Congressional Testimonies & Current Issues

STATEMENT OF CHRISTINA ROOF
Optimizing Care for Veterans with PROSTHETICs
MAY 16, 2012: Before the House Veterans Affairs Committee


Chairwoman Buerkle, Ranking Member Michaud and distinguished members of the subcommittee, I would like to extend my gratitude for being given the opportunity to share with you my views and recommendations at today’s hearing regarding the Department of Veterans Affairs Prosthetic and Sensory Aid Services, and how we can all work together in Optimizing Care for Veterans with Prosthetics.

To fully understand the magnitude of what we are about to discuss, we must start by examining the statistics of our returning servicemembers, as well as forecasting what their needs will be. As the face of warfare has so drastically changed during recent conflicts, so have the injuries servicemembers are sustaining and thankfully surviving. Injuries that would have been fatal 20 years ago are now being treated and survived through advances in military field medicine. In the decade since the Sept. 11, 2001 terrorist attacks, 2,333,972 American military personnel have been deployed to Iraq, Afghanistan or both, as of Aug. 30, 2011 according to the Department of Defense (DOD). Of that total, 1,353, 627 have since left the military and 711,986 have used VA health care between fiscal year 2002 and the third-quarter fiscal year 2011.

Currently, 58.2 percent of those still currently in uniform have served a deployment or multiple deployments since 9/11. These are the same men and women that will turn to VA after their service. These men and women, approximately 800,000 servicemembers, will transition back into civilian life over the next several years. It is of the utmost importance that VA be prepared and equipped with only the finest personnel, prosthetics and technology to care for these men and women.  As a nation, we must be able to ensure that when our wounded warriors return from the battlefield, they will have access to the highest quality of care possible.

As previously stated, recent conflicts have given way to a surge in the survival of physical injuries such as, but not limited to, amputations, hearing and sight loss, spinal cord injuries and brain injuries; all conditions which will be treated by or provided resources from the Veterans Health Administration (VHA), more specifically Prosthetic and Sensory Aid Services (PSAS).

When someone thinks of prosthetics, they usually think of a prosthetic arm or leg. Which is correct, however prosthetics encompasses so much more. I believe the simplest way to describe the care and services PSAS provides, is to say if something is in a veteran (surgical), on the veteran, or for a veteran, it falls under the responsibilities of the PSAS department. For example, items such as: prosthetic limbs, surgically implanted devices, such as heart valves, specialized footwear for diabetics, walking canes, eye glasses, wigs, wheelchairs, hearing aids, Service and Guide Dogs and thousands of other items or services needed to ensure only the highest quality of care to our veteran community will be provided through PSAS.  

Astoundingly, the number of veterans requiring the services and care of PSAS has risen from 25 percent to nearly 50 percent over the past five years. When compared to the total growth in the number of veterans seeking care from every other VHA department, which is about 13 percent, PSAS has grown by more than 78 percent during the time same period. PSAS also saw a huge growth of approximately 1,800 percent in the number of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) women veterans under their care from 2005-2009. This number is projected to steadily rise with our continued involvement in Afghanistan until 2024 and our presence in Iraq or Operation New Dawn (OND).

It is a known fact that VA has long been a leader in the development of new prosthetics and groundbreaking research. Over the past several years, VA’s prosthetic development has revolutionized the way in which prosthetics work around the world. However, with these new prosthetics and medical advances also come new challenges for VA and PSAS, including ensuring that prosthetists, both inside the VA and those with whom the Department contracts, have the skills and proper training to service these new devices. If we are to optimize prosthetic care, we must ensure the credentialing, training and abilities of the PSAS personnel tasked with treating veterans.

That being said, I believe an issue hindering PSAS and veterans equal access to care, is what I believe to be a broken qualification standards and credentialing for prosthetic orthotic professionals. This lapse in uniformed standards across the nation are hurting veterans’ access to quality and timely PSAS care and services. Currently, VHA has established requirements for VA prosthetists and orthotists, and the position requirements vary by General Schedule (GS) grade level. Certification is required at the GS-12 grade level or above. However, many times these prerequisites for credentialing are not properly enforced. While OIG was able to verify that all required prosthetists and orthotists staff in Regional Amputation Center (RACs) and Polytrauma Amputation Network Sites (PANS) were certified according to VA policy in their March 2012 report, I have serious concerns as to whether or not all other PSAS departments around the country are adhering to the same requirements for their prosthetists and orthotists staff.

