Supporting Survivors of Military Sexual Trauma: VA Must Redouble Efforts to Improve

Submitted Written Testimony

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.

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 on-site 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.

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

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.

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.

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.

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 twenty points in seven years, from 35.6 percent in fiscal year (FY) 2011 to 56.6 percent in FY 2018, while the rate for non-MST causes has hovered around 54 percent for several years, as shown in Figure 1.

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.

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.

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.

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.