EIGHTEEN

The Veterans Health Administration Response to Military Sexual Trauma

MARGRET E. BELL AND SUSAN J. MCCUTCHEON

The Department of Veterans Affairs’ (VA) mandate to address the issue of sexual assault and sexual harassment during military service dates to 1992, when legislation was first passed authorizing the Veterans Health Administration (VHA) to establish “counseling” services for women Veterans who had experienced “physical assault of a sexual nature, battery of a sexual nature, or sexual harassment” while on active duty. A key impetus for this legislation was a series of Congressional hearings held earlier in the year in which female Veterans described experiences of sexual assault and harassment during their military service and provided emotional testimony about how these experiences had impacted their lives. One major concern raised during the hearings was the difficulty that these and other Veterans encountered in finding healthcare services to assist them in their recovery.

Later legislation expanded VA’s authorization to include treatment not only of mental health conditions secondary to a Veteran’s experiences of what came to be called “military sexual trauma,” or MST, but also physical health conditions. Services were also authorized for men who had experienced MST; the definition of MST was expanded to include experiences while on active duty for training (for example, boot camp) and inactive duty training (for example, weekend drill); and some of the initial restrictions on eligibility and duration of treatment were removed.

As we will detail in this chapter, Veterans who need help in recovering from experiences of MST encounter a very different landscape in 2014 than they did 20 years ago. Nonetheless, stories from those original hearings in 1992 serve as a poignant reminder of the crucial role that VHA plays in assisting both female and male Veterans who have experienced MST. After reviewing background information about definitions, prevalence, and associated conditions among VHA users, this chapter will provide an overview of the MST-related treatment services available through VHA, as well as its extensive staff education, Veteran outreach, and access to care efforts.

During her deployment to Iraq, Kristen prided herself on her ability to keep up with the guys and told herself that all the jokes about her sleeping around, laughing requests for her to perform sexual acts on others, and comments about her body were just part of being “one of the gang.” One night, her Commanding Officer (CO) called her into his office and ordered her to stand watch in the hallway while he met with another female Service member. Kristen could hear him make sexual advances to the woman, and then heard the woman’s verbal and physical attempts to resist, but felt unable to intervene when she eventually heard her CO force the woman to have sex with him. Afterward, her CO dismissed her without any comment about what had happened in his office. However, in the days to come, he would make offhand remarks to Kristen about how he might need to “schedule a night meeting” with her in his office. Since then, she’s felt jumpy and on edge all the time, and chronically worries that she’s in danger. She also has had difficulty trusting others, meaning that she has few close relationships and struggles with significant symptoms of depression. Knowing that a friend received treatment at VA for problems related to MST, Kristen called her local facility after her discharge and asked to speak to the MST Coordinator to learn more about services available.

Jonas was leaving a club one night when he was suddenly surrounded by a group of men. One of them threw a blanket over his head while the others began kicking and beating him. Although he collapsed to the ground in pain, one of the men jerked his body upward and forced him to perform oral sex on him. In the days and months following the assault, Jonas’s work performance declined, he began isolating himself from others, and he was disciplined several times for aggressive behavior. Out of shame and fear of how others might react to hearing about the sexual assault, he came up with various excuses to explain away his behavior. Since leaving the service he has had a hard time keeping a job, and symptoms of post-traumatic stress disorder (PTSD) and depression have greatly circumscribed his life. Finally, 10 years following his discharge, his wife threatened to leave him because of his drinking and behavior at home. Because of this pressure, Jonas went to VA for help. At his first visit, his healthcare provider screened him for MST; Jonas sat quietly after hearing the question, but eventually nodded his head “yes.” The provider and Jonas talked further about how his experience of MST might be contributing to his current difficulties, and discussed what services might best help him in his recovery.

“Military sexual trauma,” or MST, is the term used by VA to refer to experiences of sexual assault or repeated, threatening sexual harassment that a Veteran experienced during his or her military service. The definition used by VA comes from federal law (Title 38 U.S. Code 1720D) and is “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.” Sexual harassment is further defined as “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.”

MST includes any sexual activity during military service in which a Service member is involved against his or her will—he or she may have been pressured into sexual activities (for example, with threats of negative consequences for refusing to be sexually cooperative or with implied better treatment in exchange for sex), may have been unable to consent to sexual activities (for example, when intoxicated), or may have been physically forced into sexual activities. Other experiences that fall into the category of MST include unwanted sexual touching or grabbing; threatening, offensive remarks about a person’s body or sexual activities; and threatening and unwelcome sexual advances. The identity or characteristics of the perpetrator, whether the Service member was on or off duty at the time, and whether he or she was on or off base at the time do not matter. If these experiences occurred during an individual’s military service, they are considered by VA to be MST.

