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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

June 2014: 

Military Sexual Trauma: 

Improvements Made, but VA Can Do More to Track and Improve the 
Consistency of Disability Claim Decisions: 

GAO-14-477: 

GAO Highlights: 

Highlights of GAO-14-477, a report to congressional requesters. 

Why GAO Did This Study: 

In 2012, 1 in 5 female and 1 in 100 male veterans told VA that they 
had experienced sexual abuse in the military. Referred to as military 
sexual trauma or MST, such abuse can result in disabling conditions 
like PTSD, which may entitle a veteran to VA benefits. Yet, 
establishing that MST occurred-—a prerequisite for approving these 
claims-—can be difficult, given that servicemembers may be unwilling 
to file formal complaints. In 2002, VA broadened the scope of 
allowable evidence for MST-related claims to include indicators, such 
as behavioral changes. Beginning in 2011, VBA took additional steps to 
clarify the 2002 changes. GAO was subsequently asked to review these 
actions. 

This report examines: (1) steps VA took to improve MST-related 
decisions, (2) results of its actions, and (3) the extent it is 
evaluating the quality of claim decisions. GAO reviewed relevant 
federal laws, regulations, and guidance; analyzed VA data on MST-
related claim decisions (fiscal years 2010-2013); interviewed national 
VBA and VHA officials, key advocates, and stakeholders, VBA officials 
at 5 of 57 regional offices (with varying workloads and quality review 
scores), and VHA examiners associated with 3 of these offices; and 
reviewed a non-generalizable sample of 18 claim files completed in 
2013 for examples of how evidence was evaluated. 

What GAO Found: 

The Veterans Benefits Administration (VBA), within the Department of 
Veterans Affairs (VA), has taken several steps to improve decision-
making on disability claims involving military sexual trauma (MST) and 
to rectify past errors. In 2011, VBA began assigning MST-related 
claims to adjudicators with expertise in complex cases and required 
them to receive MST-specific training, such as on the broadened scope 
of evidence allowed since 2002. In 2012, the Veterans Health 
Administration (VHA) also provided some optional training to medical 
examiners who provide key input into decisions for such claims. Noting 
that some MST-related claims may have been erroneously denied prior to 
the specialization and training of staff, VBA in April 2013 invited 
2,667 veterans with denied claims for post-traumatic stress disorder 
(PTSD) to resubmit them. 

According to VBA data, national approval rates for claims based on MST 
have markedly increased since fiscal year 2010, a change that agency 
officials attributed to the additional training and a better general 
understanding of MST requirements. However, GAO found wide variation 
in approval rates among regional offices, which ranged from 14 to 88 
percent in fiscal year 2013. Half of the offices had approval rates 
close to the average (between 40 and 60 percent), but the rest were 
higher or lower. While variation does not necessarily signify 
inconsistency, staff GAO interviewed from four of five offices 
described ongoing difficulty applying the broadened standards, and GAO 
found several instances of widely varying interpretations. Both VBA 
and VHA staff also described variation in the thoroughness of VHA 
medical exams used by adjudicators to reach decisions. Some VHA 
medical examiners GAO spoke with required more evidence than others to 
establish that an MST incident occurred. VBA and VHA staff in almost 
every office GAO contacted said that further training would be useful, 
feedback that is consistent with good practices previously identified 
by GAO and others for reinforcing training. More recently, VHA has 
decided to make upcoming training on MST-related exams required for 
all medical examiners who conduct them. With respect to reviewing 
previously denied claims, VBA was only able to contact veterans whose 
claims had been denied since September 2010, although those with older 
claims can also resubmit. VBA's national outreach to other affected 
veterans was limited to two group meetings with veteran service 
organizations. 

While VBA has taken some steps to evaluate decisions for MST-related 
claims, its quality reviews and analyses of claim decisions have 
shortcomings. For example, a 2013 quality review focusing on 
consistency may under-estimate challenges associated with adjudicating 
MST claims. Also, due to varying methods and samples, quality reviews 
conducted to date are insufficient to measure improvement over time-—a 
standard part of internal control. In addition, while VBA analyzes 
data on national approval rates to gauge the effect of process 
improvements, GAO's analysis of approval rates by regional office and 
veteran gender found wide variation. VBA also does not systematically 
collect data on the number of exams received or why claims are denied—-
information that could help VBA identify potentially problematic 
trends. VBA officials said the agency's many competing priorities have 
precluded additional data collection and analysis to date, but added 
that they plan to review variations in approval rates in the near 
future. 

What GAO Recommends: 

GAO is recommending that VA improve training, conduct more outreach, 
and enhance its MST-related quality reviews and analyses. VA concurred 
with all of GAO's recommendations. 

View[hyperlink, http://www.gao.gov/products/GAO-14-477]. For more 
information, contact Daniel Bertoni at (202) 512-7215 or 
bertonid@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

VA Has Taken Several Steps to Improve Processing of Claims Related to 
MST: 

Since Improvements, Approval Rates Have Increased Nationally yet Vary 
Widely by Region: 

VBA Has Not Optimized Opportunities to Evaluate or Collect Information 
about MST-Related Decisions: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Text of Notification Letter Sent to Previously Denied 
Claimants: 

Appendix III: Comments from the Department of Veterans Affairs: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Figures: 

Figure 1: Disabilities Claimed in Relation to Military Sexual Trauma, 
Fiscal Year 2010 through Fiscal Year 2013: 

Figure 2: VBA's Disability Compensation Claim Process for PTSD Claims 
Based on Military Sexual Trauma: 

Figure 3: Training for VBA Adjudicators and VHA Medical Examiners 
Regarding Claims Related to Military Sexual Trauma (MST): 

Figure 4: Approval Rates for PTSD Claims Related to Military Sexual 
Trauma versus Other Stressors, Fiscal Year 2010 through Fiscal Year 
2013: 

Figure 5: Range of Regional Office Approval Rates for Claims Related 
to Military Sexual Trauma in Fiscal Year 2013: 

Figure 6: Number of Veterans Sent Notification Letters Regarding 
Previously Denied PTSD Claims Related to Military Sexual Trauma and 
Claims Resubmitted and Resolved between May 1, 2013 and March 26, 2014: 