Furthermore, in regards to women veteran’s care there is also a distinct lack of certified mastectomy fitters in the VA.  There is actually a shortage of fitters and technicians throughout the system.  These broken qualification standards are the reason for this.  They do not allow medical centers to properly recruit and retain qualified individuals into these roles.  The government needs to maximize an individual’s function.  Having a certified prosthetist orthotist fitting shoes is not an efficient use of that clinical practitioner’s time.  VA should have the ability to hire GS 5/6/7 fitters and technicians to accomplish this work and free up certified prosthetists and orthotists to do more direct patient care to maximize a Veteran’s function and independence.

I urge PSAS to immediately develop and implement uniformed qualification standards that shall encompass all areas of orthopedic and prosthetic care, beyond the GS level. I would further recommend regular continuing education and credentialing verifications to accurately verify that the prosthetists and orthotists treating our severely disabled veterans are providing cutting edge, quality care to every single veteran they care for.

Amputations are another injury PSAS serves as the primary care and rehabilitation providers. According to the Defense Manpower Data Center, the numbers below illustrate the number of amputations sustained during service, as of November 2011.

  • There are 1,286 service members who are now amputees as a result of the Iraq and Afghanistan wars.

  • In 2011, 240 deployed troops had to have at least an arm or a leg amputated, compared with 205 in 2007, the height of the surge in Iraq, according to data published by the Armed Forces Health Surveillance Center.

  • The increase in 2011 coincides with the surge of troops in Afghanistan, who often dismount on foot patrols in the country’s austere and rugged terrain.

Troops wounded in Iraq and Afghanistan also have suffered the loss of multiple limbs — of the 187 service members with major limb loss in 2010, 72 of them lost more than one limb, according to the report from the Army’s Dismounted Complex Blast Injury Task Force.

While the number of veterans having sustained a battlefield amputation has steadily risen, it is also very important to remember that PSAS not only cares for those veterans having sustained battlefield amputations. They also perform and care for thousands of veterans every year who undergo amputations related to other medical issues while already under VA care. This can be due to a number of medical issues, such as diabetes or infection.

For example, in FY 2011, 6,026 veterans underwent an amputation, with 2,248 having major amputations. Of the 6,026 veterans, 107 (1.8 percent) were female and 24 of the 107 women were veterans of OEF/OIF/OND.  The chart below provided by VA OIG in March 2012 shows the distribution of amputations performed at all VA facilities in FY 2011.


Regardless of the cause, PSAS is tasked with providing and caring for all amputees  and that is why they must get it right for every veteran amputee they care for.

This is another issue in which I believe PSAS could be more effective and improve their care models, specifically speaking to female amputees. The number of women veterans utilizing PSAS has continued to rise over the past five years. From FY07 to FY11, the number of items provided to female veterans rose 191% from 638,000 to nearly 1.9 million. With that in mind, VHA decided to update VHA Handbook 1330.01 in 2010 to reflect this change. VHA Handbook 1330.01 as amended states:

“Women Veterans Program Manager (WVPMs) need to work closely with the Prosthetics Service and Supply, Purchase and Distribution Department to ensure that supplies specific to women’s health are properly stocked, easily requested, and provided in a timely manner (e.g., intra-uterine devices (IUDs), breast pumps, compression stockings, etc.).”

While I absolutely agree with this part of the amended handbook, I also believe that this handbook and several other internal publications still fall short when outlining the policies and procedures that guide the care of VA’s female amputee population. I strongly recommend that PSAS immediately adapt several policies, as well as the limb prosthetics they purchase to better fit and meet the needs of women veterans undergoing care for amputations.

