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Dr. Barbara Van Dahlen

Dr. Barbara Van Dahlen, Founder and President, Give an Hour

Thank you for this opportunity to provide testimony regarding the issue of improving the access to care through the Department of Veterans Affairs for veterans who have been sexually assaulted while serving in our military. It is an honor to appear before this Committee, and I am proud to offer my assistance to those who serve our country.

Background on Military Sexual Trauma

Over the past several months we have seen an increase in the attention given to a very serious issue affecting our military community: military sexual assault. One reason for the increase in interest has been the release of a documentary film called The Invisible War. The film—which debuted at the Sundance Film Festival and opened in theaters in June—presents the stories of several women and men who were sexually assaulted while serving in the military. The service members who stepped forward to share these stories chose to serve our country by joining the armed forces—and were devastated by the assault they experienced and the lack of support they received from the institution they had devoted themselves to.

The film has received critical acclaim and has stimulated conversations in both the civilian and military communities regarding a brutal reality that affects far too many men and women who serve. In 2011 alone, 3,192 men and women reported that they were sexually assaulted while serving. By telling the painful stories of several victims of sexual assault, the film provides an important framework to understand the impact of this type of attack on those who serve and their families. It sets the stage for discussions and actions that must be taken if we are to protect those who defend our country from attacks that can occur from within. And it confirms that we must ensure services are available for those who have already been harmed.

Understandably, this type of attack and betrayal often leads to the development of severe mental health difficulties for the men and women who are victimized. Indeed, today many of the female veterans treated by the Department of Veterans Affairs and other programs receive a diagnosis of Military Sexual Trauma (MST), and this type of trauma is now the leading cause of post-traumatic stress disorder among female veterans, surpassing combat trauma. In addition, the experience of military sexual assault increases the likelihood of other serious and devastating conditions and consequences such as substance abuse, homelessness, and suicide.

This hearing focuses on a set of very important questions related to assisting the victims of military sexual trauma who seek care through the Department of Veterans Affairs (VA). Specifically, this committee seeks to explore the process and procedures involved in obtaining VA disability compensation benefits for post-traumatic stress disorder based on military sexual trauma. And it aims to determine how to improve the evaluation process for veterans who have been sexually assaulted so that those in need are quickly identified and treated.

While this issue is getting significant attention today, sexual assault has been affecting—and often destroying—the lives of those who serve for decades. As I began to prepare testimony for this hearing, I had occasion to speak with a colleague who devoted over 20 years of service to the military. He continues to serve as a civilian in a high level position with the Department of Defense. I happened to mention to him that I was invited to testify before this committee on this important topic. After stating that he was about to share something with me that he had never shared with anyone, not even his wife, he told me the following story.

He enlisted in the military at the age of 17. It was the late 1970s. Within the first year of his service, he was sexually assaulted by two men with whom he served, as part of an initiation process. He was humiliated and devastated. He told no one. He said, “There was no one to tell—reporting would have made my life much worse. The stigma would have further damaged me and my career. I felt overwhelming guilt and shame.” This veteran suffered the consequences of the attack, psychologically and physically, for years. At one point he contemplated suicide and went so far as to put all his affairs in order and make arrangements for the care of his two-year-old daughter and young wife. His marriage eventually fell apart and he and his wife separated. Fortunately, this veteran found help, repaired his marriage, and has healed psychologically—though he continues to have significant physical problems that stem from the attack that shattered his life 30 years ago.

He shared his story now because he wants the members of this committee to understand that service members who are sexually assaulted are unlikely to report the assault to their command, to their peers, to anybody. Data from the Department of Defense substantiate his claim. Reports indicate that an estimated 86% of service members do not report an assault when it occurs. There are many reasons for this, one being that for 25% of military sexual assault survivors, the person they would report the assault to is the perpetrator.

We in the mental health profession know that it is absolutely critical for victims of sexual trauma to seek and receive assistance, support, and treatment as soon as possible. We also know, however, that many who suffer sexual attacks within the military will not seek care while they continue to serve. We must, therefore, ensure that all of those who seek services through the Department of Veterans Affairs for sexual assault once they leave the service are treated as quickly and as supportively as possible.

Trained mental health clinicians are quite capable of determining the veracity of a veteran’s claim of sexual assault. The signs and symptoms are well known, and VA mental health providers have already been given the appropriate responsibility for making this type of determination regarding reports of combat stress injuries. It would be appropriate and consistent, therefore, to allow trained mental health professionals to determine—as they currently do within the VA for combat-related trauma—that the claimed stressor of military sexual trauma is adequate to support a diagnosis of post-traumatic stress disorder and that the veterans symptoms are related to the claimed stressor for the purposes of seeking and receiving appropriate care and services through the VA.