Figure 7: Examples of Credible Supporting Evidence Needed to 
Substantiate that an In-Service Stressor Occurred by Type of PTSD 
Claim: 

Figure 8: Percentage of Claims Related to Military Sexual Trauma 
Approved for Males versus Females, Fiscal Year 2010 through Fiscal 
Year 2013: 

Figure 9: The Number of Claims Related to Military Sexual Trauma 
Completed, Received, and Pending, Fiscal Year 2010 through Fiscal Year 
2013: 

Abbreviations: 

DOD: Department of Defense: 

MST: military sexual trauma: 

PTSD: post-traumatic stress disorder: 

STAR: Systematic Technical Accuracy Review: 

VA: Department of Veterans Affairs: 

VBA: Veterans Benefits Administration: 

VHA: Veterans Health Administration: 

[End of section] 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

June 9, 2014: 

Congressional Requesters: 

Trauma resulting from sexual abuse while in military service--referred 
to as military sexual trauma (MST)--has recently gained attention as a 
pervasive and continuing problem among U.S. servicemembers. In fiscal 
year 2012, the Department of Defense (DOD) estimated that about 26,000 
servicemembers had experienced some form of unwanted sexual contact, 
an increase from about 19,000 in fiscal year 2010.[Footnote 1] At 
Department of Veterans Affairs (VA) health care facilities in 2012, 
about 1 in 5 women and 1 in 100 men stated that they experienced 
sexual abuse in the military.[Footnote 2] The effects of MST can be 
severe and long-lasting, and can result in chronic medical conditions 
such as post-traumatic stress disorder (PTSD), depression, and anxiety 
disorders. Federal law generally entitles veterans with service-
connected disabilities (i.e., injuries or diseases incurred or 
aggravated in active military service) to disability compensation 
benefits.[Footnote 3] This includes disabilities resulting from MST. 
The Veterans Benefits Administration (VBA), within VA, is charged with 
processing these claims. From fiscal year 2008 through fiscal year 
2013, veterans filed over 29,000 claims for disabilities related to 
MST. Yet, such claims can be difficult to substantiate, given that 
servicemembers may be unwilling to file formal complaints at the time 
of the precipitating incident or incidents and, hence, lack official 
documentation to support their claim.[Footnote 4] 

In response to a court ruling,[Footnote 5] VA in 2002 revised its 
regulations for adjudicating PTSD claims related to in-service 
personal assault, including MST.[Footnote 6] The revised regulation 
provides that evidence outside a veteran's service record may be used 
to corroborate his or her account of MST. As revised, the PTSD 
regulation acknowledges that VA may take into account, for example, 
records from civilian law enforcement authorities or rape crisis 
centers, statements from friends and family members, and evidence of 
behavioral changes, such as requests for transfer to another military 
duty assignment.[Footnote 7] 

Even after the 2002 regulatory changes, members of Congress and VBA 
continued to raise concerns that adjudicators were not accurately and 
consistently using the broader standard of evidence when adjudicating 
PTSD claims related to MST. These concerns were substantiated by the 
agency's own quality assurance reviews, which revealed high error 
rates for these claims. As a result, VBA in 2011 undertook additional 
steps to improve decisions for all claims attributed to MST, 
especially those for PTSD. 

You asked us to assess whether VA has adequately addressed concerns 
about how MST-related claims are adjudicated. This report examines: 

1. The steps VA has taken to improve decisions for claims related to 
military sexual trauma; 

2. the results, to date, of VA's actions to improve such decisions; 
and: 

3. the extent to which VBA is assessing the quality of its claim 
decisions related to military sexual trauma. 

To identify steps VA has taken to improve MST-related claim decisions, 
we reviewed related federal laws and regulations as well as guidance, 
training materials, and planning documents for VBA's improvement 
initiatives. In addition, we spoke with VBA and Veterans Health 
Administration (VHA) officials responsible for implementing the 
initiatives. To examine the results of VA's actions, we analyzed VBA 
administrative data from fiscal year 2010 to fiscal year 2013 on the 
number of MST-related claims received, completed, and either approved 
or denied by disability claimed (e.g., PTSD, depression, or anxiety 
disorders), gender of the veteran, and VBA regional office.[Footnote 
8] We also spoke with VBA and VHA officials responsible for 
implementing the improvement initiatives, and with relevant VBA staff 
in 5 of 57 regional offices to gain their perspective on these 
initiatives.[Footnote 9] For the 3 offices that we visited in person, 
we also conducted telephone interviews with VHA medical examiners 
affiliated with those VBA offices to learn about exams associated with 
MST-related claims. In each of those offices, we also reviewed a non-
generalizable sample of six claim files completed in 2013 to provide 
illustrative examples of how VBA adjudicates MST-related claims. We 
selected claim files from among those recently closed at the time of 
our site visit and that included approved and denied claims and claims 
submitted by both men and women. To gain their perspective on VA's 
handling of MST-related claims, we interviewed representatives from 
national veteran advocacy organizations, including veteran service 
organizations, as well as those locally associated with the 3 VBA 
regional offices we visited.[Footnote 10] We also weighed VBA's 
actions against its internal guidance, federal internal control 
standards, and good practices for implementing training. To assess the 
extent to which VBA is assessing the quality of its decisions for MST-
related claims, we examined VA quality assurance efforts, including 
results of completed reviews and planning documents for future 
reviews. We also analyzed VBA administrative data for potential trends 
in MST-related claim decisions. We assessed the reliability of VBA 
administrative data used for all our analyses by (1) performing 
electronic testing for obvious errors in accuracy and completeness, 
(2) reviewing existing information about the data and the system that 
produced them, and (3) interviewing agency officials knowledgeable 
about the data. We determined that the data were sufficiently reliable 
for the purposes of providing information on trends in claim decisions 
starting in fiscal year 2010.[Footnote 11] For additional details on 
our objectives, scope, and methodology, see Appendix I. 

