-11-vet-fall-2016/mst.asp (last visited 
June 17, 2019).
    \6\ This is supported by the most recent data released by the 2018 
Department of Defense report on sexual assault. DEP'T OF DEFENSE, ANN. 
REP. ON SEXUAL ASSAULT IN THE MIL., 3 (2018), https://www.sapr.mil/
sites/default/files/DoD--Annual--Report--on--Sexual--Assault--in--the--
Military.pdf. Overall, an estimated 20,500 service members, 
representing about 13,000 women and 7,500 men, experienced some type of 
contact or penetrative sexual assault in 2018. Id. This is up from 
approximately 14,900 in 2016. Id.
    \7\ Id. at 4.
---------------------------------------------------------------------------
    By allowing veterans' lay statements to establish the occurrence of 
the stressor, as it does in cases of PTSD related to combat or fear of 
hostile military or terrorist activity, the VA would be recognizing the 
trauma and burden imposed on veterans by the requirement of marker 
evidence. The current standard reinforces victim-blaming and rape myths 
and as a result, veterans may be reluctant to reapply for benefits 
after receiving denials in decision letters that offer little to no 
explanation. The process can be stressful for veterans because it 
forces them to relive trauma, and the process of submitting a claim can 
result in undue stress and confusion. \8\ When the VA erroneously 
denies an MST claim, a veteran is essentially being told that the event 
did not happen, fulfilling the worst fear of many MST survivors: that 
they will not be believed.
---------------------------------------------------------------------------
    \8\ DEP'T OF VETERANS AFFAIRS OFFICE OF INSPECTOR GENERAL, 17-
05248-241, DENIED POSTTRAUMATIC STRESS DISORDER CLAIMS RELATED TO MIL. 
SEXUAL TRAUMA, 9 (2018), https://www.va.gov/oig/pubs/VAOIG-17-05248-
241.pdf
---------------------------------------------------------------------------
    H.R. 1092 also allows for the expansion of mental health diagnoses, 
beyond PTSD, to be included in the proposed standard. Trauma manifests 
in different ways for different people and the effects of conditions 
such as depression and anxiety can be crippling and harmful to our 
veterans. Including other mental health conditions in the proposed bill 
is a much-needed addition and will go a long way in recognizing that 
veterans are impacted and suffer in different ways beyond just PTSD. 
The current standard does not even allow for the use of markers for 
mental health diagnoses other than PTSD. For veterans claiming other 
mental health conditions related to MST, such as anxiety or depression, 
this creates an almost impossible standard to meet unless a stressor 
event was reported in service or they received mental health treatment 
in service.
    Potential fixes within VA employee trainings, while helpful, would 
still not fully address the heavy burden that the markers standard 
places on veterans. Even if the VA did in fact address inconsistencies 
in the adjudication of MST claims, as proposed in the 2014 Government 
Accountability Office (GAO) report and 2018 Inspector General report, 
the high amount of subjectivity remains. The 2014 GAO report noted that 
two VA claims adjudicators could come to entirely opposite conclusions 
about a marker, and that both could be considered correct under the 
current VA standard. \9\ The burden to find what the VA deems to be 
credible supporting evidence is difficult enough for professional 
claims adjudicators, let alone veterans. \10\
---------------------------------------------------------------------------
    \9\ U.S. GOV'T ACCOUNTABILITY OFF., supra note 3, at 17-18.
    \10\ See id.
---------------------------------------------------------------------------
    By definition, MST includes not only assaults, but harassment as 
well. MST is defined as ``psychological trauma, which in the judgment 
of a mental health professional employed by the Department, resulted 
from a physical assault of a sexual nature, battery of a sexual nature, 
or sexual harassment which occurred while the veteran was serving on 
active duty or active duty for training.'' \11\
---------------------------------------------------------------------------
    \11\ 38 U.S.C.  1720D (2019)
---------------------------------------------------------------------------
    From this definition, it is clear that there are additional 
requirements for service-connecting a PTSD claim resulting from MST 
beyond proving an in-service incident occurred. These additional 
requirements remain in the proposed changes. Medical evidence must 
establish a link between a veteran's current symptomatology and the 
claimed in-service stressor, and a diagnosis by a psychologist or 
psychiatrist is still required in H.R. 1092. For the VA, however, this 
is not enough.
    Changing the burden of evidence will assist those veterans who do 
decide to submit a claim and this change would likely expedite the 
processing of MST claims and lead to fewer appeals. Allowing for the 
submission of lay evidence from veterans, as proposed by H.R. 1092, 
would lessen the psychological burden on veterans and create a more 
streamlined process for claims adjudicators.
    In summary, the current standard for proving an MST-related PTSD 
claim is overly burdensome on veterans. It forces them to determine 
what a marker could be and to scour records, if they still exist, to 
prove to the VA that a traumatic event has taken place. The wounds 
associated with PTSD and MST are not always visible, and many veterans 
will go decades without disclosing the trauma to anyone, including 
medical health professionals. While the VA may claim to have 
``lowered'' the standard of proof in MST-related PTSD cases, these 
changes have had the chief effect of burdening veterans who are 
submitting these claims. The reforms contained in H.R. 1092 require the 
VA to listen to veterans and are a much-needed step in the right 
direction.

