Mr. Chairmen, Ranking Members Lamborn and Brown, and distinguished committee members, on behalf of AMVETS, I would like to extend our gratitude for being given the opportunity to share with you our views and recommendations regarding the treatment of military sexual trauma within the Department of Veterans Affairs (VA), more specifically the Veterans Health Administration (VHA).

AMVETS feels privileged in having been a leader, since 1944, in helping to preserve the freedoms secured by America’s Armed Forces.  Today our organization prides itself on the continuation of this tradition, as well as our undaunted dedication to ensuring that every past and present member of the Armed Forces receives all of their due entitlements.  These individuals, who have devoted their entire lives to upholding our values and freedoms, deserve nothing less.

By way of background and clarification, AMVETS understands that Military Sexual Trauma (MST) is in no way exclusive to the female veterans population, however much of our testimony today will be based on specialized treatments for women whom have experienced and are being treated for MST.

Women veterans are the fastest growing subgroup of the American military veterans’ population today. In fact, 2009 estimates show that women compose 14 percent of today’s military forces, and within the next 10 years this number is expected to nearly double. If those estimates hold true than upwards of 30 percent of America’s military forces and veteran community will be comprised of women. Women are also being deployed to combat zones at a rate in which this country has never seen and are carrying out vital roles on the frontlines.  A 2008 VA study showed that 45-49 percent of female OEF/OIF veterans were enrolled in the VA Health Care System and were using VA provided services on a regular basis. This same study also showed that over 50 percent of the women currently enrolled in the VA health care system, 46 percent were under the age of 30.  Now, more than ever, we must make sure that VA is ready and equipped with the necessary staff, facilities, and gender specific care programs to offer the best available care to today’s returning women servicemembers. According to VHA officials more than 1,000 new cases involving MST are uncovered each month, yet little is known to VHA staff about mental health needs of MST-exposed patients, or access to and utilization of services by these patients. While AMVETS understands that the VA health system is facing a very large endeavor in providing and implementing effective care models to their patients regarding MST, we also find self proclaimed lack of knowledge on the subject unacceptable. VA’s health care providers must have the experience and knowledge to treat all wounds of war.

Treatment and care models of MST do not differ so dramatically from VHA to care provided by private sector physicians to the extent that VHA should be having trouble understanding MST and the related metal disorders that often accompany it. There are already many established and long used models that can serve as guiding principles for VA in the establishment and implementation of care relating to MST. If VHA believes they are lacking in the prior experience needed to effectively provide care, AMVETS believes VHA may be best served in reaching out to private sector or other agency care providers for guidance and assistance.  In fact, on March 3, 2009 VA’s Principal Deputy under Secretary for Health, Dr. Gerald Cross, stated “We believe it is essential that our medical professionals across the system be able to effectively recognize and treat the manifestations of sexual trauma and PTSD,” further proving VA’s agreement with AMVETS on this matter.

VA defines Military Sexual Trauma as sexual or psychological trauma resulting from sexual harassment or abuse that either men or women are subjected to while serving in the military. Due to further research by AMVETS, we were able to gather a further breakdown of the terms used to define MST as recognized by VA. AMVETS research of current VA policies produced the following definitions:

1. Sexual Assault is defined as intentional sexual contact, characterized by the use of force, psychical threat, and/or abuse of authority when the victim does not consent.
2. Sexual Assault is further defined as encompassing force or the threat of force, coercion is used, or when the un-consenting party is asleep, incapacitated, or unconscious.
3. Sexual Abuse is defined as, but not limited to, insistence on unwanted touching, forcing of unwanted sexual acts and demeaning remarks, treating as a sexual object with no regards to emotional well-being.
4. Sexual Harassment is defined as a form of gender discrimination involving unwanted sexual advances, the requesting of sexual acts,  and any other verbal or physical conduct of a sexual nature when a person job, pay or rank are placed in jeopardy, creates an intimidating or hostile workplace, and/or offensive work environment.
5. Sexual Misconduct is defined as act is committed without intent to harm another and where, by failing to correctly assess the circumstances, a person believes unreasonably that effective consent was given without having met his/her responsibility to gain effective consent. Situations involving physical force, violence, threat or intimidation fall under the definition of Sexual Assault, not Sexual Misconduct.