We conducted this performance audit from April 2013 to June 2014 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

VBA's Disability Compensation Process for MST-Related Claims: 

While DOD is responsible for prevention, prosecution, and in-service 
treatment related to sexual abuse, VA is responsible for assisting 
veterans who experience health problems associated with MST after they 
leave the military. VA uses the following definition of MST: 
"psychological trauma, which in the judgment of a mental health 
professional employed by the Department, 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 
or active duty for training."[Footnote 12] Perpetrators may be 
colleagues, superiors, or individuals not affiliated with the 
military, and MST can happen during working as well as nonworking 
hours. 

While MST is not, itself, grounds for a disability claim, VA provides 
compensation for physical or mental health disabilities caused or 
aggravated by it, such as PTSD or depression.[Footnote 13] From fiscal 
year 2010 through fiscal year 2013, PTSD was the most common 
disability claimed as a result of an incident or incidents of MST, 
making up about 94 percent of all MST-related claims completed during 
that time (see figure 1). 

Figure 1: Disabilities Claimed in Relation to Military Sexual Trauma, 
Fiscal Year 2010 through Fiscal Year 2013: 

[Refer to PDF for image: pie-chart] 

Post-traumatic stress disorder (PTSD): 93.5%; 
Major depressive disorder: 2.7%; 
Anxiety disorder (Not specified): 1.3%; 
Other conditions: 1.7%: 
- Generalized anxiety disorder: 0.4%; 
- Bipolar disorder: 0.4%; 
- Mood disorder (Not specified): 0.3%; 
- Chronic adjustment disorder: 0.3%; 
- Dysthymic disorder: 0.1%; 
- Schizophrenia (Paranoid type): 0.1%; 
- Neurosis (Other and not specified): 0.1%. 

Source: GAO analysis of Veterans Benefits Administration data. 

[End of figure] 

As with all disability compensation claims, VBA evaluates MST-related 
claims through its 57 regional offices. The process starts when a 
veteran submits a claim and VBA adjudicators help him or her gather 
relevant evidence.[Footnote 14] To receive benefits for PTSD related 
to MST, a veteran must show: (1) a medical diagnosis of PTSD, (2) 
evidence of an incident or incidents of personal assault while in the 
military, and (3) a link between current symptoms and the incident or 
incidents.[Footnote 15] If sexual assault is documented in the 
veteran's service record and a recent PTSD diagnosis is present in the 
veteran's claim file supporting all three of these requirements, VBA 
adjudicators may approve the claim without extensive research or 
consultation with medical examiners. However, in most cases related to 
MST, some or all of this information is not readily available and 
adjudicators must take additional steps to develop the claim. 
Specifically, since 2002, VBA's regulations for PTSD claims have 
expressly allowed for a broad range of evidence to corroborate a 
veteran's claim that the MST incident or incidents occurred.[Footnote 
16] Adjudicators must consider a range of indicators, whether or not 
there is anything to support the claim in the veteran's service 
record.[Footnote 17] Referred to by the agency as "markers," such 
indicators include, but are not limited to: 

* records from law enforcement authorities, rape crisis centers, 
mental health counseling centers, hospitals, or physicians; 

* pregnancy tests or tests for sexually transmitted diseases; 

* statements from family members, roommates, and fellow 
servicemembers; and: 

* evidence of behavioral changes, such as requests for transfer to 
another military duty assignment, deterioration in work performance, 
and substance abuse. 

If the adjudicator does not find any formal reports or markers to 
suggest that an MST incident occurred, the PTSD claim is denied by the 
adjudicator without further review because the occurrence of the 
assault has not been corroborated. Conversely, VA officials stated 
that adjudicators should order a medical exam if a claim file contains 
both evidence of the MST incident--such as a marker--and evidence from 
lay statements or other sources suggesting the veteran has symptoms 
consistent with a diagnosis of PTSD. 

These medical exams are conducted by medical examiners from VBA's 
sister organization, the Veterans Health Administration (VHA), or by 
contractors retained by VBA and VHA.[Footnote 18] Depending on the 
information needed to decide the claim, the medical examiner is 
expected to provide the adjudicator with an assessment of one or more 
of the following: (1) whether the veteran has PTSD; (2) the likelihood 
that the claimed MST incident occurred (based on his or her interview 
with the veteran and a review of available markers); and (3) whether 
there is a link between the diagnosis and the MST incident. 

Using the results of the medical exam and other evidence in the 
veteran's claim file, the VBA adjudicator determines whether the 
veteran is entitled to compensation and denies or approves the claim. 
If the claim is approved, the adjudicator also assigns a percentage 
rating based on the severity of the claimed disability. If the veteran 
disagrees with the final claim decision, he or she may submit an 
appeal.[Footnote 19] See figure 2 for an overview of the process for 
adjudicating MST-related claims. 

Figure 2: VBA's Disability Compensation Claim Process for PTSD Claims 
Based on Military Sexual Trauma: 

[Refer to PDF for image: process illustration] 

1. Veteran submits claim. 

2. VBA adjudicator looks for formal complaints or markers: 
Formal complaint(s) or marker(s) found: go to #3; 
No formal complaint(s) or marker(s) found: go to #5. 

3. Medical exam[A] ordered and a VHA medical examiner provides an 
opinion about whether the claimant: 
* has PTSD,
* an incident of military n sexual trauma occurred, and, 
* the incident caused or aggravated PTSD; 
Positive opinion on 3-part test: go to #4; 
Negative opinion on 3-part test: go to #6. 

4. VBA adjudicator likely to approve claim. 

5. PTSD denied: 
Veteran can appeal claims decision. 

6. VBA adjudicator likely to deny claim: 
Veteran can appeal claims decision. 

Source: GAO analysis of Department of Veterans Affairs regulations, 
policies, and guidance. 

[A] A medical examiner may not need to assess one or more of these 
questions if sufficient evidence is present in the file. 

[End of figure] 

VBA's Quality Assurance Programs: 

VBA has a number of quality assurance programs to help ensure that 
adjudicators accurately and consistently follow VA regulations and 
policies. Under the national Systematic Technical Accuracy Review 
(STAR) program, VBA selects a random sample of all completed claim 
files each month from each of its regional offices. Using a standard 
checklist, STAR staff review each claim file and assess whether 
adjudicators took correct actions during various parts of the process 
and ultimately made accurate decisions. In addition, in 2012 VBA 
established local quality review teams in each regional office that 
assess adjudicator performance using the same review checklist as the 
national STAR program. For each adjudicator, each month, these 
reviewers assess five randomly-chosen claims and assess them using a 
similar process. 