While I can give my recommendations to this committee, I felt that it would be more appropriate for an actual female double amputee to share her concerns with you regarding this issue. A very close friend of mine, Sue Downes, lost both of her legs in Afghanistan when multiple Improvised Explosive Devices (IEDs) hit her convoy in the winter of 2008. Sue was the only survivor in her Humvee that day.  Sue is the first woman double amputee from the war in Afghanistan. She is resilient to say the least and has a sense of dedication to country and her fellow soldiers like I have never seen before. Sue survived her grueling eight hour ordeal in Afghanistan and was transferred to Germany to be stabilized and then to Walter Reed Medical Center where she and her family would spend the next 20 months. Army doctors told Sue, that she most likely would be confined to a wheel chair for the rest of her life.  However, Sue was a wife and is a mother of two young children, thus she told the doctors, that was simply not an option and she would walk. Given the fact that Sue was the first female soldier double amputee the hospital and staff struggled to find prosthetics legs that would correctly fit and support her female frame. Up until this time, the Department of Defense (DOD), and most VA facilities, had become accustomed to treating, individualizing and fitting male amputees and thus only had the equipment and experience fitting our male wounded warrior amputees. This was a milestone for both DOD and VA. They now needed to be changed to meet the needs of America’s new returning wounded warrior amputees- women.

While, VA PSAS does provide the world’s leading limb and prosthetics care and equipment, many women amputees I have spoken with strongly believe that their facilities in their VAMC’s PSAS departments, more specifically limb care and fitting, are still designed to primarily meet the needs of their male counter parts.

Sue told me that when she was first being treated at Walter Reed Army Hospital they made a statement to her, that it was very difficult to work with her injuries since her body was so different from a male when it came to prosthetics. Sue stated, “Our bodies are totally different than our male counterparts. So even though working with me was a challenge, we got through and actually helped the physicians start to master treating female double amputees.”

“I feel like that since I left Walter Reed I have had to fend for myself within the VA system. I live in a rural area of Tennessee and have to drive two hours each way for my prosthetics visits. Thus far, VA has yet to meet my needs in fitting my two prosthetic legs properly. While I have encountered several caring individuals from VACO PSAS since Christina Roof has become involved in my case, I still feel like I am not given the same care or respect as my male counterparts. I feel as though I am often yelled at because of certain female issues beyond my control. For example, I cannot help if I fluctuate in weight and that I retain water certain times of the month, causing my sockets not to fit properly. I feel like I always have to “beg” for new fittings because I’m constantly changing in volume and water weight in my legs.”

Sue continued, “I can’t shave what legs I have left either. It is embarrassing and prevents me from wearing anything other than long pants. I am not going to walk around with hairy legs. As a female double amputee life is hard enough, the fact that I just want to feel like a normal woman should not be too much to ask. So, if VA PSAS does not want women amputees to shave their legs then maybe they could provide us laser hair removal treatments. I am not asking for special treatment, I am just asking to feel as normal as possible. As far as the types of prosthetics go, yes I would like to look like I have normal flesh colored legs, instead of two metal rods. Again, I just want to look as normal as possible, so my kids do not have to answer questions to schoolmates about why their mom has metal legs. I love my country and would do it all again, but I, we, have sacrificed for our country and would at least like somewhat of a normal life back. Is that too much to ask? Yes, to women looks matter. My image and outer appearance means a lot to me as a strong woman. While I have recently received a pair of much better legs, I really just want a single pair of cosmetic legs. However, every time I ask my VA PSAS department they tell me that it will cost too much and to just “make due” with what they have already given me.”

Sue is not alone in feeling as if not all of her needs as a woman amputee are being met. I have spoken with several women who are encountering the same types of issues. I cannot say whether these problems are due to a lack of education at the individual VAMC level, problems in credentialing or purchasing, or purely a funding problem. Whatever the cause may be, I sincerely ask this committee to immediately examine and take actions on what can be done to meet the needs of our women amputee wounded warriors.

A problem I also believe to be hindering the optimization of every veteran under PSAS for an amputation is the lack of “Complete Patient Centered Care”. What I mean by this is, that I believe veterans receiving care for amputations are not treated as a “whole” person needing assistance in multiple areas, but rather are treated in a more reactionary way by individual departments who might not always share information with each other. While I am aware of and applaud VA’s initiative calledPatient Aligned Care Teams” (PACT), however VA has been very slow to implement this initiative even in their pilot sites, and I also believe that this is a model of care that must be integrated into the care of all veterans, not just amputees. That being said, I will keep my comments focused on amputees today.