AMVETS believes that it is very important to bring attention to the fact that the Department of Defense does not currently include “Sexual Harassment” in their definition of sexual assault, as VA does. This difference of definition poses a problem in itself. AMVETS believes there needs to be a single definition on what constitutes “Military Sexual Assault” used by both VA and DoD to better recognize and treat victims of MST, as well as removing any questions regarding reporting of sexually related incidents.  

Studies conducted by VHA and private sector organizations from 2006-2009 show that on average 24 percent of all female veterans screened during their initial VA healthcare assessment displayed the criteria necessary for having experienced a MST event during their service. One must remember that these numbers were obtained during initial screenings and do not factor in the female veteran population that were later given a diagnosis of a condition stemming from a MST event. Furthermore, with DoD and VA using separate definitions of MST it is impossible to know how many veterans have truly experienced a sexually traumatic event during their service.

MST and it’s correlation to a magnitude of mental health disorders has been long documented and accepted within the medical community. However, it has not been until recently that women veterans under VA care have been specifically studied for the correlations of MST to PTSD and other mental health disorders.  In 1996, a survey to determine the prevalence of physical and sexual abuse experiences, during and outside of military service, was conducted among 828 women veterans at the Baltimore Veterans Affairs Medical Center. Data collection was through anonymous, mailed questionnaire. Three questions were used to elicit histories of physical abuse, sexual abuse, and rape. From the survey, 429 completed forms (52 percent) were returned. Most of the veterans had at least some college education and about 50 percent served 4 or more years on active duty. About 68 percent of the respondents reported at least one form of victimization, while 27 percent reported to have undergone all three forms, of which sexual abuse was the most common, followed by physical abuse and then rape. It was during adulthood that all three forms of abuse took place, with one-third of the women reporting victimization during active duty. Coyle also found that single women and divorced women were more likely to report victimization than married women.  In conclusion, physical and sexually abused women veterans were the ones more likely seeking care at the center. [i]

Research has shown that veterans who have experienced MST are at a high risk for developing a range of mental health conditions such as PTSD, major depression, anxiety, and panic disorder. MST victims may also struggle with other problems, including low self-esteem, difficulties with interpersonal relationships, and sexual dysfunction. To the best of AMVETS knowledge there have only been two scientifically valid studies conducted since 2001 that examined rates of DSM-IV PTSD diagnoses in women veterans with MST. First, Suris et al.,[ii] using a sample of female Veterans Administration (VA) patients, compared rates of PTSD related to two types of civilian sexual trauma with PTSD rates related to MST. Suris found that MST was more frequently traumatizing than civilian assault. Thus, the data indicates that MST is more predictive of PTSD than are other types of military trauma or civilian sexual trauma.

The second study was conducted in 2006 by Dr. Deborah Yaeger.  Yaeger et al.,[iii] compares rates of Post Traumatic Stress Disorder (PTSD) in female veterans who had military sexual trauma (MST) with rates of PTSD in women veterans with all other types of trauma.  Both studies had findings that suggested that MST is common and that it is a trauma especially associated with PTSD. Yaeger’s research actually showed correlation between the MST group and Other Trauma group (r=.13, P=.07) reflected a weak relationship. Dr. Yaeger also conducted a logistic regression analysis in which PTSD was regressed on MST and Other Trauma. Both the MST group (Wald χ2=20.3, df=1, P=.0001) and Other Trauma group (Wald χ2=5.4, df=1, P=.02) significantly predicted PTSD, but MST predicted it more strongly. This finding is significant because the number of women positive for MST was less than half of those positive for Other Trauma, yet the relationship of the MST group with PTSD was stronger.[iv] This is only one example of data showing the almost unquestionable link between MST and PTSD. Finally, in 2007 the Medical University of South Carolina wrote an article that reviewed the literature documenting the nature and prevalence of traumatic experiences, trauma-related mental and physical health problems, and service use among female veterans. Existing research indicates that female veterans experience higher rates of trauma exposure in comparison to the general population. Emerging data also suggest that female veterans may be as likely to be exposed to combat as male veterans, although not as directly or as frequently. Female veterans also report high rates of posttraumatic stress disorder, which has been associated with poor psychiatric and physical functioning. USC concluded that while sexual assault history has been related to increased medical service use, further research is needed to understand relationships between trauma history and patterns of medical and mental health service use. Researchers also are encouraged to employ standardized definitions of trauma and to investigate new areas, such as treatment outcomes and mediators of trauma and health.[v]  AMVETS believes this review further demonstrates the importance of a uniformed definition of MST throughout all agencies, more specifically DoD and VA.  AMVETS also believes these studies to show the importance of integrating mental health care, as outlined by VHA 1160.01, into all VAMCs and CBOCs providing primary care.