Periodically, VBA also conducts targeted reviews to assess adjudicator 
accuracy or consistency in processing specific types of claims. In 
August 2011, VBA conducted a special accuracy review in response to 
concerns that adjudicators were not making accurate decisions for PTSD 
claims related to MST. The review found errors in 98 of 385 randomly 
selected claims that had been denied (about 25 percent).[Footnote 20] 
In particular, adjudicators should have identified markers and ordered 
medical exams rather than denied the claim in 61 cases because the 
files contained markers. The reviewers made several recommendations 
for improving the adjudication process, such as to: (1) clarify VA 
policies on markers, (2) build expertise in adjudicating such claims, 
and (3) develop training. 

VA Has Taken Several Steps to Improve Processing of Claims Related to 
MST: 

VBA Added Specialization and Training for Adjudicators while VHA 
Provided Some Training to Its Examiners: 

To help improve adjudicator adherence to processing requirements for 
MST-related claims, in 2011 VBA began directing regional offices to 
designate MST specialists from among their adjudicators with 
experience processing complex claims.[Footnote 21] The purpose of 
specialization was to allow regional offices to identify staff with 
the appropriate skills and sensitivity and afford specialists the 
opportunity to hone their knowledge of the MST requirements over many 
claims. At one of the offices we visited, for example, an MST 
specialist and her backup served as the only points of contact for any 
communication with MST claimants. These specialists compiled evidence 
for MST-related claims and then passed the claims on to another MST 
specialist who identified markers, ordered medical exams, and made 
final decisions about whether to approve or deny the claims. 

Also starting in 2011, VBA developed additional guidance and training 
for MST specialists (see fig 3). Specifically, in late 2011, the 
agency issued a guidance letter and rolled out 1.5-hour and 4-hour 
training sessions on how to process PTSD claims related to MST. VBA 
also rolled out a one-hour training session on sensitivity in June 
2011. All MST specialists were required to take each course once. The 
guidance letter and trainings on processing claims highlighted the 
breadth of evidence that may serve as a marker and support that the 
MST incident occurred. For example, the 4-hour training session 
described actual cases in which VA's 2011 quality reviewers had found 
that adjudicators missed markers--such as disciplinary problems and 
childbirth approximately nine months after the alleged MST incident--
that should have qualified as markers and triggered a medical exam. 
The course material for the 1.5-hour session also noted the high 
degree of judgment required of adjudicators when evaluating whether a 
claimant's claim file includes markers. Specifically, course materials 
and presenters stated that there is "no bright line" about what 
qualifies as a marker and that decisions must be made on a case-by-
case basis. 

With regard to medical examiners who conduct exams for MST-related 
claims, VHA has instituted comparatively limited training to date (see 
figure 3). The one-hour certification course, required of medical 
examiners who conduct any type of PTSD exam, devotes 2 of 54 slides to 
describing how examiners should use markers to assess the likelihood 
that an MST incident occurred.[Footnote 22] In collaboration with VBA, 
VHA had also developed and held a 1.5-hour information session 
specific to conducting MST-related medical exams. This session was 
available for on-demand viewing between April 2012 and September 2012. 
However, because this training is not part of VHA's formal training 
curriculum, it was optional for in-house medical examiners and not 
made available to contractors who conduct MST-related exams but are 
not directly employed by VHA. Over the course of our review, VHA 
officials said they began developing more formal training on 
conducting MST-related exams and will start providing it in September 
2014. More recently, they also decided to require the training for 
both in-house examiners and contractors. 

Figure 3: Training for VBA Adjudicators and VHA Medical Examiners 
Regarding Claims Related to Military Sexual Trauma (MST): 

[Refer to PDF for image: illustration] 

Veterans Benefits Admin. (VBA) Adjudicators: 

Video training on sensitivity toward MST claimants (1 hour): 
June 2011 to current time; 

Guidance letter on adjudicating MST-related claims: 
October 2011-May 20131; 
Letter updated: 
June 2013 to current time. 

In-person training on adjudicating MST-related claims (4 hours): 
December 2011 to current time. 

Video training on adjudicating MST-related claims (1.5 hours): 
December 2011 to current time. 

Veterans Health Admin. (VHA) Medical Examiners: 

PTSD certification course [contains content on MST-related claims] (1 
hour): 
May 2013 to current time. 

Video on MST-related claims: Optional (1.5 hours); 
May 2012-September 2013. 

Source: GAO analysis of Department of Veterans Affairs documents and 
interviews. 

[End of figure] 

VBA Has Notified Some Veterans of the Opportunity to Resubmit 
Previously Denied Claims: 

VBA began allowing veterans to resubmit previously denied PTSD claims 
related to MST in April 2013. While veterans always had the option of 
resubmitting denied claims to VBA if, for example, they obtained new 
evidence, this initiative is unique in that it does not require 
veterans to provide any additional information. The initiative was 
designed to correct any development errors that had occurred before 
VBA undertook its specialization and training initiatives. VBA sent 
2,667 notification letters to veterans whose PTSD claims related to 
MST were denied between September 2010 and April 2013. VBA officials 
also told us they provided the veterans' information to the veteran 
service organizations that represented them during the original claim 
process. (For the content of the notification letter, see appendix 
II). While veterans whose claims were denied prior to September 2010 
were also eligible to resubmit, VBA officials said most of these 
veterans did not receive notification letters because the agency did 
not systematically track such claims as being related to MST. 

