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



                           EXAMINING HOW THE
                    DEPARTMENT OF VETERANS AFFAIRS
             SUPPORTS SURVIVORS OF MILITARY SEXUAL TRAUMA

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

                             JOINT HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                AND THE

                       WOMEN VETERANS TASK FORCE

                                 OF THE

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION
                               __________

                      WEDNESDAY, FEBRUARY 5, 2020
                               __________

                           Serial No. 116-53
                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       


                    Available via http://govinfo.gov
                    
                              ___________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
48-958 PDF                WASHINGTON : 2023   
                    
                    
                    
                    
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tennessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. 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.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY 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 OVERSIGHT AND INVESTIGATIONS

                 CHRIS PAPPAS, New Hampshire, Chairman

KATHLEEN M. RICE, New York           JACK BERGMAN, Michigan, Ranking 
MAX ROSE, New York                       Member
GILBERT RAY CISNEROS, JR.,           AUMUA AMATA COLEMAN RADEWAGEN, 
    California                           American Samoa
COLLIN C. PETERSON, Minnesota        MIKE BOST, Illinois
                                     CHIP ROY, Texas

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

                              ----------                              

                      WEDNESDAY, FEBRUARY 5, 2020

                                                                   Page

                           OPENING STATEMENTS

Honorable Chris Pappas, Chairman, Subcommittee on Oversight and 
  Investigations.................................................     1
Honorable Jack Bergman, Ranking Member, Subcommittee on Oversight 
  and Investigations.............................................     2
Honorable Julia Brownley, Chairwoman, Women Veterans Task Force..     4
Honorable Mark Takano, Chairman, Full Committee..................     5

                               WITNESSES

Mr. Willie Clark, Deputy Under Secretary for Field Operations, 
  Veterans Benefits Administration, U.S. Department of Veterans 
  Affairs........................................................     6

        Accompanied by:

    Ms. Beth Murphy, Executive Director, Compensation Service, 
        Veterans Benefits Administration, U.S. Department of 
        Veterans Affairs

    Dr. Margret Bell, National Deputy Director for Military 
        Sexual Trauma, Veterans Health Administration, U.S. 
        Department of Veterans Affairs

Dr. Julie Kroviak, Deputy Assistance Inspector General for 
  Healthcare Inspections, Office of the Inspector General, U.S. 
  Department of Veterans Affairs.................................     8

Ms. Tammy Barlet, Health Policy Coordinator, The American Legion.     9

Ms. Kayla Williams, Senior Fellow and Director, Military, 
  Veterans and Society Program, Center for a New American 
  Security.......................................................    11

Ms. Samantha Kubek, Staff Attorney, New York legal Assistance 
  Group..........................................................    13

                                APPENDIX
                    Prepared Statements Of Witnesses

Mr. Willie Clark Prepared Statement..............................    37
Dr. Julie Kroviak Prepared Statement.............................    40
Ms. Tammy Barlet Prepared Statement..............................    44
Ms. Kayla Williams Prepared Statement............................    47
Ms. Samantha Kubek Prepared Statement............................    52

                       Statements For The Record

Paralyzed Veterans of America....................................    57
Iraq and Afghanistan Veterans of America.........................    59
Disabled American Veterans.......................................    61

 
                           EXAMINING HOW THE
                    DEPARTMENT OF VETERANS AFFAIRS
            SUPPORTS SURVIVORS OF MILITARY SEXUAL TRAUMA

                              ----------                              


                      WEDNESDAY, FEBRUARY 5, 2020

              U.S. House of Representatives
       Subcommittee on Oversight and Investigations
                          Women Veterans Task Force
                             Committee on Veterans' Affairs
                                                   Washington, D.C.
    The subcommittees met, pursuant to notice, at 10 o'clock 
a.m., in room 210, House Visitors Center, Hon. Chris Pappas 
[chairman of the Subcommittee on Oversight and Investigation] 
presiding.
    Present from Subcommittee on Oversight and Investigation: 
Representatives Pappas, Rose, Cisneros, Peterson, Bergman, 
Bost, and Roy.
    Present from Women Veterans Task Force: Representatives 
Brownley, Takano, Luria, and Brindisi.

 OPENING STATEMENT OF CHRIS PAPPAS, CHAIRMAN, SUBCOMMITTEE ON 
                  OVERSIGHT AND INVESTIGATIONS

    Mr. Pappas. The hearing will come to order.
    Without objection, the chair is authorized to declare a 
recess at any time.
    I ask unanimous consent for our colleague Representative 
Chu to participate in today's hearing, should she be able to 
attend.
    Today's Oversight and Investigation Subcommittee hearing is 
being held jointly with the Women Veterans Task Force, chaired 
by Congresswoman Brownley. Our panel will examine a question of 
great importance: How well does the Department of Veterans 
Affairs support survivors of military sexual trauma?
    Sexual harassment and sexual assault during military 
service is, unfortunately, widespread. Military sexual trauma 
remains one of the most harmful problems for the military and 
veterans communities, representing an insidious cultural 
failure throughout the Department of Defense and Department of 
Veterans Affairs.
    According to VA, at least 25 percent women veterans report 
experiencing military sexual trauma, as do 1 percent of men. 
The numbers are likely far higher. Recent estimates show that 
at least 70 percent of cases go unreported. In addition, men 
and women who are lesbian, gay, or bisexual, are twice as 
likely to experience sexual assault than heterosexual service 
members, even after the repeal of ``don't ask, don't tell.''
    Let us be clear, military sexual trauma is profound 
violence at the hands of fellow servicemembers, but it is also 
followed by institutional betrayal. It represents a destruction 
of confidence in individuals and institutions with whom 
servicemembers entrust their lives.
    The risk for suicide among military sexual trauma survivors 
is among the highest levels in the veteran population, and 
survivors also have twice the risk of homelessness. Although 
access to benefits and health care has a direct preventative 
effect on veteran homelessness and suicide, these survivors 
continue to face numerous hurdles that block access to these 
vital resources.
    As we will hear from our witnesses, VA is widely considered 
to be the best service provider for survivors of military 
sexual trauma. However, oversight conducted by the Subcommittee 
on Health and the Women Veterans Task Force identified many 
barriers for survivors who try to access VA treatment. Many 
veterans are being turned away from care under the 
misunderstanding that they are ineligible.
    Furthermore, survivors applying for benefits face barriers 
that can worsen mental anguish. Applying for benefits for 
military sexual trauma is an arduous, lengthy process that 
requires the veteran to prove that he or she has a disabling 
condition and that it is connected to an in-service trauma. 
This process can be exhausting and even re-traumatizing.
    Our panel represents key officials and experts with 
important knowledge and perspectives. It is my hope that we 
will hear critical information about the extent of this 
problem. Equally important, we need to determine the solutions 
to ensure that survivors are not re-traumatized when seeking 
care. Our veterans need access to high-quality care and they 
deserve nothing less.
    With that, I would like to recognize Ranking Member Bergman 
for 5 minutes for any opening remarks that he may have.

OPENING STATEMENT OF JACK BERGMAN, RANKING MEMBER, SUBCOMMITTEE 
                ON OVERSIGHT AND INVESTIGATIONS 

    Mr. Bergman. Thank you, Mr. Chairman. Thank you to all of 
you for coming today. We are here to discuss the vitally 
important, but tragic topic of Military Sexual Trauma, or MST.
    MST is a serious and immediate issue facing both women and 
men in uniform. In Fiscal Year 2018, the Department of Defense 
found that there was a significant increase in the number of 
sexual assault crimes filed by servicemembers.
    The men and women of our military joined to defend our 
freedoms and values, they accepted the risks and dangers 
inherent in serving in the military; however, they should 
never--and I repeat, never--have to face physical and mental 
trauma resulting from sexual assault or harassment by a fellow 
soldier, sailor, airman, or Marine. Those who perpetrate these 
crimes must be held accountable and appropriately punished for 
their actions; we cannot tolerate anything less.
    It breaks my heart to know that this subcommittee cannot 
remove the pain, suffering, and hurt caused to those who have 
experienced these assaults. However, what this body can and 
must do is work to ensure that VA is providing comprehensive, 
innovative, and empowering care and benefits to MST survivors. 
In order to do this, today we will look at the services and 
benefits provided by the Veterans Health Administration, VHA, 
and the Veterans Benefits Administration, VBA, for MST 
survivors.
    According to Fiscal Year data provided by VA, roughly 
142,000 women and 81,000 men have a positive MST screening. For 
these veterans seeking MST-related health care, we need to look 
at the environment of care, the staff providing the care, and 
whether policies are being followed and are meeting MST 
survivors' needs.
    Currently, VHA requires an MST coordinator at every medical 
facility. MST coordinators are responsible for implementing 
national and local policies, serving as a point of contact for 
MST survivor care, providing staff education, conducting 
outreach, and communicating with leadership and other 
stakeholders.
    In Fiscal Year 2019, the VA Inspector General found, quote, 
``high compliance with several of the selected VHA requirements 
regarding MST coordinators, their activities, and the provision 
of care to patients after positive screening,'' end quote. 
However, there were areas where improvements can and must be 
made, such as staff training and communication with local 
leaders.
    I hope to discuss the workload and staffing of MST 
coordinators, particularly the VHA policy that permits the MST 
coordinator function to be a collateral duty. I am interested 
in hearing from our VA witnesses about how they determine the 
appropriate coverage level. I would like also to hear from our 
non-governmental witnesses as to whether they believe MST 
coordinator coverage is adequate and, if not, why not.
    I also want to explore environment of care issues. The 
committee has heard accounts of MST survivors who have felt 
uncomfortable or unwelcome at VA facilities because of a lack 
of privacy, stigmas around MST survivors, and a lack of gender-
specific care locations. VA has done a lot of work to make 
veterans feel at ease in a VA medical center; however, we need 
to hear what VA can do to ensure that all veterans feel safe, 
secure, and welcome in VA facilities while seeking care.
    Turning to VBA, we need to make sure that veterans applying 
for benefits for MST-related conditions are treated with 
dignity and evaluated fairly. In August 2018, the VA Inspector 
General found that MST survivors claims for Post Traumatic 
Stress Disorder (PTSD) benefits were inaccurately adjudicated. 
Since that report, my colleagues on the Disability Assistance 
and Memorial Affairs Subcommittee, which is led by my good 
friend and fellow Marine, Mike Bost, and which Representative 
Radewagen and I had the pleasure of serving on last Congress, 
has held two hearings that address the IG's findings. VA has 
closed two of the six recommendations. I hope to hear more 
about the progress VA is making in closing the remaining 
recommendations as they work toward improving the disability 
claims, the process for MST survivors.
    I want to take a moment to thank our non-governmental 
witnesses for being here today. Your written testimony includes 
personal accounts or the accounts of your clients in coping 
with sexual trauma. MST is a difficult and painful issue to 
discuss, but your testimony personalizes the issue for us. 
Thank you for being here today to give MST survivors a voice.
    With that, Mr. Chairman, I yield back.
    Mr. Pappas. Thank you, General Bergman.
    I would now like to recognize Congresswoman Brownley, chair 
of the Women Veterans Task Force, for 5 minutes for any opening 
comments she may have.

OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN, WOMEN VETERANS 
                          TASK FORCE 

    Ms. Brownley. Thank you, Chairman Pappas, for holding this 
hearing today and then you for your support in working with the 
Women Veterans Task Force.
    Since launching the task force last year, 81 other Members 
of Congress, both Democrats and Republicans, have joined 
together to advance equity and access to resources, benefits, 
and health care for our women veterans. Together, in November, 
we passed the Deborah Sampson Act, which will transfer VA 
resources for women veterans. I am hopeful that the Senate will 
also pass the bill.
    The Women Veterans Task Force has heard from women veterans 
both at events here in D.C. and all over the country. We have 
been to Guam and Puerto Rico, Alaska and the Dakotas, to New 
York, and of course my home State of California. Everywhere we 
go, we meet with women veterans who are so proud of their 
service, and VA employees and veteran and community 
organizations who are committed to serving them. We also have 
heard consistently that military sexual trauma represents the 
single most destructive problem within the military and veteran 
community.
    Sexual violence in the military by one servicemember 
against another is the ultimate betrayal of the values and 
trust that servicemembers are required to put in one another. 
Sexual violence in the military impacts both men and women. 
Today, women who serve in the military are up to seven times 
more likely to experience MST than men.
    The Veterans Health Administration is the leading provider 
of health care in the Nation for treating military sexual 
trauma. In November, I visited the National Center for PTSD, 
Women's Health Sciences Division in Boston, where I met with 
researchers who developed innovative ways of treating post-
traumatic stress in women. While in Boston, I also met with 
women veterans who shared that VA health care saved their 
lives. Accessing the care is a different story, a completely 
different story. When it comes to accessing VA care and 
benefits, both women and men often face barriers that can make 
recovering from trauma much more difficult.
    Toward the end of 2019, multiple incidences highlighted 
these barriers. One in San Diego, a physician contracted to 
perform Compensation and Pension (C&P) exams for the Veterans 
Benefits Administration was convicted of sexually assaulting 
five women veterans. In West Virginia, Federal authorities 
investigated allegations of multiple sexual assaults against 
veterans at a West Virginia VA hospital. Here in Washington 
D.C., a Navy veteran and member of my own staff was sexually 
assaulted in the atrium of Washington D.C.'s VA Medical Center.
    In fact, VA's own research found that one in four women 
veterans experience sexual harassment at VA facilities. This is 
unacceptable. No veteran should have their well-being and 
livelihood endangered because of hostility in what should be a 
safe and welcoming environment.
    We must highlight that it is on the Department of Defense 
to end its culture of sexual violence. Just last week, we 
learned that sexual assaults at the service academies increased 
by 30 percent in the past year. Meanwhile, this committee will 
always work to make every effort to ensure VA provides adequate 
resources to survivors of military sexual trauma. It is 
imperative that we have policies in place that work for all 
veterans.
    Today, I wish to say once again to survivors, we believe 
you and we are committed to enabling safe and welcoming access 
to the support that you need and deserve.
    Thank you, and I yield back.
    Mr. Pappas. Thank you, Congresswoman.
    I would now like to recognize Chairman Takano, the chair of 
our Full Committee, for 5 minutes for any opening comments he 
may have.

  OPENING STATEMENT OF MARK TAKANO, CHAIRMAN, FULL COMMITTEE 

    Mr. Takano. Thank you, Chairman Pappas.
    I want to first make note about the importance of this 
hearing. The committee and the Women Veterans Task Force have 
focused much-needed attention on a problem experienced by too 
many servicemen and women. As my colleagues have already 
stated, sexual harassment and sexual assault during military 
service is widespread. Today's testimony will show that VA 
recognizes how much these violent crimes affect the well-being 
of our veterans. However, the Department must demonstrate that 
it is doing everything it can to provide survivors with the 
services they need and deserve. Oversight by the committee and 
task force staff, as well as testimony of our witnesses, will 
show both significant advances, as well as some major 
shortfalls.
    I understand that VA's Office of Inspector General (OIG) 
will give some disappointing statistics. For example, the IG 
concluded that a significant portion of primary care and mental 
health clinicians hired after 2012 had not taken the required 
training on military sexual trauma.
    We know that sexual and gender harassment remains prevalent 
at VA medical facilities; this is simply unacceptable. I also 
understand that there are major inconsistencies between 
different elements of the Department when responding to the 
needs of survivors, which leads to eligible veterans not being 
allowed to access critical services, including mental health 
counseling.
    Last year, I made reducing veteran suicide this committee's 
top priority, and last week our committee announced our new 
strategy to address this crisis, inspired by the Center for 
Disease Control's seven core strategies for suicide prevention. 
Today's hearing will focus on two of these goals: strengthening 
the access and delivery of care, and creating protective 
environments.
    We know that survivors of military sexual trauma are among 
the most at risk for suicide. I have heard of many positive and 
effective VA programs that provide help and support for 
survivors. Many VA employees are dedicated to making a 
difference and I am sure all of my colleagues will join me in 
applauding these efforts. However, given the importance and 
nature of these issues, many of the solutions we will explore 
today will require attention from the top levels of the 
Department. We cannot talk about suicide prevention without 
addressing fairness and compassion in accessing benefits and 
eliminating all barriers to accessing health care, including 
ending sexual violence at VA facilities.
    I call on Secretary Wilkie to elevate addressing military 
sexual trauma to a much higher priority throughout VA.
    I look forward to hearing from today's witnesses and, Mr. 
Chairman, I yield back the balance of my time.
    Mr. Pappas. Thank you, Chairman Takano.
    I will now recognize our witnesses. First, we have from VA 
Mr. Willie Clark, Deputy Under Secretary for Field Operations 
of the Veterans Benefits Administration. He is accompanied by 
Ms. Beth Murphy, Executive Director, Compensation Service at 
VBA, and Dr. Margret Bell, National Deputy Director for 
Military Sexual Trauma at the Veterans Health Administration.
    Mr. Clark will provide the testimony for all the VA 
witnesses and you have 5 minutes.

                   STATEMENT OF WILLIE CLARK

    Mr. Clark. Good morning, Chairman Pappas, Ranking Member 
Bergman, members of the subcommittee, Chairwoman Brownley, and 
members of the Women Veterans Task Force. Thank you for the 
invitation to speak today on this very and vitally important 
topic of VA support for survivors of military sexual trauma.
    Accompanying me today is Ms. Beth Murphy, Executive 
Director of Compensation Service at VBA, and Dr. Margret Bell, 
National Deputy Director for Military Sexual Trauma for VHA.
    VBA strives to deliver accurate and timely benefits to our 
veterans. To ensure compassionate assistance is provided to 
veterans who experience military sexual trauma while serving in 
the Armed Services, we have made process improvements, 
including establishing specially trained teams to process 
claims, mandating quality checklists, requiring second-level 
reviews for claims processors, until high accuracy is achieved.
    In addition to benefits, VA provides care for mental and 
physical health conditions related to military sexual trauma 
free of charge. This includes out-patient, residential, and in-
patient care, as well as pharmaceuticals. Eligibility for this 
care is very broad and veterans may be able to receive free 
care even if they are not eligible for other VA care.
    VBA has significantly updated and improved its annual 
training for the processing of military sexual trauma-related 
claims, health care services, and cultural sensitivities for 
identified positions. VBA also plans to hold its first 
collaborative military sexual trauma training symposium this 
year to provide participants with education, networking 
opportunities with employees, veterans service officers, 
Department of Defense, and our VA leadership. Participants will 
exchange resources and ideas, and ultimately work together to 
enhance the veteran's experience with VA programs and services.
    VHA also has a range of initiatives to ensure both clinical 
and front-line staff are prepared to assist survivors. The 
Military Sexual Trauma Consultation Program is available to any 
VHA staff member or provider with questions related to 
assisting veterans.
    VA is dedicated to improving outreach to veterans, 
especially those affected by military sexual trauma. VA 
conducts recurring targeted outreach that includes briefings to 
inform, educate, and empower veterans to access VA benefits, 
health care, and resources. Every regional office has 
coordinators who are specially trained to assist veteran 
survivors in the claims processes, and collaborate with VHA and 
other stakeholders to provide a holistic VA experience. We 
require a male and a female coordinator at every one of our 
regional offices.
    VBA Central Office also has program managers that provide 
recurring guidance to the field on military sexual trauma-
related outreach, including a quarterly teleconference. I 
personally sit in on this conference and speak to our military 
sexual trauma coordinators in the field.
    For transitioning servicemembers, the Transition Assistance 
Program briefing provides information about military sexual 
trauma and related health care benefits.
    Furthermore, VBA ensures that all public contact 
representatives who interact with veterans and families receive 
annual training to help them identify indicators of stressors 
and signs that a veteran may have experienced military sexual 
trauma. VBA and VHA coordinators collaborate on outreach to 
ensure there is a warm handoff to VHA coordinators for 
assistance with access to counseling and treatment.
    Throughout the year, VHA coordinators engage in local 
outreach, which includes educational advances designed to 
increase knowledge and awareness among all staff throughout the 
medical facility, informational events about the impact of 
military sexual trauma and services for veterans, and 
awareness-raising events that include opportunities for 
survivors to share their stories of military sexual trauma and 
recovery.
    Providing veterans with the benefits and services they have 
earned in a manner that honors their service is a priority for 
VA. Due to the difficult nature of military sexual trauma, it 
is particularly critical for us to ensure all interactions with 
veterans and survivors are compassionate and sensitive. To that 
end, VA ensures claims are processed by highly skilled, 
experienced employees who have received training to process 
these claims, VA and staff have the information and resources 
they need to provide streamlined access to specialized veteran-
centric care, and comprehensive action is taken to improve 
outreach.
    This concludes my testimony. My colleagues and I will be 
happy to address any question from members of the committee and 
the Women Task Force.

    [The Prepared Statement Of Willie Clark Appears In The 
Appendix]

    Mr. Pappas. Thank you very much, Mr. Clark.
    Next, we have Dr. Julie Kroviak, Deputy Assistant Inspector 
General for Healthcare Inspections, and I would like to 
recognize you for 5 minutes.

                   STATEMENT OF JULIE KROVIAK

    Dr. Kroviak. Thank you. Chairman Pappas, Ranking Member 
Bergman, Chairwoman Brownley, and members of the subcommittee 
and task force, thank you for the opportunity to discuss the 
Office of Inspector General's oversight of VA policies and 
procedures related to military sexual trauma.
    The OIG has done extensive work regarding benefits and care 
to veterans who have experienced MST. In August 2018, the OIG 
issued a report regarding claims processing, and that report 
was the subject of two hearings before the Disability 
Assistance and Memorial Affairs (DAMA) subcommittee.
    Today, I look forward to discussing the OIG's Office of 
Healthcare Inspections' Comprehensive Healthcare Inspection 
Program, or CHIP, results for Fiscal Year 2019. These reviews 
at 43 randomly selected VHA facilities focus on compliance with 
selected VHA requirements related to MST, including processes 
carried out by the MST coordinators, the provision of care to 
patients after positive screening, and mandatory staff 
training.
    MST is recognized as a patient experience, not a diagnosis 
or mental health condition. Although post-traumatic stress 
disorder is commonly associated with MST, other frequently 
associated diagnoses include depression and other mood, 
psychotic, and substance use disorders. Depending on an 
individual's experience and stage of recovery, treatment needs 
can vary.
    The OIG produces a wide variety of reports to evaluate 
VHA's health care quality and delivery; our CHIP program is one 
such element. OIG CHIP teams evaluate nine areas of clinical 
and administrative operations, and rotating high-interest sub-
topics at each facility approximately every 3 years. The recent 
mental health care review focused on MST performance 
indicators.
    Each of the facilities we evaluated had a designated MST 
coordinator. The OIG found that 98 percent had generally 
established and monitored informational outreach activities and 
91 percent tracked and monitored MST-related data. The OIG, 
however, noted several opportunities for improvement.
    First, VHA must ensure coordinators communicate issues 
concerning MST services and initiatives with local leadership. 
Important data trends could require leadership decisions 
regarding resource allocation and other operational decisions 
to better support the needs of veterans seeking care for their 
MST experiences. The OIG found that only 79 percent had a 
process for accomplishing this responsibility.
    Oversight of staff training is also a critical function of 
the MST coordinator. The OIG found that only 88 percent had 
established and monitored MST-related staff training. Without 
evidence of up-to-date training, VHA cannot ensure that staff 
is trained and prepared to react and respond to the often 
complex needs of veterans who have experienced MST.
    VHA requires that all veterans seen in VHA medical 
facilities be screened for experiences of MST and those results 
documented in the electronic medical record. Veterans should be 
screened at least once and then re-screened following 
additional military service, separation, or declination of the 
initial screening. Those who screen positive must have access 
to appropriate MST-related mental health care.
    The OIG reviewed the provision of MST-related care for 
1,903 patients from these 43 facilities who had a positive 
screening and observed a high compliance with each of VHA's 
requirements that were assessed.
    Additionally, VHA requires that all mental health and 
primary care providers complete their respective mandatory MST 
training no later than 90 days after entering their position; 
however, only 62 percent of these clinicians hired after July 
1st of 2012 had completed that MST within the 90 days. This 
could potentially result in newly hired clinicians providing 
counseling, care, and service without the required MST 
training.
    My written statement references an OIG audit report 
regarding MST claims process and I want to update the status of 
these recommendations. Four of the six recommendations remain 
open. OIG staff will continue to work with VBA staff on 
obtaining sufficient documentation to close these 
recommendations.
    The OIG recognizes the need for VA to provide compensation 
and health care services to veterans who experienced MST during 
their military service. These services must be delivered timely 
and by staff with appropriate training and sensitivity. Recent 
and ongoing OIG work has detailed the challenges some veterans 
face when accessing and receiving these much-needed services, 
as well as experiencing unnecessary delays and unfair denial of 
benefits.
    Reporting such experiences can be traumatic in itself for 
these men and women, thus we are committed to continuing 
efforts to highlight opportunities for streamlining the process 
of compensation and access to high-quality treatment, with the 
ultimate goal of active coping and healing for each survivor.
    Chairman Pappas, this concludes my statement. I would be 
happy to answer any questions you or other members may have.