                                 
                Prepared Statement of Shane L. Liermann
    Chairwoman Luria, Ranking Member Bost, and Members of the 
Subcommittee:

    Thank you for inviting DAV (Disabled American Veterans) to testify 
at today's hearing on ``Ensuring Access to Disability Benefits for 
Veterans Survivors of Military Sexual Trauma (MST).''
    DAV is a congressionally chartered national veterans' service 
organization of more than one million wartime veterans, all of whom 
were injured or made ill while serving on behalf of this nation.
    To fulfill our service mission to America's injured and ill 
veterans and the families who care for them, DAV directly employs a 
corps of more than 260 National Service Officers (NSOs), all of whom 
are themselves wartime service-connected disabled veterans, at every VA 
regional office (VARO) as well as other VA facilities throughout the 
nation. Together with our chapter, department, transition and county 
veteran service officers, DAV has over 4,000 accredited representatives 
on the front lines providing free claims and appeals services to our 
nation's veterans, their families and survivors. We represent over one 
million veterans and survivors, making DAV the largest veterans service 
organization (VSO) providing claims assistance.
    As a DAV Service Officer for nearly twenty one years, I have 
personal experience in representing thousands of veterans in claims and 
appeals, including MST-related claims, before four different VA 
Regional Offices and the Board of Veterans' Appeals. Based on this 
collective experience, our testimony will discuss DoD's recent annual 
report on military sexual trauma, VA's claims process for MST-related 
claims and its persistent inability to properly train, develop, and 
adjudicate claims for PTSD based on MST, and the impact that H.R.1092, 
the Servicemembers and Veterans Empowerment and Support Act of 2019, 
would have on MST-related claims.
            DoD'S 2018 ANNUAL MILITARY SEXUAL TRAUMA REPORT
    Madame Chair, military sexual trauma has become an all-too-common 
experience for women and men who serve in our armed forces. According 
to DoD's 2018 annual report, sexual assault was experienced by 6.2 
percent of women and 0.7 percent of men in military service during the 
preceding 12 months. However, the number of men and women experiencing 
MST are nearly equal. Significant growth in this rate among women has 
occurred in every service branch, with the highest prevalence rate in 
the Marine Corps (10.7 percent) and the lowest rate in the Air Force 
(4.3 percent). Men are also affected by the experience, but growth in 
the prevalence rates is more contained.
    Sexual harassment occurs even more frequently than assault. Almost 
a quarter of service women (24.2 percent) and 6.3 percent of men 
indicated that they had experienced it. Sadly, 20 percent of service 
women and about eight percent of men who experience harassment also 
experienced assault. This indicates that units with significant numbers 
of service members reporting sexual harassment may be workplaces with 
climates that seem to sanction sexual assault to perpetrators.
    Despite the feelings of pain, fear, shame, embarrassment and 
betrayal that many survivors feel after being sexually attacked, rates 
of reporting the assault are growing from 1 out of 14 in 2006 to 1 out 
of 3 of those service members who experienced assault reporting it to a 
DoD authority in 2018.
    DoD has also learned that survivors' fears of retaliation for 
reporting are real. Twenty-one percent of service members who reported 
an incident of assault reported experiencing actions that meet the 
legal definition of retaliatory behavior. Unfortunately, this justified 
fear of reporting incidents of sexual assault and harassment has 
compounding effects for survivors who often forego the care and 
treatment they require.
    DAV's 2018 report, Women Veterans: The Journey Ahead, which 
examines the challenges women veterans face, detailed the story of 
member and Navy veteran, Leeia Isabelle, who, like so many MST 
survivors, did not report the crime against her claiming she wanted to 
``bury it and make it go away.''
    ``I was just going through the motions and I wasn't really fully 
engaged in my life,'' she reported. Seeing the effects of MST on her 
relationships motivated her to begin the long road to recovery for 
which she credits VA group therapy with other women veterans, cognitive 
behavioral therapy, and local involvement with DAV.
    Ms. Isabelle's story is typical of many veterans with post-
traumatic stress disorder. Symptoms include numbness, hypervigilance, 
irritability, and lack of interest in the people or activities that 
once brought them joy. These changes can strain relationships, threaten 
employment, and isolate them from their families and communities.
    When these incidents are not reported to military authorities, it 
complicates VA's current process for establishing service-connection 
for PTSD related to personal assault. Although current regulations do 
not require verification of the incident, it does require 
corroboration, thus unreported incidents in the military can frustrate 
MST survivors in the existing claims process.
  VA CLAIMS PROCESSING FOR PTSD BASED ON MST AND 38 C.F.R. 3.304(F)(5)
    Currently, claims based on PTSD are not codified, but rather 
controlled by VA regulations, 38 C.F.R. 3.304(f). These regulations 
require a diagnosis of PTSD, and in most instances, a verified 
stressful event in service, and a medical opinion linking the diagnosis 
to the stressful event in service.
    Specifically for MST-related or assault based PTSD claims, in 2002, 
38 C.F.R. 3.304(f)(5) was added to explain the requirements for PTSD 
based on personal assault and notes that verification of the stressful 
event is not required, only corroboration.
    It provides, ``if a posttraumatic stress disorder claim is based on 
in-service personal assault, evidence from sources other than the 
veteran's service records may corroborate the veteran's account of the 
stressor incident. Examples of such evidence include, but are not 
limited to: records from law enforcement authorities, rape crisis 
centers, mental health counseling centers, hospitals, or physicians; 
pregnancy tests or tests for sexually transmitted diseases; and 
statements from family members, roommates, fellow service members, or 
clergy. Evidence of behavior changes following the claimed assault is 
one type of relevant evidence that may be found in these sources. 
Examples of behavior changes that may constitute credible evidence of 
the stressor include, but are not limited to: a request for a transfer 
to another military duty assignment; deterioration in work performance; 
substance abuse; episodes of depression, panic attacks, or anxiety 
without an identifiable cause; or unexplained economic or social 
behavior changes. VA will not deny a posttraumatic stress disorder 
claim that is based on in-service personal assault without first 
advising the claimant that evidence from sources other than the 
veteran's service records or evidence of behavior changes may 
constitute credible supporting evidence of the stressor and allowing 
him or her the opportunity to furnish this type of evidence or advise 
VA of potential sources of such evidence. VA may submit any evidence 
that it receives to an appropriate medical or mental health 
professional for an opinion as to whether it indicates that a personal 
assault occurred.''
    This means that PTSD claims based on MST do not require survivors 
to have absolute verification of the incident, only corroboration. This 
is a lower threshold that differs from other PTSD related claims. 
However, the Veterans Benefits Administration (VBA) has persistent and 
systemic problems implementing this regulation. VBA has shown its 
inability to properly train, develop, and adjudicate claims for PTSD 
based on MST, as evidenced by the numerous reports of the VA Office of 
the Inspector General (OIG) and the United States Government 
Accountability Office (GAO).