Amputees are a special population of veterans and usually have more medical complex medical needs than other non-amputee veterans have. This being said, the current broken system of often-reactionary care has caused many problems and unnecessary stress for the veterans already having to deal with the loss of a limb. While I understand that several VAMCs are utilizing this team approach to a veterans care, I strongly believe that all severely disabled veterans need to have the option of receiving this team approach, regardless of location. If we are truly to optimize a veterans quality of health care, we need to ensure that veterans in all parts of the country have access to the same care approaches, such as the team approach.

Veterans having sustained a single or multiple amputations will need far more than simply “limb” care. This group of veterans will have very complex medical needs that need to be addressed and treated in conjunction with all other medical care they are receiving. For example, an amputee will have most likely suffered a Polytraumatic Injury and will need much more assistance and guidance than other veterans will. This will range from medical care coordination between an army of doctors, social workers and care providers. This may include, but is in no way limited to, people such as a Neurologist for the treatment for Traumatic Brain Injuries (TBI), Plastic Surgeons to repair physical wounds and skin grafts for burns or limb re-construction, Psychiatrists and Psychologists for mental health care, Social and Case Workers to inform the veteran about their eligibility for benefits such as clothing allowances, home adaptations and so much more. This is why I believe it to be critical that VA PSAS, and VA as a whole, start treating the entire veteran in a proactive manner, instead of treating the veteran by individual symptoms and needs that may arise. Each veteran receiving care for an amputation should be assigned a dedicated “Care Team” that meets on regular basis to discuss the veterans care and treatments by each of the individual physicians and care providers assigned to the veterans “Care Team.”  This is a very simple and cost free way of ensuring every veteran undergoing care for their amputations and related medical issues will receive the highest quality of coordinated care VA has to provide.

This “Care Team” should be composed of the veterans PSAS representative, social worker and every physician who regularly treats the veteran.  This will help ease the stress the veterans experience trying to remember to tell their different doctors about something they learned from another doctor, will greatly improve the quality and safety of the care the veteran receives and will provide the highest quality of coordinated care VA has to offer.

Another issue we must revisit, is the issue of timely access to quality prosthetics care and services. I strongly believe that access to PSAS care, services should be a top priority for VA, and that overall PSAS has done an outstanding job developing several new methods to meet the needs of today’s veteran population, I also believe that there are several factors actually hindering a veteran’s access to timely and quality PSAS care and internal hurdles PSAS staff must overcome every day in order to meet the most basic of today’s veteran’s needs. In order to optimize the PSAS system of care and internal issues there must be several changes addressed immediately.

An issue hindering a veteran’s timely access to PSAS care and services is the fact that VHA has not established, nor does it maintain any system of national patient records or the physician’s original corresponding request to PSAS. I believe this not only negatively affects the veteran, but also poses a threat to the integrity of VA’s purchasing policies and procedures.

The lack of a centralized tracking and data exchange system available to physicians and purchasing agents simply hinders a veteran’s timely access to care. Moreover, due to fragmented patient records, veterans may not receive the care they need should they have to visit any VA Medical Center (VAMC) or Community-based Outpatient Clinic (CBOC) other than their home VAMC or CBOC. For example, if a veteran utilizing a wheel chair is on vacation or on travel for their job, and the wheel chair requires immediate assistance or service from PSAS, the veteran will most likely encounter bureaucratic obstacles at the nearest PSAS department as result of the missing PSAS data exchange system. This same fragmentation puts veterans at a high risk in the event of an emergency.  Whether it is another Hurricane Katrina, or even a snowstorm in Buffalo, VHA’s lack of a national record and request system means that a veteran’s order cannot be processed if those local employees that are unable to get to work.  Moreover, if veterans are displaced, there will be a substantial delay in replacing essential equipment.  This is a simple IT solution that VHA has no ability to execute due to the centralization of VA’s IT.

A recent OIG report found that Prosthetics was lacking some basic inventory controls, but this too indicated a lack of appropriate IT resources to have a modern inventory system to track and monitor stock and reorder levels.  This extends out to surgical implants where there is a high risk of expiration- costing VA millions of dollars and possibly veteran lives. 

VA’s issue, negatively affecting PSAS, associated with not having a comprehensive modern inventory solution goes back to the calamity of the Core Financial and Logistic System (Core FLS) programs, and more recently the abandoning of Financial and Logistic Integrated Technology Enterprise (FLITE) and Strategic Acquisition Management (SAM) programs.  Although VHA is trying to salvage some aspects of these programs, any real implementation is several years away. I urge VA to act swiftly on developing a data exchange system for the use of PSAS personnel to avoid a potentially large backlog where veterans would be unable to obtain the immediate resources and care provided to them by VHA PSAS.