    [The Prepared Statement Of Julie Kroviak Appears In The 
Appendix]

    Mr. Pappas. Thank you, Dr. Kroviak.
    I would now like to recognize Ms. Tammy Barlet, Health 
Policy Coordinator for The American Legion. Thank you for 
joining us and you have 5 minutes.

                   STATEMENT OF TAMMY BARLET

    Ms. Barlet. After 18 years, U.S. Coast Guard Veteran Emma 
Dale finally had the courage to file a claim for PTSD due to a 
military sexual assault that she endured while serving on 
active duty. Six months after filing her claim, she received a 
letter from the VA denying her benefits. Another 6 months, 
after she received another letter from the VA, detailing that 
her PTSD claim was reinvestigated and she was rated at 50 
percent.
    Chairman Pappas, Ranking Member Bergman, and distinguished 
members of the subcommittee, in addition to the members of the 
Women Veterans Task Force, on behalf of our National Commander, 
James W. ``Bill'' Oxford, representing nearly 2 million 
members, it is my duty and honor to present The American 
Legion's testimony on the VA's MST policies.
    Emma, an Oregon native, overcame one barrier only to arrive 
at another: appropriate care at VA health care facilities.
    After 18 months with her initial psychiatrist, the provider 
told Emma she would be given a new therapist. Her new provider 
abruptly discontinued her medications after only one session 
and informed Emma that they were retiring in 2 months, causing 
an adverse effect on her health care. This disruption in her 
health care might have been avoided if she was aware that an 
MST coordinator even existed at her VHA facility.
    Emma's experience is just one of many veterans who are 
survivors of MST facing barriers within the VA system. The 
American Legion, though the System Worth Saving program, works 
to assess the quality and timeliness of veterans' claims and 
health care delivery, and provides feedback for veterans about 
their health care.
    The American Legion System Worth Saving program includes a 
3-day visit to VA medical centers. The American Legion staff 
meet with the medical center's MST coordinators to ensure the 
facility is compliant with VA Directive 1115, the MST Program. 
Many of the MST coordinators we interviewed stated they work 
well over the 20 percent of their full-time equivalent 
allotment just to ensure they meet the requirements of the 
directive.
    Another part of the System Worth Saving program is our 
Regional Office Action Review, which affords us the opportunity 
to interview VA employees and assess how VBA policies affect 
timely and accurate claims delivery.
    An August 2018 VA OIG report recommended that VA update the 
current training on processing MST-related claims, monitor the 
effectiveness of the training and take action as necessary. 
VBA's response at that time was to update the four lessons and 
mandate training. This updated training informed employees how 
to better identify markers which point to an in-service event 
in the veteran's service record. This process requires time-
consuming work on the part of the claims adjudicators. The 
American Legion's initial assessment revealed that MST 
coordinators, like VBA claims adjudicators, are not afforded 
enough time to properly review a veteran's file. Other factors 
such as inadequate training, high attrition rate, and 
overworked MST coordinators threatened to maintain the status 
quo. This is inconsistent with VBA's stated policies and 
commitment to due diligence on behalf of our veterans.
    We cannot talk about MST without acknowledging harassment, 
which is an ongoing problem within our VA health care. There 
are veterans who do not return to the VA because they 
experienced a hostile environment. The VA's End Harassment 
campaign should be updated to send a clear zero-tolerance 
policy. VHA must work harder to bring awareness, empower 
bystanders, create a reporting structure, provide victim 
support, follow through with the investigations, and enforce 
consequences to change behaviors and culture.
    The American Legion believes that our Nation's heroes 
should not suffer at the hand of the institutions whose sole 
mission is to care for them. We believe in the quality of care 
at VA facilities, remain committed to a strong VA, and maintain 
that the VA is a system worth saving. The American Legion 
recommends Congress to ensure that VA has all the necessary 
resources to remain committed to provide veterans access to the 
help they need to recover from MST and end harassment within 
VHA facilities.
    We thank Chairman Pappas and Ranking Member Bergman for 
their incredible leadership, and for always keeping veterans at 
the core of their mission.
    It is my privilege to represent The American Legion before 
this subcommittee and I look forward to answering any questions 
you may have.

    [The Prepared Statement Of Tammy Barlet Appears In The 
Appendix]

    Mr. Pappas. Thank you for your testimony.
    Next, we have Ms. Kayla Williams, Senior Fellow and 
Director of the Military, Veterans, and Society Program at the 
Center for a New American Security.
    You are recognized for 5 minutes.

                  STATEMENT OF KAYLA WILLIAMS

    Ms. Williams. Chairman Pappas, Ranking Member Bergman, 
distinguished members of the subcommittee and committee, thank 
you for the opportunity to discuss a topic I believe is of 
vital importance to the long-term well-being of too many of 
America's veterans.
    As a VA user, former VA employee, advocate, and researcher, 
I have seen significant improvements in VA's provision of care 
and benefits to MST survivors over the past 15 years. However, 
when MST survivors seek care at a VHA facility and/or file a 
claim for disability compensation with VBA, they still do not 
always receive adequate or consistent services and support. It 
is imperative that VA redouble its efforts to ensure continual 
improvement in its support for MST survivors.
    First, health care services. VHA offers an impressive array 
of physical and mental health services to veterans who have 
experienced MST, including universal screening and evidence-
based mental health treatment that ranges from telehealth to 
in-patient care. However, inconsistencies and inadequacies 
negatively impact veterans' ability to access and utilize care 
across the system.
    One barrier is difficulty accessing initial care. During a 
recent Women Veterans Task Force meeting, VA leaders 
demonstrated a lack of understanding of this issue, repeatedly 
stating that MST survivors are eligible for care related to MST 
without grasping that veterans cannot make it past the first 
gatekeeper to attain the required provider determination that 
their problem is MST-related.
    Another barrier relates to the environment of care in VA 
medical centers. Stakeholders in interviews CNAS recently 
conducted as part of research undertaken on behalf of the New 
York State Health Foundation routinely reported that many women 
veterans are reluctant to seek services at VA medical centers, 
which are perceived to be male-dominated spaces that are 
unwelcome to women.
    VA is well aware of this concern, which is why Central 
Office developed and launched the End Harassment campaign. 
Unfortunately, recent events have undercut public and 
Department-level perceptions of how seriously senior VA leaders 
take the severity of the problem and their willingness to 
address it. The Department should redouble its commitment to 
the campaign while concurrently taking other steps to increase 
the comfort levels of women seeking care in the meantime.
    For example, the Office of Mental Health and Suicide 
Prevention should ensure all women's clinic have onsite mental 
health care in accordance with the Patient Aligned Care Team 
model; increased funding for women veterans mental health; 
enhanced monitoring of assault and harassment in in-patient 
mental health units; develop a women veterans mental health 
provider subspecialty; and create a strategic plan to address 
the rapid growth of the women veteran patient population.
    VA should also increase availability of the Sister Assister 
peer escort program, particularly at VA medical centers with 
higher rates of harassment. The 25 percent rate of women 
veteran patients who have experienced sexual harassment at VA 
medical centers that VA publicly reports, as mentioned by 
Representative Brownley, that is an average. Between different 
sites, it ranged from 11 to 40 percent.
    Moving on to VBA. Disability ratings can provide a vital 
source of support for veterans' financial well-being, 
especially if service-connected disability negatively affects 
their ability to attain or keep a job. Unfortunately, the data 
appears to show that men who seek disability compensation for 
PTSD related to MST are being systematically discriminated 
against by VBA despite overall improvements to the claims 
system going back several years.
    VBA has already made a number of changes in how it 
processes PTSD claims related to MST to reduce disparities that 
had previously been identified between the rate of claims 
granted when the cause of PTSD is MST compared to other 
precipitating events such as combat. While both men and women 
have seen substantial increases in the percent of PTSD claims 
granted due to MST, the grant rate for men has lagged 
significantly behind at just 44.7 percent as of Fiscal Year 
2018 compared to 57.7 percent for women. It is glaringly 
apparent that men's cases are not being handled equitably.
    I urge this committee to request VBA provide an update on 
these grant rates for 2019 and early 2020 by gender. Should 
these disparities remain, I urge increased oversight and 
strongly suggest VBA roll out specialized trainings for raters 
on both implicit bias and the specific MST experiences of men.
    I further recommend this committee request more detailed 
information from VA on each of the issues I have identified, 
and also request Government Accountability Office (GAO) or OIG 
conduct an investigation of the extent and severity of 
harassment and assault in in-patient wards.
    Members of Congress, as well as advocates, must closely 
monitor actions by VA, VHA, and VBA to ensure rapid 
improvements are made in improving care and services for 
survivors, and that that progress is sustained in the long run.
    Thank you.

    [The Prepared Statement Of Kayla Williams Appears In The 
Appendix]

    Mr. Pappas. Thank you, Ms. Williams.
    Our final witness is Ms. Samantha Kubek, the Staff Attorney 
for the New York Legal Assistance Group. You are recognized for 
5 minutes.

                  STATEMENT OF SAMANTHA KUBEK

    Ms. Kubek. Chairman Pappas, Ranking Member Bergman, and 
members of the subcommittee, thank you for the opportunity to 
testify today.
    I am a staff attorney at the New York Legal Assistance 
Group, a nonprofit providing free legal services to low-income 
New Yorkers. My division, LegalHealth, provides legal services 
at hospitals across New York, including VA hospitals, where we 
have served over 5,000 veterans.
    In 2017, we opened the Nation's first legal clinics for 
women veterans, a space where women, particularly MST 
survivors, could receive trauma-informed legal services. I 
represent male and female survivors from every branch and era. 
What is true for every single one is the VA's current system 
has at one time or another stood as a barrier to recovery.
    The impact of a service-connection award on survivors is 
more than just income; it validates the veteran's experience 
and trauma. Often this results in less frequent mental health 
visits and greater engagement in their lives. One client was 
surviving on food stamps, living in a cramped studio with her 
son and granddaughter. We spent a year putting together a 
claim. Despite minimal in-service records and almost 30 years 
since her service, she was awarded 100-percent compensation, 
enabling her to obtain a VA home loan and buy a house. Her 
entire family will live a completely different life because of 
these benefits, but the process to get there is too difficult.
    While proposed changes in bills such as H.R. 1092 go a long 
way to improving the system, I want to provide insight from my 
experience of the ways this system re-traumatizes survivors and 
changes that could help alleviate this.
    In every survivor's claim, they must submit a statement of 
their assault and its impact, the first of many re-tellings 
this process requires; each one forces them to relive it. Many 
do not sleep for days before and after. Some become suicidal or 
struggle to fight relapsing into addiction.
    We must also provide their records from military and 
civilian life. Often records are illegible or incomplete and 
finding them takes months. I was once told by Department of 
Defense (DOD) that restricted reports of assault were only kept 
for 5 years before being thrown out. Sometimes I am told 
reports cannot be found. Sometimes the VBA cannot obtain 
records from the VHA. This causes unique harm to survivors. 
Many have no corroborating military records as they did not 
seek treatment or report. These cases, therefore, rely heavily 
on VHA records. When the VA's two bodies do not effectively 
communicate, the system fails survivors.
    Once I have filed the case, the veteran receives a call 
from someone at VBA, a stranger, asking about their assault and 
whether they reported it. This happens even when their 
statement addresses this and regardless of whether the veteran 
specifically requests the VA to speak with their attorney 
rather than with them.
    Then they have their Compensation and Pension exam, where 
another stranger will ask more questions regarding the assault. 
They have no choice in whether this exam is with a man or a 
woman. Clients have left this exam so distraught they are 
admitted to the hospital, others are unwilling to go.
    Finally, a decision is issued and, when claims are denied, 
the VA's wording matters. A client once called me expressing 
suicidal ideations after receiving her decision. Her daughter 
was conceived from her in-service rape, detailed in her claim, 
along with years of medical treatment. The denial letter stated 
that there was, quote, ``no credible evidence that would 
establish reasonable doubt and allow us to conclude that you 
were in fact assaulted.''
    This language is inhumane and insensitive, particularly 
from a department that prioritizes reducing veteran suicide. It 
is one thing to State that a veteran has not met a burden of 
proof, it is another thing to State that their most traumatic 
experience never happened.
    Military sexual trauma endures long after the assault. It 
is an intimate and personal invasion that occurs where you work 
and live, possibly by someone who is your boss, in a situation 
that you have no way to escape. In recognition of this, the VA 
now allows survivors, regardless of discharge status, to obtain 
related mental health care.
    One of my clients was ineligible for VA care, but due to 
this policy she was eligible to obtain MST-related care, but at 
every appointment she was told that she was ineligible or, 
worse, that she was not a veteran. Only after revealing she was 
there for care relating to her rape was she able to check in 
for her appointment.
    I respectfully propose the following recommendations. The 
VA, as in any other legal proceeding, should respect veteran-
appointed representatives and speak directly with them rather 
than the veteran.
    When records are unobtainable due to no fault of the 
veteran, the VA should bear that responsibility. Veterans 
should not be denied benefits because government agencies lost 
their files.
    Examiners should be required to review a veteran's 
statement prior to their exam and avoid rehashing details 
already in the record.
    The VA must establish trauma-informed language and 
protocols to be used across the VBA and VHA to ensure they are 
not creating further trauma when they are addressing survivors.
    Congress should enable the VA to fund free legal services 
for veterans. This system is extremely complex and legal 
representation is often a necessity, yet there are not enough 
of us.
    The VA must become the place that fixes the wrong the 
military has failed to fix. It must do better to serve 
survivors, bearing in mind their trauma.
    Mr. Chairman, I want to thank you and the subcommittee for 
your continued interest in this issue. I will be happy to 
respond to any questions you may have.

    [The Prepared Statement Of Samantha Kubek In The Appendix]