December 2010 OIG Report

    The December 16, 2010, OIG report, Review of Combat Stress in Women 
Veterans Receiving VA Health Care and Disability Benefits, found 
differences in VBA's denial rates among male and female veterans' 
claims for PTSD or for other mental health conditions. Specifically, 
VBA denied female veterans at a higher rate than male veterans for 
PTSD. The report estimated that VBA denied 49.8 percent of female 
veterans compared to 37.7 percent of male veterans who applied for PTSD 
disability compensation.
    The 2010 report further revealed that none of the regional offices 
visited had specialized workgroups dedicated to processing MST-related 
claims. The report concluded that VBA had not assessed the feasibility 
of implementing MST-specific training and testing for claims processors 
who work on MST-related claims because it has not analyzed available 
data on its MST-related workload and how consistently these claims were 
adjudicated.

May 2011 OIG Report

    In the OIG report of May 18, 2011, Systemic Issues Reported During 
Inspections at VA Regional Offices, it was noted that 50 percent of the 
VAROs reviewed did not follow VBA policy when processing PTSD claims. 
OIG projected VARO staff did not correctly process about 1,350 (8 
percent) of approximately 16,000 PTSD claims completed from April 2009 
through July 2010. This generally occurred because VARO staff lacked 
sufficient experience and training to process these claims accurately. 
Additionally, some VAROs were not conducting monthly quality assurance 
reviews. For these reasons, veterans did not always receive accurate 
benefits.

VBA Subsequent Actions

    Starting in 2011, VBA began directing VAROs to designate MST 
specialists from among their adjudicators with experience processing 
complex claims. This was designed to improve adjudicator adherence to 
processing requirements for MST-related claims. The purpose of 
specialization was to allow regional offices to identify staff with the 
appropriate skills and sensitivity and afford specialists the 
opportunity to hone their knowledge of the MST requirements over many 
claims.
    Subsequently, VBA developed additional guidance and training for 
MST specialists. Specifically, in late 2011, the agency issued a 
guidance letter and rolled out 1.5-hour and 4-hour training sessions on 
how to process PTSD claims related to MST. VBA also rolled out a one-
hour training session on sensitivity in June 2011. All MST specialists 
were required to take each course once. With regard to medical 
examiners who conduct exams for MST-related claims, during this period, 
VHA instituted comparatively limited training.
    Recognizing the systemic problems processing MST claims, in April 
2013, VBA sent 2,667 notification letters to veterans whose PTSD claims 
related to MST were denied between September 2010 and April 2013. VBA 
advised the veterans to resubmit previously denied PTSD claims related 
to MST. The initiative was designed to correct any development errors 
that had occurred before VBA undertook its specialization and training 
initiatives.

June 2014 GAO Report

    In June 2014, GAO released its report, Military Sexual Trauma: 
Improvements Made, but VA Can Do More to Track and Improve the 
Consistency of Disability Claim Decisions. The report concluded that in 
contrast to VA's actions to date, which largely have been taken in 
response to external requests, a more proactive and systematic approach 
could further dispel confusion among adjudicators and examiners, 
identify errors, and inform veterans of opportunities to resubmit 
denied claims. The GAO report recommended the Under Secretary for 
Benefits (USB) undertake a number of actions:

      Expand existing training and guidance to adjudicators 
responsible for MST-related claims by, for example, providing mandatory 
refresher courses or regularly distributing examples of relevant errors 
identified from quality assurance reviews.
      Develop a plan for conducting more comprehensive quality 
reviews of MST-related claims that allows the agency to identify 
problem areas, target improvement efforts, and track performance over 
time.
      Further analyze existing data on MST-related claim 
decisions by, for example, determining approval rates by regional 
office and veteran gender.
      Explore ways to systematically collect additional data on 
MST-related claims that might allow the agency to better track 
consistency. Such data could include reasons for denials, whether claim 
evaluations included a medical exam, and how often related medical exam 
reports are returned to VHA for clarification or deemed insufficient.
      Expand outreach to veterans who are eligible to resubmit 
their previously denied PTSD claims related to MST. The agency should 
conduct this outreach in partnership with the Veterans Health 
Administration or external organizations, such as veteran service 
organizations

August 2018 OIG Report

    On August 21, 2018, VA OIG published its findings on Denied Post-
traumatic Stress Disorder Claims Related to Military Sexual Trauma. The 
OIG report team found that VBA staff did not always follow VBA's policy 
and procedures, which may have led to the denial of veterans' MST-
related claims.
    The review team found that VBA staff did not properly process 
veterans' denied MST-related claims in 82 of 169 cases. As a result, 
the OIG estimated that VBA staff incorrectly processed approximately 
1,300 or 49 percent of the 2,700 MST-related claims denied during that 
time. Due to the severity and volume of these errors, VA OIG 
recommended that VBA review all denied MST-related claims since the 
beginning of FY 2017 and reopen the cases with errors to ensure 
veterans receive accurate claims decisions as well as better customer 
service.
    In reviewing the MST-related claims denied by VBA, the review team 
found that staff did not follow the required claims processing 
procedures. The most commonly encountered errors in processing were:

      Evidence was enough to request a medical examination and 
opinion, but staff did not request one;
      Evidence-gathering issues existed, such as Veterans 
Service Representatives (VSRs) not requesting veterans' private 
treatment records;
      MST Coordinators did not make the required telephone call 
to the veteran, or VSRs did not use required language in the letter 
sent to the veteran to determine whether the veteran reported the 
claimed traumatic event in service and to obtain a copy of the report; 
and
      Rating Veterans Service Representatives (RVSRs) decided 
veterans' claims based on contradictory or otherwise insufficient 
medical opinions.