Currently, VA has no way of tracking vital information on patients’ care and purchasing orders, thus opening themselves up to potential fraud and abuse, and the inability to provide the highest quality care to the veterans they serve. The inability to provide all veterans equal access to care through centralized purchasing units—instead of the current fragmented paper copy system—also prevents PSAS from maximizing efficiencies.

Over the past couple years, VA has been moving to professionalize the acquisition workforce and adhere to archaic federal acquisition laws and regulations, none of which were written with an individual’s health care needs in mind.  It is my understanding that VHA has concluded a pilot to move procurements from the Prosthetic and Sensory Aids Service to VHA Procurement for those items over the micro purchase threshold.

I implore the committee to make it clear to VA that not only do they have the authority to procure outside of Federal Acquisition Regulations (FAR)- 38 USC 8123- they have a duty to do so to ensure that our veterans are provided the most appropriate devices in the most expeditious manner possible.  We have slowly begun to hear rumors of delays where veterans, even those most at risk such as amputees, spinal cord injuries, and those with ALS (Amyotrophic Lateral Sclerosis) are having their life critical devices held up in a bureaucratic nightmare.  Congress and VA must recognize a clinician’s autonomy and ability to prescribe what is best for that individual veteran. 

While VA’s Senior Procurement Executive has repeatedly touted a new Strategic Acquisition Center, the fact remains that this is simply in addition to the National Acquisition Center, the Denver Acquisition Logistics Center, and the Technology Acquisition Center.  At the department level, VA seems to be building a substantial level of duplication, all in an attempt to standardize prosthetics procurement for veterans. Duplications of efforts are not the fiscally responsible way to run any federal agencies, nor is it helpful in optimizing a veterans care and access to PSAS services. 

However, when this executive is asked, the Department will state that this is not meant to reduce the ability to give veterans the most appropriate items, their actions run contrary in that without these contracts, VA is forcing these orders to be competed.  Even within a given contract award, there is a push for procurements to be distributed amongst all awardees.  This means there is still a complete lack of respect for a veteran and their clinical team’s decisions. These inefficient practices must immediately be addressed and corrected, if we wish to provide timely and quality access to PSAS services for our veteran community.

Finally, a large problem that poses a hurdle to care to veterans requiring PSAS resources is the location and availability of resources to veterans living outside of major metropolitan cities. Over 4 million of the veterans enrolled in the VA Healthcare System live in rural areas. There is an overwhelming national misconception that all veterans in need of PSAS  have equal access to the comprehensive care and other programs provided by VHA’s PSAS.  Unfortunately, this is not true. Access to the most basic primary care is often difficult in rural America, let alone the extensive individualized care that accompanies amputations or other serious conditions in which PSAS would provide care. Currently, PSAS does not have the necessary prosthetic or orthotic professionals in-house needed to meet the demand for services by the veterans’ community. This is especially true for veterans living in rural areas. Some veterans have to drive hours for something as simple as getting their prosthetic limb adjusted or for physical rehabilitation. PSAS has approximately 600 contracts with local vendors across the nation to provide care closer to home for these rural veterans. However, as VA moves to their new procurement model, I am sincerely concerned that when a veteran has a unique situation, or medical need, requiring the services of a vendor not on contract with PSAS that this will no longer be an option under this new model of care where PSAS procurements are accomplished through VHA’s acquisition service.  I concur with the IG’s recent report on limb procurement that VA needs to assess its internal capabilities and determine the correct number of contracted vendors to have in a particular area.  This should not preclude a Veteran from being able to utilize a vendor not on contract when that Veteran has a unique medical need or lives in an extremely remote area.  I believe strongly in the authority granted PSAS by Congress in 38 USC 8123.