Since Improvements, Approval Rates Have Increased Nationally yet Vary 
Widely by Region: 

Approval Rates for MST-Related Claims Increased Nationwide: 

Our review of VBA data shows that national approval rates for all 
types of claims related to MST have increased since fiscal year 2010, 
almost doubling during that time period. In addition, the approval 
rates for PTSD claims related to MST have also become more comparable 
to PTSD claims related to other stressors, such as combat (see figure 
4).[Footnote 23] 

Figure 4: Approval Rates for PTSD Claims Related to Military Sexual 
Trauma versus Other Stressors, Fiscal Year 2010 through Fiscal Year 
2013: 

[Refer to PDF for image: vertical bar graph] 

Percentage of claims approved: 

Fiscal year: 2010; 
Military sexual trauma: 28%; 
Other stressors: 46%. 

Fiscal year: 2011; 
Military sexual trauma: 36%; 
Other stressors: 59%. 

Fiscal year: 2012; 
Military sexual trauma: 50%; 
Other stressors: 59%. 

Fiscal year: 2013; 
Military sexual trauma: 50%; 
Other stressors: 55%. 

Source: GAO analysis of Veterans Benefits Administration data. 

[End of figure] 

While these trends do not necessarily attest to the accuracy of claim 
decisions or establish whether any specific initiatives caused the 
change, VBA officials said they believe the trends indicate that the 
initiatives are working. Specifically, the new guidance and training 
on MST-related requirements highlighted the many sources that could be 
used as markers and lead to medical exams, and officials thought this 
led to the increased approval rates. They also viewed the increased 
comparability with other types of PTSD claims as a sign that veterans 
are having less difficulty establishing that an MST incident occurred 
than in the past. 

Almost all VBA regional office staff we spoke with said that the 
specialization and training helped reinforce or clarify MST-related 
requirements. For example, adjudicators in three of five offices we 
spoke with specifically noted that it was useful to collaborate with 
other MST specialists about whether evidence qualified as a marker. At 
the same time, a few regional staff members and veteran service 
organization representatives expressed concern that MST specialists 
are being held to the same performance standards for timeliness as 
other adjudicators and, as such, may prioritize speed over quality. In 
terms of training and guidance, adjudicators or managers in three of 
the five offices we spoke with cited the written guidance on MST-
related claims as particularly helpful for making decisions about 
markers and other requirements. We also found that VA followed a 
number of good practices in developing and implementing its 
training.[Footnote 24] For example, the agency developed training 
content based on its research on errors commonly made with MST-related 
claims, and the Under Secretary for Benefits publicized the importance 
of the training. 

Approval Rates Varied by Region and Some Adjudicators and Medical 
Examiners Have Interpreted Processing Requirements Differently: 

While national approval rates have risen, our analysis of VBA data 
shows wide variation in approval rates among regional offices. 
Regional office approval rates for MST-related claims varied from 
about 14 to 88 percent in fiscal year 2013, and although about half of 
the offices had approval rates close to the average (between 40 and 60 
percent), the rest were higher or lower (see figure 5).[Footnote 25] 

Figure 5: Range of Regional Office Approval Rates for Claims Related 
to Military Sexual Trauma in Fiscal Year 2013: 

[Refer to PDF for image: vertical bar graph] 

Average rate of claims approved among all 57 regional offices: 50%. 

Percentage of claims approved: 0-20%; 
Number of regional offices: 2. 

Percentage of claims approved: 21-40%; 
Number of regional offices: 14. 

Percentage of claims approved: 41-60%; 
Number of regional offices: 30. 

Percentage of claims approved: 61-80%; 
Number of regional offices: 10. 

Percentage of claims approved: 81-100%; 
Number of regional offices: 1. 

Source: GAO analysis of Veterans Benefits Administration data. 

[End of figure] 

Some variation in approval rates may be expected given that, for 
example, offices may receive claims with differing characteristics or 
strengths of evidence. As such, high denial rates or high approval 
rates do not necessarily equate to inappropriate denials or approvals. 
However, the extent of the variation raises the question of whether 
the data reflect real differences in evidence or differences in how 
the requirements are interpreted and applied. VBA officials we asked 
said that such variation could result at least in part from 
inconsistent implementation of MST specialization across regions, 
varied understanding of how to identify markers, and less experienced 
adjudicators in some locations. 

Our interviews and observations suggest that VBA adjudicators 
sometimes differ in how they interpret MST-related requirements and 
make approval decisions. Adjudicators or quality review staff in four 
of five offices we spoke with said that--even with better guidance and 
training--identifying markers remains a difficult task. We also 
learned of cases where adjudicators varied widely in their 
interpretation of what qualified as a marker, particularly with regard 
to elapsed time. Specifically: 

* An MST adjudicator in one regional office told us she only counts 
evidence as a marker if it occurred within 2 months of the stated MST 
incident. However, VBA guidance does not provide a specific time frame 
for markers. 

* In one 2013 claim file we reviewed, the adjudicator had not 
considered as a marker an HIV test taken 2 months before the veteran 
claimed that the MST incident occurred. Two supervisors reviewing the 
file with us said that a different adjudicator may well have 
considered the test to be a marker, given its proximity to the claimed 
date and the possibility that the veteran forgot the precise date of 
the MST incident. 

* An MST adjudicator in another regional office told us that she once 
counted as a marker a pregnancy test that occurred 2 years after the 
cited MST incident. She said that she had initially determined that 
the test was not a marker, but received an error report for this from 
national quality review staff, perhaps because veterans with PTSD may 
not remember the exact date of the MST incident. She said she 
disagreed with this error, but reversed her decision. Since that error 
report, the adjudicator and quality review staff in the regional 
office said adjudicators' definition of what qualifies as a marker has 
been very expansive. 

* In one of the offices we interviewed, quality review staff said that 
"vague" complaints of pain or anxiety around the time of the MST 
incident would, in their view, qualify as markers. However, they 
described claim files from other offices in which the adjudicator did 
not consider such complaints to be markers. 

* A key VBA official involved in developing agency policy on MST-
related claims said that medical records documenting PTSD diagnoses 
related to MST should be interpreted as markers, even if they occurred 
many years after the claimed MST incident. However, at least 2 of the 
15 claims made in 2013 that we reviewed included medical treatment 
records of this type that were not treated as markers. 