    The reasons MST-related claims were incorrectly processed were due 
to lack of previous specialization, lack of additional level of review, 
discontinued special focused reviews and inadequate training.
    VBA previously implemented the Segmented Lanes model, which 
required VSRs and RVSRs on Special Operations teams to process all 
claims VBA deemed highly complex, as well as sensitive issues such as 
MST-related claims. The OIG review team concluded that staff on the 
Special Operations teams developed subject matter expertise on these 
highly sensitive claims due to focused training and repetition. Under 
the National Work Queue (NWQ), VBA no longer utilized the Special 
Operations teams. Under this new model, the NWQ distributed claims 
daily to each VARO and the VARO determined the distribution of MST-
related claims.
    As a result, MST-related claims were processed by any VSR or RVSR, 
regardless of their experience and expertise. The OIG review team 
determined VSRs and RVSRs that did not specialize, lacked familiarity 
and became less proficient at processing MST-related claims.
    VARO staff suggested VBA reestablish specialized processing, 
allowing employees to develop the necessary expertise to ensure 
consistency and accuracy in processing these sensitive claims. The 
Deputy Under Secretary for Field Operations agreed that dedicated staff 
working MST-related claims would help improve the quality of claims 
processing.
    VBA currently requires an additional level of review for some types 
of complex claims, such as traumatic brain injury cases, but does not 
require this additional level of review for MST-related claims. RVSRs, 
quality review personnel, and supervisors interviewed at the four VAROs 
visited generally thought an additional level of review would be 
helpful and could improve accuracy. The Deputy Under Secretary for 
Field Operations and Compensation Service Quality Assurance personnel 
agreed that an additional level of review would help improve the 
accuracy of processing MST-related claims.
    The national Systematic Technical Accuracy Review (STAR) team for 
Compensation Service and the Quality Review Teams (QRT) at each VARO 
execute VBA's quality assurance programs. MST-related claims are 
included in the STAR and QRT claim reviews. However, MST-related claims 
are only a small percentage of the overall claim volume and are less 
likely than other claim types to be randomly selected for STAR and QRT 
reviews. Therefore, STAR and QRT staff did not frequently review them.
    STAR staff completed special focused quality improvement reviews of 
MST-related claims beginning in 2011, based on the deficiencies 
identified in a 2010 OIG report related to combat stress in women 
veterans. These reviews continued based on a 2014 Government 
Accountability Office (GAO) report on MST-related claims that found the 
problems persisted. Staff performed the reviews twice a year and 
identified errors like those this OIG review team found, such as missed 
evidence or markers and failure to request necessary medical 
examinations.
    The STAR office stopped completing special focused quality 
improvement reviews of MST-related claims in December 2015. VBA's 
Quality Assurance Officer indicated the STAR office stopped performing 
special focused quality improvement reviews because it had met the GAO 
requirement. The Assistant Director of Quality Assurance for 
Compensation Service also stated that they reallocated resources 
towards other areas because the error rate declined for MST-related 
claims from 2011 to 2015.
    Given the high error rate identified during its review, the OIG 
review team determined the STAR office should reinstate special focused 
quality improvement reviews of MST-related claims.
    Compensation Service delivered MST training through four modules 
using VBA's online training management system. The MST-related claims 
training was one-time only and there was no requirement for annual 
refresher training.
    The OIG report concluded their report with six recommendations:

    1.The Under Secretary for Benefits reviews all denied MST-related 
claims since the beginning of FY 2017, determines whether all required 
procedures were followed, takes corrective action based on the results 
of the review, renders a new decision as appropriate, and reports the 
results back to the Office of Inspector General.

    2.The Under Secretary for Benefits focuses processing of MST-
related claims to a specialized group of VSRs and RVSRs.

    3.The Under Secretary for Benefits requires an additional level of 
review for all denied MST-related claims and holds the second-level 
reviewers accountable for accuracy.

    4.The Under Secretary for Benefits conducts special focused quality 
improvement reviews of denied MST-related claims and takes corrective 
action as needed.

    5.The Under Secretary for Benefits updates the current training for 
processing MST-related claims, monitors the effectiveness of the 
training, and takes additional actions as necessary.

    6.The Under Secretary for Benefits updates the development 
checklist for MST-related claims to include specific steps claims 
processors must take in evaluating such claims in accordance with 
applicable regulations, and requires claims processors to certify that 
they completed all required development action for each MST-related 
claim.