    Mr. Pappas. Thank you very much, Ms. Kubek. I want to thank 
all our witnesses for their testimony here today.
    I will now begin the questioning portion of today's hearing 
and I would like to begin by recognizing myself for 5 minutes.
    As we have heard here today, for many survivors of military 
sexual trauma details of their experiences will be one of the 
hardest, perhaps the hardest story that they are ever going to 
tell.
    Mr. Clark, I am wondering if I could turn to you and to our 
VA witnesses. Why do VA's eligibility processes often result in 
a survivor having to relive their trauma by providing specific 
details about an assault to VA staff multiple times?
    Mr. Clark. Chairman Pappas, we have worked to fix some of 
these challenges that are brought up here and this one in 
particular is like a gut punch to us. We have been working, 
providing additional training to our processors to basically 
say that if we can corroborate, if we can substantiate, if we 
can grant a claim based upon the evidence in the file, there is 
no need to make a call. Unfortunately, what has happened is, is 
that some of our folks--and we have to get better at fixing 
this--is they follow a checklist that basically says we need to 
call the survivor to ask these questions.
    So we are changing our processes to make our claims 
processors, put them in a better position, because they do not 
want to make these calls; they are tough, they are difficult. 
As has been explained here, it makes an individual have to 
relive these processes, what are their experiences that they 
have gone through, and we have to do better at that. We are 
doing better with that.
    We are updating our checklists, we are conducting training, 
we are--later this year, we are having our first symposium 
where we are inviting claims processors in along with the 
military sexual trauma coordinators, and we are inviting some 
survivors in to talk about these types of experiences, so we 
can impress upon our processors of the need to adequately, 
compassionately process these claims.
    I do not know if Ms. Murphy wants to speak to that.
    Ms. Murphy. Mr. Chairman, if I could quickly add. There is 
a statutory requirement in service connection, we are looking 
for an in-service event or a condition that occurred in 
service, we are looking for a current diagnosis of a condition, 
and a link or nexus between the two. That goes for all sorts of 
claims, including military sexual trauma. This can be a 
difficulty for anybody.
    What makes military sexual trauma different is that often, 
as we have heard and we all know, it often is not reported in 
service, so we have to lean in and dig a little deeper to look 
for markers or indicators that would signal that something may 
have happened. That is why, unfortunately, there are situations 
where we do have to talk to the survivor a little more and try 
to connect those dots. We understand that it can be difficult, 
it is difficult for us too, but we do it as compassionately and 
sensitively as we can.
    Mr. Pappas. Well, I appreciate that. As Ms. Kubek 
testified, clients have left exams and interactions with VA 
distraught, even with suicidal ideations. I hope you will look 
for ways to continue to hear the stories of these survivors, to 
find out ways where there are barriers, and look for ways to 
improve.
    Certainly I want to commend VA for its world-class physical 
and mental health care services, particularly as it is related 
to military sexual trauma, but it is concerning to hear that 
veterans have been turned away from VA in some instances 
because staff do not always fully understand who is eligible 
for these services.
    Dr. Bell, who are the first people that veterans interact 
with when they arrive at a medical center and how are they 
trained on eligibilities for VA services?
    Dr. Bell. Thank you for that question. It is obviously 
going to vary from veteran to veteran and I think that is 
important. I think it is important that we have no-wrong-door 
approach to this, so whoever they make first contact with can 
help get them to a person who can help if they are not person 
directly. In particular we try and really make people aware of 
our MST coordinators as a first person they can go to. They are 
a clinician, they are going to be able to talk with you in a 
private and confidential setting in a sensitive way about this, 
and run interference for you a little bit in the system, if 
that is something that makes you more comfortable.
    Those folks, we provide a great deal of training to them on 
MST-specific eligibility issues to make sure that they are well 
equipped to be able to assist veterans in getting connected to 
care.
    Some veterans will show up in the eligibility office, 
perhaps because they do not know that we have specialized 
services and broad eligibility. It is important for us to make 
sure that those staff have good training as well and have good 
relationships with the MST coordinators.
    I see time has run out, so I will stop.
    Mr. Pappas. Well, thank you very much. Yes, my time is up.
    I will now turn things over to Ranking Member Bergman for 5 
minutes.
    Mr. Bergman. Thank you, Mr. Chairman.
    Dr. Bell, what type of outreach does VA conduct to inform 
veterans who are otherwise ineligible to enroll in VA that they 
are eligible for MST-related care through the VA at no cost?
    Dr. Bell. That is a core message in all of our outreach 
materials, that that--a version of the line you just gave about 
veterans may be eligible for MST-related care even if they are 
not eligible for other VA care. That, again, is a message that 
is going to occur in all of our major outreach materials.
    Mr. Bergman. This is in your written material and other----
    Dr. Bell. Written materials, on our websites----
    Mr. Bergman. Okay.
    Dr. Bell.--and we do major campaigns in honor of Sexual 
Assault Awareness month, it is a core message during that time.
    Mr. Bergman. The last fiscal year, how many veterans who 
were otherwise ineligible to enroll in VHA actually received 
MST-related treatment from a VA medical facility?
    Dr. Bell. That is a good question. I know historically it 
has been a little challenging for us to get those data because 
of the way things get administratively categorized. I do not 
have that information on hand----
    Mr. Bergman. Well, if you could take that----
    Dr. Bell.--but we would be happy to get that----
    Mr. Bergman.--for the record, that would be great.
    Dr. Bell.--we would be happy to get that to you.
    Mr. Bergman. Are these veterans also eligible for community 
care through VA? If they are, why, and, if they are not, why 
not?
    Dr. Bell. Our legal--our treatment authority for MST does 
permit us to provide community care for MST-related care.
    Mr. Bergman. Okay. Ms. Barlet, with over 2 million members, 
The American Legion is in a unique position to assist VA in 
educating veterans about the availability of no-cost MST-
related care. Would you please describe The American Legion's 
outreach efforts?
    Ms. Barlet. The American Legion's outreach efforts come 
through our magazine and our websites, along with news article 
that we will do that we see in our publications. We will also 
be mentioning that in our Commander's testimony coming up.
    Mr. Bergman. Dr. Kroviak, you are a primary care physician; 
correct?
    Dr. Kroviak. I am--I was; I am no longer delivering care.
    Mr. Bergman. But you were?
    Dr. Kroviak. I was.
    Mr. Bergman. For roughly 20 years or so?
    Dr. Kroviak. Eleven years at the VA.
    Mr. Bergman. Eleven years, Okay. Your written testimony 
indicates that only 62 percent of the VHA providers hired after 
July 1st of 2012 completed MST training within 90 days of their 
hiring, whereas 94 percent of providers hired before 2012 
completed the required training. Did OIG review the cause of 
this discrepancy and, if so, what did it find?
    Dr. Kroviak. The 62 percent is the concerning finding in 
the 90-day time line, so that gave an opportunity for providers 
in mental health and primary care to potentially be counseling 
and triaging patients with MST symptoms without appropriate 
training. That was the concern, not that 94 percent were 
getting it, it was within the timeframe that they were getting 
it. There was a gap in them servicing patients and them having 
the appropriate training to counsel patients with MST.
    Mr. Bergman. Any ideas in explaining that 30-percent 
increase?
    Dr. Kroviak. It is data through our CHIP program, which is 
basically we do a menu of subtopics that look at specific care 
delivery programs within VHA. Locally, we get a lot of 
responses from leadership that it is inadequate training and 
mostly competing priorities of the providers from the time they 
are on board to the oversight that they are getting appropriate 
training.
    Mr. Bergman. Okay, thanks.
    Ms. Barlet, in your written testimony you discuss VBA 
employees processing MST-related claims have discussed a 
feeling of compassion fatigue when developing MST-related 
claims. What is the prevalence of compassion fatigue among VBA 
staff and how did you arrive at your conclusion?
    Ms. Barlet. During our System Worth Saving visits, we have 
the opportunity to meet with at least ten VA employees who 
volunteer to meet with us and we are able to interview with 
them. The prevalence, I will have to get back to you for the 
record, but we have seen it overall to make it a concern for us 
to add it to our System Worth Saving reports. Those reports are 
transparent between the VA before we publicize them.
    Mr. Bergman. Okay. Well, I know the Legion has field 
officers who provide veterans assistance in filing claims. Do 
any of your field officers experience compassion fatigue and, 
if so, what does the Legion do to address compassion fatigue in 
its officers?
    Ms. Barlet. Unfortunately, I deal more on the VHA side, but 
I will be more--I will align your staff with those who are in 
our VBA side of the----
    Mr. Bergman. Well, the point is, if compassion fatigue is 
real and one entity or other entities have a solution to deal 
with it, we would love to hear it, because this is about 
improvement.
    With that, Mr. Chairman, hopefully we will have a second 
round, and I yield back.
    Mr. Pappas. Thank you.
    Ms. Murphy. Mr. Chairman, would you allow me to just 
interject quickly? Last year----
    Mr. Pappas. Sure, you can briefly respond.
    Ms. Murphy. Last year, we completed about 1.4 million 
rating claims last year----
    Mr. Pappas. Do you want to hit the mike? I do not know if 
you are----
    Ms. Murphy. Last year, we processed about 1.4 million 
rating claims in VBA and we received about 14,000 MST, military 
sexual trauma-related claims last year. It is about 1 percent 
of our workload. We have specialized folks doing this work, it 
is about 1,000 people that are earmarked for this. We do try to 
honor their requests if they are being overwhelmed or if they 
want to cycle off of this work, but it is not all of their work 
all day long, they are mixed in with other cases.
    We are sensitive to that and I just wanted to point that 
out. Thank you.
    Mr. Pappas. Thanks for your comments.
    Mr. Clark. Sir, Chairman, if I can just add one quick 
thing? We are----
    Mr. Pappas. Quickly, and then we will move on to the next--
--
    Mr. Clark. Quickly. We are adding compassion fatigue to our 
training that we are having this year, we are leveraging a 
collaboration with VHA, and specifically we are speaking to 
compassion fatigue to address that issue.
    Thank you.
    Mr. Pappas. Thank you.
    I will turn things over to Congresswoman Brownley for 5 
minutes.
    Ms. Brownley. Thank you, Mr. Chairman.
    Just in response to that last conversation, 14,000 MST 
claims out of an abundance of other claims, I get that, but we 
know that that 14,000 is a really low--it is a low number and 
the reason is, is because women are not accessing the VA 
because they have been traumatized or re-traumatized to actual, 
you know, pursue these cases. I think we have just got to get--
you know, we have got to get to the core of the problem.
    I know that there are areas of excellence across the 
country. I have been to Boston, I have seen what they are 
doing. If we could replicate Boston across the entire country, 
we would be in really good shape; however, that is not where we 
are at the moment.
    I have to say, and I want to ask the OIG, when we talk 
about MST coordinators, that was one of the first responses to 
this issue by the VA and always the testimony is, we have an 
MST male/female coordinator at every location across the 
country. To the OIG, did you ask the question, how many are 
full-time?
    Dr. Kroviak. We did not look at the actual Full-time 
Equivalency (FTE) status of the MST.
    Ms. Brownley. I think we need to clear that up, because 
there are very few, based on all of the visits that I have done 
across the country and hearing from women veterans here in D.C. 
and across the country, there are very few MST coordinators 
that are full-time. West LA, the largest medical center in the 
country, has a part-time MST coordinator. She only spends a 
couple of hours a week on MST, most of her other 
responsibilities have nothing to do with MST. The largest 
medical facility, you have to assume that is the largest area 
of need, and yet only a part-time MST coordinator.
    To me--and I know, I have brought this up many, many times, 
but I know at medical centers, the leaders of medical centers 
have a lot of autonomy, but we have got to figure out 
accountability here, because we are not really fulfilling what 
we are saying we are doing, and I think that that is just 
really, really important to point out.
    Ms. Williams, when you talked about the first gatekeeper, 
this is like so important. And, Ms. Kubek, you supported this 
issue. If a woman or man, you know, is entering a medical 
facility and asking for help, and we are responding by saying, 
sorry, you are not a vet, or, sorry, you do not have your 
records, without saying, you know, we want to make sure you 
have got to have those in order to get medical attention from 
us with the exception of X, Y, and Z, and one of them being 
military sexual trauma. This woman has to say I am raped, in 
earshot of a waiting room to say I have been raped and I am 
suffering from military sexual trauma, because I served my 
country? That is just--it is unacceptable.
    You know, the testimony about spending a year to be rated, 
the fact that, you know, in some cases VBA will blame VHA for 
not providing the record, hence the longer period of time.
    You know, there is, I think, a lot that needs to be done 
and accountability just continues to ring true for me in this 
instance.
    If you put all the policies down on paper, they look pretty 
good, you know, but the fulfillment of those policies, you 
know, are not happening across the country.
    Ms. Williams.
    Ms. Williams. Thank you very much, Ms. Brownley. To your 
point, a friend of mine described once going into a VA medical 
center seeking care and when they were trying to turn her away, 
in a crowded waiting room, in front of many strangers, had to 
pound on the table and say, loudly, ``I am an MST survivor.'' 
Nobody should have to be that outspoken to get care.
    I would also note that the lack of awareness universally 
about the presence of MST coordinators extends beyond VHA. In a 
site visit we did to a VBA regional office, they had prominent 
signs raising awareness that they have women veteran 
coordinators available to assist, but nothing about the fact 
that they also have male and female MST coordinators that could 
make it a more comfortable process for survivors on the VBA 
side.
    Ms. Brownley. If they are full-time.
    Ms. Williams. They did not raise awareness that they 
existed at all. Yes, they should be full-time and also 
awareness should be raised.
    I would also urge that when all the folks who are that 
front-line interaction, in addition to referring folks to MST 
coordinators, should be able to let veterans know that, if they 
need immediate support, they can go to Vet Centers while they 
are navigating the rest of these processes, determining 
eligibility, getting that first appointment, waiting for a 
claim to be processed. Vet Centers are already there and 
available and can provide that non-medical support throughout 
the process, but it seems as if big VA is less likely to talk 
about the benefit that exists on the Vet Center side, which is 
eligibility is broader.
    Thank you.
    Ms. Brownley. Thank you for that. Mr. Chairman, I yield 
back.
    Mr. Pappas. Thank you.
    I will now recognize Congressman Bost for 5 minutes.
    Mr. Bost. Thank you, Mr. Chairman.
    Mr. Clark, something that was said in Ms. Williams' 
testimony and according to the VA report, the grant rate for 
MST-related claims for females is 63 percent, whereas the grant 
rate for males is 51 percent. The VA is--what are we seeing in 
the trends in terms of the types of MST-based claims filed by 
male veterans compared to female veterans that may explain the 
12 percent difference?
    Mr. Clark. Thank you, Mr. Bost. We are working providing 
additional training and, particularly, we have leveraged our 
partnership and collaboration with VHA to develop sensitivity 
training, among the other types of training, to give to our 
claims processors, making them aware of this disparity.
    It is true that, as has been said, that female survivors 
the grant rate is higher, but the males, grant rates for male 
survivors has been improving, it continues to improve. This is 
something that we know, this is something that we address. We 
obviously can not say grant cases so we can, you know, 
equalize----
    Mr. Bost. I understand that----
    Mr. Clark.--the percentages, but we----
    Mr. Bost.--but it seems strange.
    Mr. Clark.--make them aware. It does and, yes, sometimes 
biases creep in and this is where training--it is not a one-
and-done--we have to continually go back and talk to our 
people, train them on these differences, because that is what 
sensitivity training is.
    It is to make you aware that there is a disparity there and 
that you need to be aware when you make decisions that you have 
considered that in your decision.
    We work VHA to help us get training to provide to our 
folks.
    Mr. Bost. Okay. Dr. Kroviak, I understand that the OIG has 
requested additional information from the VA, close 
recommendations for 4 and 5 from August of the 2018 report on 
denied PTSD claims related to MST.
    Can you elaborate on that?
    Dr. Kroviak. Yes, so, when we request--or when VA provides 
us with data, we actually do a pretty intense review and not 
only look for implementation, but also that the results have 
been sustained. We had some concerns related with some of the 
data provided, regarding the review that we recommended in that 
report.
    Mr. Bost. Well, let me tell you my frustration with this. 
We had two hearings in the DAMA committee. This issue came up, 
both of them. We asked for it to get done and nothing has been 
resolved.
    Mr. Clark, where we at?
    Mr. Clark. Well, sir, again, this is something that we are 
working on and, you know, when we have these kinds of 
disparities, it takes time to--for these processes to be 
implemented.
    Again, making a decision about granting to survivors, a 
service connection for, you know, if there is a male claimant, 
we can not just say, We need to close this gap, so we want you 
to grant this case. What we have to do is just leverage our 
training for these individuals.
    Ms. Murphy, if you have something else to add?
    Ms. Murphy. Certainly. As far as the IG report from 2018--
from August 2018, there were six recommendations. We have asked 
for 5 of those to be closed on the VA side, based on work that 
we have done to satisfy those recommendations. We are still 
doing some work on one.
    It is not uncommon for us to go back-and-forth after we 
have asked for something to be closed. IG will come back and 
ask for additional information or clarification about something 
and we have seen this on many different types of reports.
    We are in the interactive process with IG. From our side, 
we believe that we have finished 5 of them. We are still 
working on the last one.
    Mr. Bost. I have got a minute left, but I just want to say 
this, this issue is an issue--let me tell you back whenever I 
was in the service, it was just put your head in the sand and 
ignore it. We can not be putting our heads in the sand and 
ignoring it. We need to deal with it, whether it is male or 
female, and we need to get it done and done correctly.
    I understand we are all trying, but while we are working 
trying, other people are out there suffering and adding to, as 
was mentioned, that suicide level that we fight so hard and the 
Chairman and all of us on this committee have tried desperately 
to reduce.
    This issue is something that we are going to continue to 
look at. Obviously, when it takes two subcommittees and a 
special committee to try to deal with this issue, it is 
something that we have got to deal with.
    With that, Mr. Chairman, I yield back.
    Mr. Pappas. Thank you.
    I will now recognize Chairman Takano for 5 minutes.
    Mr. Takano. Thank you, Mr. Bost, for those sentiments. I 
appreciate what you said, and coming from a former Marine who 
understood----
    Mr. Bost. What is that old saying?
    Mr. Takano. Learning for life--I get it.
    I appreciate the authority you bring to this.
    I also want to express regret on behalf of Ms. Brownley. 
She had to leave and she really wanted to stay.
    I know I want to build on Mr. Bost saying Ms. Brownley's 
line of questioning--I do not doubt the sincerity and the 
desire of everyone here, including those at the VA, for want to 
address this issue effectively, but it is unacceptable that 
four women veterans, 1 in 4 women veterans experiences sexual 
or gender harassment at VA facilities.
    A key part of the solution is to ensure that all parts of 
VA are working together. It also sounds like we need a lot more 
focus from the top of VA leadership. Ms. Barlet, Ms. Williams, 
and Ms. Kubek, could you quickly comment on the need for 
elevating important solutions to military sexual assault within 
VA to elevate it to higher levels.
    Ms. Barlet. Thank you for the question, Chairman Takano.
    Things like the end VA Anti-Harassment Campaign need to be 
in your face. It needs to be just more than posters on the 
wall. It needs to be in the waiting rooms.
    One of the best practices that we have experienced is 
during our--program was a women's health clinic in Salisbury, 
North Carolina, where they take advantage of that room in 
there, the waiting room, to not only educate the women that are 
there weight for their appointments, by displaying VA-
authorized and YouTube videos, giving hint--giving explanations 
on what to look for harassment, how to report harassment, and 
things of that nature, along with materials throughout the 
room.
    That needs to be expanded to other VAs and it is a best 
practice that is in your face.
    Mr. Takano. Very quickly, because I want to get to the VA. 
Go ahead, yes.
    Ms. Williams. Thank you, sir.
    When I worked at VA, as part of the Suicide Prevention 
Campaign, every senior leader was expected to sign a pledge 
affirming their commitment to being part of the campaign to end 
veteran suicide.
    That should be replicated with ending harassment. Every VA 
leader should publicly State their commitment to ending 
harassment in VA facilities should sign a pledge, take a photo, 
write blogs about it, be open and transparent with their staff 
about how important they believe it to be. I believe that 
should start at the secretary and trickle-down through all 
levels of VA leadership.
    It is incredibly important that the rate of sexual 
harassment and appropriate level of response to it at VA 
medical centers, be a part of the rating of the success of VA 
Medical Center directors. Hold them accountable for what is 
happening in their facilities. Make this part of how their 
performance is assessed.
    If they are not being held accountable for what is 
happening in their facilities about this, they will be much 
less likely to take it as seriously as it needs to be.
    Mr. Takano. Thank you.
    Ms. Kubek. I would just like too add that you see massive 
discrepancies across VA hospitals of how this issue is being 
handled and I think that really reflects the fact that this 
message really needs to be coming from the top so that you do 
not have some VAs that are doing great at this and some VAs 
that are not; all VAs have to do great at this issue. It is too 
important for there to be even one hospital that is not doing 
great.
    I agree with Ms. Barlet, that the messaging has to be in 
your face everywhere. There should be signs. You should not be 
able to turn a direction in the VA without seeing messaging 
about this.
    Mr. Takano. At a recent suicide-prevention hearing, we 
listened to an expert about systems and aiming for zero 
occurrences within the VA system of suicides.
    For the VA witnesses, could you describe who you report to 
within the secretary's office when there is a need for higher-
level attention, such as improved coordination between 
different entities.
    Mr. Clark. I will start.
    You know, our secretary has made it very clear--Secretary 
Wilkie--sexual harassment will not be tolerated. Our direct 
boss in VBA, Dr. Lawrence, our Under Secretary has made it very 
clear that military sexual trauma, suicide-prevention training 
has to be inculcated throughout our agency----
    Mr. Takano. Who do you report to?
    Mr. Clark. We report to the secretary, but if we would have 
a problem with that, our secretary--our Under Secretary would 
then meet with the secretary to discuss any challenges that 
would need to be handled throughout the agency.
    We have been leveraging with our--with VHA that we have not 
had that challenge thus far, because our folks are accountable. 
Our regional office directors in VBA have been told that they 
must deal with military sexual trauma training. They must deal 
with suicide prevention, and failure is not an option.
    Mr. Takano. Thank you.
    If you would, Mr. Chairman.
    Could you answer the question--yes, thank you.
    Ms. Murphy. Sir, same chain of command for myself. Up to 
the Under Secretary's Office and then up to the Secretary's 
Office.
    Ms. Bell. In VHA, the MST program is located within the 
Office of Mental Health and Suicide Prevention. We report to 
Dr. Dave Carol, but then up the chain within VHA.
    Mr. Takano. All right. Thank you.
    I yield back, Mr. Chairman. Thank you.
    Mr. Pappas. Thank you very much, Chairman Takano.
    I would now like to recognize Ms. Luria for 5 minutes.
    Ms. Luria. Thank you and thank everyone for being here 
today to discuss this very important issue. I wanted to start 
by first mentioning a September 2019 review that VBA did of 
approximately 9,700 previously denied MST claims. It is my 
understanding that of that 9,700, approximately 1900 required 
additional development.
    Can you give us an update since September how many of those 
are complete, what phase the remaining percentage are currently 
in.
    Mr. Clark. Yes. Of the 9700, we still have 1900 that we 
have--are working with Congresswoman Luria. Of those, 
approximately 460 of those, we have found that we needed to 
increase and we have increased the compensation on those 460. 
There is another 500 that we are still developing, that are 
under development, which may mean that we need additional 
information. We need an exam.
    The remaining number, roughly 900 or so, we have and it may 
be a few less than that; those, the decision was sustained. 
Again, once we go through and make a decision, we have to go 
back and review those cases to ensure that they are done 
correctly, and that is one of the recommendations that the IG 
is waiting on us to finish working these cases so we can go 
back to them.
    As Ms. Murphy mentioned, this back-and-forth between the 
IG, we do have to negotiate and sometimes go back and get 
additional information before they will close out the action 
item.
    Ms. Luria. Okay. Well, thank you for the update on that 
progress.
    Do you anticipate another periodic review in 2020 and what 
timeframe will that happen?
    Ms. Murphy. If I could answer that, ma'am?
    Mr. Clark. Yes.
    Ms. Murphy. I think earlier it was referenced that these 
9700 cases were inaccurately adjudicated. I would clarify that. 
The IG found that they were improperly processed, which means 
that a step of some sort was skipped. Maybe the necessary phone 
call was not made----
    Ms. Luria. Well, actually, to make 9700 significant, out of 
how many? What percentage was that?
    Ms. Murphy. These were denials.
    Ms. Luria. Denials? Out of how many----
    Ms. Murphy. Denials over----
    Ms. Luria.--cases overall.
    Ms. Murphy.--a couple-year period. So----
    Mr. Clark. We looked from 1 October 2016 until June 2018.
    Ms. Luria. Okay. Would you mind following up with the 
numbers so I can understand the percentage and the scale of 
this.
    Ms. Murphy. Sure.
    Mr. Clark. We will follow up.
    Ms. Luria. Since we only have a little time remaining, I 
would like to shift to some comments that Ms. Kubek made and 
thank you for the work that you do providing legal assistance.
    I found your remarks very important, talking about how we 
process this. We frequently talk about how difficult this is 
for a veteran to have to relive this, and I was not necessarily 
aware that throughout the process that they are not allowed to 
designate an alternate representative, either a medical 
professional or a lawyer representing them to provide this 
information so that they do not have to continue to relive this 
in the process of answering questions about their claim.
    I also noticed when Ms. Kubek brought this up during some 
of her comments, Ms. Murphy, you shook you head, you said, you 
know, that is not true. I am kind of understanding why there is 
a disconnect and also that just made me feel like there is an 
unwillingness on your part to, perhaps, listen to people who 
are dealing face-to-face with real-life veterans, like we do in 
our office when constituents come in.
    Ms. Kubek's stories are stories I hear over and over again 
from real people, and, I mean, are you--do you have a mechanism 
to listen to this kind of information that you are getting from 
the field where people are just not--the process is not working 
for them, it is causing more pain, you know, more people are 
actually having, you know, suicidal ideations are feeling more 
in distress after trying to go through a process where they are 
seeking help.
    Ms. Murphy. Sure. No question, this is a horrible 
situation. It is difficult to talk about it. It is difficult to 
engage with people on it, and that is why it makes it even more 
necessary to bring light to this, and that is what Congress is 
doing with these oversight hearings. It is very necessary that 
the whole greater veteran community continue to talk about this 
and bring visibility to it. That we do training, that we work 
together----
    Ms. Luria. I have got it. You have got a lot of training. I 
think you are putting effort into it in ways that----
    Ms. Murphy. Yes.
    Ms. Luria.--you know, you think are going to be productive 
and I hope that those are actually helping with the problem, 
but can a veteran who wants to have a claim, you know, filed, 
can they have a lawyer or someone else designated, speak on 
their behalf?
    Is that allowed in the process?
    Ms. Murphy. They certainly can take advantage of working 
with one of our veteran service organizations----
    Ms. Luria. When the person--when the claims person calls 
and needs more answers, can that veteran say or can it be 
documented in their file that they have a representative 
speaking on their behalf?
    Can Ms. Kubek speak for her client?
    Ms. Murphy. It is documented in the file and if the veteran 
chooses to have them speak, I do not see a reason that that 
would not be----
    Ms. Luria. Are your people trained for that?
    Mr. Clark. We will make sure that they are trained.
    Ms. Luria. You are telling us that it is not really a 
problem with the rules; it is a problem with, potentially, how 
the agents who were processing the claims have interpreted it.
    Mr. Clark. Potentially, yes.
    Ms. Luria. That they can speak to a different person.
    Mr. Clark. Yes, Congresswoman Luria.
    If you have an accredited representative and you are----
    Ms. Luria. Like, what do you have to do to be accredited? A 
lawyer?
    Mr. Clark. Well, we just can not discuss--we cannot discuss 
intimate, sensitive information from any claimant about that 
claimant's information unless we have been served notice by a 
representative who has been----
    Ms. Luria. What is this, a power of attorney from an 
individual?
    Mr. Clark. It is a power of attorney, that is correct. That 
is correct.
    Ms. Luria. Okay. I mean, I think that could help improve 
this process, because it really was not brought to light and 
if--I think we are out of time, but it looks like Ms. Kubek 
would like to follow up with a remark, if that is Okay?
    Mr. Pappas. Sure. I will--yes, you are welcome to respond, 
Ms. Kubek.
    Ms. Kubek. Yes, I just wanted to say, so the appointment of 
representation form, which the VA has, which is what I use to 
say that I am representing my clients. It is filed in all of my 
cases. It required me to provide my contact information, all of 
that information.
    What happens is when the veteran receives this call, first 
of all, I feel that when someone has appointed a 
representative, as in other legal proceedings--and Social 
Security does this--they would talk directly with me at that--
from that point on, but, second of all, if that is not going to 
be the choice, I have had veterans who receive a call from the 
VBA say to the person on the phone, please speak with my 
representative. I do not want to talk about this.
    I have never once received a call after that has a 
happened. I have never received follow-up on those claims, ever 
in my years of doing this. It has not happened.
    Mr. Clark. What we will do, Congresswoman Luria, if we know 
about those, we need specifics. Now, obviously, if there are 
thousands going on--and we will make sure that we get training 
out to our employees to make sure that these kinds of 
occurrences--again, we need this kind of feedback; that is how 
we get better.
    Speaking to specifics are kind of tough, because we do 
grant thousands of claims daily--MST-survivor-type claims. We 
do get these right in some cases.
    Where we get them wrong, we need to know about it so we can 
improve upon our processes, leverage our collaboration with the 
Veteran Service Organizations (VSOs) and the Members of the OIG 
and Members of Congress to tell us where we are getting it 
wrong, and afford us the opportunity to get it better. If we do 
not, then we discourage more people from coming from the VA and 
that is why we are here, for people that have served this great 
country and we need to do a great job, but we have to be 
informed.
    Of course, even in this environment, we are being informed, 
you let us know where there is a problem--specifics--and we 
will deal with specifics.
    Mr. Pappas. Thank you very much, Mr. Clark. We will do a 
second round of questioning, because, obviously, we have some 
issues that we would like to further take a look at. I will 
begin by taking 5 minutes and Ms. Kubek, you know, you talked 
about in your testimony, ways that survivors relive their 
trauma and we just had a discussion about one particular issue 
in terms of representation for these individuals about ways 
that VA can become more trauma-informed and institute better 
practices.
    I am wondering if you can emphasize some other ways or 
suggestions that you have that VA can learn how to become 
trauma-informed.
    Ms. Kubek. Yes, I think the fact that when veterans are 
scheduled for their compensation and pension exam, they have no 
say whether this exam is done by a man or a woman. It is 
incredibly problematic to me.
    Given that the VA seems to acknowledge that veterans may 
have a preference of whether they discuss such traumatic 
memories with a male or female representative with their MST 
coordinators, they should do the same thing with the 
compensation and pension exam.
    I also sympathize that these exams are often unnecessarily 
repetitive of things that are already in the record. If the 
veteran has provided, in some cases, you know, a six-page 
statement of what occurred to them in the military, what has 
happened since the military, all the ways their symptoms are 
impacting them, the medical treatment they have been receiving, 
all of these things, I, then, basically have to tell my clients 
you are going to have to go into this exam and they are going 
to re-hash every single thing all over again with you.
    I know that examiners are required to read the veteran's--
they have to assert that they have read the veteran's file 
before they can submit the exam. I do not know whether or not 
the requirement exists that they review the file before meeting 
the veteran, and I feel that that would be helpful to avoiding 
unnecessary elaboration on things that have already been very 
clearly stated.
    Mr. Pappas. Well, thank you for that.
    I wonder if we could ask VBA, you know, what prevents us 
from being able to allow an individual to choose the option of, 
you know, deciding what gender their medical benefits examiner 
will be to, you know, make sure that we are protecting these 
individuals.
    Mr. Clark. Well, I will--if I can start, please--and, 
certainly, Ms. Murphy, and certainly Dr. Bell can follow up--
but it is our understanding that a claimant can select the 
gender of the physician that they would like to have do the 
exam and, of course, for the practicing physician for 
outpatient treatment. That is our understanding that that does 
happen.
    Ms. Murphy. Yes. If I could just add, my offices--I am 
responsible for the C & P exam--contract exam program for VBA 
and all of the providers. If you ask for a male or a female for 
an MST--military sexual trauma sort of examination, we do honor 
those.
    If there is a situation where we can not, we may have to 
work with the VHA or find a different contract examiner in the 
area that could. I think it is limited by folks not knowing 
that is available, number 1, and, number 2, maybe in the most 
rural areas, if there is not another provider available, that 
is something that we would have to work through.
    I think maybe one of the takeaways from this and other 
engagements is public information that you can request that. I 
would also ask all of our partners in the VSO community and 
veteran advocate community to reach out to us if this is not 
happening, because we need that information, and to please 
socialize that with the folks that you represent to make sure 
they know that that is available.
    Mr. Pappas. Does VBA ask the question?
    Ms. Murphy. I would have to check with our specific 
language that we use in our letters. I will have to get back to 
you on that.
    Mr. Pappas. Well, I think that would be important to know--
--
    Ms. Murphy. Okay. Your Honor.
    Mr. Pappas.--and, certainly, if that is an option, we 
should be getting word out to individuals as best we can.
    Ms. Kubek, if I can come back to you, you noted in your 
testimony that cases where there is a lack of communication 
across VA where the benefits side does not talk to the health 
side to process MST claims and requests for these records are 
sometimes denied. In some cases, you know, the VHA has actually 
provided you with the requested records which kind of raises 
the question why VA struggles to communicate internally.
    How does this affect efforts to obtain benefits for MST-
related conditions?
    Ms. Kubek. The records struggle affects all veterans. This 
is not unique to MST survivors, but what happens for MST 
survivors is twofold. The VA is frequently looking for markers 
from their in-service. When a client's marker is, well, they 
filed their restrictive report or when their marker is they had 
a pregnancy test or they had an STD test done and I can not 
access those records, whether it be from the military side of 
things, from DoD--whatever the reason is that I can not access 
them--all I have is the veteran's statement, which is going to 
result in further probing of the veteran, because there is 
nothing else substantiating their claim.
    A lot of veterans do not have a lot to go on in their 
military file, but they do have years of treatment--possibly, 
for some of them, 40 years where they have been telling the 
same story of what occurred to them--and when I can not--when I 
get a letter back from VBA saying we were unable to obtain the 
records from such and such a VA medical facility and I am 
holding those records in my hand, I am confused, I think about 
veterans who do not have representatives, which there is a lot 
of them who do not necessarily know what to do with that 
information--they may just think there is nothing they can do--
I know that I can then provide it directly to VBA, but I should 
not have to. These are two halves of one body, and sometimes I 
do not find it out until the decision letter, denying the 
claim.
    The VA has a duty to assist in these claims, and so when I 
am first hearing about a failure or an inability to get record 
at the decision level, something has gone wrong.
    Mr. Pappas. Okay. I am over my time, but maybe VA could 
just comment and respond to that internal communication.
    Ms. Murphy. Certainly. If there were specific instances of 
that, I would really be interested in seeing them so that we 
could figure out a solution if there was an issue there.
    I will say that we work closely with VHA. We have reach-in 
ability in our systems to retrieve VHA records, ourselves, in 
VBA, so that works for us, and if it were DoD or military 
records, you know, that would be a separate situation from VHA 
and we do have a VBA employee embedded in that community who 
can look at sensitive records and give information to us.
    Mr. Pappas. Thank you, Ms. Murphy.
    I will turn things over to the Ranking Member Bergman for 5 
minutes.
    Mr. Bergman. Thank you for the second round, Mr. Chairman.
    You know, the one thing that all VA facilities have in 
common is they are all different. Some are full-service, some 
are limited-service, but the point is as we bridge the gaps in 
the differences and try to create standardized, if you will, 
procedures, standardized business models, we know that there 
are going to be a certain percentage of variance based upon 
that VA.
    Dr. Bell, I was pleased to see that the IG found that each 
of the facilities it evaluated did have an MST coordinator, who 
was required by policy; however, the testimony in VHA policy 
indicate that serving as the MST coordinator may be a 
collateral duty.
    Is there a formula for determining whether the MST 
coordinator should be a part-time or a full-time duty and what 
metrics are used to determine effectiveness?
    Ms. Bell. I think in the precursor to your question, you 
highlighted some of the challenges around this, which is that 
every healthcare system varies widely; there are some that are 
very small, have one medical facility. There are some that have 
several large medical facilities with a number of community-
based outpatient clinics with it. Obviously, those systems have 
very different needs in terms of how much time their MST 
coordinator has.
    Our national policy does specify a minimum amount of time 
that an MST coordinator should be given that is really meant to 
be queued toward the smaller system, the less-complex-type 
system, but then delineates factors that leadership at that 
facility should be considering in determining what additional 
time the coordinator should----
    Mr. Bergman. I guess what I--because we could talk about 
it--I would like to see if there are any kind of metrics--you 
can take it for the record, because to help--you know, if you 
are one facility and you are trying to model it after a 
different facility and you may not have the full-time--you may 
not have the population. You may not have the need, okay, but 
it would be helpful if you could give us some kind of, if you 
will, basic metric to help those facilities understand at what 
level you go from full time to collateral duty or whatever it 
happens to be.
    Ms. Williams, in your written testimony you reference the 
Sister to Sister program that provides women veterans a battle 
buddy to escort them in the VA. Quite honestly, it is troubling 
to think that any veteran feels so unsafe at a VA facility that 
they need a battle buddy to escort them.
    Based on your comments, what are three immediate and 
concrete actions that VHA can take to address to improve the 
environment of care at VA to make veterans feel safer?
    Ms. Williams. Thank you, sir.
    As I previously mentioned, I think that additional emphasis 
on the end harassment campaign will be very helpful to have 
visible signage everywhere to ensure that all employees know 
how they should respond if they witness an incident or are 
informed about an incident and corrective actions can be taken.
    I do think extending the Sister to Sister program is a 
potential avenue, as well. This is not just for women that feel 
unsafe, but also for those who are intimidated by how large 
some of these facilities are and may be lost trying to wind 
their way through them.
    Another way that it can be helpful is that it makes women 
veterans, in particular, aware that they can have somebody with 
them and one area that that can be particularly important--and 
we have heard from women veterans that during gynecologic 
exams, if they have experienced MST, that can be a particularly 
triggering event and having a supportive individual with them 
can be helpful.
    Just making women veterans aware that they can have 
support, whether it is through a formal peer program that VA 
runs or that they are allowed to bring in, you know, bring a 
friend with them----
    Mr. Bergman. Okay.
    Ms. Williams.--could be very helpful, as well.
    Mr. Bergman. Okay. Thank you.
    Dr. Bell, who is responsible for educating frontline staff 
and what does VHA do to measure effectiveness, and what do you 
think about Ms. Williams' suggestion to use a secret shopper 
program as a tool to improve awareness?
    Ms. Bell. Frontline staff, in terms of--specific to MST? 
Yes.
    The secret shopper program, I believe she may have actually 
been referring to, is a program that my office, the Office of 
Mental Health and Suicide Prevention runs. We make phone calls 
to all of the medical facilities and--all the healthcare 
systems throughout the country and ask to speak to the MST 
coordinator and then take note of whether they were connected 
to them directly, how sensitive our interactions are, what our 
experience was like, as if we were a veteran.
    We make two calls; one from a male caller and one from a 
female caller and then we provide the feedback from those 
experiences back to the facility and then, of course, 
congratulate them when they go well and when they do not go 
well, ask them to take steps to improve the situation.
    Mr. Bergman. Okay. I have got one quick one, can I go over 
a little bit?
    Okay. Dr. Bell----
    Ms. Williams. I am so sorry. May I clarify to Dr. Bell?
    My suggestion was that that excellent program be expanded, 
instead of simply asking for connection to the MST coordinator, 
but to that frontline eligibility team so that they know that 
if somebody is seeking care, that that is where they should be 
connected. Somebody should not have to say by name, I need the 
MST coordinator, but if they walk in and say, I need care about 
this, instead of being told, oh, well, you are not eligible to 
be routed appropriately, and to model a program that those 
eligibility officers that mimics the very successful one.
    Mr. Bergman. I would suggest that you two have coffee and 
work it out.
    Ms. Williams. Thank you, sir.
    Mr. Bergman. Okay. Dr. Bell, are members of the Guard and 
Reserve who do not meet the definition of veteran eligible for 
MST-related care and are differences in the healthcare services 
available to them; if so, what are those differences?
    Because, you know, as we know the last--for the last 17 
years, plus, the extended and literally unprecedented use of 
the Guard and Reserve has put those Guardsmen and Reservists 
into a different category than they maybe were before 9/11.
    Ms. Bell. Unfortunately, our treatment authority is limited 
to individuals who have veteran status or are currently in the 
service. Former servicemembers, particularly, former members of 
the National Guard and Reserve who do not have veteran status, 
are unfortunately not eligible for MST-related care.
    Mr. Bergman. Okay. Well, that is something that we can work 
on as a committee.
    Thank you, you Mr. Chairman, I yield back.
    Mr. Pappas. Thank you, Ranking Member Bergman.
    I will recognize Chairman Takano for 5 minutes.
    Mr. Takano. General Bergman, you asked questions that were 
definitely on my mind. They were excellent questions. Thank 
you.
    Mr. Bergman. I have got to get home, soon.
    Mr. Takano. Mr. Clark, Members of Congress have proposed 
legislation to address many of the barriers to accessing 
benefits in the current application process. This includes a 
bill by Representative Pingree, H.R. 1092.
    In June, you testified on behalf of VBA that VA opposed 
section--a section of H.R. 1092 that would significantly reduce 
the burden on the veteran to prove that the sexual assault 
occurred in service.
    Why does VA oppose this section?
    Mr. Clark. Congressman Takano, we will have to take that 
back for the record.
    Mr. Takano. Okay.
    Mr. Clark. On this, specifically, I want to be clear about 
addressing that.
    If I can speak briefly to the outreach coordinator, 
military sexual trauma coordinator, please?
    We have talked about why it was not a full term----
    Mr. Takano. Okay. I do want to know about it, I mean, I do 
want to know what the VA's position is on it, if they are going 
to continue to oppose it.
    Mr. Clark. We will take that for the record.
    Mr. Takano. I wanted to ask for the Center for a New 
American Security (CNAS) and The American Legion (TAL) and New 
York Legal Assistance Group (NYLAG), how could this legislation 
and other statutory changes provide relief to MST survivors?
    Ms. Barlet. Excuse me, Chairman Takano, would you mind 
reminding me what the legislation was for?
    Mr. Takano. Well, what this section does is it reduces, 
significantly, the burden on the veteran to prove that sexual 
assault occurred in service. You know, when veterans have PTSD 
associated, say, with combat, it is--the burden is a lot less, 
but when it comes to MST, the burden on the veteran is still 
pretty high----
    Ms. Barlet. Yes.
    Mr. Takano.--so this legislation would address--would 
reduce that burden.
    Ms. Barlet. I would like to refer to our resolution 67 and 
147. 67 urges that VA has enough qualified and treated 
employees to correctly process the MST claims with the hope 
that that would help alleviate the retraumatization on the 
veteran; in addition, our VA and our Benefits Division does 
annual training with our VSOs to encompass and help that 
veteran through the process.
    Mr. Takano. Great.
    Go ahead.
    Ms. Kubek. This legislation, I think, would be hugely 
beneficial to survivors. I think it would change this process 
dramatically.
    The rules were changed for combat, because of the fact that 
combat is a chaotic environment. I know this was said in the 
hearing that you had on 1092 that combat is a unique 
environment where the mission controls, there is not time to be 
sitting there documenting every single thing that happens, and 
so you can not always connect it back when you are trying to 
track through the records.
    I would argue that MST is like combat. I would argue that 
sexual assault in the military is also a chaotic environment in 
which you have absolutely no ability to be sitting there 
documenting what occurred to you. There are so many reasons why 
veterans would not have an ability to do the same--in the same 
way that it occurred in combat.
    I think that--I know that hesitations were brought up 
against the bill because of that, but I think that I would 
argue that the similarity are so strong that I think that makes 
the case for why the changes proposed in this bill are needed.
    Mr. Takano. Thank you very much for that.
    Mr. Chairman, I may go over a little bit, but I want--I 
think this is a very important question to ask.
    We heard some concrete steps forward in response to General 
Bergman's questions about the next steps.
    For the VA witnesses, given the urgency, given how the--
from our other witnesses about how in your face the--the 
quote--the word ``in your face'' or the term ``in your face'' 
was used, what concretely are the next steps to take this 
issue, to elevate it?
    My earlier question about taking this to the top levels, if 
you were to go to the secretary or the Under Secretary or the 
deputy secretary, what are the action steps that you would 
recommend that need to be--to actually bring the two different 
entities, the VHA and the VBA together to coordinate, what 
needs to happen?
    Mr. Clark. I think we are already doing some of that. We 
are collaborating.
    I mentioned earlier about our symposium that we are having 
later on this year, that we are bringing in all of our 
processors and our MST coordinators, who, by the way, they 
conduct other forms of outreach. Often times, homelessness is 
wrapped up into, you know, survivors of military sexual trauma. 
That is one reason why they do a multitude of outreach things, 
rather than just solely just to military sexual trauma.
    We are working together, leveraging and collaborating 
between our two agencies. We are meeting this year, and our 
undersecretary has mandated that all of our regional office 
leaders, our claims processors, on military sexual trauma, our 
outreach coordinators, these individuals will be here in D.C. 
later this year, and we will leverage things that we have 
learned to improve upon this process.
    We have heard the Inspector General. We have heard Members 
of Congress. We have heard, and we continue to hear from 
veterans when we conduct outreach, when we receive phone calls 
from national call centers, solid State is a--Solid Start is a 
program where we are contacting claimants as they leave the 
service at particular points.
    We are trying to get the word out to say to survivors of 
military sexual trauma, and through our transition-assistance 
program, to veteran servicemembers, even before they become 
veterans, that we are improving upon this process and here are 
the benefits that you are entitled to. When you leave service, 
come to us. If we do not do something properly, let us know and 
we will work to fix that. It is a continuous improvement type 
of a process, not a one and done.
    I feel that we are working together to do some of these 
things and we look for--the same group--the Members of 
Congress, the VSOs--to let us know where we can improve upon 
our processes and we will implement those things.
    Mr. Takano. Could you also respond.
    Ms. Murphy. Certainly.
    I think we have heard a lot of good ideas today. I 
particularly like the idea about the signs we do have in our 
public contact areas to add information that male and female 
are available--coordinators are available--I think that is very 
concrete.
    I would say continuing to get the word out about the 
availability of the military sexual trauma coordinators in VHA 
and VBA so that folks know who they are and how to reach them. 
For VBA, the information by name, by facility is available on 
our website. With their phone numbers, you can contact them.
    I think getting the word out about the free healthcare that 
is available for military sexual trauma and VHA, regardless, if 
you are service-connected or getting benefits, I think that is 
very important. We keep that message going. Also, that if you 
are going to a C & P exam, you do have the right to ask for 
somebody who is gender-specific.
    I think we have made strides and it just is a continued, 
focused whole-veteran community effort to keep in touch this 
going, to keep the visibility going.
    Mr. Takano. I think you have made strides.
    Given the urgency of this issue, I just want to push you to 
take this to the top levels, identify those next steps, share 
them with the committee.
    Mr. Chairman, I yield back.
    Mr. Pappas. Well, thank you very much.
    Before the closing of today's hearing, I would just like to 
make a final few points.
    First, today's testimony showed that VA provides vital 
services for survivors of military sexual trauma; however, 
accessing these services continues to pose major obstacles for 
veterans. The testimony of the Inspector General, along with 
oversight by the committee, the task force, and non-
governmental organizations like those who are here today has 
made this clear--additional oversight is needed to dive deeper 
into the root causes and equally important, identify the 
necessary next steps toward solutions.
    Second, I think it is very clear here today that there is 
strong bipartisan interests in pursuing this issue and in 
collaborating toward results. You saw that from the Members who 
were here during this hearing, and I think that is shared 
across Congress.
    I look forward to working closely with Chairman Takano, 
with Ranking Member Bergman, with Congresswoman Brownley, and 
the task force, and all Members on both sides of the aisle, as 
we continue to conduct our oversight, monitor developments and 
press for improvements.
    We also need to work together to pass more bills into law 
that are now before Congress, as well as to develop additional 
legislation. I mentioned that the Deborah Sampson Act is a 
critical piece of legislation that would expand eligibility for 
MST-related services at VA.
    I wish to thank our witnesses today for their testimony, 
our non-governmental experts and representatives from the 
veterans community provided important testimony. Your 
knowledge, personal experiences, and perspectives represent 
critical resources for Congress and for the VA.
    I applaud your ongoing work to ensure that those surviving 
military sexual trauma have access to the care that they need 
and that they deserve.
    The VA officials here today from both, VBA and VHA, have a 
critical role in supporting survivors of MST. You are clearly 
dedicated to our Nation's veterans and are working hard to 
ensure that the programs you lead are effective. I appreciate 
your ongoing service and I know that you will convey, on behalf 
of our subcommittee, our thanks to the many, many employees and 
staff throughout the VA who are working hard to provide vital 
resources and care.
    Clearly, there is much more to be done and improvements to 
make and implement and, however, I am confident that we will 
continue to work together so that survivors of military sexual 
trauma receive the services they need and deserve.
    I would like to see if Ranking Member Bergman has any 
closing comments?
    Mr. Bergman. I am good.
    Mr. Pappas. Chairman Takano.
    Mr. Takano. No, thank you.
    Mr. Pappas. While seeing none, members will have 5 
legislative days to revise and extend their remarks and include 
any extraneous material, and, without objection, the 
subcommittee stands adjourned.
    [Whereupon, at 11:45 a.m., the subcommittee was adjourned.]