The high degree of judgment required for identifying and weighing 
markers, as acknowledged in training and by officials with whom we 
spoke, could account for some variation in decision-making. For 
example, supervisors in one regional office told us that, 
hypothetically, two adjudicators could come to opposite conclusions 
about whether a piece of evidence qualified as a marker, and both 
decisions might comply with the VA requirements. Nonetheless, the 
importance of consistent decision-making has been underscored by VBA's 
quality assurance plan, our former evaluation of VBA disability claim 
processing, and the Institute for Defense Analyses.[Footnote 26] 
Adjudicators and regional office quality review staff in almost every 
office we interviewed cited actions that could further clarify their 
understanding, given the relative complexity of MST-related cases and 
the grey areas involved in identifying markers. They suggested, for 
example, refresher courses and the opportunity to see examples of the 
errors found during quality assurance reviews as a way to reinforce 
training. This is consistent with Office of Personnel Management 
guidance and our past work, which state that training and guidance 
should be reinforced or adjusted in circumstances where staff members 
remain confused about their responsibilities or when there is a gap 
between desired and actual practice.[Footnote 27] 

We also heard concerns that VHA medical examiners vary in the 
thoroughness of their reviews. VBA adjudicators generally rely on 
examiners' assessments when deciding whether to approve a claim, and 
staff from four of five offices expressed concern about the quality of 
some medical examiners' opinions. For example, quality review staff in 
one office noted that medical examiners vary in how thoroughly they 
sift through the claim files to identify markers. Seven of the nine 
medical examiners we spoke with also noted that their colleagues vary 
in their level of thoroughness in reviewing claims related to MST. For 
example, one medical examiner cited examples of examiners who complete 
exams in 15 minutes whereas she said it should take multiple hours, if 
done correctly. The medical examiner noted that less thorough reviews 
might lead to less informed assessments. 

Moreover, medical examiners we spoke with cited different evidentiary 
thresholds for providing a positive opinion about the occurrence of 
the MST incident. Five of the nine medical examiners we spoke with 
said if they do not find specific evidence of a marker in a veteran's 
claim file, they will not provide a positive opinion about the 
occurrence of the MST incident. For example, two of these examiners 
said that they do not always agree with markers identified by the 
adjudicator and, in those cases, may spend hours sifting through the 
files to identify their own markers. If they do not find any markers 
after this search, they told us they would not provide a positive 
opinion about the occurrence of the MST incident. Alternatively, three 
other examiners said that they may still provide a positive opinion 
that the MST incident occurred if they believe the veteran but cannot 
find evidence in the file.[Footnote 28] Given these variations, 
veterans may have differing chances of getting positive opinions that 
the MST incident occurred, depending on a given examiner's approach. 
Almost all of the examiners we spoke with said that more training on 
identifying markers would be useful. While all examiners conducting 
PTSD exams receive required training that includes high level 
information about MST-related exams, VHA's more detailed information 
session on the topic was optional for VHA medical examiners and not 
offered to contractors at the time of our review. 

Despite variation in examiner training and practices, VBA does not 
collect information that would help determine the extent to which MST-
related claims are handled appropriately or consistently by VHA 
examiners. For example, VBA does not track the number of exams that 
adjudicators return to the medical examiner because the examiner's 
opinion was deemed confusing or incomplete. At the same time, such 
information might provide a low estimate of less thorough exams 
because some examiners said that exams are only returned if they have 
very pronounced errors or omissions. 

Veterans May Be Unaware of the Opportunity to Resubmit Previously 
Denied Claims: 

Few veterans to whom VBA sent notification letters had resubmitted 
their previously denied claims as of March 26, 2014 (see figure 6). 
According to VBA analysis, 587 of the 2,667 veterans to whom VBA sent 
notification letters resubmitted their claims between May 1, 2013 and 
March 26, 2014. VBA made decisions on resubmissions from 429 of these 
veterans and overturned original denials for 150 of them. 
Resubmissions from the remaining 158 veterans were pending.[Footnote 
29] 

Figure 6: Number of Veterans Sent Notification Letters Regarding 
Previously Denied PTSD Claims Related to Military Sexual Trauma and 
Claims Resubmitted and Resolved between May 1, 2013 and March 26, 2014: 

[Refer to PDF for image: illustration] 

2,667 Veterans were sent notification letters: 
2,080 had not resubmitted claims. 

587 Resubmitted claims. 

429 Had claims resolved by VBA; 
158 had pending claims; 

150 Had their decisions overturned. 

279 Had their denials upheld. 

Source: GAO analysis of Veterans Benefits Administration data. 

[End of figure] 

Some veterans who received notification letters may not resubmit their 
claims because the letters were confusing or the process was too 
emotionally taxing to revisit, according to staff from five veteran 
advocacy organizations and three VBA regional offices. For example, 
one regional staff member characterized the notification letters as 
impersonal and expressed concern that they did not provide a direct 
phone number to VBA staff with experience assisting MST claimants. 
Staff from another regional office noted that reopening a claim would 
require the veteran to revisit very painful memories. Given this, 
veterans may be unwilling to risk having their claim denied a second 
time. 

Furthermore, an undetermined number of eligible veterans did not 
receive notification letters and may be unaware of the opportunity to 
resubmit their claims. Veterans with claims denied before September 
2010 did not receive letters because prior to that time, VA data 
systems did not systematically flag claims as MST-related. Between May 
1 and December 2, 2013, VBA made decisions on 174 resubmitted claims 
from veterans who were not sent notification letters, such as those 
with claims denied before September 2010. However, it is unclear what 
proportion of older denied MST-related claims this number represents, 
given the limitations with VBA's data tracking. It is also unknown 
whether these claims were resubmitted in response to the initiative or 
because they were already eligible for resubmission due to new 
evidence. Moreover, even veterans with newer claims may not have 
received notification letters if they moved since submitting their 
original claims to VBA and providing a mailing address. 