    VBA responded to the OIG recommendations and indicated the target 
dates for implementation. At the time of this testimony, VBA has 
complied with recommendations number two and six. VBA responded in 
reference to recommendation number three and advised that a second 
level review was only completed by local quality review and requested 
the issue to be closed. However, the OIG has indicated their 
recommendation was not for a peer review but a second tier review to 
include Quality Review. The other recommendations are still considered 
pending as they were assigned target dates in the near future.
    As noted by the several OIG reports and the GAO report, VA has 
persistently and improperly developed and adjudicated PTSD claims 
related to MST. The reasons MST-related claims were incorrectly 
processed were due to lack of previous specialization, lack of 
additional level of review, discontinued special focused reviews and 
inadequate training. These problems have continued since first 
identified in 2010. After nine years of incorrect processing, it 
becomes paramount to establish unrelenting congressional oversight and 
implementation of all of the OIG recommendations to alleviate VA's 
systemic problem with PTSD claims related to MST.
      SERVICEMEMBERS & VETERANS EMPOWERMENT & SUPPORT ACT OF 2019
    As we have indicated above, it is necessary for Congress to take 
legislative action and codify H.R. 1092, the Servicemembers and 
Veterans Empowerment and Support Act of 2019. It would essentially 
codify several parts of 38 C.F.R. 3.304(f)(5) but also would add other 
mental health conditions, in addition to PTSD, as being related to MST. 
This is a significant change over the current regulatory provision that 
only considers PTSD as a related mental health condition.
    The legislation would require the Secretary to accept as sufficient 
proof of service-connection a diagnosis of such mental health condition 
by a mental health professional together with satisfactory lay or other 
evidence of such trauma and an opinion by the mental health 
professional that such covered mental health condition is related to 
such military sexual trauma, if consistent with the facts of such 
service, notwithstanding the fact that there is no official record of 
such incurrence or aggravation in such service. It also requires the 
Secretary to resolve every reasonable doubt in favor of the veteran.
    The bill would also add technological abuse, defined as behavior 
intended to harm, threaten, intimidate, control, stalk, harass, 
impersonate, or monitor another person, that occurs via the Internet, 
through social networking sites, computers, mobile devices to the types 
of trauma and resulting conditions for which survivors may seek both 
benefits and health care.
    H.R. 1092 would require VA to re-establish specially trained teams 
to adjudicate MST-related claims for mental health conditions. We 
appreciate the role of the NWQ; however, as was found by the OIG, the 
removal of the specially trained teams for MST claims was part of the 
improper claims processing.
    Finally, the bill would require VBA to report MST claims annually 
to Congress to ensure that these claims are adjudicated equitably. We 
believe this congressional oversight is required given the nine-year 
history of processing failures.
    This bill is consistent with DAV Resolution No. 042, which calls 
for VA to conduct rigorous oversight of adjudication personnel who are 
responsible for evaluating disability claims associated with military 
sexual trauma and review of data to ensure existing policies are being 
faithfully followed and standardized in all VA regional offices.
    In conclusion, DoD's recent annual report on military sexual trauma 
clearly notes the continuing problem with sexual trauma in the military 
including the substantial under reporting by the survivors of the 
trauma. As demonstrated, since the inclusion of personal assault 
provisions in 2002, VA has struggled to properly train, develop, and 
adjudicate claims for PTSD based on MST. It is time for decisive 
congressional action to alleviate VA's systemic problem with PTSD 
claims related to MST and pass H.R.1092, the Servicemembers and 
Veterans Empowerment and Support Act of 2019.
    Madame Chair, this concludes my testimony on behalf of DAV. I would 
be happy to answer any questions you or other members of the 
Subcommittee may have.

                                 
            Prepared Statement of Sharyn J. Potter, PhD, MPH
    Chair Luria, Ranking Member Bost, Representatives Kuster and 
Pingree and Subcommittee Members,
    I am honored to testify today. My name is Sharyn Potter, I am a 
professor of sociology and executive director of research at the 
Prevention Innovations Research Center at the University of New 
Hampshire. I have spent the better part of the last 20 years 
developing, administering, and evaluating sexual violence prevention 
and response strategies. The focus of my recent work has been the 
economic impact of sexual assault. My research shows the devastating 
cost of sexual violence and its catastrophic impact on victims' health, 
education, and career trajectories. One participant we interviewed 
described the sexual assault perpetrated against her as the ``bomb that 
shattered everything'' as no part of her life was left intact following 
the assault (Potter et al. 2018).
    House Bill 1092 will amend the evidentiary standards that veterans 
need to prove in-service Military Sexual Trauma (MST) providing an 
easier path for veterans to prove they suffered MST, making them 
eligible to receive disability benefits. Under House Bill 1092 the 
Department of Veteran Affairs will be able to accept secondary markers, 
including behavior changes, requests to transfer, reporting to a 
friend, or obtaining testing for pregnancy or sexually transmitted 
infections. These secondary markers are well documented in the research 
as legitimate substantiation of victimization and will support 
veterans' claims of MST, facilitating their ability to receive 
disability benefits for MST.
    Additionally, the proposed bill's inclusion of technological abuse 
is critical for addressing the increasing prevalence of technology as a 
tool for perpetrators. While I have developed a technology application 
that assists victims, I have also seen how the technology we use every 
day is used by perpetrators to isolate, control, scare and intimidate 
victims, adversely affecting victims' daily lives.
    The proposed bill would provide economic assistance to veterans 
suffering from MST. In the 2018 Department of Defense Annual Report on 
Sexual Assault in the Military, 0.7% of enlisted men and 6.2% of 
enlisted women reported an assault. In other words, approximately 7,500 
active duty military men and 13,000 women were sexually assaulted in 
2018. However, only one-third of these victims reported the assault to 
a Department of Defense authority. The low reporting rates are 
consistent with research on colleges and workplaces. There are many 
sound reasons victims choose not to report, including fear of 
jeopardizing their careers, retaliation, and shame. Furthermore, the 
Office of Inspector General (OIG) found that, of the incidences that 
were reported, nearly half of denied MST-related claims were not 
properly processed following Veterans Benefits Administration (VBA) 
policy (Department of Veterans Affairs, Office of Inspector General, 
2018).
    The mental and physical health consequences that MST victims suffer 
in the aftermath of sexual assault, including drug abuse and suicide, 
are well documented in the research (Office of Women's Health, 2019), 
as are the long-term health impacts (Thurston, Chang, & Matthews, 
2019). Additionally, victims face substantial impediments to completing 
their education and meeting their career goals, further undermining 
their economic success. A non-representative study of campus sexual 
assault victims, ages 24 to 65 years at the time of the study, 
highlights the economic and human-capital losses: One-third of the 
participants never finished college, over half took longer than normal 
to earn a degree, and many recounted serial low-wage jobs with limited 
health-care coverage (Potter, 2018; Potter, Howard, Murphy, & Moynihan, 
2018).
    Centers for Disease Control and Prevention researchers estimate the 
measureable costs (e.g., medical care costs, lost productivity) per 
rape victim are $122,461, while the life time societal cost for 25 
million U.S. rape victims is approximately $3.1 trillion dollars 
(valued in 2014 dollars) (Petersen et al., 2017).
    In my research, I have interviewed both veterans and civilians who 
were sexually assaulted as they pursued their military careers and 
their education. Many of these survivors describe the spectrum of long-
term health impacts and how these health problems hinder their ability 
to maintain stable employment. Sexual trauma victims are often 
triggered or re-traumatized by workplace incidents, including being 
alone in an office or dealing with an inappropriately behaving boss, 
client, or customer. These are factors that employees who have not 
suffered sexual trauma acknowledge, but which usually do not cause them 
to leave their positions.
    When people transition in and out of the workplace or rotate among 
low wage positions, they face economic instability, posing challenges 
in their ability to obtain food, housing, transportation and health 
care. Access to disability benefits will reduce the veteran's MST 
burden, allowing them to attain medical assistance and financially 
support themselves and their families.
    Victims of MST suffer unimaginable personal and financial loss. 
Further, the significant societal costs of not treating MST include 
drug addiction, homelessness, and incarceration. In a recently 
published study, researchers found that veterans who were victims of 
MST were 50% more likely to be homeless 30 days, 1 year, and 5 years 
after their discharge date when compared to veterans who did not suffer 
MST (Brignone et al., 2016).
    Finally, in a review of the research on MST, compared to female 
veterans who were victims of MST, male veterans who suffered MST 
reported higher rates of suicide, alcohol abuse, and other psychiatric 
health problems (Suris & Lind, 2008). Yet, providing help for male 
veterans who are victims of MST poses unique challenges, as military 
culture expects men ``to be hypermasculine, and physically strong,'' 
(Turchik et al., 2013, p. 214). Therefore, male victims of MST are less 
likely than their female counterparts to report and seek treatment 
(Eckerlin, Kovalesky, & Jakupcak, 2016), exacerbating the impact of the 
MST in all areas of the veteran's life (e.g., health, relationships, 
work).
    Veterans who have suffered active duty injuries from an explosion 
or vehicle crash are eligible for disability benefits. However, the 
shame of being a victim of MST prevents the majority of active duty men 
and women from coming forward. Yet, we know that when MST victims 
receive help, even belatedly - their lives, the lives of their 
families, and our society are improved.
    Amending evidentiary standards in claims for compensation for MST-
induced psychological trauma is critical in supporting our service 
members who have suffered sexual assault while serving their country. 
Thank you.