Moreover, given the humiliation survivors of sexual assault contend with, it is highly unlikely that many women or men will fabricate stories of military sexual trauma in order to receive VA benefits. In addition the lives that are saved by adjusting the process by which victims of sexual assault can qualify for and receive services through the VA will far out weigh the very few cases that “beat the system.”

In addition to changing the process for victims of sexual assault to apply for and receive services through the VA, we should continue to expand the network of providers available to meet the growing needs of the military community at large. The VA has made tremendous strides in recognizing that partnerships with community-based organizations are critical if we are to provide the mental health services that the men, women, and families who serve our country need when they come home to our communities. For example, the Department of Veterans Affairs recently signed an MOA with my organization, Give an Hour, which provides free mental health services to military personnel, veterans, and their loved ones. This MOA will facilitate appropriate referrals to GAH providers from the VA’s Veterans Crisis Line.  It is easy to imagine how community-based efforts such as those provided by Give an Hour and other organizations can assist the VA in their efforts to provide swift and effective care to those who have given so much to our country.

Scope and History of the Problem

The issue of military sexual trauma has indeed received increased attention over the past few years. Looking at the number of reports filed with DoD in recent years confirms the magnitude of the problem. In 2010 there were 3,158 total reports of sexual assault in the military. The Department of Defense estimates that this number represents only 13.5% of total assaults in 2010. If this estimate is accurate then the total number of military sexual assaults would have been upwards of 20,000. Of the 3,158 reports that were made in FY2010, only 529 ever went to trial.

Of the 3,192 military sexual assaults reported in 2011, service members were the victims in 2,723 of those assaults. Eighty-four percent of the incidents reported occurred in FY11, 14% were related to incidents occurring from FY08 to FY10, and 2% concerned incidents occurring in FY07 and prior. Of the 3,192 reports filed in 2011, only 791 individuals received some form of disciplinary action, and of that group 489 individuals had courts martial charges initiated against them.

On February 15, 2011, fifteen female and two male military veterans filed a class action lawsuit against former Defense Secretaries Donald Rumsfeld and Robert Gates. The case was ultimately dismissed but an appeal is being considered. The film The Invisible War profiles several of the victims involved in this class action suit.

But this is not the first time that the issue of military sexual assault has received this type of public attention. Americans became aware of the issue during the Tailhook scandal in 1991. Tailhook  refers to a series of incidents in which more than 100 U.S. Navy and Marine Corps aviation officers were alleged to have sexually assaulted or otherwise engaged in “improper and indecent” conduct with at least 87 women at the Las Vegas Hilton.

In July 1992, a series of hearings on women veterans’ issues conducted by the Senate Committee on Veterans Affairs brought the problem of military sexual assault to policy makers' attention. Congress responded to these hearings by passing a public law that, among other things, authorized health care and counseling for women veterans who were experiencing mental health consequences resulting from sexual assault or sexual harassment during their military service. Signed into law in November 1992, this public law was later expanded to include male veterans. Following the passage of these laws, a series of Department of Veterans Affairs directives mandated universal screening of all veterans for a history of military sexual trauma and mandated that each facility identify a Military Sexual Trauma Coordinator to oversee the screening and treatment referral process.

Although careers ended and policies changed following the Tailhook scandal, far too many men and women serving in our armed forces continue to be sexually assaulted at home and abroad. Most of these (often young) men and women were unable to protect themselves from an attack from one of their “battle buddies.” But why would they think that they would ever need to protect themselves from this type of assault? They joined the military to serve their country. They were taught that those with whom they serve share their dedication and commitment, are there to protect them, are closer than family. It is no surprise that military sexual assault often leads to a shattering of trust and a sense of despair. Many have likened military sexual assault to incest in the sense that many victims of military sexual assault are devastated by the betrayal and brutality they experience at the hands of one of their own.

Fortunately, additional measures are now under way within the military to protect those who serve and to prosecute those who prey on them.  Secretary of Defense Panetta has proposed new steps the military will take to address the problem of sexual assaults. One recommended policy change is the requirement that a higher authority within the military review the most serious cases, a step to ensure that cases remain within the chain of command and leaders are held responsible. Secretary Panetta also announced the creation of a special victims unit within each of the services and an explanation of sexual assault policies to all service members within 14 days of their entry into the military. In addition, the secretary has proposed intensified investigations, heightened training, and more resources. These are all excellent recommendations that may begin to stem the tide of victimization. We must also increase access to care for those who have already been affected.

Impact of Military Sexual Assault/Trauma

Military sexual assault has been associated with an increased risk of depression, post-traumatic stress disorder, and substance abuse. Women who have been sexually assaulted in the military are more than four times more likely to have post-traumatic stress disorder than peers who have not been sexually assaulted. They are also more likely to suffer from multiple mental health concerns. In FY2011 19.4% of the OEF/OIF/OND female veterans reported a history of military sexual assault. In addition, one in five women veterans who present to the VA for health care screen positive for Military Sexual Trauma. Not surprisingly, women who enter the military at younger ages and those of enlisted rank appear to be at an increased risk for MST.