VBA's national efforts to inform veterans who did not receive 
notification letters were limited to two meetings with national 
veteran service organization representatives in June 2013. VBA did not 
require that regional offices publicize the initiative and we did not 
see any examples of targeted outreach related to this initiative at 
the five offices we visited. Local veteran service organization 
representatives we spoke with said that few to no veterans had 
approached them about the resubmission initiative. Although these 
local organizations play a key role in informing veterans about 
benefits and assisting them with claims, for one VBA regional office, 
only 1 of the 10 representatives we spoke with had heard about the 
initiative. At the national level, most veteran service organizations 
we spoke with also said they knew little about the initiative. An 
official from one of the organizations said they heard about the 
initiative by chance and subsequently publicized it on the 
organization's Facebook page. Keeping stakeholders--such as veterans 
and veteran service organizations--informed about initiatives is a key 
component of internal control and important for ensuring that eligible 
veterans know about available opportunities.[Footnote 30] 
Representatives from two veteran advocacy organizations and 
adjudicators from one regional office we spoke with said that VBA 
should conduct more outreach regarding this initiative, including 
posting flyers in VHA medical centers, where veterans--including those 
with denied MST-related claims--may visit to receive counseling or 
other services. 

VBA's Evidentiary Requirements Evoke Differing Concerns outside and 
within the Agency: 

In our interviews outside and within VBA, we found continuing, albeit 
differing, concerns about the fairness of the evidentiary requirements 
for MST-related claims. First, stakeholders outside and within the 
agency disagreed on whether the requirements for PTSD claims 
attributed to MST were too stringent, particularly when compared to 
those for PTSD claims attributed to other stressors. On the other 
hand, staff within VBA expressed concern that MST-related evidentiary 
requirements for mental health disabilities other than PTSD were more 
stringent than those for PTSD because markers cannot be used for other 
mental health disabilities. 

Concerns Regarding the Evidentiary Requirements for PTSD Claims: 

Stakeholders we interviewed expressed divergent views about the 
fairness of the requirements for PTSD claims related to MST and the 
implications for expanding them. Outside of the agency, 
representatives from four of five veteran advocacy organizations we 
interviewed expressed concern that the requirement to substantiate an 
MST incident is still difficult to meet for many with valid 
claims.[Footnote 31] Some of these representatives said that even 
markers can be difficult to find or may not exist, since veterans may 
have initially tried to hide their experience due to fear of reprisal 
or feelings of shame or embarrassment, among other reasons. These 
representatives contrasted the requirements for other PTSD claims with 
those for PTSD claims related to MST. For example, they noted that for 
PTSD claims related to fear of hostile military or terrorist activity, 
a veteran's own testimony alone generally may establish the claimed 
incident (i.e., in-service stressor),[Footnote 32] and took the 
position that this constitutes a far lower burden of proof than for 
PTSD claims related to MST. However, in contrast to these 
perspectives, VBA officials pointed out that in such cases, a 
veteran's own testimony alone may establish the claimed in-service 
stressor only if that stressor is consistent with the places, types, 
and circumstances of the veteran's service. For example, officials 
said that the veteran's testimony could be sufficient if the military 
record established that the veteran was located in an area where the 
claimed stressful military event could have occurred (see figure 7). 
VBA officials noted that the 2002 allowance for MST markers was the 
agency's way of broadening the range of permissible evidence while 
still requiring some level of proof beyond the veteran's own 
testimony. They said that to eliminate or further ease these 
requirements would eliminate the agency's ability to verify the claim, 
as is required for all other types of claims.[Footnote 33] 

Figure 7: Examples of Credible Supporting Evidence Needed to 
Substantiate that an In-Service Stressor Occurred by Type of PTSD 
Claim[A]: 

[Refer to PDF for image: illustration] 

Type of PTSD claim: Combat; 
Military records: Veteran treated for combat-related wounds, or earned 
medals or awards; 
Testimonial: Veteran's description of what happened in combat; 
Outcome: Claim likely approved. 

Type of PTSD claim: Fear of hostile activity; Military or terrorist; 
Military records: Information on veteran's duty station and/or squad 
activities; 
Testimonial: Veteran's description of what happened on duty; 
Medical examiner confirmation: Positive opinion that stressful event 
likely occurred; 
Outcome: Claim likely approved. 

Type of PTSD claim: Personal assault, Including military sexual trauma 
(MST), or: “Markers;”
Military records: Formal complaint of sexual assault made by veteran; 
Other corroborating: “Markers;”
Medical examiner confirmation: Positive opinion that MST likely 
occurred[B]; 
Outcome: Claim likely approved. 

Source: GAO analysis of Department of Veterans Affairs regulations, 
policies, and procedures. 

[A] To receive benefits for all types of PTSD claims, a veteran must 
also show a diagnosis of PTSD and a causal association between the 
diagnosis and the stressful event. 

[B] Such an exam would include interviewing the veteran about the MST 
incident. 

[End of figure] 

Concerns Regarding the Evidentiary Requirements for Other Mental 
Health Claims: 

VBA staff we interviewed in all five regional offices expressed 
concern that the MST-related evidentiary requirements for mental 
health disabilities other than PTSD are more stringent than those for 
PTSD. Because VA's 2002 regulatory changes allowing for markers only 
apply to PTSD claims, staff said that MST-related claims for other 
mental health disabilities, such as depression or anxiety disorders, 
are more difficult to substantiate. They explained that, unlike PTSD, 
a claimant diagnosed with depression or an anxiety disorder must have 
evidence other than markers to connect his or her disability to 
military service, such as medical records related to treatment 
received while the veteran was in the military. For example, if a 
veteran has no in-service treatment history, is diagnosed with 
depression years after leaving service, and says that the depression 
is a result of MST, he or she would need to have documentation such as 
a formal complaint of sexual assault in his or her military records to 
substantiate that the event occurred in military service and evidence 
linking the assault to the depression. In one file we reviewed, a 
veteran's PTSD claim related to MST was denied when the medical 
examiner diagnosed the veteran with depression instead of PTSD. The 
letter sent to the veteran regarding the decision noted that the 
markers would have served as evidence to support the occurrence of MST 
if the diagnosis had been PTSD. However, the letter said the markers 
could not be used because the veteran was subsequently diagnosed by 
the medical examiner with depression. No formal complaint of sexual 
assault was present in the file. Regional staff in four offices 
expressed concern that it is difficult for them to substantiate claims 
for other mental health disabilities that are related to MST, given 
that veterans infrequently file formal complaints of sexual assault 
while in service.[Footnote 34] 

VBA plans to reevaluate its evidentiary requirements for non-PTSD 
mental health claims related to MST, according to officials. They said 
the 2002 regulatory changes allowing for MST markers were aligned with 
broader evidentiary requirements for all PTSD claims--which include 
other types of in-service events, such as combat, and are also 
specific to PTSD--and the agency did not intentionally exclude other 
types of mental health claims. One official noted that any changes 
would involve reviewing relevant diagnostic criteria and considering 
any implications for mental health claims that are unrelated to MST. 

