Women Veterans' Health Care: VA Efforts to Respond to the Challenge of
Providing Sexual Trauma Counseling (Testimony, 04/23/98,
GAO/T-HEHS-98-138).

Pursuant to a congressional request, GAO discussed sexual trauma
counseling services for women veterans in the Department of Veterans
Affairs (VA), focusing on: (1) the extent to which sexual trauma
counseling services are available in VA; (2) the extent to which women
veterans use these services; and (3) what VA is doing to assess the
effectiveness of its sexual trauma counseling programs.

GAO noted that: (1) VA, which began offering sexual trauma counseling
services in 1993, offers these services at all of its 172 hospitals and
62 of its 206 Vet Centers; (2) four VA hospitals offer specialized
sexual trauma counseling programs through Women Veterans Stress Disorder
Treatment Teams; (3) these counseling programs provide care to women
veterans who have been more severely affected by their traumatic
experiences; (4) VA has also conducted a number of outreach efforts to
increase staff awareness and inform women veterans about available
sexual trauma counseling services; (5) these efforts have included
segments on a national television program and letters to women veterans;
(6) finally, to facilitate accessibility to sexual trauma counseling, VA
has provided a toll-free number for women veterans to obtain information
about available counseling services and has designated women veteran
coordinators at medical facilities and Veterans Benefits Administration
offices to assist women veterans in obtaining these services; (7) as a
result of VA's efforts, women veterans are increasingly using VA's
sexual trauma counseling services; (8) between fiscal year 1993 and
fiscal year 1997, the number of women veterans receiving sexual trauma
counseling has almost quadrupled, from about 2,350 to about 9,000; and
(9) although not yet done, VA plans to systematically evaluate the
effectiveness of the sexual trauma counseling programs provided by the
four Women Veterans Stress Disorder Treatment Teams and its Vet Centers.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-98-138
     TITLE:  Women Veterans' Health Care: VA Efforts to Respond to the 
             Challenge of Providing Sexual Trauma Counseling
      DATE:  04/23/98
   SUBJECT:  Sexual abuse
             Women
             Veterans
             Veterans hospitals
             Program evaluation
             Rehabilitation counseling
             Mental health care services

             
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Cover
================================================================ COVER


Before the Subcommittee on Health, Committee on Veterans' Affairs,
House of Representatives

For Release on Delivery
Expected at 9:30 a.m.
Thursday, April 23, 1998

WOMEN VETERANS' HEALTH CARE - VA
EFFORTS TO RESPOND TO THE
CHALLENGE OF PROVIDING SEXUAL
TRAUMA COUNSELING

Statement of Stephen P.  Backhus, Director
Veterans' Affairs and Military Health Care Issues
Health, Education, and Human Services Division

GAO/T-HEHS-98-138

GAO/HEHS-98-138T


(406139)


Abbreviations
=============================================================== ABBREV

  GAF - Global Assessment of Functioning
  NEPEC - Northeast Program Evaluation Center
  PTSD - post-traumatic stress disorder
  VA - Department of Veterans Affairs
  VBA - Veterans Benefits Administration
  VHA - Veterans Health Administration

WOMEN VETERANS' HEALTH CARE:  VA
EFFORTS TO RESPOND TO THE
CHALLENGE OF PROVIDING SEXUAL
TRAUMA COUNSELING
============================================================ Chapter 0

Mr.  Chairman and Members of the Subcommittee: 

We are pleased to be here today to discuss sexual trauma counseling
services for women veterans in the Department of Veterans Affairs
(VA).  In the early 1990s, repeated allegations of sexual assault
while serving on active duty were made by women veterans of the U.S. 
armed forces.  A number of these women suffer from sexual trauma,
including post-traumatic stress disorder (PTSD), and experience
emotional and physical symptoms such as increased stress, impaired
concentration, and nightmares, which can impede their daily lives. 

While women represent a small segment of the nation's veteran
population--less than 5 percent--their numbers are rapidly growing. 
In 1982, there were about 740,000 women veterans; by 1996, that
number had almost doubled to over 1.2 million.  It is expected that
by 2010, the number of women veterans will increase an additional 7
percent to 1.3 million, which would represent 6.4 percent of all
veterans.  Thus, it is possible that more women veterans will be
diagnosed with PTSD and other mental and health problems related to
sexual trauma. 

To help ensure these veterans receive the counseling care and
services they require, the Congress enacted the Veterans Health Care
Act of 1992 (P.L.  102-585), which in addition to authorizing new and
expanded health care services, authorized VA to provide sexual trauma
counseling for women veterans through 1995.  The sexual trauma
counseling provisions of this act were amended by the Veterans Health
Programs Extension Act of 1994 (P.L.  103-452), which extended sexual
trauma counseling care and services to all eligible veterans, not
just women, through December 1998. 