References:

    Brignone, E., Gundlapalli, A. V., Blais, R. K., Carter, M. E., Suo, 
Y., Samore, M. H., Fargo, J. D. (2016). Differential risk for 
homelessness among us male and female veterans with a positive screen 
for military sexual trauma. JAMA Psychiatry, 73(6), 582-589. doi: 
10.1001/jamapsychiatry.2016.0101

    Department of Veterans Affairs, Office of Inspector General. 
(2018). Denied Posttraumatic Stress Disorder Claims Related to Military 
Sexual Trauma. Retrieved from website: https://www.va.gov/oig/pubs/
VAOIG-17-05248-241.pdf

    Eckerlin, D. M., Kovalesky, A., & Jakupcak, M. (2016). Military 
sexual trauma in male service members. American Journal of Nursing, 
116(9), pages unavailable. doi: 10.1097/01.NAJ.0000494690.55746.d9

    Office on Women's Health. (2019). Effects of violence against 
women. Retrieved from website: https://www.womenshealth.gov/
relationships-and-safety/effects-violence-against-women

    Peterson, C., DeGue, S., Florence, C., & Lokey, C. (2017). Lifetime 
economic burden of rape in the United States. American Journal of 
Preventive Medicine, 52(6), 691-701. https://doi.org/10.1016/
j.amepre.2016.11.014

    Potter, S. J. (2018). Why Society Can't Afford Campus Sexual 
Violence. TEDxPortsmouth. https://www.youtube.com/watch?v=JFgYreDQ25o

    Potter, S. J., Howard, R., Murphy, S., & Moynihan, M. M. (2018). 
Long-term impacts of college sexual assaults on women wurvivors' 
educational and career attainments. American Journal of College Health, 
66(6), 496-507. https://doi.org/10.1080/07448481.2018.1440574

    Suris A., & Lind L. (2008). Military sexual trauma: A review of 
prevalence and associated health consequences in Veterans. Trauma, 
Violence, & Abuse, 9(4), 250-269. https://doi.org/10.1177/
1524838008324419

    Thurston, R. C., Chang, Y., & Matthews, K. A. (2019). Association 
of Sexual Harassment and Sexual Assault with Midlife Women's Mental and 
Physical Health. JAMA Internal Medicine, 179(1), 48-53. doi: 10.1001/
jamainternmed.2018.4886

    Turchik, J. A., McLean, C., Rafie, S., Hoyt, R., Rosen, C.S., & 
Kimerling, R. (2013). Perceived barriers to care and provider gender 
preferences among veteran men who have experienced Military sexual 
trauma: A qualitative analysis. Psychological Services, 10, 213-222. 
doi: 10.1037/a0029959

    United States Department of Defense Sexual Assault Prevention and 
Response. (2018). The fiscal year 2018 annual report on sexual assault 
in the Military. Retrieved from website: https://sapr.mil/reports