?

      
      
      
      
      
      
      
      
      
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                         A  P  P  E  N  D  I  X

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                    Prepared Statement of Witnesses

                              ----------                              


                   Prepared Statement of Willie Clark

    Good afternoon Chairman Pappas, Ranking Member Bergman, Members of 
the Subcommittee, Chairwoman Brownley, and Members of the Women 
Veterans Task Force. Thank you for the invitation to speak today on the 
important topic of the Department of Veterans Affairs' (VA) support for 
survivors of Military Sexual Trauma (MST). Accompanying me today is Ms. 
Beth Murphy, Executive Director of Compensation Service, Veterans 
Benefits Administration (VBA), and Dr. Margret Bell, National Deputy 
Director for Military Sexual Trauma, Veterans Health Administration 
(VHA).
    VA is strongly committed to supporting Veterans who experienced 
Military Sexual Trauma, or MST, which is defined as sexual assault or 
repeated and threatening sexual harassment that occurs during military 
service. Nobody should ever have to experience such trauma, much less 
the men and women who are serving our Nation and protecting our 
freedoms. And yet, too often, they do. Survivors of MST can experience 
both physical and mental health issues as a result of that trauma. VA 
is committed to helping these survivors receive the health care 
services they need to treat MST-related mental and physical health 
conditions. When Veterans suffer from MST-related conditions, VA may 
also be able to provide disability compensation. In this statement, I 
will provide an update on specific efforts within VBA and VHA to 
improve services and care for Veterans who have experienced MST and on 
the collaboration between VBA and VHA in support of MST survivors.

MST-Related Claims Processing

    VA strives to provide accurate and timely benefits to our Veterans. 
The sensitive and complex nature of MST-related claims makes it 
critically important that VBA provide compassionate assistance to 
affected Veterans in gathering all necessary evidence to fairly and 
accurately decide their claims. To ensure MST-related claims are 
prioritized, VBA designates specialized Veterans Service 
Representatives (VSR) and Rating Veterans Service Representatives 
(RVSR) at each Regional Office (RO) to be accountable for these claims. 
These VSRs and RVSRs are specifically trained to process MST-related 
claims. As a quality check, a second-signature review is required for 
all MST-rating decisions until the specialized processors achieve a 
required accuracy rate of 90 percent.
    In September 2019, VBA completed its review of approximately 9,700 
previously denied MST claims from October 1, 2016, through June 30, 
2018. If, upon review, the denial was deemed incorrect, VBA initiated 
corrective actions, as recommended by VA's Office of Inspector General. 
Of the 9,700, approximately 1,900 required additional development.

MST-Related Health Care

    VA provides care for mental and physical health conditions related 
to MST free of charge. This includes outpatient, residential, and 
inpatient care as well as pharmaceuticals. Eligibility for MST-related 
care is very broad: Veterans may be able to receive free MST-related 
care even if they are not eligible for other VA care. For example, 
there are no length of service or income requirements to receive MST-
related care. Very importantly, an adjudicated service connection is 
not required. Veterans do not need to have reported their experiences 
of MST at the time they occurred or have other documentation that the 
trauma occurred in order to receive MST-related health care. Veterans 
do not need to initiate MST-related health care within a certain time 
period after their experiences of MST or within a certain time after 
discharge.
    VHA offers a full continuum of mental health services for both male 
and female Veterans who experienced MST. Specialty services are 
available to target problems such as posttraumatic stress disorder, 
substance use disorders, depression, and homelessness. Outpatient MST-
related services are available at every VA health care system, and MST-
related outpatient counseling services are available through VA's 
community-based Vet Centers. VHA also offers residential programs for 
Veterans who need more intensive treatment and support, and inpatient 
programs are available for acute care needs. As with other VA health 
care services, Veterans can receive care for MST-related conditions 
from community providers if they meet the requirements for community 
care referrals more generally
    Every VA health care system has a VHA MST Coordinator who serves as 
a point of contact for Veterans seeking help for MST-related issues. 
VHA also works to ensure that Veterans are aware of MST-related 
services and promotes engagement into care. Recognizing that many 
survivors of sexual trauma do not disclose their experiences unless 
asked directly, it is VA policy that all Veterans seen in VA medical 
facilities must be screened for experiences of MST. This is an 
important way to ensure that Veterans are aware of and offered the free 
MST-related care available through VHA. For Veterans who experienced 
MST, it also helps ensure that their trauma history is considered in 
the provision of care.

MST-related Training

    VBA has significantly updated and improved its training for the 
processing of MST-related claims. During Fiscal Year (FY) 2019, VBA 
required all MST claims processors to complete a mandatory course on 
claims development and rating procedures. The training included 
detailed descriptions of the types of evidence that may be considered 
in support of MST-related claims. Another mandatory course featured 
step-by-step instructions on how to utilize the new checklists. The 
claims development checklists were designed to assist decisionmakers by 
ensuring those reviewing a Veteran's claim for disability compensation 
complete specific steps for MST-related claims. These courses are 
available to ROs, as needed, to train new MST claims processors and as 
refreshers for those who were previously certified.
    Also, in Fiscal Year 2019, VBA provided a national refresher course 
that included an in-depth review of MST error trends and pertinent 
procedural and manual references. Going forward, this training will be 
offered annually. Furthermore, in December 2019, at a semi-annual 
training event for VBA managers, multiple small group breakout training 
sessions were held that focused on the importance of handling MST 
claims appropriately and with sensitivity. The importance of 
consistency in claims development and ratings is reinforced during 
other interactions as well. Throughout fiscal year 2019 and into Fiscal 
Year 2020, MST-related claims have been a regular topic of discussion 
on VBA's national Compensation Service Quality calls. Additionally, VBA 
conducted a Special Focus Review (SFR) of MST claims in Fiscal Year 
2019 to establish a baseline accuracy level. VBA will conduct another 
SFR on MST claims in Fiscal Year 2020 to monitor progress and adjust 
our process based on lessons learned.
    VBA plans to host its first MST Training Symposium in April 2020. 
MST Coordinators and employees designated to process MST-related claims 
will be brought together for training to enhance their ability to 
improve the Veteran experience. We plan to invite MST survivors to 
speak directly on their experiences. In collaboration with VHA, the 
training symposium will also feature an MST panel discussion with VHA 
clinicians and a session on suicide prevention.
    VA recognizes that all staff members in our health care system play 
a role in improving access and reducing barriers to care. VHA has a 
range of initiatives to ensure both clinical and frontline staff are 
prepared to assist MST survivors. Since 2006, VHA has funded a national 
MST Support Team to promote best practices in the field. The Team has 
established an MST Consultation Program that is available to any VHA 
staff member with questions related to assisting Veterans who 
experienced MST. These consultations are a key way to assist staff in 
providing high quality care and services. In addition, all VHA mental 
health providers and primary care providers are required to complete 
mandatory training on MST. VHA also offers a range of supplemental 
national MST-related training for staff, including monthly training 
calls, an annual conference on treatment program development, online 
courses, and a community of practice intranet Website.
    The MST Support Team also conducts an ``Answer the Call'' campaign 
to ensure that Veterans calling VA medical facilities with MST-related 
questions have positive experiences with frontline staff and are 
quickly connected with a VHA MST Coordinator. As part of the campaign, 
VHA employees conduct test calls to VA medical centers and select 
Community-Based Outpatient Clinics to verify that frontline staff, such 
as telephone operators and clinic clerks, are familiar with the terms 
``military sexual trauma'' and ``MST,'' can readily identify and direct 
callers to a VHA MST Coordinator and are sensitive to Veterans' privacy 
concerns. Facilities receive feedback on the results of these calls and 
use them to improve the Veteran experience.
    MST-related training also is provided to those who conduct Medical 
Disability Examinations (MDE). VBA requires completion of a general 
certification for all contracted clinicians who conduct MDEs for MST-
related issues. This certification includes training courses that equip 
contracted examiners with the sensitivity and skills to interact with 
Veterans who have experienced MST and to recognize behavioral changes 
indicative of MST. The training courses are designed for both contract 
clinicians who perform these examinations and VHA clinicians. VBA and 
VHA continue to collaborate to improve and update these training 
courses.

MST Outreach

    VA is dedicated to improving outreach to Veterans, especially those 
affected by MST. Every RO has coordinators who specialize in outreach 
for certain Veteran populations, such as homeless, former Prisoners of 
War, and minority Veterans to assist them with benefits and services 
including two MST Coordinators (a male and a female). MST Coordinators 
working in the RO are specially trained to assist those who have 
experienced MST and come to submit or follow up on their claim. To 
support the RO MST Coordinators, there are two program managers in VBA 
Central Office. The program managers provide recurring guidance to the 
field on MST-related outreach, including through a quarterly 
teleconference.
    VBA conducts recurring targeted MST outreach that includes 
briefings to inform, educate, and empower Veterans to access VA 
benefits and resources. These briefings include information on how to 
file an MST-related claim and how to contact an MST Coordinator near 
the Veteran. In the first quarter of Fiscal Year 2020, VBA completed 
187 hours of MST-related outreach at 22 events, reaching over 500 
Veterans, family members, and other stakeholders. A complete list of 
MST Coordinators serving in ROs, by State, can be found at https://
www.benefits.va.gov/benefits/mstcoordinators.asp.
    VBA MST Coordinators also collaborate with VHA to conduct outreach, 
ensure there is a warm hand-off to VHA MST Coordinators who are 
available at every VA health care system for assistance with access to 
counseling and treatment, and provide MST-related training to 
Department of Defense (DoD) personnel.
    VBA's MST Coordinators also work with the Women Veteran 
Coordinators (WVC) at each RO, including in the National Call Centers 
and at Pension Management Centers. WVCs conduct local outreach and VA 
benefit briefings to women Veterans within their jurisdiction. At some 
locations, the WVC also fulfills the role of the female MST 
Coordinator. MST and WVCs work together with Veterans, their families, 
and local groups advocating for Veterans to increase awareness of and 
access to VA services and programs.
    Furthermore, VBA ensures that all public contact representatives 
who interact with Veterans and families receive annual training on a 
daily basis to help them identify indicators of stressors and signs 
that a Veteran may have experienced MST.
    VHA also engages in a variety of outreach efforts to ensure 
Veterans are aware that MST-related services are available.
    Throughout the year, VHA MST Coordinators engage in local outreach 
efforts, including hosting events in honor of Sexual Assault Awareness 
and Prevention Month in April. These include educational events 
designed to increase knowledge and awareness of MST among all staff 
throughout the medical facility, informational events about the impact 
of MST and VA services for Veterans, and awareness-raising events that 
include opportunities for survivors to share their stories of MST and 
recovery. To support these efforts, VHA has developed national outreach 
posters, handouts, and educational documents for Veterans, secured 
inclusion of information about MST on relevant va.gov Websites, and 
developed a publicly accessible MST-specific informational Website at 
https://www.mentalhealth.va.gov/msthome/index.asp. . Outreach materials 
include both gender-inclusive and gender-specific (i.e., targeting 
women and men) products.
    To assist transitioning Servicemembers, the VA Transition 
Assistance Program benefits and services briefing provides information 
including:

      An overview of MST;

      Information about MST-related care available at VA 
medical centers;

      Eligibility requirements for MST-related health care;

      How to locate and connect with a VA MST Coordinator; and

      How Vet Centers can also provide counseling and referrals 
for those who have experienced MST.