My remarks today will focus on (1) the extent to which sexual trauma
counseling services are available in VA, (2) the extent to which
women veterans use these services, and (3) what VA is doing to assess
the effectiveness of its sexual trauma counseling programs.  My
testimony is based on our analysis of VA policy directives and VA
sexual trauma counseling statistics; discussions with officials and
staff in VA medical facilities, the Readjustment Counseling Service's
Vet Centers, the Veterans Health Administration (VHA), and the
Veterans Benefits Administration (VBA); and discussions with women
veterans at five of the six locations we visited.  (See app.  I.)

In summary, VA, which began offering sexual trauma counseling
services in 1993, offers these services at all of its 172 hospitals
and 62 of its 206 Vet Centers.  Four VA hospitals offer specialized
sexual trauma counseling programs through Women Veterans Stress
Disorder Treatment Teams.  These counseling programs provide care to
women veterans who have been more severely affected by their
traumatic experiences.  VA has also conducted a number of outreach
efforts to increase staff awareness and inform women veterans about
available sexual trauma counseling services.  These efforts have
included segments on a national television program and letters to
women veterans.  Finally, to facilitate accessibility to sexual
trauma counseling, VA has provided a toll-free number for women
veterans to obtain information about available counseling services
and has designated women veteran coordinators at medical facilities
and VBA regional offices to assist women veterans in obtaining these
services. 

As a result of VA's efforts, women veterans are increasingly using
VA's sexual trauma counseling services.  Between fiscal year 1993 and
fiscal year 1997, the number of women veterans receiving sexual
trauma counseling has almost quadrupled, from about 2,350 to about
9,000.  Although not yet done, VA plans to systematically evaluate
the effectiveness of the sexual trauma counseling programs provided
by the four Women Veterans Stress Disorder Treatment Teams and its
Vet Centers. 


   VA'S PROVISION OF SEXUAL TRAUMA
   COUNSELING
---------------------------------------------------------- Chapter 0:1

VA has made sexual trauma counseling services available in all of its
hospitals and nearly a third of its Vet Centers.  VA also has
provided training on sexual trauma for its clinicians and support
staff to sensitize them to the issue and provide guidance on how to
interact with trauma victims.  In fulfilling its responsibility for
providing sexual trauma counseling for women veterans, VA conducted
outreach campaigns to inform women veterans of the counseling
services available to them. 


      VA OFFERS WOMEN VETERANS
      OPTIONS FOR SEXUAL TRAUMA
      COUNSELING SERVICES
-------------------------------------------------------- Chapter 0:1.1

VA offers sexual trauma counseling services at all of its 172
hospitals.  Within VA hospitals, sexual trauma counseling is
available in either its mental health clinics--psychiatry,
psychology, or both--or in the women's clinic.  Sexual trauma
counseling is generally provided both individually and in group
counseling sessions.  Four of its hospitals--Boston, Massachusetts;
Brecksville, Ohio; Loma Linda, California; and New Orleans,
Louisiana--also have Women Veterans Stress Disorder Treatment Teams,
which are specialized programs that provide sexual trauma counseling. 

The Women Veterans Stress Disorder Treatment Teams were established
in 1993 as part of a pilot program in accordance with the Veterans
Health Care Act of 1992 and are reserved for individuals who have
developed more severe disorders, such as PTSD, as a result of the
stress or sexual trauma they experienced.  The Women Veterans Stress
Disorder Treatment Teams generally employ more intense treatment
protocols and include such treatment services as individual
psychotherapy, crisis management, drug therapy, and group therapy. 

In addition, 62--or 30 percent--of VA's 206 Vet Centers offer sexual
trauma counseling.  Vet Centers that do not have a counselor
qualified to provide treatment for sexual trauma provide psychosocial
assessments and make appropriate referrals. 


      VA PROVIDES SEXUAL TRAUMA
      TRAINING AND EDUCATION
-------------------------------------------------------- Chapter 0:1.2

In 1993, VA began a multifaceted training program to educate medical
facility health care personnel--including mental health counselors,
Vet Center clinicians, and primary care practitioners--as well as
administrative personnel; veterans and their families; and the
general public about sexual trauma.  Training for clinicians includes
modules on understanding the factors that influence the assessment,
diagnosis, and treatment of women veterans who have been victims of
sexual assault.  The training is also designed to raise awareness of
and increase sensitivity to sexual trauma among the general public. 
These training initiatives include face-to-face presentations,
satellite broadcasts, conference calls, educational videos, and
printed materials.  In addition, to increase the effectiveness of
women veterans' coordinators--who play a key role in helping women
veterans obtain counseling--VA implemented a national training
program to familiarize coordinators with women veterans' issues and
increase awareness of their roles. 