                                 
                       STATEMENTS FOR THE RECORD

                         PROTECT OUR DEFENDERS
    In an era where almost everyone is connected through some form of 
social or electronic media, men and women are at greater risk of 
experiencing virtual and electronic sexual harassment and assault. 
Never before have there been so many ways of perpetuating harassment. 
While not necessarily physical, crimes of a sexual nature involving 
telephonic, electronic, and virtual communications or unpermitted 
access and tracking are no less harmful to one's psyche and mental 
well-being. Thus, Protect Our Defenders fully supports HR 1092 in 
expanding the coverage of VA counseling and treatment to include 
technological abuse of a sexual nature.
    As President of Protect Our Defenders, I have spoken with numerous 
victims of this type of abuse. One such victim was, an officer in the 
Army who received hundreds of text messages from her commander, all of 
them unwanted, and many of them of a sexual nature. At first, the abuse 
manifested itself solely via electronic communications. However, the 
commanding officer escalated his abuse to the level of physical 
assault, which resulted in the victim fearing to go anywhere on base 
alone. The commanding officer continued to message her inappropriately, 
even after she told him on multiple occasions to stop.
    In another instance, an officer's wife began receiving flirtatious 
messages via Facebook from her husband's superior officer. The 
harassment continued, and the victim was eventually ostracized by the 
unit.
    In yet another instance, a woman's image was taken from her 
personal webpage and was manipulated to look like an advertisement for 
pornography. The perpetrators then disseminated the image over 
Facebook, made T-shirts bearing the image (which they then sold 
online), and began a smear campaign against her.
    In each of these cases, the perpetrators utilized social media, 
text messaging or crowd- sharing mechanisms to abuse their victims. 
Each of these survivors were severely traumatized, expressed distrust 
in forming relationships or building online portfolios, and were 
mentally, emotionally, and physically exhausted from battling for 
justice. They also experienced debilitating depression, anxiety, and 
PTSD. While two of the three were never physically assaulted or 
harassed, they were all victims of MST and thus deserving of treatment.
    We can also look to the national news for the impact of these cyber 
crimes. The recent Marines United scandal highlighted the pervasiveness 
of this conduct. The Facebook group consisted of over 30,000 members 
and became infamously known for the dissemination of intimate pictures 
of hundreds of women without their consent. Sadly, Marines United is 
just one example of a military-themed social media group engaged in 
this criminal activity. The outcry over Marines United was intense and 
justified. Before the Senate Armed Services Committee, Gen. Robert 
Neller asked the following: ``Was it enough when Maj. Megan McClung was 
killed by an IED in Ramadi? Or Capt. Jennifer Harris was killed when 
her helicopter was shot down while she was flying blood from Baghdad to 
Fallujah Surgical? Or corporals Jennifer Parcell and Hallie Ann Sharat 
and Ramona Valdez all killed by the hands of our enemies? What is it 
going to take for you to accept these Marines as Marines?'' What he 
didn't address in his testimony to Congress was the phycological damage 
that these crimes leave in their wake for the women and men whose 
privacy has been violated, whose identities have been tainted, and 
whose images will forever linger on who knows how many web pages, dark 
or otherwise. The scale of abuse is unmeasurable.
    More often than not, crimes involving sexual assault and sexual 
harassment don't leave physical traces or evidence that an assault or a 
crime occurred. However, the impact may last a lifetime and often goes 
untreated. When left untreated, survivors face life altering 
consequences impacting their work and family lives. It was for these 
reasons, that it is critical that VA services be expanded to include 
victims of this scourge, and I urge you to pass HR 1092.

    Col. Don Christensen, USAF (Ret.)
    President, Protect Our Defenders

                                 
                   VIETNAM VETERANS OF AMERICA (VVA)
Submitted by

Kate O'Hare Palmer
Chair, Women Veterans Committee

    Good morning, Madam Chairwoman Luria, Ranking Member Bost, and 
distinguished members of the Subcommittee on Disability Assistance and 
Memorial Affairs. Thank you for giving Vietnam Veterans of America 
(VVA) the opportunity to submit our statement for the record regarding 
``Ensuring Access to Disability Benefits for Veterans Survivors of 
Military Sexual Trauma.''
    Since the founding of Vietnam Veterans of America in 1978, we have 
been working with Congress to address the unmet needs of our veterans 
and to ensure they receive the health care and benefits they have 
earned by virtue of their service to our nation.
    We have been at the forefront in advocating for expanded care for 
Military Sexual Trauma survivors. By the VA's own numbers, one in four 
females and one in one hundred males report a history of MST when 
screened by a health care provider at a VA facility, and these numbers 
only reflect the veterans who use the VA. In 2014, VVA worked with 
Senator Gillibrand and Service Women Action Network (SWAN) on the 
Military Justice Improvement Act of 2014. This Bill was accepted 
without a key component that we still support: the removal of the chain 
of command within the judicial process for military sexual trauma 
cases. The current SAPRO reports still show a lack of improvement in 
statistics regarding MST in our military academies and in our military 
forces.
    CSP 579, Health Views: Health of Vietnam Era Veteran Women's Study 
is the only study that has looked at female active-duty members serving 
around the world, including those women who served in Vietnam during 
the Vietnam era. The prevalence of lifetime PTSD in these women was 27 
percent; and the prevalence of partial PTSD in women serving in-country 
was 21 percent. The higher prevalence of PTSD for in-country women is 
not due to preservice trauma. Rather, the variables are related to age 
at enlistment (older age, a protector); service time (20+ years); 
wartime sexual discrimination/harassment; and performance.
    Ten percent of women who served outside a war zone experienced 10 
percent lifetime PTSD, and 50 percent of all women serving throughout 
the world reported a combination of exposure to sexual harassment and/
or military sexual trauma.
    It wasn't until 1980 that PTSD was added to the DSM III. In 1992, 
after a series of hearings on women veterans' issues, the VHA was first 
authorized to provide outreach and counseling for sexual assault to 
women veterans. Vietnam Veterans of America was involved in these 
hearings, and the issues facing women veterans were highlighted during 
the dedication of the Vietnam Women's Memorial 1993. The term 
``Military Sexual Trauma'' was adopted by the VHA in 2003. Public Law 
108-422, made the VA's provision of sexual trauma services a permanent 
benefit. Today, while DoD continues to implement programs to contain 
military sexual trauma and harassment, the data indicates that the 
population of sexually traumatized men and women who are under the care 
of the VHA is alarmingly large and suffers from substantial morbidity.
    The Veterans Benefits Administration (VBA), and to a lesser extent, 
the National Cemetery Administration (NCA), have been less proactive 
than the Veterans Health Administration in targeting outreach to women 
veterans and in ensuring competency in managing claims filed by women 
veterans.
    Today, women veterans have earned and are entitled to full health-
care services, including care for gender-specific illnesses, injuries, 
and diseases as a result of their military service. However, the 
Veterans Healthcare Administration has yet to take sufficient action to 
address the effects of combat-related Post-traumatic Stress Disorder 
(PTSD) among America's women veterans. PTSD is a recurrent emotional 
reaction to a terrifying, uncontrollable, or life-threatening event. 
The symptoms may develop immediately after the event or may be delayed 
for years. How many veterans, male and female, who are diagnosed with 
Sexual Trauma and PTSD, are eligible for VA compensation? VVA urges 
this Subcommittee to request data from the Veterans Benefits 
Administration on how many woman veterans are being compensated for 
PTSD secondary to Sexual or Personal Trauma.