In 2000, VA established a universal screening program in which every Veteran seen for healthcare is asked whether he or she experienced MST. National data from this program reveal that about 1 in 4 women and 1 in 100 men respond “yes,” that they experienced MST, when screened by their VA provider (Military Sexual Trauma Support Team, 2013). Although rates of MST are higher among women, because there are so many more men than women in the military, there are actually significant numbers of both women and men seen in VA who have experienced MST. For example, among Veterans seen for VA healthcare in fiscal year 2012, 72,497 women and 55,491 men reported experiencing MST (Military Sexual Trauma Support Team, 2013).

MST is an experience, not a diagnosis or a mental health condition, and as with other forms of trauma, there are a variety of reactions that Veterans can have in response to MST. Among Veterans seen in VA, the mental health diagnoses most frequently associated with MST are PTSD, depression and other mood disorders, and substance use disorders. Veterans who have experienced MST also often commonly experience physical health problems secondary to their experiences of MST (Kimerling, Gima, Smith, Street, & Frayne, 2007) and/or difficulties with issues like homelessness (Pavao, Turchik, Hyun, Karpenko, Saweikis, McCutcheon, et al., 2013).

Although MST has also been the subject of much attention from the Veterans Benefits Administration (VBA), which administers VA’s disability compensation and other related benefits, in this chapter we focus on VA’s MST-related initiatives and policies specific to healthcare services. This is the domain of the Veterans Health Administration (VHA).

Screening and Treatment Services

Kristen and Jonas both decided to participate in VHA’s outpatient mental health services to help with their recovery. Kristen quickly established a strong working relationship with her therapist, and was able to discuss how her experiences of MST had affected her beliefs about others, herself, and the world. She pushed herself to join some local community groups in order to meet other people with similar interests, and over time, she began to expand her network of friends and her engagement in activities that were meaningful to her. She eventually discontinued individual therapy, but continued to participate in group therapy at VA to assist her in applying the skills she’d developed in individual therapy.

After being sober for a year, Jonas decided he was ready to confront his memories of MST, but he felt afraid he would “fall apart” if he did so. His therapist and he agreed that it would helpful for him to participate in one of VHA’s residential treatment programs, and to engage in this trauma-processing work while he had the support and structure of the residential environment. After some time spent learning additional coping strategies that he could draw upon to manage emotional distress, Jonas completed 12 sessions of Cognitive Processing Therapy and experienced a significant reduction in his symptoms of PTSD. He returned home and resumed outpatient mental health treatment to help him consolidate his gains from his time in the residential program. He also decided to begin physical therapy to improve the strength in his left knee, which had been injured during the physical violence involved in his experience of MST.

Recognizing that many survivors of sexual trauma do not disclose their experiences unless asked directly, it is national policy that VA healthcare providers ask every Veteran whether he or she experienced MST. This is an important way of ensuring not only that healthcare providers know to adapt their care to be sensitive to a given Veteran’s history of sexual trauma, but also that Veterans know about the services available to them. This effort to streamline access to services is visible in VHA’s MST-related policies more generally, which eliminate many potential barriers to accessing care. For example, all care related to a Veteran’s experiences of MST is provided free of charge. This includes care for both mental and physical health conditions, whether provided via outpatient, inpatient, residential, or pharmaceutical modalities. To receive this free treatment, Veterans do not need to have reported the incident(s) when they happened or have other documentation that they occurred; they also do not need to be service connected (that is, have a VA disability rating). There are no length of service requirements, meaning that some Veterans may be able to receive this benefit even if they are not eligible for other VA care. Pre-military trauma and pre-existing conditions do not impact eligibility for MST-related care.

Further reducing potential barriers to care, MST-related services are available at every VA healthcare facility, and every facility has a designated MST Coordinator who serves as a point person for MST-related issues and who can assist Veterans in accessing care. Typically, MST-related care for physical health conditions is provided through VHA’s general and specialty medical clinics. There is more variability in how facilities have outpatient MST-related mental health services organized, with some facilities providing this care through identified “MST clinics” and others providing it in a more distributed fashion, integrating services into General Mental Health, PTSD, and other clinics. Community-based Vet Centers, which provide counseling services in a non-hospital environment, also have specialized MST-related services available. Complementing these outpatient services, VA has mental health residential rehabilitation and treatment programs and inpatient mental health programs to assist Veterans who need more intense treatment or support. Some of these programs focus specifically on MST or have specialized MST tracks.

VHA’s MST-related mental health services are designed to meet Veterans where they are in their recovery from MST, whether that is focusing on strategies for coping with emotions and memories or, for Veterans who are ready, actually talking about their MST experiences in depth. This is consistent with national VHA policy that mental health services be provided in a Veteran-centric, recovery-oriented manner. Similarly, Veterans are welcome to ask to meet with a provider of a certain gender, if they think this would facilitate their engagement in treatment.

Staff Education

In 2006, program responsibility for MST was transitioned from VHA’s national Women’s Health program office to its Mental Health Services (MHS) program office, in recognition that both women and men experience MST. That same year, MHS funded a national MST Support Team. Among its responsibilities, the Team is specifically charged with coordinating and expanding national MST-related education and training, as well as providing resources, technical assistance, and consultation to promote best practices in treatment and clinical programming. For example, the Team hosts monthly continuing education calls on MST-related topics that are open to all VA staff and are available online afterward; there are typically upward of 190 attendees on these calls. Since 2007, the MST Support Team has hosted an annual conference focused on MST-related program development. It also maintains the MST Resource Homepage, a VA intranet Community of Practice website where VA staff can access MST-related resources and materials and participate in MST-related discussion forums.