      VA OUTREACH EFFORTS
-------------------------------------------------------- Chapter 0:1.3

In May 1995, VHA published a directive to implement the provision of
P.L.  103-452, which required that information on counseling services
for veterans who have experienced sexual trauma in the military be
provided by telephone.  VA used its general benefits information
toll-free number to disseminate this information.  When a veteran
calls seeking information about sexual trauma services, the call is
routed to the women veterans' coordinator at the nearest VBA regional
office.  If the veteran wishes to contact a VA hospital, a referral
is made to the women veterans' coordinator at the VA hospital or the
Vet Center team leader, if the Vet Center offers sexual trauma
counseling. 

Women veterans' coordinators are VA employees who have been tasked
with conducting outreach to women veterans and helping them obtain VA
benefits and services.  VA increased the time allotted for some women
veterans' coordinators to perform these duties by creating more
full-time positions.  As of January 1998, about 40 percent of the
women veterans' coordinators in VA medical facilities were full-time. 
Women veterans' coordinators and VA clinicians have begun to screen
women veterans for sexual trauma--asking them if they experienced
sexual trauma while on active duty--when they come to VA for other
health care services.  The screening process has been an important
and productive tool in allowing VA to identify trauma victims,
especially since women veterans often do not reveal that they have
been sexually traumatized. 

In November 1996, a national television network's weekly news program
aired two segments on sexual trauma in the military.  In addition, VA
sent letters to 400,000 women veterans informing them of the
counseling services available to those who had experienced sexual
trauma while on active duty. 


   THE NUMBER OF WOMEN VETERANS
   RECEIVING SEXUAL TRAUMA
   COUNSELING CONTINUES TO
   INCREASE
---------------------------------------------------------- Chapter 0:2

The number of women veterans who seek sexual trauma counseling has
dramatically increased over the past several years.  This increase
has caused concern among some sexual trauma counselors that they may
not be able to meet the demand for care and services.  However, women
veterans who have received counseling are generally satisfied with
the care and services they have received through VA. 

Between fiscal year 1993 and fiscal year 1997, the total number of
women veterans receiving sexual trauma counseling increased over 280
percent.  The number of women veterans receiving sexual trauma
counseling services from VA hospitals and outpatient clinics
increased almost 230 percent, from about 2,100 to 6,900.  The number
who received counseling from Vet Centers increased about 375 percent,
from about 270 to over 1,270.  Between fiscal year 1994 and fiscal
year 1997, the number of women veterans receiving counseling from the
Women Veterans Stress Disorder Treatment Teams increased over 220
percent from about 270 to 870.  (See app.  II.)

Staff associated with the sexual trauma counseling programs at one of
the five VA hospitals and two of the three Vet Centers we visited
expressed some concern about their ability to adequately respond to
the demand for sexual trauma counseling.  Staff at one VA hospital
explained that their workload is not decreasing because sexual trauma
patients remain in counseling for some time.  Although it is too
early to estimate how long sexual trauma patients will need to
receive counseling, one clinician told us that literature suggests
they would probably receive counseling for an average of about 2
years.  The other locations we visited seemed to be managing their
sexual trauma workload fairly well. 

Women veterans we talked with liked having the different options
available to them for sexual trauma counseling.  Some veterans liked
receiving their counseling in the women's clinics because they felt
more comfortable going there than the mental health clinic.  Their
view was that mental health clinics were for "crazy" people and they
were not crazy.  Several women veterans preferred the more private,
informal setting at the Vet Centers. 

The women veterans we talked with told us they are grateful for the
counseling services they have received and believe the counseling is
helping them.  One veteran commented that the counseling has saved
her life.  However, a few veterans expressed the desire to receive
counseling more frequently than once a month.  One veteran told us
that she sometimes has difficult periods and finds it hard to get an
appointment before her next scheduled visit.  Yet she has found that
the counselor is very committed and has helped her through crisis
periods over the phone when an in-office appointment was not
possible. 

The primary complaints we heard about VA sexual trauma services were
directed at VA's claims process for awarding compensation related to
sexual trauma.  While documentation of sexual trauma is not required
to receive counseling, it is required for filing claims for
compensation.  A women veterans' coordinator at VBA explained that it
is sometimes difficult to document sexual trauma cases since personal
assault is often not reported.  VBA has developed guidance it hopes
will help alleviate some of the problems associated with the
documentary evidence that is required to apply for compensation
related to sexual trauma.  Veterans are now asked to provide any
documentation that will help to substantiate their claims, which can
cover primary evidence--such as service medical records and personnel
records--or alternative sources, including civilian medical records,
police reports, statements from others, or personal diaries. 