    Through the Transition Assistance Program, VA also informs 
transitioning Servicemembers of where to find MST-related information 
including the MST Fact Sheet and other VA resources on VA.gov. 
Information about VA's MST-related services is also provided through 
the Separation Health Assessment and DoD's Safe Helpline for 
Servicemembers who experience sexual assault during their service.
    Finally, VA utilizes an online presence by publishing MST-related 
information across its public-facing Websites and social media 
channels. One such VA Fact Sheet for Veterans filing claims for MST-
related disability conditions provides guidance, including how VA can 
assist even if the assault was never reported.

Culture Change

    VBA continues to maintain focus on MST-related claims and ensure 
Veterans who file claims based on MST are properly served. 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 office leaders. Dr. Lawrence has also made it a priority to 
emphasize VBA's commitment to supporting those who have experienced MST 
at all VBA national training conferences.
    VBA ensures all staff are trained to assist Veterans with 
compassion and sensitivity and has mandated that all RO personnel in 
identified positions complete MST Sensitivity Training VHA developed 
for VBA. Additionally, 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.

Conclusion

    Providing Veterans with the benefits and services they have earned 
in a manner that honors their service is a priority for VA. Due to the 
difficult nature of MST, it is particularly critical for VA to ensure 
all interactions with survivors are compassionate and sensitive. To 
that end, VA ensures claims are processed by highly skilled and 
experienced employees who receive specialized training on MST claims; 
VHA staff have the information and resources they need to provide 
streamlined access to specialized, Veteran-centric care, and 
comprehensive action is taken to improve outreach. There is strong 
commitment across VA to sustain and enhance these efforts moving 
forward.
                                 ______
                                 

                  Prepared Statement of Julie Kroviak

    Chairman Pappas, Ranking Member Bergman, Chairwoman Brownley, and 
members of the Subcommittee and Task Force, thank you for the 
opportunity to discuss the Office of Inspector General's (OIG's) 
oversight of the Department of Veterans Affairs' (VA's) policies and 
procedures related to military sexual trauma (MST). The mission of the 
OIG is to help improve the efficiency and effectiveness of VA's 
programs and operations through independent audits, inspections, 
evaluations, reviews, and investigations. The OIG's prior work has 
identified deficiencies in Veterans Benefits Administration (VBA) 
processing of MST-related claims, which in part can be attributed to 
lack of specialization, inadequate staff training, deficient internal 
controls, and discontinued special focus reviews.\1\ The OIG has also 
reviewed how the Veterans Health Administration (VHA) implements its 
policies and procedures for treating patients who have MST-related 
conditions.
---------------------------------------------------------------------------
    \1\ The OIG testified before the House Veterans' Affairs 
Subcommittee on Disability Assistance and Memorial Affairs on June 19, 
2019 and November 29, 2018.
---------------------------------------------------------------------------
    Sexual trauma experienced while in the 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, which is the most recent data 
available.\2\ This statistic is an increase of about 12.6 percent from 
2017. Understandably, many veterans who have experienced MST are 
reluctant to report the sexual assault either at the time of its 
occurrence or even much later. It is vital that VA makes every effort 
to properly communicate available MST services to veterans and that 
both VHA and VBA staff work expeditiously and with sensitivity to 
ensure the provision of needed care, treatment, and benefits.
---------------------------------------------------------------------------
    \2\ Department of Defense Annual Report on Sexual Assault in the 
Military, Fiscal Year 2018.

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

    VA uses the term ``military sexual trauma'' to refer to sexual 
assault or repeated, unsolicited, threatening acts of sexual harassment 
that occurred while a veteran was serving on active duty or active duty 
for training.\3\ Furthermore, VA defines MST as ``psychological trauma, 
which in the judgment of a VA mental health professional, 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, active duty for training, or inactive duty training.'' \4\
---------------------------------------------------------------------------
    \3\ VHA Directive 1115, Military Sexual Trauma (MST) Program, May 
8, 2018.
    \4\ Military Sexual Trauma. https://www.mentalhealth.va.gov/docs/
mst_general_factsheet.pdf.
---------------------------------------------------------------------------
    MST is an experience, not a diagnosis or a mental health 
condition.\5\ Although posttraumatic stress disorder is commonly 
associated with MST, other frequently associated diagnoses include 
depression and other mood, psychotic, and substance use disorders.\6\
---------------------------------------------------------------------------
    \5\ Military Sexual Trauma. https://www.mentalhealth.va.gov/docs/
mst_general_factsheet.pdf.
    \6\ PTSD: National Center for PTSD. https://www.ptsd.va.gov/
understand/types/sexual--trauma--military.asp.
---------------------------------------------------------------------------
    In 1992, Congress began passing a series of laws that provided 
outreach and MST counseling and treatment programs for active duty 
women veterans who experienced sexual trauma while on active duty.\7\ 
In 1994, these services where extended to men who have experienced 
MST.\8\ Furthermore, the Veterans Health Program Improvement Act of 
2004 permanently extended VA's authority and added MST counseling and 
related treatment to veterans who experience sexual trauma while 
serving on active duty or active duty for training (if service was in 
the National Guard or Reserves).\9\
---------------------------------------------------------------------------
    \7\ 38 U.S.C. Sec.  102-585, Women Veterans Health Programs Act of 
1992. https://www.gpo.gov/fdsys/pkg/STATUTE-106/pdf/STATUTE-106-
Pg4943.pdf.
    \8\ 38 U.S. C 101 note. Veterans Health Programs Extension Act of 
1994. (Public Law 103-452). https://www.Congress.gov/103/bills/hr3313/
BILLS-103hr3313enr.pdf.
    \9\ 38 U.S.C 101 note. Veterans Health Programs Improvement Act of 
2004. https://www.gpo.gov/fdsys/pkg/PLAW-108publ422/pdf/PLAW-
108publ422.pdf.

THE OIG'S COMPREHENSIVE HEALTHCARE INSPECTION PROGRAM FOCUSES ON MENTAL 
---------------------------------------------------------------------------
HEALTH ISSUES RELATED TO MST

    The OIG uses its Comprehensive Healthcare Inspection Program (CHIP) 
to provide cyclical, focused evaluations of the quality of care 
delivered in the inpatient and outpatient settings of VHA facilities. 
These inspections are one element of the overall efforts of the OIG to 
ensure that the Nation's veterans receive high-quality and timely VA 
healthcare services. OIG CHIP teams evaluate nine areas of clinical and 
administrative operations that reflect quality patient care, with some 
focused review areas changing every fiscal year.\10\ Additionally, the 
OIG may annually rotate high-interest subtopics in the areas of mental 
health care, women's health, high-risk processes, and medication 
management.
---------------------------------------------------------------------------
    \10\ The nine areas for Fiscal Year 2019 were leadership and 
organizational risks; quality, safety, and value; credentialing and 
privileging; environment of care; medication management; mental health 
related to MST; geriatric care; women's health; and high-risk 
processes.
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    For Fiscal Year 2019, the CHIP mental health care review focused on 
VHA facilities' compliance with selected VHA requirements related to 
MST, including processes carried out by MST coordinators, the provision 
of care to patients after positive screening, and mandatory staff 
training. To accomplish this at 43 randomly selected facilities, OIG 
inspectors reviewed the electronic health records of approximately 50 
patients that had a positive MST screen from July 1, 2017, through June 
30, 2018. They also conducted interviews and reviewed relevant facility 
documents and training records.

MST Coordinators

    VHA requires that MST coordinators be designated at each facility 
and be a licensed credentialed clinician or possess expertise related 
to trauma, mental health, and MST-related issues. VHA outlines MST 
coordinator responsibilities as

      Supporting the implementation of national and Veterans 
Integrated Service Network-level policies concerning MST-related care;

      Serving as a point person and source of information for 
MST-related care issues;

      Directing and providing facility staff education to 
improve MST-related care;

      Directing and engaging in outreach activities within the 
facility and with community allies;

      Developing facility-wide partnerships; and

      Communicating with national, VISN, and facility-level 
leadership, and other stakeholders.\11\
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    \11\ VHA Directive 1115, Military Sexual Trauma (MST) Program, May 
8, 2018.

    The OIG noted high compliance with several of the selected VHA 
requirements regarding MST coordinators, their activities, and the 
provision of care to patients after positive screening. Specifically, 
each of the evaluated facilities had a designated MST coordinator. The 
OIG found that 42 of 43 coordinators (98 percent) had generally 
established and monitored informational outreach activities, and 39 of 
43 coordinators (91 percent) tracked and monitored MST-related data.
    The OIG, however, noted several opportunities for improvement. 
First, VHA must ensure these coordinators communicate issues concerning 
MST services and initiatives with local leaders. The OIG found that 
only 34 of 43 coordinators (79 percent) had a process for accomplishing 
this responsibility. Also, VHA must make facility staff aware of MST 
issues, and make sure personnel have the knowledge and skill to work 
with veterans who have experienced MST. Only 38 of 43 coordinators (88 
percent) had established and monitored MST-related staff training. 
These deficiencies may hinder the facility leaders' efforts to identify 
and address opportunities for improvement.

Mental Health Referral and Follow-Up Process

    VHA also requires that all veterans seen in VHA medical centers and 
associated community-based outpatient clinics be screened for 
experiences of MST and results documented in the VA's electronic health 
record. Veterans should be screened at least once and then rescreened 
following additional military service, separation, or declination of 
initial screening.\12\ Those who screen positive must have access to 
appropriate MST-related mental health care.\13\
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    \12\ Department of Veterans Affairs, Military Sexual Trauma 
Clinical Reminder Referral Question and Re-Deployment Activation Patch 
PXRM*2.0*43 Installation and Setup Guide, Product Development, June 
2015.
    \13\ VHA Directive 1115, Military Sexual Trauma (MST) Program, May 
8, 2018.
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    If a veteran requests any mental health services, a referral should 
be entered in the electronic health record. If a veteran declines 
mental health services or is currently enrolled in those services, that 
information also should be documented in his or her electronic health 
record.\14\ Evidence-based mental health care must be available to all 
veterans with mental health conditions related to MST. All new patients 
requesting or referred for mental health services must receive an 
initial evaluation within 24 hours to identify urgent care needs and a 
more comprehensive diagnostic and treatment planning evaluation within 
30 days.\15\
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    \14\ Department of Veterans Affairs, Military Sexual Trauma 
Clinical Reminder Referral Question and Re-Deployment Activation Patch 
PXRM*2.0*43 Installation and Setup Guide, Product Development, June 
2015.
    \15\ VHA Handbook 1160.01, Uniform Mental Health Services in VA 
Medical Centers and Clinics, September 11, 2008, Amended November 16, 
2015.
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    The OIG reviewed the provision of MST-related care for 1,903 
patients (from all 43 facilities) who had a positive screening and 
observed high compliance with each of the VHA requirements assessed. 
The OIG found that 1,832 of the 1,903 patients (96 percent) received a 
referral for MST-related services or had an acceptable reason for 
nonreferral.\16\ Further, of the 713 patients who were subsequently 
referred to mental health services, 667 (94 percent) received an 
initial mental health evaluation within one business day of referral or 
had an acceptable reason for (1) non-evaluation or (2) evaluation 
greater than one business day from referral.\17\ Finally, of the 713 
applicable patients referred to mental health services, 667 (94 
percent) received a mental health diagnostic and treatment planning 
evaluation within 30 days of referral or had an acceptable reason for 
(1) not receiving a mental health diagnostic and treatment planning 
evaluation or (2) evaluation greater than 30 days from referral.\18\
---------------------------------------------------------------------------
    \16\ Examples of acceptable reasons included patient refusal and 
MST-related issues already being managed by mental health providers.
    \17\ Examples of acceptable reasons included patient declination, 
patient no-show for appointment, and other patient causal factors.
    \18\ Examples of acceptable reasons included patient declination, 
patient was receiving mental health MST services, and patient no-show 
for appointment.

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Mandatory MST Training

    VHA requires that all mental health and primary care providers 
appointed or utilized on a full-time, part-time, intermittent, 
consultant, attending, without compensation, on-station fee-basis, on-
station contract, or on-station sharing agreement basis must complete 
their respective mandatory MST training no later than 90 days after 
entering their position.\19\ Full-time providers must complete a web-
based training program in VA's Talent Management System as a one-time 
requirement.\20\ Additionally, providers who started ``before July 1, 
2012, were required to complete the training no later than September 
30, 2012. Providers starting after July 1, 2012, must complete the 
training within 90 days of entering their position to be in 
compliance.'' \21\ Because the MST coordinator may provide clinical 
care to veterans who experienced MST, they are also subject to the 
mandatory training requirements for mental health and primary care 
providers.\22\
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    \19\ ``On-station'' refers to the location where healthcare 
services were provided through fee-basis, contract, and sharing 
agreements when they are VA premises.
    \20\ VHA Directive 1115.01, Military Sexual Trauma (MST) Mandatory 
Training and Reporting Requirements for VHA Mental Health and Primary 
Care Providers, April 14, 2017.
    \21\ Acting Deputy Under Secretary for Health for Operations and 
Management (10N) memorandum, Compliance with Military Sexual Trauma 
(MST) Mandatory Training for Mental Health and Primary Care Providers 
(VAIQ 7663786), February 2, 2016.
    \22\ VHA requested that facility-level MST coordinators or VISN-
level MST Points of Contact complete ``MST Training for Mental Health 
Clinicians and MST Coordinators'' in June 2011.
---------------------------------------------------------------------------
    Providers in the following professions must be assigned the 
training requirement for mental health providers: psychiatrists, 
psychologists, social workers (includes primary care and other non-
mental health clinics or services), psychiatric nurses, marriage and 
family therapists, licensed professional mental health counselors, and 
mental health clinical pharmacy specialists. The primary care patient-
aligned care team (PACT) providers working in the following professions 
must also be assigned the training requirement: physicians, advanced 
practice registered nurses, clinical pharmacy specialists, physician 
assistants, registered nurses, and licensed practical/vocational 
nurses.\23\
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    \23\ VHA Directive 1115.01 defines the mental health providers as 
``licensed professionals and license-eligible trainees who deliver 
mental health clinical care in accordance with their privileges, scope 
of practice, functional statement, or labor mapping. VHA policy does 
not in general specify the occupational titles of those considered 
qualified to deliver mental health care (see VHA Handbook 1160.01), so 
providers from a range of professional disciplines may meet this 
definition.'' VHA Directive 1115.01 defines primary care providers as 
``licensed professionals and license-eligible trainees who deliver 
clinical primary care services in accordance with their privileges, 
scope of practice, functional statement, or labor mapping to patients 
receiving care from VHA.''
---------------------------------------------------------------------------
    The OIG found that of 324 clinicians hired before July 1, 2012, 
there were 304 (94 percent) who had completed MST training. However, of 
the 529 applicable clinicians hired after July 1, 2012, only 330 (62 
percent) had completed MST training within 90 days of entering their 
position. This could potentially result in newly hired clinicians 
providing counseling, care, and service without the required MST 
training.

OTHER OIG WORK RELATED TO MST

    In previous years, the OIG has released reports on matters related 
to MST and claims for benefits that can significantly affect veterans.

Review of Combat Stress in Women Veterans Receiving VA Health Care and 
Disability Benefits

    In a December 2010 report, 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 VA 
regional offices to designate MST specialists beginning in 2011.

Denied Posttraumatic Stress Disorder Claims Related to Military Sexual 
Trauma

    In August 2018, the OIG reported that nearly half of denied MST-
related claims were not properly processed following VBA policy and 
procedures.\24\ The potential impact on veterans seeking benefits 
related to MST is considerable given that VBA processes an estimated 
12,000 MST claims per year and the number of MST incidents reported 
within the DoD continues to grow. These improperly denied claims 
potentially resulted in undue stress for veterans in need. The OIG 
audit team identified several deficiencies that led to the improper 
denial of benefits such as lack of specialization, inadequate MST-
related claim-processing training for VBA staff, deficient internal 
controls, and discontinued special focus reviews.
---------------------------------------------------------------------------
    \24\  Denied Posttraumatic Stress Disorder Claims Related to 
Military Sexual Trauma, August 21, 2018.
---------------------------------------------------------------------------
    The OIG made six recommendations to ensure the accurate processing 
of MST-related claims. Two of the six recommendations have been closed. 
In VBA's response to the OIG report, VBA leaders provided action plans 
and dates of completion, ranging from November 30, 2018, to October 31, 
2019, for the remaining four recommendations. VBA requested closure for 
three recommendations; however, the OIG recently advised VBA that it 
would need to provide additional information in order for the OIG to 
consider closing them.\25\
---------------------------------------------------------------------------
    \25\  VBA requested recommendations 1, 4, and 5 be closed. VBA did 
not request recommendation 3 be closed. The OIG requested additional 
information for recommendations 4 and 5.
    ------------
---------------------------------------------------------------------------
    VBA requested closure of the recommendation related to reevaluating 
all denied MST-related claims since the beginning of Fiscal Year 2017. 
However, during a follow-up OIG sample review of that information, 
reviewers became concerned about that process. As a result, the OIG is 
conducting another audit to determine whether VBA properly reevaluated 
those claims. Specifically, the audit will assess whether VBA has made 
improvements and is correctly processing more recent MST-related claims 
based on updated VBA policies, procedures, and training that resulted 
from the OIG's August 2018 report recommendations. A final report is 
expected to be published in the fall of 2020.

CONCLUSION

    It is critical for VA to provide compensation and healthcare 
services to veterans who experienced MST during their military service. 
These services should be delivered promptly and with sensitivity. 
Recent and ongoing OIG work has detailed the challenges some veterans 
face when accessing and receiving these much-needed services. VHA must 
ensure that MST coordinators carry out assigned administrative and 
oversight responsibilities and clinicians complete mandatory MST 
training in a timely manner. Although VBA has expressed a strong 
commitment to addressing deficiencies identified by the OIG, its 
delayed action in fully implementing recommendations may cause undue 
stress to men and women deserving of care and discourage other eligible 
veterans from stepping forward to report misconduct and seek 
assistance. The OIG will continue to monitor all efforts to improve the 
care and services provided to veterans who have suffered MST.
    Chairman Pappas, Ranking Member Bergman, Chairwoman Brownley, and 
members of the Subcommittee and Task Force, this concludes my 
statement. I would be happy to answer any questions.
                                 ______
                                 

                   Prepared Statement of Tammy Barlet

    Chairman Pappas, Ranking Member Bergman, and distinguished members 
who proudly serve on this subcommittee; on behalf of our National 
Commander, James W. ``Bill'' Oxford, thank you for the opportunity to 
comment on the important issue of how the Department of Veterans 
Affairs (VA) supports survivors of military sexual trauma (MST). It is 
my duty and honor to represent The American Legion and assist this 
subcommittee in better understanding this issue, how it impacts our 
veterans, and provide recommendations for improvement. It is imperative 
that we address these issues in an effort to ensure the institutions we 
built to care for our veterans are giving them the quality care and 
support they deserve.
    The American Legion believes that our Nation's veterans should 
never suffer at the hands of institutions whose existence and mission 
is to care for them. We believe in the quality of care at VA 
facilities, remain committed to a strong VA, and maintain that VA is a 
``system worth saving.''

                          System Worth Saving

    The American Legion uniquely understands the challenges VA faces in 
order to support survivors of MST due to our routine site visits 
through our System Worth Saving (SWS) program. This innovative 
partnership was launched in 2003 to promote best practices at VA 
Medical Centers (VAMC), identify any challenges, and make 
recommendations to improve the quality of care for veterans. The 
mission of the SWS program is to assess the quality and timeliness of 
veterans' healthcare at VAMCs, the claims process at VA Regional 
Offices (VARO), and provide feedback from local veterans about the care 
and services offered. To accomplish this mission, The American Legion 
conducts site visits to VAMCs and VAROs nationwide. The American Legion 
compiles the reports from each visit for publication and distribution 
to the President of the United States, Congress, VA officials, and 
members of The American Legion.\1\ This comprehensive report provides 
an understanding of VA challenges, best practices, and offers 
recommendations based on our observations through our 100 years of 
experience.
---------------------------------------------------------------------------
    \1\ https://www.legion.org/systemworthsaving/reports
---------------------------------------------------------------------------
    As a part of this program, Regional Office Action Reviews (ROAR) 
are conducted at VAROs nationwide. During ROAR visits, the American 
Legion randomly selects formerly adjudicated claims to review in order 
to determine development accuracy, examination efficiency, and rater 
competency related to the percentage assigned for each claimed 
disability contention by the veteran. Additionally, ROAR visits afford 
The American Legion an opportunity to interview employees on training, 
climate, leadership, systems and adjudication; and provides VARO 
leadership real time information of how a representative sample of 
employees are perceiving the aforementioned issues.

                            Lack of Training

    In 2011, the Veterans Benefits Administration (VBA) began special 
training for employees who are involved in the MST-related claims 
process, including mental health clinicians and office personnel.\2\ A 
VA Office of Inspector General (OIG) report, released in August 2018, 
recommended the Under Secretary of Veterans Affairs for Benefits to 
update the current training for processing MST related claims, monitor 
the effectiveness of the training, and take additional action as 
necessary.\3\ VBA's response to the OIG report at that time was to 
update the four lessons in the ``PTSD Due to MST'' training course, and 
mandate training to be completed by March 2019. In future ROAR visits, 
we will pay close attention to studying the quality and completion of 
the 2019 update. Investing in the training of Veteran Service 
Representatives (VSR) and Rating Veteran Service Representatives (RVSR) 
will correct errors in claims before they occur, saving time and money.
---------------------------------------------------------------------------
    \2\ https://www.benefits.va.gov/BENEFITS/factsheets/
serviceconnected/MST.pdf
    \3\ https://www.va.gov/oig/pubs/VAOIG-17-05248-241.pdf
---------------------------------------------------------------------------

              Lack of Adequate Time to Process MST Claims

    In Fiscal Year 2019, the American Legion conducted a total of 12 
ROAR site visits to VAROs nationwide. During these visits, VA employees 
who previously worked as MST coordinators, or who are currently working 
as MST coordinators, reported to The American Legion several internal 
issues, such as not being granted excluded time (extra time) to develop 
an MST claim by VA's Central Office and local leadership. Those 
interviewed stated that because MST coordinators had received the 
required MST training, it was perceived that the MST coordinators 
should not need extra time. However, we cannot verify the veracity of 
these complaints.
    Since sexual assault or sexual harassment is not always reported 
during service, part of VSR and RVSR training includes how to identify 
markers in a veteran's medical record and personnel record.\4\ Markers 
such as a sudden decrease in work performance, substance abuse, 
pregnancy tests, tests for sexually transmitted disease, panic attacks, 
and a request for transfer to another military duty assignment, are 
used to build the disability claim evidence of the MST claims.
---------------------------------------------------------------------------
    \4\ Morral, A. R., Gore, K. L., & Schell, T. L. (2015). Sexual 
assault and sexual harassment in the US military. Volume 2. Estimates 
for department of defense service members from the 2014 RAND military 
workplace study. RAND NATIONAL DEFENSE RESEARCH INST SANTA MONICA CA.
---------------------------------------------------------------------------
    During our ROAR interviews, employees have reported that although 
they really want to perform quality work on these claims, they feel 
forced to choose between quality and quantity due to the current 
standards.\5\
---------------------------------------------------------------------------
    \5\ The American Legion. (May 2019). Wilmington Regional Office 
Action Reivew After Action Report. The American Legion System Worth 
Saving. https://www.legion.org/documents/legion/pdf/
SWS_ROAR_Report_Wilmington_2019.pdf
---------------------------------------------------------------------------

             High Rate of Attrition and Compassion Fatigue

    VAROs expressed to The American Legion their challenge and concern 
over employee burnout and turnover due to employee stress. During our 
ROAR interviews, VARO employees mentioned being conflicted over their 
passion to help claimants, while working in an environment where morale 
is low and unequal workload, adds to the workplace stress. Employees 
confessed that the cost to fulfilling their quota usually means 
foregoing lunch and breaks, mental fatigue, suicide ideations, and 
increased requests for time off.\6\
---------------------------------------------------------------------------
    \6\ The American Legion. June 2019. St. Petersburg VA Regional 
Office Action Review After Action Report. The American Legion System 
Worth Saving. https://www.legion.org/documents/legion/pdf/
SWS_ROAR_Report_St_Petersburg_2019.pdf
---------------------------------------------------------------------------
    It should be noted that when MST coordinators call the veteran to 
discuss the MST-related claim, it could expose them to the veteran's 
trauma.\7\ The conversation can also potentially revictimize and 
trigger the veteran. Both veteran and non-veteran employees have 
expressed to American Legion representatives their feelings of 
compassion fatigue when developing MST claims.
---------------------------------------------------------------------------
    \7\ Suris A, Lind L, Kashner TM, Borman PD, Petty F. Sexual assault 
in women veterans: an examination of PTSD risk, health care 
utilization, and cost of care. Psychosom Med. 2004;66(5):749-756.
---------------------------------------------------------------------------

              Implication of Biases and Subjective Ratings

    The rating scale for PTSD ranges from 0 to 100 in increments of 
ten.\8\ Therefore, a PTSD claim from MST can vary widely depending on 
the rater. Coordinators have reported repeated instances of the 
violation of 38 CFR 4.23, ``the attitude of the rater,'' which states:
---------------------------------------------------------------------------
    \8\ United States Department of Veterans Affairs. Veterans Benefits 
Administration References: 38 CFR-Book C, Schedule for Rating 
Disabilities. http://www.benefits.va.gov/warms/bookc.asp

        ``It is to be remembered that the majority of applicants are 
        disabled persons who are seeking benefits of law to which they 
        believe themselves entitled. In the exercise of his or her 
        functions, rating officers must not allow their personal 
        feelings to intrude; an antagonistic, critical, or even abusive 
        attitude on the part of a claimant should not in any instance 
        influence the officers in the handling of the case. Fairness 
        and courtesy must at all times be shown to applicants by all 
        employees whose duties bring them in contact, directly or 
---------------------------------------------------------------------------
        indirectly, with the Department's claimants.''