Also prominent among VHA’s educational initiatives related to MST is the mandatory training requirement for mental health and primary care providers. Since 2012, all mental health providers are required to either complete a web-based training that provides a comprehensive review of issues relevant to provision of mental healthcare to MST survivors or pass a knowledge assessment that demonstrates significant pre-existing expertise in mental health issues related to MST. Primary care providers must complete a web-based training that reviews a range of issues including health conditions associated with MST, screening sensitively for MST, how MST can affect a Veteran’s experience of healthcare, how to appropriately adapt care to address the needs of MST survivors, and VA documentation requirements.

In addition to this mandatory training requirement for mental health and primary care providers, MST Support Team training initiatives have also targeted chaplains, Veterans Crisis Line staff, clerks and telephone operators, staff charged with assisting newly discharged Veterans, and other groups to ensure that all staff have the knowledge they need to provide sensitive, informed assistance to Veterans who have experienced MST. The Team has also sought to have information about MST included in non-MST-specific training initiatives such as Mental Health Services’ national rollouts of empirically-based psychotherapies. Many of the conditions targeted by these rollouts are strongly associated with MST, meaning that these national rollout initiatives have been an important means of expanding MST survivors’ access to cutting-edge treatments. Furthermore, several of these treatments were originally developed in the treatment of sexual assault survivors and have a particularly strong research base with this population.

Complementing these national offerings, at a local level, MST Coordinators and others host grand rounds and other educational presentations, distribute informational materials, provide clinical consultation, and engage in other training activities.

Veteran Outreach and Access to Care

Equally important to ensuring that specialized services are available and that staff are knowledgeable about Veterans’ MST-specific needs is ensuring that Veterans are aware of and able to access services.

VHA’s universal screening program noted earlier is one important means of disseminating information and connecting Veterans with appropriate services. The MST Support Team also has developed national outreach posters, handouts, and educational documents for Veterans, has secured inclusion of information about MST on relevant va.gov websites, and has developed an MST-specific website (www.mentalhealth.va.gov/msthome.asp). MST is also one of the topics included in VHA’s innovative “Make the Connection” (www.maketheconnection.net) website, which features videos of Veterans sharing their stories of recovery from mental health difficulties. VHA has also worked closely with the Department of Defense to disseminate information about VA’s MST-related services to Service members leaving active duty and otherwise ensure a seamless transition to VA care.

At a local level, MST Coordinators engage in a range of efforts to raise awareness of MST-related services, including disseminating outreach materials throughout their facility, participating in community events, connecting with local military installations and community organizations, and integrating information about MST into facility outreach efforts more generally. Although these outreach efforts occur throughout the year, MST Coordinators also often capitalize on Sexual Assault Awareness Month (SAAM) as an opportunity to raise general awareness, among both Veterans and staff, about MST.

In addition to these outreach efforts, facility MST Coordinators are charged with addressing systems issues that might create barriers to care; they also directly assist, as needed, individual Veterans in accessing services. Recognizing that frontline staff often also play a key role in Veterans’ ability to access care, the MST Support Team has developed an “Answer the Call” campaign to verify that Veterans calling VA medical centers with MST-related questions can reach the facility MST Coordinator. As part of this campaign, members of the Team conduct test calls to VA medical centers to confirm that telephone operators and clinic clerks are familiar with the terms “military sexual trauma” and “MST,” are readily able to identify and direct callers to the MST coordinator, and are sensitive to Veterans’ privacy concerns. The campaign provides an excellent platform for MST Coordinators to provide education about their role to a wide range of staff and to raise awareness about some of the unique barriers to care faced by Veterans who have experienced MST.

Many Veterans show incredible resilience after experiences of trauma, including after experiences of MST. Not all will need or want treatment, but it is crucial that there are easily accessible, specialized services available for those who do. VHA has helped ensure this is the case, by establishing treatment services with expansive eligibility, and widespread staff education and extensive Veteran outreach and access to care initiatives. Together, these efforts have created a comprehensive network of programs to ensure that all Veterans have access to specialized, tailored care to assist them in their recovery from MST.

Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne, S. (2007). The Veterans Health Administration and military sexual trauma. American Journal of Public Health, 97, 2160–2166.

Military Sexual Trauma Support Team. (2013). Military Sexual Trauma (MST) Screening Report, fiscal year 2012. Washington, DC: Department of Veterans Affairs, Office of Patient Care Services, Mental Health Services.

Pavao, J., Turchik, J. A., Hyun, J. K., Karpenko, J., Saweikis, M., McCutcheon, S., et al. (2013). Military sexual trauma among homeless Veterans. Journal of General Internal Medicine, 28(Suppl 2), S536–S541.