MILITARY SEXUAL TRAUMA

    It has become clear in the last decade that sexual harassment and 
sexual abuse are far more rampant than what had been acknowledged by 
the military. Reported instances of sexual harassment and abuse 
represent only the tip of the proverbial iceberg. While we are pleased 
that both the Departments of Defense and Veterans Affairs seem now to 
be taking this seriously, finally explicitly acknowledging sexual 
trauma as a crime under the Uniform Code of Military Justice (UCMJ) in 
the Defense Authorization Act of 2005, there is still a long road to 
travel to change the current culture that conditions victims of sexual 
abuse to not report this abuse to authorities. VVA urges your 
colleagues on the House Armed Services Committee to ensure that 
penalties for military sexual trauma under the Uniform Code of Military 
Justice are enforced in all branches of the military, and to explore 
such mechanisms to achieve quality assurance on uniformity of 
enforcement, such as a worldwide Internet address and a nationwide 
toll-free number, that would be staffed by counselors 24/7 who are 
trained to effectively assist, counsel, and refer service members (or 
family members) who have been the victim of sexual assault. VVA 
believes that only by means of such a mechanism that is not dependent 
on local command can there be uniformity of quality assistance and 
equal application of justice.
    Vietnam Veterans of America has been at the forefront of advocating 
for the needs of veterans of all genders since the Vietnam War. The 
number of women in the military has risen consistently since the two 
percent cap on their enlistment in the Armed Forces was removed in the 
early 1970s.
    Since then, Congress has passed laws to ensure greater equity, 
safety, and provision of services for the growing number of women 
veterans in the VA system. However, these changes and improvements have 
not been implemented throughout the entire VA system. In some 
locations, women veterans are still experiencing significant barriers 
to adequate health care. As a result, VVA had asked former VA Secretary 
Shinseki to ensure senior leadership at all VA facilities and in each 
VISN be held accountable for making certain that women veterans receive 
appropriate care in an appropriate environment by appropriate staff. 
VVA also recommended that the Subcommittee and the Secretary seek 
guidance from the VA Center for Women Veterans and the VA Advisory 
Committee on Women Veterans, both of which have done considerable work 
and analysis of these issues.
    In addition, VVA wrote to former Secretary Shulkin, requesting the 
implementation status of Section 402 for the Veterans Access, Choice, 
and Accountability Act of 2014 - P.L. 113-564, which expanded 
eligibility for care and services related to Military Sexual Trauma at 
VA medical facilities to active-duty service members. Active-duty 
service members would not be required to obtain referrals from the 
Department of Defense before seeking treatment at a VA facility for 
MST. This section would take effect on the date that is one year after 
the date of the enactment of this Act. In a 2014, Congressional 
Briefing Report for the 114th Congress, the VA wrote that its focus and 
priority is on efficient and effective implementation of this highly 
complex law. In this 2014 report, the VA stated collaboration had begun 
with Department of Defense Health Affairs to discuss the implementation 
of Section 402 of VACAA. Section 402 authorizes VA to provide MST-
related health-care services to active-duty service members without a 
referral from TRICARE or a military treatment facility. This 
collaboration will require continued and close collaboration between VA 
and DoD. https://www.va.gov/OCA/114th%20Congress%20Welcome%20Packet/
114th-New-Member-Packet-Final-508-Version-for-Website.pdf An article 
written in The Washington Post, ``Trusted troops become accused of 
assault,'' by Craig Whitlock drew our attention to what the ``Catch-
22'' members of the Armed Forces on duty status are subjected to in 
cases of sexual assault and trauma. More importantly, we see that the 
implementation of authorizations included in 38 US Code 1720D for VA 
``counseling and care and services'' for these servicemembers, without 
a referral from the Department of Defense, is an immediate need for the 
health, wellbeing and safety of these survivors.
    Madam Chairwoman, VVA has not seen any movement on the 
implementation of Section 402 of Public Law-113-564, since the law was 
signed, and we request that the VA provide the Subcommittee with a 
detailed timeline outlining what the VA has done to date to implement 
this section of the law.
    In regards to H.R. 1092, Servicemembers and Veterans Empowerment 
and Support Act of 2019, introduced by Congresswoman Chellie Pingree, 
D-ME-1, the bill, when enacted into law, would amend Title 38, United 
States Code, to expand health care and benefits from the Department of 
Veterans Affairs for military sexual trauma and for other purposes. The 
inclusion of technological abuse is way past due. The risk of cyber 
harassment is prevalent for anyone who uses Facebook or similar social 
media platforms. It takes one tap to tag someone in a photograph, 
revealing both their location and behavior. Stalkers and harassers use 
such tactics to intimidate or shame their victims. If veterans have 
experienced sexual harassment, abuse, or bullying online, they may 
experience negative feelings or other mental or physical effects. This 
bill, which would add technological abuse defined as ``behavior 
intended to harm, threaten, intimidate, control, stalk, harass, 
impersonate, or monitor another person, that occurs via the Internet, 
through social-networking sites, computers, mobile devices'' to the 
types of trauma and resulting conditions for which survivors may seek 
compensation benefits and health care. VVA supports the bill as 
written.
    VVA would like to thank Congresswoman Luria for her hard work and 
dedication to women veterans, and we thank this Subcommittee for the 
opportunity to submit our views for the record.

                                 [all]