Alarmingly, a 2006 study of the Carsey Institute reported that the death rate for rural veterans is up to 60 percent higher than the death rate of veterans residing in urban areas. Given the difficulties that already accompany being an amputee then couple it with the multiple obstacles rural veterans often face in their efforts to receive medical and PSAS care is resulting in many veterans missing appointments or foregoing care for a number of reasons beyond the long distances they must travel.  VA has stated that over 50 percent of the veterans they treat live in areas of the country they consider to be “remote” or “highly rural”. This statistic alone should be more than enough of a reason to establish a better system of care of locations were that care can be received.

I do however applaud several VAMCs PSAS departments who are actively seeking out and treating rural veterans. For example, PSAS teams from Colorado and Wyoming have established a Prosthetic Treatment Center Mobile Laboratory. According to VA “A certified Prosthetist-Orthotist will travel to rural areas in Colorado and Wyoming in a van equipped with a mini prosthetic-orthotic fabrication laboratory, computer assisted design and manufacturing capabilities, and telehealth equipment. This program will bring expertise in high end-orthotics and in prosthetic fabrication and fitting to rural Veterans, and the van will be used for tele-consultations with prosthetic and orthotic rehabilitation specialists, the Amputation Rehabilitation Coordinator, podiatrists, and wound care specialists from the Denver VAMC. This mobile laboratory will provide rural Veterans with access to the Regional Amputation System of Care (RAC) based in the VA Eastern Colorado Health Care System. This mobile laboratory will provide a more consistent standard of care for rural veterans than is currently possible with community vendors.”

I would lastly like to note that PSAS has been under “acting leadership” for nearly a year and a half.  A department offering services of this magnitude cannot hope to improve the services they provide to to veterans as long as they are languishing without a leader to provide the proper direction.  Prosthetics needs to have a senior leader appointed as soon as possible. I believe this leader should at minimum be currently serving at the Chief Consultant level, if not Chief Officer given the unique nature of the program and it's far reaching, significant impact it has on all veterans, especially our most vulnerable veterans with severe disabilities.

In closing, the current conflicts, along with an aging veteran population and tighter budgets have placed VA PSAS under tremendous strain.  Congress and VA have both made an effort to ensure that the budget for medically prescribed devices is substantial enough to ensure that veterans receive the highest quality devices.  Unfortunately, many at VA seem to be devolving themselves into a bureaucracy where the people who were successfully procuring prosthetic items are no longer going to be involved.  VA PSAS has IT systems that are woefully out of date, placing veterans at risk for not receiving their required care, while also putting VA at risk for increased fraud, waste and abuse.  High-risk populations, such as rural and women veterans, continue to be the ones in danger of not receiving the care they have earned through their selfless service.  Congress has already recognized that federal procurement laws and regulations do not always work for the personalized health care many of our most severely disabled veterans require.  I beseech you to ensure VA respects the autonomy of their physicians and the preferences of veterans by continuing to use 38 USC 8123 to provide medically prescribed devices to veterans in the most efficient way possible. I also urge this subcommittee to have the strictest of oversight to ensure VHA PSAS is provided with the necessary resources to develop and implement a national prosthetics record, a modern inventory system and the clinical and administrative staff required to properly support our veterans and optimize their prosthetics care.

Madam Chair, and distinguished members of the subcommittee, I would like to again thank you for inviting me to share my views and recommendations on this critical matter with the subcommittee today.   I stand ready to address any questions or concerns you may have for me. Thank you.  

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STATEMENT OF CHRISTINA ROOF (AMVETS)

HEALING THE WOUNDS: EVALUATING MILITARY SEXUAL TRAUMA ISSUES
May 2010

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).

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% of today’s military forces and more recently DOD has indicated that number has grown to approximately 18 percent, and within the next 10 years this number is expected to nearly double. If those estimates hold true than upwards of 30% 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% 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% of the women currently enrolled in the VA health care system, 46% 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% 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%) were returned. Most of the veterans had at least some college education and about 50% served 4 or more years on active duty. About 68% of the respondents reported at least one form of victimization, while 27% 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. [1]

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.,[2] 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.,[3] 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.[4] 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.[5]  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.

  1. 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.

Thank you again for giving AMVETS the opportunity to share with you our thoughts and recommendations on Military Sexual Trauma care within VA. AMVETS applauds the subcommittees dedication and actions to this very important, and often overlooked,  issue. This concludes my testimony and I will be happy to answer any questions the subcommittees may have for me.



[2] 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.
[3] 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.
[4] 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.
[5] 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.




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