Women and men in the military must face unique challenges associated with the experience of sexual assault. They must decide if they are willing to report the incident—and face whatever personal or professional reprisals that follow. But there are symptoms that all victims of sexual assault share, whether the attack occurs within the military or civilian community. Indeed, in addition to the physical and psychological pain of the attack itself, women and men who are sexually assaulted often experience years of emotional distress, damaged relationships, and overall dysfunction.

Post-traumatic stress disorder refers to a collection of symptoms that occur for a prolonged period of time following a severe trauma. As we know, many victims of sexual assault develop post-traumatic stress. These symptoms can be grouped into three main categories:

-          Re-Experiencing: This is a repeated reliving of the event that interferes with daily functioning. This cluster of symptoms includes flashbacks, frightening thoughts, recurrent memories or dreams, and physical reactions to situations that remind a person of the event.

-          Avoidance: These symptoms stem from the desire of a person to change his or her routine to escape similar situations to the trauma. Victims might avoid places, events, or objects that remind them of the experience. Emotions related to avoidance are numbness, guilt, and depression. Some individuals have a decreased ability to feel certain emotions like happiness. They might also be unable to remember major parts of the trauma and feel that their future offers fewer possibilities than other people have.

-          Hyper-arousal: Hyper-arousal symptoms are primarily physiological. They include difficulty concentrating or falling asleep; being easily startled; feeling tense and “on edge”; and being prone to angry outbursts.

It is easy to see how the presence of one or more of these symptoms can dramatically interfere with one’s ability to pursue a career, engage in meaningful relationships, or live one’s life.

In addition, victims of sexual assault often turn to alcohol or other substances in an attempt to relieve their emotional suffering. Victims of sexual assault report higher levels of psychological distress and higher levels of alcohol consumption than non-victims. And when compared to non-victims, sexual assault survivors are 3.4 times more likely to use marijuana, 6 times more likely to use cocaine, and 10 times more likely to use other major drugs. Many of the women veterans who are now living among the homeless population in the United States have what is referred to as a “dual diagnosis”—a consequence of the sexual trauma they endured. They have a mental health condition such as post-traumatic stress disorder, depression, or severe anxiety and they have a substance abuse problem, making it even more difficult for them to receive or benefit from treatment for the assault that injured them.

Furthermore, it is common for victims of sexual assault to engage in behaviors that result in physical and/or psychological harm to themselves. Deliberate "self-harm" or "self-injury" refers to incidents when a person inflicts physical harm on him or herself, usually in secret. Some victims of sexual assault may use self-harm to cope with the difficult or painful feelings associated with their experience of sexual trauma. Self-harm can cause permanent damage to the body, as well as additional psychological problems that hinder the healing process, such as guilt, depression, low self-esteem or self-hatred, along with a tendency toward isolation. Some common methods of self-harm include cutting, burning, pulling out hair, scratching, and eating disorders.

For sexual assault victims specifically, self-injury may

-          provide a way to express difficult or hidden feelings

-          provide a way of communicating to others that support is needed

-          provide a distraction from emotional pain

-          provide self-punishment for what they believe they deserve

-          provide a feeling of control—it is not uncommon to feel that self-harm is the only way to have a sense of control over life, feelings, and body, especially if other things in life seem out of control

Finally, one of the most concerning consequences of sexual assault is associated with the depression that so many experience following an attack. Depression that goes untreated can continue for years following the attack. And untreated depression results in an increased risk of suicide. Indeed, of the group of men and women who have experienced sexual assault many experience suicidal thoughts, and many attempt or complete suicide. 

Access to Care

We know that early intervention following the experience of trauma promotes healing and decreases the likelihood that the trauma will result in chronic and disabling mental health conditions.  And we know that it is extremely difficult for victims to overcome the common feelings of fear, guilt, and shame they feel following an assault. As a result, many are reluctant to come forward to report an assault or seek treatment. And we know that if veterans are further victimized by the reporting and investigative process itself, they are likely to suffer additional psychological damage that worsens their condition. We must, therefore, assure that those who seek care for military sexual assault are treated with respect and given the attention and treatment they need and deserve.

We have the systems and programs in place—through the Department of Veterans Affairs, through state and local governmental agencies, and through community-based programs like Give an Hour—to provide the education, support, and treatment that service members who have been sexually assaulted and their families need and deserve. We have treatment strategies that can relieve suffering and heal relationships. We have trained clinicians working within the VA and in surrounding communities who have the requisite skills to accurately assess those who present with symptoms related to sexual trauma. We must allow our trained clinicians to make these determinations so that the veterans who have suffered these acts of betrayal and violation are able to reclaim and rebuild their lives.