    VBA processes and raters can cause harm with implicit biases if 
they lack sufficient knowledge regarding PTSD and MST. The scope of 
this issue encompasses discrediting the claim, victim-blaming, and 
accepting that men could also be victimized. Per Resolution 67 (August 
2014), Military Sexual Trauma, The American Legion urges the VA to 
conduct an analysis of MST claims volume, assess the consistency of how 
these claims are adjudicated, and determine the need, if any, for 
additional training and testing on processing of these claims and urge 
the VA to employ additional Women Veterans Coordinators (WVCs) and to 
provide MST sensitivity training to claims processors and WVCs.\9\
---------------------------------------------------------------------------
    \9\ https://archive.legion.org/bitstream/handle/20.500.12203/3716/
2014N067.pdf?sequence=1&isAllowed=y
---------------------------------------------------------------------------

                     VHA Facility MST Coordinators

    In addition to ROAR, our SWS program includes 3-day visits to VAMCs 
to inquire about that facility, as a whole, and how the departments 
within the facility operate. During a visit, The American Legion staff 
meets with the MST Coordinator to ensure the facility is in compliance 
with Veterans Health Administration (VHA) Directive 1115, MST program. 
This directive outlines the responsibilities of implementing policies, 
educating staff, directing, engaging in outreach activities, developing 
partnerships, and serving as the expert for MST-related care. They are 
also responsible for communicating with national, VISN, facility-level 
leadership, and other stakeholders.
    Per Resolution No. 147, August 2014, Women Veterans, The American 
Legion supports the VA's establishment of a women veterans awareness 
training programs that educates employees about the changing roles of 
women in the military, their combat-related exposures and MST 
sensitivity.\10\
---------------------------------------------------------------------------
    \10\ https://archive.legion.org/bitstream/handle/20.500.12203/5488/
2016N147.pdf?sequence=1&isAllowed=y
---------------------------------------------------------------------------

                        End Harassment Campaign

    No discussion about MST would be complete without acknowledging 
harassment. Harassment has been a widely reported and ongoing cultural 
problem within the military \11\, and many believe continues in VA 
facilities. It has been reported that many veterans do not return to 
the VA because of the hostile environment.\12\ The current VA 
#EndHarassment Campaign must be updated. The message of zero-tolerance 
must be clearly stated to bring awareness, empower bystanders, lay out 
instructions for reporting incidents, and provide support for the 
victim. The campaign should also follow through with investigations and 
establish consequences in order to change behavior and culture. One 
best practice at a VAMC that The American Legion saw during the SWS 
program, was the use of televisions in waiting areas to display 
messages about health conditions, details on VBA and VHA benefits, and 
other pertinent information. Televisions displaying VA #EndHarassment 
Campaign videos, along with other valuable messaging can be a useful 
tool to spread awareness. Studies show when leadership takes harassment 
seriously, their employees raise their concern to the same level.\13\
---------------------------------------------------------------------------
    \11\ https://www.militarytimes.com/news/pentagon-congress/2019/05/
02/defense-department-to-make-sexual-harassment-a-crime/
    \12\ https://www.nytimes.com/2019/03/12/us/politics/women-veterans-
harassment.html
    \13\ National Academies of Sciences, Engineering, and Medicine. 
2018. Sexual Harassment of Women: Climate, Culture, and Consequences in 
Academic Sciences, Engineering, and Medicine. Washington, DC: The 
National Academies Press. doi: https://doi.org/10.17226/24994.
    ------------
---------------------------------------------------------------------------

                            Recommendations

    The American Legion believes all veterans deserve to have their 
claims developed and rated by knowledgeable, competent, and bias-free 
VSRs and RVSRs. Veterans deserve to have access to healthcare providers 
for mental and physical health as a result of their MST experience. 
Therefore, The American Legion recommends the following steps to 
alleviate this issue:

        1. Reevaluate and change policy, if necessary, to set a 
        specified amount of excluded time that can be allotted for the 
        development of MST claims.

        2. Enforce the existing zero-tolerance policy concerning 
        attitude of the rater with regard to MST claims. Any rater 
        violating this policy should face appropriate disciplinary 
        action.

        3. Enforce that document raters who repeatedly fail to consider 
        markers in their rating decision of MST claims be retrained. If 
        they continue with the same behavior, they should face 
        appropriate disciplinary action.

        4. Provide resources and remind employees of existing resources 
        they can use for self-care when triggered or experiencing 
        compassion fatigue due to handling MST cases.

        5. Re-educate VBA employees about immediate healthcare 
        resources at VA facilities and Vet Centers so veterans may 
        begin the path to healing.

        6. Re-evaluate the duties and responsibilities of MST 
        coordinators and consider a possible increase of the percentage 
        of full-time equivalent.

    The American Legion recommends Congress ensure the VA has all the 
necessary resources to remain committed to providing veterans access to 
help they need to recover from MST and end sexual harassment within VHA 
facilities.

                               Conclusion

    Chairman Pappas, Ranking Member Bergman, and distinguished members 
who proudly serve on this subcommittee, The American Legion thanks you 
for the opportunity to illuminate the positions of the nearly two 
million veteran members of this organization. Safeguarding those who 
have selflessly raised their right hand in defense of this Nation 
receive the benefits and care they deserve is a priority of The 
American Legion. By the action of this committee, we can see that it is 
for you as well.
    As always, The American Legion thanks this committee for the 
opportunity to elucidate the position of the nearly 2 million veteran 
members of this organization. For additional information regarding this 
testimony, please contact Mr. John Medin, Legislative Associate, at 
[email protected] or (202) 263-5756.
                                 ______
                                 

                  Prepared Statement of Kayla Williams

I. Overall

    Chairman Pappas, Ranking Member Bergman, distinguished members of 
the Committee, thank you for the opportunity to discuss a topic I 
believe is of vital importance to the long-term well-being of too many 
of America's veterans.
    The problem of sexual harassment and assault in the United States 
military has been widely reported upon, often framed as a predominantly 
women's issue.\1\ However, many survivors are men: though a higher 
percent of women are assaulted, the total number of men who experienced 
Military Sexual Trauma (MST) remains high, since men comprise 90 
percent of veterans.\2\ VA offers both care and benefits for veterans 
who experienced MST if they subsequently develop conditions such as 
post-traumatic stress disorder (PTSD) as a result of being harassed or 
assaulted. However, when MST survivors seek care at a Veterans Health 
Affairs (VHA) facility and/or file a claim for disability compensation 
with the Veterans Benefits Administration (VBA), they do not always 
receive adequate or consistent services and support. It is imperative 
that VA redouble its efforts to improve care for MST survivors.
---------------------------------------------------------------------------
    \1\ Zachary Cohen, ``From fellow soldier to `monster' in uniform: 
#MeToo in the military'', CNN, February 7, 2018, https://www.cnn.com/
2018/02/07/politics/us-military-sexual-assault-investigations/
index.html; and ``Sexual Assault Reports in U.S. Military Reach Record 
High: Pentagon'', NBC, May 1, 2017, https://www.nbcnews.com/news/us-
news/sexual-assault-reports-u-s-military-reach-record-high-pentagon-
n753566.
    \2\ DoD Sexual Assault Prevention and Response Office, ``Department 
of Defense Annual Report on Sexual Assault in the Military'', April 
2019, https://www.sapr.mil/sites/default/files/
DoD_Annual_Report_on_Sexual_Assault_in_the_Military.pdf, page 3 
includes estimated past-year prevalence of sexual assault from 2006-
2018.

---------------------------------------------------------------------------
VHA

    VHA offers an impressive array of mental health services to 
veterans who experienced MST, including universal screening and 
evidence-based care that ranges from telehealth to inpatient. However, 
inconsistencies and inadequacies negatively impact veterans' ability to 
access and utilize care across the system.
    One barrier is difficulty accessing initial care. While VA may be 
able to provide care for MST to veterans who are otherwise ineligible 
for care, some veterans report experiencing challenges overcoming the 
first barrier of simply getting access to a provider who can make the 
determination that they need care related to MST. During a recent Women 
Veterans Task Force meeting, VA leaders demonstrated a woeful lack of 
understanding of this issue, repeatedly stating that MST survivors are 
eligible for care related to MST without grasping that veterans cannot 
make it past the first gatekeeper. That process should be improved. 
VA's office of mental health services has an excellent ``secret 
shopper'' style program to ensure frontline staff connect both men and 
women veterans requesting MST services to the MST Coordinator at VA 
Medical Centers (VAMCs) across the country. This should be expanded to 
confirm that those first assessing eligibility for care know to connect 
veterans seeking services for MST-related conditions with the MST 
coordinator to facilitate their navigation of the processes required 
for them to access care if they are not otherwise eligible for VA care. 
Additionally, staff should be trained to inform veterans pending 
eligibility notification that they can also seek immediate support at 
Vet Centers, where more veterans are eligible for care.
    Additional oversight is also needed on inpatient mental health 
care. Inpatient VA sites can be terrifying for women and vulnerable 
men, with young, physically strong men in the early stages of learning 
to manage what can be severe mental health symptoms; there are very few 
women and few protections. There are numerous reports of harassment and 
even assault, yet VA continues to maintain that there is insufficient 
need for more women-only options and is reluctant to refer women to 
inpatient community care options, where mixed units are more likely to 
have better monitoring, locks, and separate wings. Congress should 
request regular, detailed reports of harassment and assault instead of 
annual statistical data, to better understand the extent and severity 
of the challenges; alternatively, Congress could consider requesting 
GAO or OIG investigation.
    VA should also develop a mental health equivalent of Women's Health 
Primary Care Providers, allowing mental health providers to specialize 
or choose to focus on treating women. There is a growing community of 
practice that seeks to understand and offer best treatment for complex 
conditions such as combat PTSD combined with MST-related depression, 
understanding how these mental health conditions intersect with 
reproductive issues or parenting, and other complex issues requiring 
both interest and proficiency. In the future, one can imagine a 
specialty in women's mental health. VA could be an early leader in the 
field by supporting women's mental health providers and the 
psychologists, psychiatrists and others who want to specialize in 
developing such a specialty and best treatment practices, which in VA 
would also include cultural competency for women's military 
experiences.
    VA's Office of Mental Health and Suicide Prevention should also 
develop a strategic plan for improving MST care, particularly for the 
rapidly growing population of women veteran VHA patients. Between 2007 
and 2016 the rate of women veterans using VHA increased by 45 percent, 
compared with an 8 percent increase in the women veteran population.\3\ 
That rapid growth is particularly important when considering 
appropriate mental health staffing: the Sourcebook indicates that 42 
percent of women using VA have a mental health condition.\4\ However, 
despite the goals of the Patient Aligned Care Team model, not all 
women's clinics have onsite mental health. Funds are not increasing for 
women's mental health, and the women's mental health champion role is a 
collateral duty, not a full-time job, making it inadequate to address 
this rapidly growing need. For women with a history of MST, access to 
mental health care is made significantly more challenging - if not 
impossible - when they are required to ``walk the gauntlet'' of 
catcalling men while on their way to see mental health providers.
---------------------------------------------------------------------------
    \3\ ``VA Utilization Profile Fiscal Year 2016'' (U.S. Department of 
Veterans Affairs' National Center for Veterans Analysis and Statistics, 
November 2017), https://www.va.gov/vetdata/docs/QuickFacts/
VA_Utilization_Profile.PDF.
    \4\ Frayne SM, Phibbs CS, Saechao F, Friedman SA, Shaw JG, Romodan 
Y, Berg E, Lee J, Ananth L, Iqbal S, Hayes PM, Haskell S., 
``Sourcebook: Women Veterans in the Veterans Health Administration. 
Volume 4: Longitudinal Trends in Sociodemographics, Utilization, Health 
Profile, and Geographic Distribution'', Women's Health Evaluation 
Initiative, Women's Health Services, Veterans Health Administration, 
Department of Veterans Affairs, Washington DC. February 2018 , https://
www.womenshealth.va.gov/WOMENSHEALTH/sourcebookvol4onlineappendix.asp.
---------------------------------------------------------------------------
    In CNAS research, stakeholders routinely report that women are 
reluctant to seek services at VA Medical Centers as they are, or are 
perceived to be, male-dominated spaces and thus less sympathetic, 
understanding, or welcoming to women. Women with a history of MST are 
more likely to find this to be an insurmountable barrier to care, 
preferring not to reenter an environment full of prior military men; 
however, few providers in the civilian setting are familiar with the 
effects of MST. Experience with not only VA staff and providers but 
also fellow patients informs veterans' willingness to engage with the 
system, trust the care they receive, and seek care in the first place. 
For example, according to VA's own research, 25 percent of women 
veterans reported inappropriate/unwanted comments or behavior by men 
veterans while at VA.\5\ Women veterans who reported harassment were 
less likely to report feeling welcome at VA, which related to delaying 
and/or missing care. Interviews CNAS recently conducted supported VA's 
conclusions; one stakeholder said about experiencing harassment at VA: 
``A veteran doesn't necessarily go back to VA. If they have a negative 
experience, they're not coming back.'' \6\
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    \5\ 2015 VA Health Services Research and Development, through an 
interview with 1,387 women veterans in 2015. Of the women reporting an 
incident on VA grounds, 61 percent reported harassment, 16 percent 
reported that their veteran status was questioned, 7 percent reported 
both harassment and that their veteran status was question, and 5 
percent reported threatening/criminal behavior, https://
www.hsrd.research.va.gov/publications/vets--perspectives/0419-How-
Stranger-Harassment-of-Women-Veterans-Affects-Healthcare.cfm.
    \6\ Forthcoming report, Nathalie Grogan, Emma Moore, Brent Peabody, 
Margaret Seymour, and Kayla Williams, ``New York State Minority 
Veterans Needs Assessment'', CNAS, 16.
---------------------------------------------------------------------------
    VA is well aware of this concern, which is why Central Office 
developed and launched the End Harassment campaign.\7\ Unfortunately, 
recent events have undercut public perception of how seriously senior 
VA leaders take the severity of the problem and their willingness to 
address it. In January, Secretary Robert Wilkie updated Representative 
Takano on the department's response to staffer Andrea Goldstein's 
allegation of being sexually assaulted at the DC VA Medical Center that 
the matter had been closed with no charges filed, stating ``VA is a 
safe place for all Veterans to enter and receive care and services'' 
and calling Ms. Goldstein's claims ``unsubstantiated.''\8\ This letter 
undermines efforts to end harassment at VA.
---------------------------------------------------------------------------
    \7\ Patricia M. Hayes, ``VA: It's our responsibility to end 
harassment'', Vantage Point, August 15, 2019, https://www.blogs.va.gov/
VAntage/64559/va-our-responsibility-end-harassment/.
    \8\ Jennifer Steinhauer, ``No Charges in Assault Complaint at V.A. 
Hospital, and a Public Fight Erupts'', The New York Times, January 16, 
2020, https://www.nytimes.com/2020/01/16/us/politics/sexual-assault-va-
hospitals.html.
---------------------------------------------------------------------------
    Changing the culture that has allowed this behavior to flourish 
requires strong leadership. Employees take sexual harassment seriously 
when leaders do.\9\ By publicly sending such a dismissive, belittling 
letter about the negative experience of a woman veteran patient, 
Secretary Wilkie sent a strong message to VA staff, including VA 
police, as well as women veteran patients and potential perpetrators, 
that senior VA leadership does not take this problem seriously. This 
messaging tells women veterans that should we report sexual harassment 
or assault in a VA facility, not only will there be no consequences to 
the bad actor, but that we ourselves may face public humiliation for 
coming forward, because calling the claims ``unsubstantiated'' subtly 
impugns a woman's reputation. A reported sexual assault may be 
determined to be ``unfounded'' or ``unsubstantiated'' for any number of 
reasons, such as a lack of physical evidence. That does not mean it was 
a false report or that the incident did not occur, and conflating 
concepts like false and unproven perpetuates dangerous myths that false 
accusations are common. More concerningly, in this specific case, VA's 
Inspector General wrote, ``Neither I nor my staff told you or anyone 
else at the Department that the allegations were unsubstantiated.''\10\ 
This subcommittee should seek clarification on how such a 
miscommunication occurred and was conveyed by the Secretary to HVAC and 
the public, as well as impressing the importance of taking these 
concerns seriously upon the Secretary.
---------------------------------------------------------------------------
    \9\ Chloe Hart, Alison Dahl Crossley, and Shelly J. Correll, 
``Study: When Leaders Take Sexual Harassment Seriously, So Do 
Employees'', Harvard Business Review, December 14, 2018, https://
hbr.org/2018/12/study-when-leaders-take-sexual-harassment-seriously so-
do-employees.
    \10\ Richard Sisk, ``IG Rebukes VA Secretary for Saying Navy LT's 
Sexual Assault Claim `Unsubstantiated' '', Military, January 16, 2020, 
https://www.military.com/daily news/2020/01/16/ig-rebukes-va-secretary-
saying-navy-lts-sexual-assault-claim-unsubstantiated.html.
---------------------------------------------------------------------------
    This incident demonstrates that VA staff at both the national and 
local level did not understand their obligation to take complaints 
seriously and respond appropriately. It is imperative that the End 
Harassment campaign be reinvigorated and taken seriously at all levels 
of the organization. In the meantime, telehealth can help increase 
access, but still is not available widely enough. VA should accordingly 
immediately expand the ``Sister Assister'' program to better support 
women veterans, particularly those who have experienced MST, and raise 
awareness about its availability. That program, currently available at 
some VAMCs, allows women veterans to request a ``battle buddy'' to meet 
them at a designated entrance, escort them through the facility, and 
either accompany them during appointments or stay in the waiting 
room.\11\ For women veterans who are uncomfortable navigating the male-
dominated VA hospital environment or want companionship during 
appointments, this program can offer valuable support from vetted and 
trained volunteers, reducing a barrier to seeking care. VAMC directors 
should work closely with MST coordinators, Women Veterans Program 
Managers, Voluntary Services managers, Community Veteran Engagement 
Boards, and other local stakeholders to identify barriers that may 
disproportionately affect MST survivors and jointly develop a local 
action plan to vigorously implement the End Harassment campaign, launch 
the Sister Assister program, and take any additional steps needed to 
improve the environment of care.
---------------------------------------------------------------------------
    \11\  See more at https://www.madison.va.gov/giving/
assignments.asp; the program appears to be available at several VAMCs 
in Wisconsin, Minnesota, and Michigan.

---------------------------------------------------------------------------
VBA

    Disability ratings can provide a vital source of support for a 
veteran's financial well-being, especially if a service-connected 
disability negatively affects their ability to attain or keep a job. 
Unfortunately, the data appears to show that men who seek disability 
compensation for PTSD related to MST are being systematically 
discriminated against by VBA, despite overall improvements to the 
claims processing system going back several years.
    VBA previously made a number of changes in how it processes PTSD 
claims related to MST.\12\ These changes were instituted to reduce 
stark disparities that had been previously identified between the rate 
of claims granted when the cause of PTSD is MST compared to other 
precipitating events, such as combat.\13\ Overall, these efforts were 
largely successful in eliminating the gap: PTSD claims granted for MST-
related causes climbed 20 points in 7 years, from 35.6 percent in 
Fiscal Year (FY) 2011 to 56.6 percent in Fiscal Year 2018, while the 
rate for non-MST causes has hovered around 54 percent for several 
years, as shown in Figure 1.
---------------------------------------------------------------------------
    \12\ Government Accountability Office, Military Sexual Trauma: 
Improvements Made, but VA Can Do More to Track and Improve Consistency 
of Disability Claim Decisions, GAO-14-477 (June 9, 2015), https://
www.gao.gov/products/GAO-14-477.
    \13\ Karen McVeigh, ``Obama administration sued by veterans over 
military sexual assault'', The Guardian, April 30, 2014, https://
www.theguardian.com/world/2014/apr/30/us-military-veterans-lawsuit-
military-sexual-assault.
---------------------------------------------------------------------------
    FIGURE 1

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Source: File sent to the author by VA in January 2019 responding to 
FOIA request 19-00345-F.

    However, this generally positive trend masks a more complicated and 
concerning story. When broken down by gender, it becomes clear that 
these gains have not benefited men and women equally. While both men 
and women have seen substantial increases in the percent of PTSD claims 
granted due to MST, the grant rate for men has lagged significantly 
behind, at just 44.7 percent, compared to 57.7 percent for women. This 
is not to discount the real improvements - the grant rate for men in 
2011 was a shockingly low 26.9 percent, an appalling 33 points behind 
their grant rate for combat-related PTSD that same year. However, the 
rate for women who file for disability compensation because they 
developed PTSD after surviving MST has been higher than for any other 
category reviewed since 2015. It is glaringly apparent that men's cases 
are not being handled equitably.

    FIGURE 2

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Source: File sent to the author by VA in January 19 responding to 
FOIA request 19-00345-F.

    Why might this be the case? VA's Inspector General found in 2018 
that thousands of MST survivors may have been incorrectly denied 
benefits due to paperwork and procedural mistakes.\14\ They made a 
series of recommendations, including that VBA have specialized raters 
process MST claims, require additional review of denied claims, and 
develop a checklist for processors to use so they do not skip 
steps.\15\ These are all valid and important steps.
---------------------------------------------------------------------------
    \14\ Leo Shane III, ``Report: VA may have mishandled thousands of 
sexual assault cases'', Military Times, August 21, 2018, https://
www.militarytimes.com/veterans/2018/08/21/report-va-may-have-
mishandled-thousands-of-sexual-assault-cases/.
    \15\ Department of Veterans Affairs Office of Inspector General, 
Denied Posttraumatic Stress Disorder Claims Related to Military Sexual 
Trauma, Report #17-05248-241 (August 21, 2018), https://www.va.gov/oig/
pubs/VAOIG-17-05248-241.pdf.
---------------------------------------------------------------------------
    The Inspector General also recommended that VBA update training for 
MST claims processing and monitor its effectiveness. Given the 
disparities I identified, I believe this recommendation is 
fundamentally important and strongly urge VBA to include information 
specifically about male survivors. Their experiences of sexual assault 
are different: RAND research found that men who are sexually assaulted 
in the military are more likely to have been assaulted multiple times, 
by multiple offenders, and during duty hours; men are also more likely 
``to describe an event as hazing or intended to abuse or humiliate 
them.''\16\ Crucially important for VBA claims processors and raters to 
know, military men are even less likely than women to either officially 
report or tell anyone at all about being assaulted. Lack of knowledge 
about the large number of men who are sexually assaulted in the 
military and lack of understanding about their experiences may combine 
perniciously with implicit bias to drive claims processors and raters 
to inadvertently treat men's cases differently.\17\ Rather than generic 
training on MST, VBA must include specialized training both on the 
specific experiences of men and how raters' own implicit biases may 
color their reactions so they can actively work to overcome these 
challenges. VBA has previously shown itself capable of acting swiftly 
and comprehensively to address the overall disparity in MST claims. Now 
it must take those efforts to the next level and ensure men who have 
survived sexual harassment and assault in the military are not re-
victimized when filing claims: they deserve equitable disability 
compensation from VA. However, when I first became aware of these gaps 
as a VA employee in 2017 and notified VBA of the concern, they 
responded dismissively that their training was adequate. I urge this 
committee to request VBA provide an update on these grant rates for 
2019 and the beginning of 2020, and demand more specialized trainings 
and oversight be implemented if they remain.
---------------------------------------------------------------------------
    \16\ Morral, Andrew R., Kristie Gore, Terry L. Schell, Barbara 
Bicksler, Coreen Farris, Bonnie Ghosh-Dastidar, Lisa H. Jaycox, Dean 
Kilpatrick, Steve Kistler, Amy Street, Terri Tanielian, and Kayla M. 
Williams, Sexual Assault and Sexual Harassment in the U.S. Military: 
Highlights from the 2014 RAND Military Workplace Study. Santa Monica, 
CA: RAND Corporation, 2015. https://www.rand.org/pubs/research_briefs/
RB9841.html.
    \17\ ``Implicit Bias Explained'', Perception Institute, https://
perception.org/research/implicit-bias/.