In 2005, VHA published VHA Directive 2005-015, authorized under P.L. 102-85 outlining specific policies, procedures and staffing requirements as they relate to the treatment and care of veterans who have experienced military sexual trauma (MST).  To build upon this directive VHA 1160.01 as published in September of 2008 provided even more policies and procedures that all Veteran Affairs Medical Centers and Community Based Outpatient Clinics should employ when treating veterans having suffered MST. These policies and procedures provide guidance and outline all legally binding requirements of the treatment of veterans having experienced MST by all VAMCs and CBOCs.  The measures are as follows:

• The constant availability, isolation and safety of “women only” areas in each medical facility treating women veterans.
• That all medical directors ensure that every patient receiving care is screened for MST.
• The use of MST software that allows tracking of VA’s screening of veterans. The Women Veterans Health Program and the Mental Health Strategic Work Group utilize the national MST report to respond to Congressional inquiries and for expansion of MST programs and initiatives.
• Veterans receiving MST-related counseling and treatment are not billed for inpatient, outpatient, or pharmaceutical co-payments; however, applicable co-payments may be charged for services not related to military sexual trauma or for other non-service connected conditions.
• Scheduling priority for outpatient sexual trauma counseling, care, and services is consistent with the VHA performance standard of scheduling within 30 days for special populations and mental health clinics.
• Accurate documentation of screening, referral, and treatment services provided to veterans, aggregated by gender, is maintained. This process includes use of the MST software and the MST clinical reminder to track and monitor the level of compliance with the standard (100 percent of enrolled veterans screened). The nationwide tracking system to ensure consistent data on screening and treatment of victims of military sexual trauma must be used.
• MST counseling is provided by contract with a qualified mental health professional if it is clinically inadvisable to provide in Departmental facilities or when VA facilities are not capable of furnishing such counseling to the veteran economically because of geographic inaccessibility or the inability of the medical center to provide counseling in a timely manner.
• Veterans who report experiences of MST, but who are otherwise deemed ineligible for VA health care benefits based on length of military service requirements, may be provided MST counseling and related treatment only.
• The MST software application that activates the MST Clinical Reminder within CPRS has been installed at the facility. All veterans receiving VHA health care must be screened for MST using this clinical reminder.
• Veterans screening positive and requesting treatment are provided free care, with no inpatient, outpatient, or pharmacy copayments, for mental and physical health conditions resulting from their experiences of MST. Determination as to whether care is MST- related is made by the clinician providing care. All MST-related care must be designated by checking the MST box on the encounter form for the visit.
• The time frames for evaluations of veterans for possible mental disorders resulting from MST must follow the requirements in paragraph 13, of VHA 1160.01.
• Evidence-based mental health care is available to all veterans diagnosed with mental health conditions resulting from MST.

While AMVETS does realize that VA has been making efforts to provide better care to all women veterans, we were quite troubled by two recent GAO reports on the standards of care our female veteran population has been receiving at VAMCs and CBOCs, especially in the areas of mental health and MST treatments.  In March 2010, GAO published a report entitled “VA Has Taken Steps to Make Services Available to Women Veterans, but Needs to Revise Key Policies and Improve Oversight Processes,”  as a follow up report to the July 2009, GAO report entitled “ VA Health Care: Preliminary Findings on VA's Provision of Health Care Services to Women Veterans.”

AMVETS believes that what GAO reported in March 2010 is unacceptable and quite negligent by many VAMCs in providing the most basics of care to our women veterans. For example, in the 2009 report GAO found that none of the facilities they visited were compliant with privacy requirements outlined by VA. Regrettably, in the more recent 2010 report, GAO reported that  most facilities still had not improved their measures to provide the required privacy to women veterans. Another area in need of compliance, as pointed out by GAO numerous times, are the requirements for treating veterans who have experienced any sort of MST, as outlined by P.L. 102-85 and 38 U.S.C. § 1720D.  Federal law specifically requires VA to establish a program to provide these MST-related services and to provide for appropriate training of mental health professionals and such other health care personnel as the Secretary determines necessary to carry out the program effectively. These laws state that every VA facility to be equipped and able to provide immediate care for any veteran who has experienced any psychological trauma as a direct result of a physical assault or harassment that was sexual in nature during their time in service.  