   VA PLANS TO EVALUATE THE
   EFFECTIVENESS OF SOME OF ITS
   SEXUAL TRAUMA COUNSELING
   PROGRAMS
---------------------------------------------------------- Chapter 0:3

The effectiveness of VA's various sexual trauma counseling programs
is not yet known.  Currently, VA plans to evaluate the effectiveness
of its four Women Veterans Stress Disorder Treatment Teams and its
Vet Center sexual trauma counseling programs.  Based on fiscal year
1997 data, these evaluations would cover about 24 percent of the
sexual trauma counseling services provided to women veterans.  At
this time, VA has no plans to systematically evaluate the
effectiveness of the sexual trauma counseling programs provided by VA
hospitals and outpatient facilities. 

The Northeast Program Evaluation Center (NEPEC) will evaluate the
effectiveness of the four Women Veterans Stress Disorder Treatment
Teams.  According to NEPEC's National Director of PTSD Program
Evaluations, it is difficult to assess the effectiveness of mental
health programs, including sexual trauma counseling, because
treatments for sexual trauma counseling--like PTSD--are still
evolving; therefore, absolute outcome standards have not been
established.  In addition, sexual trauma counseling effectiveness
evaluations--like other effectiveness studies--are difficult to
conduct because of the scientific challenges they present, such as
implementing data collection in real-world settings as well as
measuring an individual's emotional status.  Further, it is difficult
to define the treatment and determine whether a treatment--and not
time or some other occurrence--caused the particular outcome. 

To evaluate the effectiveness of the Women Veterans Stress Disorder
Treatment Teams, NEPEC plans to use a protocol similar to the one it
used to evaluate the effectiveness of VA's specialized intensive PTSD
programs.  NEPEC will use several data collection instruments that
will be administered at admission and 4- and 8-month follow-up
intervals to collect sociodemographic, symptom, social functioning,
and military and clinical background information.  NEPEC will also
collect (1) more extensive data regarding traumatic exposure in the
military, (2) information regarding personality characteristics and
health beliefs, and (3) information on the number and type of VA and
non-VA individual and group sessions received in the 4 months prior
to admission to the specialized program.  VA anticipates it will
begin its evaluation some time during fiscal year 1998. 

To determine the effectiveness of its counseling programs, Vet
Centers will use the Global Assessment of Functioning (GAF) rating
and a psychosocial rating.  GAF rates a client's overall functioning,
including psychological, social, and occupational.  Vet Center staff
will compare each veteran's GAF score before and after completing the
sexual trauma counseling program.  Vet Center staff will also compare
women veterans' before and after psychosocial ratings, which assess
the specific clinical problem areas addressed in the counseling
session, their severity, and the level of resolution achieved.  In
addition, Vet Centers will conduct satisfaction surveys upon
termination of sexual trauma counseling. 

Mr.  Chairman, this concludes my statement.  I would be happy to
respond to any questions you or the other Subcommittee Members may
have. 


VA FACILITIES VISITED
=========================================================== Appendix I

Boston, Massachusetts

Women Veterans Comprehensive Health Center
Women Veterans Stress Disorder Treatment Team

Bay Pines, Florida

Women's Clinic

Tampa, Florida

Women Veterans Comprehensive Health Center

St.  Petersburg, Florida

Vet Center (Tampa Vet Center representative also participated)

New Orleans, Louisiana

Women's Clinic
Women Veterans Stress Disorder Treatment Team
VBA regional office
Vet Center

Washington, D.C. 

Women's Clinic
VBA regional office


SEXUAL TRAUMA COUNSELING CASES
========================================================== Appendix II



                                        Table II.1
                         
                           Increase in Number of Sexual Trauma
                           Counseling Cases Between Fiscal Year
                                1993 and Fiscal Year 1997

                                             Fiscal year
                           ------------------------------------------------
                                                                                 Increase
                                                                                  FY1993-
                                                                                   FY1997
Source of treatment            1993      1994      1995      1996      1997     (percent)
-------------------------  --------  --------  --------  --------  --------  ------------
VA hospitals and              2,090     3,627     4,789     4,707     6,867         228.6
 outpatient clinics
Vet Centers                     268     1,442        \b     1,853     1,273         375.0
Women Veterans Stress            \a       271       816       906       870         221.0
 Disorder Treatment Teams
=========================================================================================
Total                         2,358     5,340     5,605     7,466     9,010         282.1
-----------------------------------------------------------------------------------------
\a Women Veterans Stress Disorder Treatment Teams were not
established until 1993. 

\b Included in the VA hospital and outpatient clinic totals except
for San Antonio. 

Source:  Department of Veterans Affairs, Veterans Health
Administration, Office of Women Veterans Health Program. 


*** End of document. ***