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II. The Way Forward

    Members of Congress as well as advocates in the veteran's community 
must closely monitor actions by VA, VHA, and VBA over the coming years 
to ensure rapid improvements are made in improving care and services 
for MST survivors, and that progress is sustained in the long run. Our 
nation must do a better job supporting those who were assaulted while 
in uniform; we cannot let them be doubly betrayed by discrimination and 
inequity within the VA system. Progress requires strong, principled 
leadership from the Secretary, who must demonstrate to veterans and VA 
employees that he will immediately redouble efforts to end harassment 
within VA Medical Centers and end inequality in claims grant rates.
                                 ______
                                 

                  Prepared Statement of Samantha Kubek

    Chairman Pappas, Ranking Member Bergman, and members of the 
Subcommittee, on behalf of the New York Legal Assistance Group (NYLAG), 
thank you for the opportunity to testify today.
    My name is Samantha Kubek, and I am a Staff Attorney in the 
LegalHealth division of the New York Legal Assistance Group, a 
nonprofit law office dedicated to providing free legal services in 
civil law matters to low-income New Yorkers. NYLAG addresses emerging 
and urgent needs with comprehensive, free civil legal services, direct 
representation, impact litigation, policy advocacy, financial 
counseling, medical-legal partnerships, and community education.
    LegalHealth, a division of NYLAG, partners with medical 
professionals to address the nonmedical needs of low-income individuals 
with serious health problems. This past year, we served 7,940 clients, 
including nearly 1,000 veterans through our partnership with three New 
York VA Hospitals. Working closely with veterans' healthcare providers, 
we expand access to needed veterans' services by upgrading bad paper 
discharges, stabilize incomes for veterans with significant health 
needs, and help to reduce veteran homelessness by preventing evictions.
    I joined NYLAG specifically to open the Nation's first women 
veterans legal clinics, with the goal of creating a safe space where 
female veterans, especially those who are survivors of sexual assault 
in the military, could receive trauma-informed legal services. In 2017, 
we opened clinics at the Bronx and Manhattan VA Medical Centers, which 
I continue to staff today.
    When we opened these clinics, we did so with the knowledge that VA 
hospitals have traditionally been male-dominated spaces, and that many 
women veterans report feeling unwelcome. We wanted to create a space 
where women could feel safe. Yet even with this goal and this 
specialized clinic, it wasn't easy to get women veterans to come to the 
clinic. After opening, I learned that because the clinic's waiting room 
was located in a mixed gender outpatient mental health space, women 
were hesitant to sit there--a fact that could have explained the many 
clients I had scheduled who would not show up for their appointment. 
With the support of our VA hospitals, I found space inside the women's 
health clinics at each hospital. Since then, I've met with over 300 
women veterans in my clinics.
    Today, in addition to my clinics for women, I also staff clinics 
for male veterans. As a consequence, I have represented male and female 
survivors of military sexual trauma, or MST. My clients have served in 
every branch of service, from WWII until just months ago. They come 
from a wide variety of backgrounds, races, and life experiences. They 
have served in combat and they have served stateside. While their 
symptoms often manifest in different ways, one thing is true for every 
single one: the current system in the VA, both in terms of benefits and 
healthcare, has, at one time or another, stood as a barrier in their 
recovery.
    Survivors of military sexual assault can apply for service-
connected benefits when their related health conditions persist. The 
impact of benefits on survivors is far more than simply increasing 
their income. I have seen the ways in which these benefits are life-
changing and transformative. I've seen clients who, after receiving 
their benefits, gain a sense of validation--a government agency has 
told them that they are seen and believed. For some, this results in 
less frequent visits to their mental health providers and an increased 
level of engagement in their daily lives. A client of mine, Rebecca, 
came to me surviving on food stamps. She lived in a cramped, studio 
apartment in the Bronx with her son and granddaughter. Rebecca had 
survived a sexual assault while in the Marines. She never knew she 
qualified for VA benefits, believing her injury had to occur during 
combat for it to ``count.'' We worked together for almost a year, 
painstakingly putting together a claim for benefits despite minimal in-
service records and the passage of almost thirty years between her 
service and the time of filing her claim. Ultimately, Rebecca was 
awarded 100 percent disability compensation. With this money and this 
new status, we worked to help her obtain a VA home loan, which she went 
on to use to purchase a home for herself and her family. All of them--
Rebecca, her son, and her granddaughter--are now living a completely 
different life as a result of these benefits. They have gained 
something intangible but essential: hope for a better future.
    The process to obtain benefits, to see outcomes like Rebecca's, is 
too difficult. Along the way, veterans are repeatedly re-traumatized 
and held to standards far too high, given the circumstances of sexual 
assault. While the changes proposed in bills such as H.R. 1092 would go 
a long way to improving this system, I offer this testimony to share 
the experiences of my clients of the ways this system often re-
traumatizes survivors, the heavy burden placed on veterans and their 
representatives, and changes that could help alleviate this situation.
    The steps required when a veteran seeks to file or appeal a claim 
for service-connected benefits relating to MST are complex and 
convoluted. For those who are represented, representatives like myself 
can bear some of the administrative burden of these claims, yet the 
system still requires too much of survivors, and unnecessarily re-
traumatizes them. For veterans without representation, they must 
navigate this system alone, which is all but impossible.
    When a client comes to me about MST, my main challenge is to show 
that I am someone they can trust; I am someone who understands that 
this system is unduly hard; and I will do my best to make it less 
difficult to the extent I can.
    I tell them right away that I do not need to hear their story 
immediately. For those who have been through the VA claims processes 
before, this is a welcome surprise. They've just met me, and telling 
someone about the sexual trauma they've endured is difficult and 
painful. And very intimate. I do tell them, because I have to tell 
them, that at some point, we will need to compose a personal 
statement--a written retelling by them of the incidents that occurred 
to them in the military, and the ways in which those incidents have 
caused them pain--pain that they still feel today. I tell them that I 
am open to their doing this in whatever way is best for them--they can 
write something for me to review, they can come in and tell me their 
story and have me help them put it onto paper, or they can work with 
their therapist.
    Nothing in law school prepares a lawyer for sitting in a room with 
someone as they pour their heart out about the worst moment of their 
life. My clients are the strongest men and women I know--if they 
weren't, they wouldn't have made it this far. But re-telling their 
story forces them to relive it. Many tell me they don't sleep for 
nights before or nights after they come to see me. I often implore them 
to schedule therapy appointments for immediately following our 
appointment in which they discuss this event in detail. That way, I 
know they will be safe in the likely event that their powerful and 
overwhelming feelings are re-triggered. I've had clients become 
suicidal after re-telling their trauma, and I've had clients struggle 
to fight relapsing into drug or alcohol addiction they have been 
fighting since their service.
    In the meantime, I must painstakingly gather all of their medical 
records, both from in the military and from since they were discharged. 
For some, this record is in the thousands of pages. I must comb through 
their personnel files, many of which are handwritten from years ago, 
searching for words like ``rape'' or ``assault,'' visits to the 
gynecologist or the base psychologist, checking for STD or pregnancy 
tests. Often, the records come back completely illegible or incomplete. 
Sometimes I get a letter back telling me the records have been sent 
elsewhere, and when I send the request to the second place, I get 
another similar letter, and this paper chase continues like this for 
months. I once received an email from the Department of Defense 
informing me that they only hold on to ``restricted reports''--a common 
form of sexual assault reporting--for 5 years. After that, they throw 
them out. In some cases, I'm told records cannot be obtained-whether 
it's due to the records being lost, destroyed, or for no reason at all. 
This is despite FOIA requests, the involvement of senators, and 
diligent and persistent follow up.
    As part of a veteran's application, they are asked to State in 
which Veterans Health Administration (VHA) facility they have received 
treatment, so that the Veterans Benefits Administration (VBA) can 
obtain the records from them directly, as they are both part of the 
larger Department of Veterans Affairs. Sometimes the VBA tells me that 
they cannot obtain records from the VHA. This happens in one of two 
ways. In the first, the veteran receives a letter after filing their 
claim or appeal in which the VBA states they cannot obtain the 
veteran's health records from a VA hospital. In almost every instance 
of this occurring with my clients, I have a copy of these same records 
in my files, and I obtained this copy by filing a request with the VHA. 
In this case, I then send the VBA the records. The second way is that 
the veteran receives a negative decision on their claim or appeal, in 
which the VBA lays out the evidence they considered in deciding the 
claim. In such a letter, they may State that they tried to obtain 
records from a VA health facility and were unable to obtain them. When 
this happens, it reflects two failures. One, the VBA should always send 
the letter laid out in the first scenario. As per their ``duty to 
assist,'' they should be requesting missing records, even ones they 
should already have, if they cannot obtain them. Second, the VBA has 
now denied a claim due to its inability to get records simultaneously 
being held within the larger VA system. The veteran is being denied 
benefits because of a failure within the VA system, not because of any 
inadequacy or failure of the veteran's claim.
    This process is infuriating for all veterans, but it creates 
greater harm in cases of MST. Most MST survivors have no in-service 
records to back-up their assertions. Most do not seek treatment during 
the service, due to the stigma for needing mental health treatment in 
the military and for the myriad reasons survivors of sexual assault in 
all walks of life rarely seek help. Many do not report the assault to 
anyone for the same reason, and so personnel files do not reflect 
anything either. As a result, these cases rely very heavily on the 
veteran's medical records from their life post-service. When the VA's 
two bodies are unable to communicate, the system fails them yet again.
    I also ask for statements--from family members, friends, in-service 
buddies--anyone who may know what happened to them and saw how it 
changed them. I speak with doctors, social workers, and psychologists. 
As an attorney in a medical-legal partnership, I have enhanced access 
to my clients' providers, and am able to have extensive conversations 
with them and to request letters directly from them to support the 
veteran's case.
    At the end of this long and frustrating process, I at last have a 
completed case to file with the VA. I tell the client that now we file 
and then we wait. I also must tell them that two things will happen 
between now and when their claim is decided.
    The first is that they will receive a call out of the blue from 
someone at the VBA. This will be a stranger, someone they do not know 
and have never spoken with. And this person, who may be male or female, 
will ask them for details about their sexual assault and whether they 
filed a report at the time of the assault. This will happen regardless 
of whether we explicitly stated in the file that they did or did not so 
file.
    This will happen regardless of the fact that they have appointed me 
as their attorney, and in any other legal proceeding, the agency would 
speak with me, rather than with the individual. Not only their answers, 
but the very wording of their answers in this conversation, will have 
an impact on the decision made in their case.
    The second is that they will be called by the VA to schedule their 
Compensation & Pension exam. For some, this will be scheduled at the 
VA. For others, it will be scheduled with an independent contractor. 
They will have no control over whether this exam is with a man or a 
woman. When it is time for their exam, they will meet with this doctor, 
who is a stranger to them, and upon meeting them, will be asked yet 
again questions regarding what happened in the service, how it impacted 
them, what their symptoms are. This will happen regardless of the level 
of detail we have included in their statement. This meeting can last 
for hours.
    I have had clients who leave this appointment so distraught that 
they are admitted to inpatient psychiatry. I have had clients who are 
unwilling to go. Other clients have struggled to maintain sobriety, 
sobriety only achieved after a long and difficult struggle. Far too 
many have called me expressing suicidal thoughts and inclinations such 
that I strongly encourage and offer to connect them with the VA's 
Crisis Line or with their therapist.
    Finally, after all of this, a process which, more often than not, 
lasts for months, or in the case of appeals, sometimes years, a 
decision is issued. When claims are denied, the VA's wording has a 
profound impact upon the veteran. A client, Sarah, called me 1 day in 
tears. Sarah had served in the Army in the 1980's. During her service, 
she was raped, and then became pregnant from the attack. She carried 
the baby to term and now has a daughter who is in her twenties. Sarah 
loves her daughter; nonetheless, the daughter is also a constant 
reminder of the brutal attack Sarah endured. We presented this to the 
VA in her personal statement, supported by years of therapy and medical 
treatment. When the VA denied Sarah's claim, they wrote, ``The evidence 
of record does not provide credible evidence that the claimed stressor 
occurred.'' Further on they expanded, ``The service treatment records 
and personnel file show no credible evidence that would establish 
reasonable doubt and allow us to conclude that you were, in fact, 
assaulted.''
    I understand that claims will be denied. I understand that 
sometimes meritorious claims may be denied improperly--that is why we 
have the appeals system. But this language is extremely insensitive and 
inhumane. Sarah called me in tears from her car. Her husband was 
driving her to the VA--she had become suicidal after reading these 
callous and unfeeling words.
    I wish that I could say that Sarah's situation is rare, but it is 
not. The VA makes many statements that it is concerned about the high 
rate of veteran suicide--a cause deserving of the highest level of 
concern--yet its own words can cause veterans to consider taking their 
lives. It is one thing to State that a veteran has not met a burden of 
proof. It is another thing altogether to discount completely their most 
traumatic moment and to tell them that they find no credibility that it 
occurred.
    Military sexual trauma is unique in the ways it can consume a 
person's life. It is an intimate and personal invasion that occurs both 
where you live and where you work, that may have been committed by 
someone who is your superior, your commander, your colleague upon whom 
you must rely. It often occurs in a place where your life may already 
been in danger, and in a situation that you have no way to escape for 
some substantial period thereafter. Many of my clients, now senior 
citizens, decades after their assault, still struggle to overcome the 
burden of that trauma.
    In recognition of the severity and duration of trauma from military 
sexual assault, the VA changed its policies to allow veterans who are 
survivors, regardless of their discharge status, to, at the very least, 
obtain care at the VA when the treatment is directly tied to their 
trauma. One of my clients, Maria, is such a survivor. She was 
discharged from the Army with an ``uncharacterized'' discharge, without 
enough days of service to qualify for care. During her time in the 
Army, Maria had been gang raped, and is engaged in an ongoing struggle 
with her mental health. As per the VA's policy, she is eligible to 
obtain mental health treatment at the VA. But every time Maria goes to 
the VA for an appointment, she is told she is ineligible for treatment. 
No explanation. On more than one occasion, she was told she was 
ineligible because she wasn't a veteran. Each time this would occur, 
Maria would say to the VA staff, ``I was raped in the service, and I'm 
here for care related to that.'' As if those were magic words, the 
staff person would then realize their error, and allow Maria to check 
in for her appointment. It is important to understand that this 
conversation, the prerequisite to her getting an appointment to have 
care she is entitled to, occurs in a crowded waiting room, filled with 
men and women who are strangers. This unnecessarily invasive revelation 
must be aired publicly.

    Considering all of this, I respectively propose the following 
recommendations to best support survivors:

    1. The VA, as in any other legal proceeding, should respect 
veteran-appointed representatives and speak directly with them, rather 
than with the veteran.

          This should be the default in all cases. The VA 
        should be required to contact a veteran's representative when 
        explicitly asked to by the veteran. To do otherwise should be 
        considered a failure of the VA's ``duty to assist.''

    2. When records are unobtainable due to no fault of the veteran, 
the VA should bear that responsibility. Veterans should not be denied 
benefits because government agencies lost, mismanaged, or have not 
found their files.

    3. Examiners and VBA employees should be required to review a 
veteran's statement prior to the exam or any other conversation with 
the veteran regarding their assault.

          Currently, VA examiners are required to State whether 
        they reviewed the veteran's electronic file before writing 
        their report. However, they are not required to do so prior to 
        meeting the veteran--if this was required, the doctor could 
        avoid rehashing details that are already stated in the record 
        and that are agonizing to relate.

          VBA staff should, when possible, avoid calling 
        veterans to provide sensitive information already present in 
        the claims file.

    4. The VA must establish trauma-informed language and protocols to 
be used across the VA, from the claims agents to the hospital 
receptionists, to ensure the VA is not creating further trauma when 
addressing survivors.

          Systems should be developed to note in the electronic 
        records that the client is eligible for care for various 
        conditions so that veterans are not turned away when checking 
        in or asked to publicly disclose extremely private and intimate 
        information.

          Trauma-informed VBA staff should be required to 
        review all language in denial letters to ensure veterans are 
        not unnecessarily re-traumatized.

    5. Congress should enable the VA to provide funding for free legal 
services to assist veterans with these claims. As demonstrated by my 
testimony today, the VA benefits system is extremely complicated and 
legal representation is often a necessity, yet there are not enough of 
us, often due to lack of resources.

          Legislation such as H.R. 3749, the Legal Services for 
        Homeless Veterans Act, would enable the VA to provide funding 
        for legal services for at-risk veterans.

    The VA needs to become the place that fixes wrongs the military has 
failed to fix. It must serve survivors--all survivors--while bearing in 
mind the unique nature of military sexual trauma.
    Chairman Pappas, Ranking Member Bergman, and members of the 
Subcommittee, in closing, I want to thank you and the Subcommittee for 
your continued interest in improving VA's response to and support of 
survivors of military sexual trauma. Now is the time to address the 
ways in which, even after service, the very system intended to help our 
veterans is often causing additional stress and harm. We must do all we 
can to ensure that survivors view the VA as a place where they are 
safe, supported, and believed. Please know that NYLAG is ready to 
assist you in these efforts. This completes my statement. I will be 
happy to respond to any questions you may have.

                       Statements for the Record

                              ----------                              


          Prepared Statement of Paralyzed Veterans of America

    Chairman Pappas, Ranking Member Bergman, and members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for the opportunity to submit our views on how the Department of 
Veterans Affairs (VA) supports survivors of military sexual trauma 
(MST). No group of veterans understand the full scope of care provided 
by the VA better than PVA's members--veterans who have incurred a 
spinal cord injury or disorder (SCI/D). Most PVA members depend on VA 
for 100 percent of their care and are among the most vulnerable when 
access and quality of care is threatened.
    MST has serious and long-term consequences for survivors that can 
continue long after the assault. Often thought of as a ``women's 
issue,'' MST affects both men and women serving in the military. To 
understand the scope of the problem, we need to examine incidents of 
MST. In 2005, the Department of Defense (DoD) enacted a restricted 
reporting option to allow for easier reporting of sexual assault. 
Although there was an increase in reporting of assaults, only about 30 
percent of sexual assaults are actually reported. While the number of 
MSTs reported for men on active duty in Fiscal Year 2018 held steady at 
0.7 percent (or about 7,500 men), the rates of MST continue to rise for 
women serving in the armed forces, from 4.6 percent in 2016 to 6.2 
percent.\1\
---------------------------------------------------------------------------
    \1\ The Department of Defense Annual Report on Sexual Assault in 
the Military, Fiscal Year 2018.
---------------------------------------------------------------------------
    According to Rand's 2014 report, Sexual Assault and Sexual 
Harassment in the U.S. Military, women on active service have almost 
five times men's risk of sexual assault. However, Rand's 2018 report, 
Needs of Male Sexual Assault Victims in the U.S. Armed Forces, found 
that only 15 percent of military male sexual assault victims file a 
report despite the fact that men in the military are more likely to 
have experienced multiple incidents, have been assaulted by multiple 
offenders during a single incident, and have been assaulted at work or 
during duty hours. Male MST survivors are also more likely to survive 
extremely violent assaults and more likely to be sexually assaulted 
with weapons, and thus, have greater risk of physical injury.\2\ When 
men are assaulted, however, they are less likely to report it because 
they often characterize their assault as an incident of hazing or 
something intended to abuse and humiliate them.
---------------------------------------------------------------------------
    \2\ Laskowski, D. (n.d.). Male Sexual Trauma: What you know, don't 
know, and wish you knew [PowerPoint slides]. Retrieved from https://
www.fcasv.org/sites/default/files/Male%20Sexual%20Trauma.pdf; Matthews, 
M., Farris, C., Tankard, M., & Dunbar, M.S. (2018). Needs of Male 
Sexual Assault Victims in the U.S. Armed Forces.
---------------------------------------------------------------------------
    It is important to understand these rates of reporting of assaults 
because VA is responsible for caring for the physical and mental 
effects sexual assault takes on the survivor. Low rates of reporting 
among all MST survivors often means that they do not have formal 
reports of the assault. In 2011, due to difficulties in obtaining 
evidence of stressors, the Veterans Benefits Administration (VBA) 
provided further guidance to allow for a more liberal approach for 
determining MST-related claims.\3\ This liberalized approach helps 
lessen the burden on survivors who already must endure a process that 
includes describing the assault multiple times, in excruciating detail.
---------------------------------------------------------------------------
    \3\ VBA Training Letter, Adjudicating PTSD Claims Based on MST.
---------------------------------------------------------------------------
    Everyone deserves to have their VA disability claim fairly 
evaluated under a system that ensures the full weight of the evidence 
is considered before a decision is rendered. It is hard enough to come 
forward about an assault but to then have a claim unjustly denied is a 
further traumatization of the veteran and interferes with the treatment 
process.\4\ Thus, it is essential that MST claims be properly 
adjudicated.
---------------------------------------------------------------------------
    \4\ Statement of Steve Bracci before the Committee on Disability 
and Memorial Affairs Committee on Veterans' Affairs hearing on Ensuring 
Access to Disability Benefits for Veteran Survivors of Military Sexual 
Trauma, June 20, 2019.
---------------------------------------------------------------------------
    As the evidence shows, however, that is not always the case. An 
August 2018 VA Office of the Inspector General (VA OIG) report stated 
that nearly half of denied-MST claims were not properly processed by 
VBA, which may have resulted in denial of benefits to those who are 
entitled to them. In 28 percent of cases, despite sufficient evidence 
to request a medical examination and opinion, staff did not request 
such services. In 13 percent of cases, there were evidence gathering 
issues. In 11 percent of cases, MST coordinators did not make the 
required call to the veteran or the Veteran Service Representative did 
not use required language in letters to the veterans. And in 10 percent 
of cases, Rating Veterans Service Representatives adjudicated veterans' 
claims based on contradictory or otherwise insufficient medical 
opinions.\5\ These problems occurred due to lack of reviewer 
specialization, lack of an additional level of review, discontinued 
special-focused reviews, and inadequate training.
---------------------------------------------------------------------------
    \5\ Office of Inspector General. (2018, August 21). Denied 
Posttraumatic Stress Disorder Claims Related to Military Sexual Trauma. 
Retrieved from https://www.va.gov/oig/pubs/VAOIG-17-05248-241.pdf.
---------------------------------------------------------------------------
    PVA agrees with the six corrective actions proposed by VBA that 
were outlined in the VA OIG's June 20, 2019, testimony before the House 
Committee on Veterans' Affairs, Subcommittee on Disability Assistance 
and Memorial Affairs. The recommended corrective actions included:

      Reviewing all denied MST-related claims since the 
beginning of Fiscal Year 2017 to determine if all required procedures 
were followed then taking corrective action and rendering new decisions 
as needed.

      Assigning the processing of MST-related claims to a 
specialized group of reviewers.

      Requiring an additional review of all denied MST-related 
claims and holding those conducting the review accountable for 
accuracy.

      Conducting special focus quality improvement reviews of 
denied MST-related claims and taking corrective action as needed.

      Updating the current training for processing MST-related 
claims and monitoring the effectiveness of the training.

      Updating the development checklist for MST-related claims 
and requiring claims processors to certify that they completed all 
required actions.