VA’s MST-related policies require that VAMC directors appoint an MST Coordinator and that necessary staff education and training be provided.  The MST coordinators are responsible, among other things, for monitoring and ensuring that VA policies related to MST screening, education, training, and treatment are implemented at the facility.  GAO reported that VA had  taken some steps internally to make information about MST programs more readily available to VA providers. Specifically, VA has conducted monthly, nationwide MST conference calls which have included basic information on the structure and focus of the various residential and outpatient programs offering MST or sexual-trauma-specific treatment, as well as detailed presentations by key providers from several programs. VA also has a list of the various programs on its internal Web site, which is accessible by VA providers.  However, GAO went on to say that VA had not made the same information accessible to veterans through VA’s external Web sites or printed literature accessible to all veterans.  As of November 2009, the website pages reviewed by GAO from VA’s national website did not provide complete lists of facilities that have MST-related treatment programs or specialized programs for women veterans. The sites that did list specific residential treatment programs usually listed a single program, while nine VAMCs have relevant programs. AMVETS is quite concerned that VA’s outreach to women veterans is falling short. While most of us here today are very familiar with VA programs, the average veteran is not. It is the responsibility of VA to not only design and implement these MST specific programs, but to also educate the veterans living in all parts of the country on the services available to them. How can a veteran receive the care and assistance they need if they do not even know that the care exists?

It was the understanding of AMVETS that ensuring the privacy and integrity of all women veterans seeking care in a VAMC or CBOC was a requirement of federal law, not a suggestion. Women veterans seeking care for the most private and potentially damaging experiences, such as MST, must feel safe and that only their best interests are at hand by VA medical providers. What sort of message are we sending our returning female servicemembers, who have suffered a traumatic sexual experience, when VA is not able to offer them something as simple as an OB table facing away from the examine room door or a private and separate sleeping area from the male patients? Can VA honestly say, to this congressional subcommittee and to all veterans, that the oversight they have exercised over the implementation of these care measures has been nothing less than their best?  Can AMVETS be assured that every VAMC and CBOC is doing everything in their power to correct the deficiencies that have been repeatedly pointed out to them regarding the care of America’s returning war fighters?

AMVETS offers the following recommendations regarding military sexual trauma care and treatment issues:

1. AMVETS recommends these Subcommittees set forth a strict timeline in which VA will  have to report all updates on the implementation of MST policies and procedures in every VAMC and CBOC, and that the committee holds VA accountable to a specific date of system wide total implementation. AMVETS further recommends that any requests for exception on meeting the specified deadline are required to be made in writing directly to the Secretary for final approval.
2. AMVETS recommends VA immediately update the information on their website, as well as written literature, to guarantee that all veterans are aware of the services available to them and where they may go to receive said services.

3. AMVETS recommends these Subcommittees maintain strict oversight on the implementation of VHA 1160.01 as it pertains to the availability of treatment for MST and all mental health care provided by VA, in efforts to implement and maintain uniformed mental health care system wide.

[i] Coyle BS, Wolan DL, Van Horn AS. The prevalence of physical and sexual abuse in women veterans seeking care at a Veterans Affairs Medical Center. Mil Med. 1996 Oct; 161(10):588-93.

[ii] Suris A, Lind L, Kashner M, Borman PD, Petter F. Sexual assault in women veterans: an examination of PTSD risk, health care utilization, and cost of care. Psychosom Med. 2004; 66:749–56.

[iii] Deborah Yaeger, MD, Naomi Himmelfarb, PhD, Alison Cammack, BS, and Jim Mintz, PhD. DSM-IV Diagnosed Posttraumatic Stress Disorder in Women Veterans With and Without Military Sexual Trauma. J Gen Intern Med. 2006 March; 21(S3): S65–S69.

[iv] Deborah Yaeger, MD, Naomi Himmelfarb, PhD, Alison Cammack, BS, and Jim Mintz, PhD. DSM-IV Diagnosed Posttraumatic Stress Disorder in Women Veterans With and Without Military Sexual Trauma. J Gen Intern Med. 2006 March; 21(S3): S65–S69.

[v] Zinzow HM, Grubaugh AL, Monnier J, Suffoletta-Maierle S, Frueh BC. Trauma among female veterans: a critical review. Trauma Violence Abuse. 2007 Oct;8(4):384-400. Review. PubMed PMID: 17846179.