    At this time, it is unclear if the goals laid out by VBA have been 
fully met.
    In addition to living with SCI/D, PVA members may also be MST 
survivors. One complaint we receive from our members is that even when 
they request a gender specific person to handle their MST-related 
claim, often that request is not honored. VA should make every effort 
to ensure these requests are accommodated. Otherwise, veterans may not 
seek needed treatment.
    Also, people with disabilities are more likely to be sexually 
assaulted than their non-disabled counterparts.\6\ People with 
disabilities experience similar forms of overt and covert sexual 
assault and abuse as people without disabilities (for example, rape; 
forced, unwanted, or disguised touching; sexual harassment; unwanted 
sexual jokes or innuendoes; and other unwanted sexual contact or 
activity). But for this population, sexual abuse can also come in the 
form of lack of respect for privacy and unwanted exposure during 
personal care (for example, bathing, dressing, and toileting).\7\
---------------------------------------------------------------------------
    \6\ Strauser, D. R., Lustig, D. C., & Uruk, A. C. (2007). 
Differences in Self-Reported Trauma Symptomatology Between Individuals 
With and Without Disability: An Exploratory Analysis. Rehabilitation 
Counseling Bulletin, 50(4), 216-225. https://doi.org/10.1177/
00343552070500040301.
    \7\ California Coalition Against Sexual Abuse. (2010). Supporting 
Sexual Assault Survivors with Disabilities. Sacramenta, CA.
---------------------------------------------------------------------------
    Persons who experience regular help with personal care may be 
desensitized to touch. They may not feel comfortable speaking out if 
handled in a confusing or uncomfortable manner. Social isolation may 
rob the individual of their opportunity to report sexual assault/abuse. 
For those people with disabilities who live in institutional or 
hospital settings, there is an imbalance of power that increases the 
opportunity for assault or abuse.
    Often, disability status is never collected, reported in assault 
cases, or even inquired about for rape survivors. If sexual assault 
advocates are not properly trained they may unwittingly contribute to 
people with disabilities remaining an under-served population.\8\
---------------------------------------------------------------------------
    \8\ Gorden, Melody L. (2013). Disabled Sexual Assault Victims: 
Perceptions of Sexual Assault Professionals on Barriers to Providing 
Services to Disabled Sexual Assault Victims. Retrieved from Sophia, the 
St. Catherine University repository website: https://sophia.stkate.edu/
msw_papers/182.
---------------------------------------------------------------------------
    One step VA can take to better serve the men and women under its 
care is to devote attention to a program that will eliminate the 
current environment of harassment at VA facilities. Harassment comes in 
all forms and is a barrier to care that is only now really being 
brought to light. VA must continue its Stand Up to Stop Harassment 
campaign in VA medical centers and ensure that adequate funding is 
available to promote and educate VA stakeholders to achieve the 
necessary cultural changes needed to remove barriers to heath care 
within VA for all veterans.
    The VA is responsible for protecting staff and patients from 
harassment. As they develop a comprehensive, department-wide strategy, 
we urge policymakers to keep in mind that in some cases, patients who 
have traumatic brain injuries, dementia, or who are confused or 
impaired for other reasons may lack appropriate self-control or 
awareness that results in inappropriate behavior toward others. VA 
needs to understand the complex personal interactions of a health care 
setting when determining harassment policies.
    This is also a good time for VA to review existing policies and 
procedures for reporting of sexual assaults within VA to ensure we are 
meeting the needs of reporting and capturing the full situation within 
its facilities. We hope part of the review process would include 
greater scrutiny of what, if any, protections are in place to promote 
the safety of catastrophically disabled veterans and ensure they are 
not re-victimized or assaulted for the first time while under VA care. 
At the same time, VA should also ensure that veterans service 
organizations have an active role in this process.
    Thank you again for the opportunity to submit our view on VA's 
efforts to support survivors of MST.

  Information Required by Rule XI 2(g) of the House of Representatives

    Pursuant to Rule XI 2(g) of the House of Representatives, the 
following information is provided regarding Federal grants and 
contracts.

Fiscal Year 2020

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events--Grant to support rehabilitation sports 
activities--$253,337.

Fiscal Year 2019

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events--Grant to support rehabilitation sports 
activities--$193,247.

Fiscal Year 2018

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events--Grant to support rehabilitation sports 
activities--$181,000.

                     Disclosure of Foreign Payments

    Paralyzed Veterans of America is largely supported by donations 
from the general public. However, in some very rare cases we receive 
direct donations from foreign nationals. In addition, we receive 
funding from corporations and foundations which in some cases are U.S. 
subsidiaries of non-U.S. companies.
                                 ______
                                 

     Prepared Statement of Iraq and Afghanistan Veterans of America

    Chairman Pappas, Ranking Member Bergman, and Members of the 
Subcommittee, on behalf of Iraq and Afghanistan Veterans of America's 
(IAVA) more than 425,000 members, thank you for the opportunity to 
share our views, data, and experiences on an issue affecting too many 
of our servicemembers, how the Department of Veterans Affairs supports 
survivors of Military Sexual Trauma. IAVA would also like to thank the 
Women Veterans Task Force for the valuable work they are doing to 
address gaps in care for women veterans.
    Millions of veterans rely on VA for both health care and benefits. 
Ensuring that the system is able and agile enough to accommodate those 
veterans is paramount to ensuring the lasting success and health of the 
veteran population, including survivors of military sexual assault. 
About 48 percent of all veterans and about 55 percent of post-9/11 era 
veterans are enrolled in VA care. Among respondents to IAVA's most 
recent member survey, 81 percent are enrolled in VA health care, and 
the vast majority have sought care from VA in the last year. Eighty-one 
percent of these VA users rated their experience at VA as average or 
above average. IAVA members have been clear that access to VA care can 
be challenging, but once in the system, they prefer that care. Further, 
independent reviews of VA health care support that the care is as good, 
if not better than the private sector.
    The topic of MST is an issue that is of high importance both to 
IAVA and to me personally. I served in the U.S. Navy from 2010-2014 as 
an Aviation Electronics Technician. It was one of the most fulfilling 
jobs that I have ever had and I miss it every day. I joined the Navy 
because I wanted to see the world and hoped to 1 day become a pilot. At 
least, that is what I told everyone. I am not a survivor of MST but I 
am a survivor of sexual assault. I joined the military to escape from 
my hometown and the constant reminder of what I had been through. I 
relived it every day when I went to college and was forced to be around 
my assailant because he was involved with my roommate. I relived it 
every day because I grew up in a small town and every single piece of 
that town reminded me of a day that I had spent with him. I relived it 
every day because it happened in my house, in my bedroom, in my bed. 
While I cannot fully comprehend the pain that these strong, resilient 
men and women have, I do know what it is like to never be able to 
escape from those that have taken something from you and be forced to 
replay the horrific memories because of your surroundings. And I know 
the pain of not wanting to exist anymore because of the helplessness 
and fear you feel. This is the reason I joined the military and this is 
also the reason I have never enrolled at VA.
    We know that MST is not a women's issue, but it is an issue that 
disproportionately affects women veterans. In IAVA's 2019 survey, 43 
percent of our women veteran members and 3 percent of male veteran 
members reported experiencing MST. Based on data from an anonymous 
survey that is created by the Department of Defense every 2 years, the 
Pentagon estimated that approximately 20,500 service members across all 
the military branches were sexually assaulted in Fiscal Year 2018 
alone. This is a substantial increase from 14,900 in 2016. Despite 
these numbers, we still have recent reports of MST claims being 
mishandled.
    In recent years, VA has taken many steps to improve its services 
for survivors of MST, but there are still gaps that need to be 
addressed. The recent reports of the mishandling of MST claims does 
nothing but scare those in need of care away from this powerhouse 
health system. In 2018, the Office of the Inspector General (OIG) found 
that nearly half of denied MST-related claims were not properly 
processed following VBA policy. They incorrectly processed claims, 
including claims where the evidence was sufficient, yet the staff 
failed to request a medical exam. There were evidence gathering issues 
such as staff not requesting veterans' records and VA staff made 
decisions based on ``contradictory or otherwise insufficient medical 
opinions.'' VA research has shown that women veterans who have 
experienced sexual trauma feel less safe at VA facilities. Since women 
veterans are 2.2 times more likely than non-veteran women to die by 
suicide, it is imperative that VA creates a safe and welcoming 
environment for the women who have selflessly served this country. 
Claims processors across VBA must be properly trained on MST-PTSD 
related claims and follow the latest guidelines.
    Retaliation is something that many MST survivors fear when it comes 
to reliving their pain and coming forward. It is known that a large 
portion of sexual assaults go unreported for fear of retaliation. Only 
one-third of IAVA members reported their assault, and of those, an 
alarming two-thirds also reported that they encountered retaliation as 
a result of their reporting. We cannot afford to let this type of 
mentality spill over into our VA health system. It takes unfathomable 
courage to talk about sexual assault and even more to report it to 
someone you do not know. I, myself, never had the courage to confront 
my assailant and did not even talk about it until recently. I blamed 
myself, as so many others do. The system for claims has to be clear and 
victims have to believe that they will be heard and that they are not 
just a file or claim number.
    A recent OIG investigation at the VA North Texas Health Care System 
found that the hospital lacked a gynecologist for almost 2 years and 
lacked women's bathrooms in clinical areas, forcing female patients to 
change out of hospital gowns back into street clothes before using 
bathrooms in public areas. This hospital serves the fourth largest 
population of women veterans in the Nation, with a population of 
approximately 13,000. It is these types of errors that communicate a 
lack of parallel between the care that female veterans receive as 
opposed to their male counterparts. Our women veterans deserve better 
and have earned better than this.
    In the last 4 months of 2019, we were told that Federal authorities 
were investigating allegations of multiple sexual assaults against VA 
patients at a West Virginia department hospital. A San Diego area 
physician working with VA pled guilty to assaulting and exploiting five 
female patients referred to him by department health officials. And 
finally, a House Veterans Affairs Committee staffer was harassed and 
assaulted by a patient at the Washington, DC. VA Medical Center. It is 
situations like these, as well as the others mentioned, that really get 
at the core problem. Culture.
    We have a culture problem within our military and it has spilled 
over into VA. A 2019 Pentagon survey showed that 747 students within 
military service academies said they received unwanted sexual contact 
in 2018. This is almost a 50 percent increase from the 504 in 2016. The 
men and women in our service academies are the future leaders of our 
military. They must be held to a higher standard and set an example for 
others to follow throughout their careers in the military and beyond. 
We cannot afford to ignore the problem and let those affected feel 
unheard. Everything stems from the culture problem. We need change, and 
the time is now.
    Passing the Deborah Sampson Act (H.R. 3224/S. 514) into law would 
be a giant step for women veterans healthcare, but even with passage, 
our fight is not finished. The VA motto does not help. It explicitly 
excludes women from its mandate, and it reads as outdated: ``To care 
for him who shall have borne the battle and for his widow, and his 
orphan.'' The passage of the Honoring All Veterans Act (H.R. 3010) 
would directly impact this culture change. As women veterans are the 
fastest growing demographic, a gender-neutral VA motto would display an 
immediate commitment. We too ``have borne the battle.''
    We have fought hard but our fight is long from over. Sexual assault 
has proven to be increasing within the military and we are calling out 
for the culture change now. I want to feel safe going to the VA. I want 
to not be afraid of using the health system that 81 percent of IAVA 
members rate at an average to above average, because it is my right by 
serving in the United States Navy. Survivors deserve better. We have 
earned better.
    Members of the Subcommittee, thank you again for the opportunity to 
share IAVA's views on these issues today. I look forward to working 
with both the Subcommittee and the Task Force in the future.

Biography of Kaitlynne Hetrick

    Kaitlynne Hetrick serves as IAVA's Government Affairs Associate, 
helping to lead IAVA's advocacy efforts in Washington, DC. She served 
in the United States Navy for 4 years as an Aviation Electronics 
Technician 3d Class. Since departing from the Navy in 2014, she used 
her GI bill to obtain her bachelor's degree at Baldwin Wallace 
University while working with her fellow student veterans. Serving 
first as the Secretary of her university's Student Veteran Organization 
and then as the President, Kaitlynne worked to help fellow student vets 
take advantage of all the programs offered to them due to their 
service. Kaitlynne has also worked with several veteran non-profits to 
help disabled and transitioning former servicemembers.
                                 ______
                                 

            Prepared Statement of Disabled American Veterans

    Mr. Chairman and members of the Subcommittee:
    Thank you for inviting DAV (Disabled American Veterans) to submit 
testimony for the record on this important hearing looking at the 
Department of Veterans Affairs (VA) support for survivors of military 
sexual trauma (MST). DAV is a non-profit veterans service organization 
comprised of more than one million wartime service-disabled veterans 
that is dedicated to a single purpose: empowering veterans to lead 
high-quality lives with respect and dignity.
    The discussion on this issue is critical as the health and well-
being of far too many veterans--both male and female--has been 
negatively impacted because of this type of personal trauma. Many DAV 
members use VA's specialized mental health services and rely on the 
veterans health care system to assist them in recovery from their post 
deployment mental health challenges.
    Sadly, the most recent report (2018-2019) from the Department of 
Defense (DoD) Sexual Assault Prevention and Response Office (SAPRO) 
confirms there is increased prevalence of sexual assaults among service 
members in the active force and at military service academies between 
2014 and 2018.
    In Fiscal Year (FY) 2018, growing rates of sexual trauma were 
reported by all branches of the armed forces. Over a 1-year period, 6.2 
percent of service women and .7 percent of service men reported 
experiencing MST. Rates of exposure for service women ranged from a low 
of 4.3 percent in the Air Force to a high of 10.7 percent in the 
Marines. For service men, the rates ranged from a low of .5 percent in 
the Air Force to a high of 1 percent in the Marines. In all cases, 
these rates are higher than those reported in 2016.\1\ The rates also 
far exceed the 1.6 percent of women in the general population who have 
experienced rape in the preceding 12 months (numbers of men were too 
low to be considered representative).\2\
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    \1\ 2018 Workplace and Gender Relations Survey of Active Duty 
Members. DoD Office of People Analytics. Defense Sexual Assault 
Incident Data base, and DoD Sexual Assault Prevention and Response 
Office.
    \2\ Prevalence and Characteristics of Sexual Violence, Stalking and 
Intimate Partner and Sexual Violence Survey, United States, 2011. 
Centers for Disease Control and Prevention. Sept.5, 2014.
---------------------------------------------------------------------------
    In addition, in the same survey, more than 24 percent of service 
women and 6 percent of service men reported experiencing sexual 
harassment during the past year of service. Significant numbers of 
service members who reported experiencing sexual trauma also reported 
experiencing harassment.
    The impact and aftermath of sexual assault or harassment can be 
devastating and long lasting and many veterans turn to the Veterans 
Health Administration (VHA) following military service for treatment to 
address conditions such as post-traumatic stress disorder (PTSD) or 
depression related to MST. VA has a universal screening policy for MST 
to help identify veterans who may require treatment for health 
conditions associated with personal trauma.
    According to VA, in Fiscal Year 2019, 142,929 or 30.6 percent of 
female veterans and 80,884 or 1.7 percent of male veterans seen for 
health care at a VA facility reported a history of MST when screened by 
their VA health care provider. Because of differences in the definition 
of MST in VHA, which also includes sexual harassment of a repeated and 
threatening manner, these numbers may not directly correspond with 
those reported by the military.
    Every VHA health care system provided MST-related outpatient care 
to both women and men in Fiscal Year 2019, with more than 2 million 
MST-related outpatient visits provided. VA has specialized, high-
quality mental health care to include a full range of outpatient, 
inpatient and residential services. Individual and group therapy is 
available at Vet Centers, VA medical centers and some community-based 
outpatient clinics.
    VA also has designated MST coordinators at each VA healthcare 
system to assist MST survivors seeking care. The MST Coordinator 
position is a collateral role which can make fulfilling the 
responsibilities of this position difficult. DAV encourages the 
Subcommittee to investigate whether MST coordinators have adequate time 
to fulfill their responsibilities and required duties and, if not, 
ensure that VHA receives adequate resources to designate a full time 
employee to this critical position at all facilities. In addition, VA 
has developed specialized programs for eating and substance use 
disorders and intimate partner violence, which can be co-occurring 
issues for many MST survivors. DAV would like to see VA make 
information about accessing these programs more accessible to veterans 
who may need them, including the clinicians that may refer them to such 
care.
    DAV's 2018 report, Women Veterans: The Journey Ahead, detailed the 
story of DAV member and Navy veteran, Leeia Isabelle, who, like so many 
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 negative effects that 
MST had on her relationships and overall well-being motivated her to 
begin the long road to recovery for which she credits VA group therapy 
with other women veterans, cognitive behavioral therapy, and 
involvement with DAV. Leeia's story is typical of many veterans with 
PTSD. Chronic symptoms of feeling numb, hypervigilant, anxious, 
irritable, and a lack of interest in the people or activities that once 
brought them joy can be overwhelming. These changes can strain 
relationships, threaten employment, lead to homelessness and isolate 
them from their families and communities.
    Public Law 113-146, the Veterans Access, Choice and Accountability 
Act of 2014, required VA to report on its treatment of conditions 
caused or exacerbated by MST, specifically identifying the differences 
in treatment of men and women with these conditions. The most common 
diagnosis among those screening positive for MST for both men and women 
is post-traumatic stress disorder (55.4 percent and 58.3 percent, 
respectively) followed by depressive disorders (39.2 percent and 48.7 
percent). Substance abuse is the next most common diagnosis for men 
(15.6 percent) while anxiety follows for women (18.7 percent).\3\
---------------------------------------------------------------------------
    \3\ Department of Veterans Affairs. Report on Treatment and 
Services Available for Military Sexual Trauma in Response to Section 
403 of PL 113-146.
---------------------------------------------------------------------------
    VHA routinely uses cognitive behavioral therapy and rapid eye 
movement desensitization therapy, which are identified as effective 
treatments for veterans with PTSD due to a personal trauma. Most 
importantly, VHA primary care and mental health staff complete 
mandatory training for treating veterans with MST-related PTSD. This 
specialized training includes a focus on gender-specific issues that 
may arise in treating veterans of both sexes. VA also conducts 
education that highlights the importance of sensitivity to the needs of 
both male and female veterans who have experienced MST. VHA policy 
``strongly encourages'' facilities to allow veterans to seek care from 
a provider of their preferred sex when clinically appropriate, but VHA 
maintains that there are benefits to be derived from both gender-
exclusive and gender-neutral MST care settings and that men and women 
seeking care may request either of these types of care settings. Peer 
support specialists can also be helpful in assisting veterans with 
treatment engagement, goal setting and identifying motivators to move 
forward with their recovery. DAV urges VHA to use the broadest latitude 
in allowing veterans who have experienced MST to choose the sex of 
their provider.
    All health care providers conducting VA disability examinations 
must also complete MST-specific training that addresses gender-specific 
issues for both male and female veterans. This is an especially 
important policy that directly affects veterans filing disability 
claims for conditions resulting from MST. For years, DAV heard 
complaints from women veterans who believed their disability claims for 
MST-related PTSD were being erroneously denied. Based on continued 
complaints from women veterans, VBA took action following an initial 
review and assessment of MST-related claims and established a specific 
protocol for development and adjudication of such claims.
    VBA guidance created in 2011 requires that the same-sex MST 
Coordinator at the regional office ask the claimant if the incident for 
which he or she is seeking compensation was reported. If so, the MST 
coordinator determines how best to obtain the incident report and does 
so. Veterans Service Representatives (VSRs) contact veterans to follow 
up by letter if MST coordinators are unable to reach the veteran by 
phone. VSRs are also charged with gathering evidence in support of 
claims. In the case of claims for MST they are also required to obtain 
all military personnel files and in addition to advising claimants of 
alternative evidence that may be provided to substantiate the stressor 
such as journals, or statements of confidants or clergy who were aware 
of the incident around the time it occurred.
    Once received, VSRs review the evidence to confirm the stressor and 
also identify any additional ``markers'' in military or other records 
that may indicate the stressor took place around that time such as a 
request for transfer, changes in job performance, changes in behavior 
such as increased use of leave or medical care, documented pregnancy 
tests, or recognition of new medical or mental health conditions. If 
any markers are present, a medical exam must be ordered. Claims should 
not be denied unless there is no evidence of a stressor, or of a 
behavioral marker or of symptoms of a mental health disorder that may 
be related to MST.
    Once again, reports surfaced that VBA was falling short in 
upholding its own guidance that better assures fair adjudication of 
claims for MST-related PTSD.\4\ The Inspector General (IG) found that 
since VBA ended its practices of special queuing and audits for claims 
of PTSD related to MST, progress it made in correcting inequitable 
awards has been lost.\5\ In 2018, the IG determined, based on VBA 
policy, that almost half (46 percent) of MST-related claims reviewed 
were processed incorrectly, and that almost half of denials (49 
percent) were not processed correctly meaning that, had the adjudicated 
claims been processed appropriately, the claimant may have been awarded 
compensation and with it received higher priority for VHA health care 
treatment.
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    \4\ M21-1 Adjudication Procedures Manual, Part IV, Subpart ii, 
Chapter 1, Section D, topic 5, Developing Claims for SC for PTSD Based 
on Personal Trauma.
    \5\ VA Office of Inspector General. Denied PTSD Claims Related to 
Military Sexual Trauma. VA OIG 17-05248-241. August 21, 2018, p.2.
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    The IG recommended reestablishing specialized queues for MST and 
other claims requiring special handling, reestablishing an additional 
level of ``special focused'' review for complex claims, and updating 
training manuals and claim development checklists for adjudicators. We 
request the Subcommittee verify if VBA made changes based on 
recommendations in the IG report to ensure these claims are being 
adjudicated correctly.
    DAV fully supported the IG's recommendations and adopted DAV 
Resolution No. 043 at our 2019 National Convention, urging VA to 
conduct rigorous oversight of its adjudication personnel and review of 
data to ensure the present policy and practices for evaluating 
disability claims associated with military sexual trauma, are being 
faithfully followed and standardized in all VA regional offices. Last 
year, DAV also testified in support of legislation, H.R. 1092, the 
Servicemembers and Veterans Empowerment and Support Act of 2019. This 
bill would help to ensure that VA adheres to current policy regarding 
the adjudication of claims for mental health conditions, including 
PTSD, associated with MST. Unfortunately, Congress has not taken any 
further action on H.R. 1092 or the Senate companion bill, S. 374.
    VA reports that information about MST-related treatment and 
disability compensation is provided to every transitioning service 
member as part of the Transition Assistance Program and is available 
through key DoD resources like the Safe Helpline. Information is also 
provided as part of the Separation Health Assessments that VA conducts. 
We are pleased that VA engages in extensive outreach efforts to make 
sure MST survivors know help is available and that VA has specialized 
programs and treatment for recovery, but we want to ensure there are 
policies in place for a ``warm handoff'' of MST survivors between DoD 
and VA.
    Likewise, we are pleased that VA has established a Women's Mental 
Health Mini-Residency and National Reproductive Mental Health 
Consultation Program. These burgeoning programs cover a broad range of 
topics related to the treatment of women veterans, such as 
understanding suicide risks in female patients and working with women 
whose mental health problems are influenced by hormonal changes. This 
type of training helps to increase a clinician's competency to provide 
gender-sensitive care to women veterans and should be fully supported 
and resourced appropriately.
    Another factor that adds complexity to the issue of MST is reported 
patient-to-patient harassment on VA grounds. Sexual harassment creates 
a significant barrier to care for many women veterans seeking 
treatment. According to a recent study of women veterans one of every 
five women veterans seeking VA care reports facing harassment 
(considered unwanted comments or behavior) from male veteran 
patients.\6\ Researchers found that women veterans who reported 
experiencing harassment were more likely to have experienced MST and to 
miss or delay care because of these incidents.
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    \6\ Klap, R., et al. ``Prevalence of Stranger Harassment of Women 
Veterans at Veterans Affairs Medical Centers and Impacts on Delayed or 
Missed Care.'' Women's Health Issues 29-2 (2019). 107-115.
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    Stranger harassment can create significant anxiety for veterans who 
have previously experienced trauma and in fact be re-traumatizing. This 
may occur anytime individuals who have experienced trauma in the past 
are exposed to environmental ``triggers'' that remind them of a 
traumatic incident, including sexual trauma or harassment. In health 
care settings, the potential for triggers can be heightened--i.e., 
exposure to practitioners of the opposite sex or a new clinician, tight 
spaces where it is difficult to maneuver or exit easily, having to 
undress for a clinical examination in unsecured areas or where privacy 
is limited. VA must work to improve how it addresses and remedies 
safety, privacy and culture deficiencies reported in annual environment 
of care surveys and better assure that entrances to VA facilities are 
harassment-free zones and that all clinical space is private, secure 
and welcoming to all patients.
    VA has responded to complaints by developing the Stand Up to Stop 
Harassment! Campaign. The initiative aims to educate patients about 
what constitutes harassment and how staff and others can help stop 
harassment or intervene as necessary. While more details about the 
campaign are forthcoming, DAV is eager to assist in the Department's 
efforts to address this problem, including seeking enactment of the 
Deborah Sampson Act (H.R. 3224), which includes provisions that require 
VA to develop a strategy for responding to and stopping stranger 
harassment at VA facilities.
    Finally, because some women veterans must receive a significant 
amount or all of their gender-specific care in the private sector, VA 
should work to ensure that its community care partners are also aware 
of the high prevalence of MST in the veterans' population. VA's 
Community Care Network (CCN) providers should be required to complete 
training in dealing with trauma-exposed veterans--and use full-time MST 
coordinators to help assist with such training. CCN clinicians should 
also be made aware of VA's national MST-related training webinars 
conducted throughout the year and about VA's annual conference, both of 
which routinely address gender-specific issues. Veterans will be able 
to form more trusting and satisfying relationships with an assigned 
primary care provider (PCP) and VA must ensure that it designates PCPs 
for each woman veteran in its care.
    While progress has been made and there are many excellent programs 
and supportive services offered by VA to assist MST survivors in 
recovery--oversight is still necessary to ensure timely access to high 
quality care for MST-related conditions is available at all sites of 
care.
    Mr. Chairman, this concludes my statement. I am happy to answer any 
questions you may have.

                                 [all]