VBA Has Not Optimized Opportunities to Evaluate or Collect Information 
about MST-Related Decisions: 

VBA Has Conducted Few Quality Reviews of MST-Related Claims: 

Since conducting the 2011 quality review that triggered its 
improvement initiatives, VBA has conducted two more quality reviews of 
MST-related claims, but both have limitations. VBA conducted the first 
of these reviews in October 2012, which examined whether adjudicators 
took appropriate actions with respect to claims that received a 
medical exam and were subsequently denied. While it provided some 
information on errors made by adjudicators, for example, in 
interpreting medical examiner opinions, it did not provide any 
information about the quality of the adjudication process for approved 
claims or claims that were denied without a medical exam. However, 
adjudicators in at least one of the regional offices we visited raised 
concerns about the potential for inappropriate approvals, in addition 
to inappropriate denials. VBA officials said this review of denied 
claims was conducted at the request of Congress, which was 
particularly interested in claims denied following a medical exam. 

VBA conducted its second review in December 2013, which assessed the 
consistency of adjudicators' knowledge of how to process MST-related 
claims. Adjudicators present on the day the review was administered 
were given a case scenario involving a PTSD claim related to MST and a 
related questionnaire that probed errors found in prior reviews. They 
were asked to identify relevant markers from a multiple-choice list, 
and to determine whether a medical exam should be ordered and whether 
the case should be approved, denied, or deferred for additional 
information. VBA found that 85 percent of 755 adjudicators correctly 
approved the case, 14 percent incorrectly deferred their decision to 
approve or deny the claim, and 1 percent incorrectly denied it. 
[Footnote 35] VBA is requiring that all adjudicators who provided 
incorrect answers to the questionnaires receive more training by the 
end of April 2014. While this review provided some information on 
common errors made by adjudicators, the results may underestimate the 
challenge of adjudicating MST-related claims, given that responding to 
multiple choice questions about a hypothetical case may be less 
difficult than sifting through a real claim file to identify markers, 
order an exam, and make a decision. In addition, because the review 
was administered as a one-time test and was not mandatory, the results 
may not include adjudicators who were absent on the day of the review 
or did not participate for other reasons. 

In addition to these limitations, VBA's reviews of MST-related claims 
have not allowed it to monitor the quality of its processes over time, 
a standard part of internal control and best practice for ensuring 
that associated training is relevant and sufficient.[Footnote 36] The 
results of the MST-specific quality reviews discussed above are not 
comparable because they measured quality in different ways. Similarly, 
neither can be compared with the 2011 quality review completed prior 
to VA's improvement initiatives because (1) the quality reviews of 
denied claims were selected from overlapping time periods and (2) the 
consistency study used a different measure of quality.[Footnote 37] 
Furthermore, while VBA does conduct longitudinal reviews of the 
accuracy and consistency of all claim files through its national STAR 
and local quality reviews,[Footnote 38] only a limited number of MST-
related claims are reviewed each month, if at all, and VBA does not 
specifically track the inclusion or results of MST-related claims 
within these reviews. 

At the time of our review, VBA officials were planning to conduct two 
additional reviews of MST-related claims to identify training needs. 
Specifically, after calculating regional office approval rates at our 
request, VBA officials decided to assess the quality of claim 
decisions among offices with relatively high or rising denial rates. 
The agency planned to review approximately 500 claims from 20 offices, 
starting in April 2014. Further, officials said VBA will conduct an 
additional quality review in September or October 2014. They said this 
review will focus on randomly selected PTSD claims related to MST and 
include both those approved and denied. However, as with past reviews, 
these planned reviews will focus on different subsets of claims, and 
therefore, it is unclear how the agency will use them to monitor 
trends over time. 

VBA Has Studied Its Approval Rates for PTSD Claims Nationally, but Has 
Not Analyzed Available Data by Regional Office or Veteran Gender: 

In response to congressional requests, VBA has examined trends in 
approval rates for PTSD claims related to MST as well as those related 
to combat and other stressors. Both VBA's and our analyses show that 
approval rates for PTSD claims related to MST have increased, and are 
becoming more comparable to those for other types of PTSD claims. VBA 
officials said the increased approval rates show the effects of VBA's 
specialization and training initiatives. 

Nevertheless, VBA has not analyzed other available data that could 
help it identify potential problem areas to target training needs, 
such as approval rates by regional office and veteran gender for all 
MST-related claims. As noted earlier, our analysis of existing VBA 
data found wide variances in approval rates across regional offices, 
ranging from 14 to 88 percent. In addition, we found that approval 
rates for MST-related claims from female veterans remained 
consistently higher than those from males between fiscal years 2010 
and 2013 (see figure 8).[Footnote 39] 

Figure 8: Percentage of Claims Related to Military Sexual Trauma 
Approved for Males versus Females, Fiscal Year 2010 through Fiscal 
Year 2013: 

[Refer to PDF for image: horizontal bar graph] 

Percentage of claims approved: 

FY 2010: 
Male: 24%; 
Female: 32%. 

FY 2011: 
Male: 28%; 
Female: 42%. 

FY 2012: 
Male: 42%; 
Female: 55%. 

FY 2013: 
Male: 42%; 
Female: 55%. 

Source: GAO analysis of Veterans Benefits Administration data. 

[End of figure] 

As discussed earlier, variations in approval rates do not necessarily 
mean that decisions were inaccurate, as they could be attributed to 
actual differences among claims and their levels of evidence. However, 
they do pose reasonable questions as to the level of consistency among 
adjudicators. VBA officials said the agency's many competing 
priorities have precluded their following up with more data collection 
and analysis to date, although they do plan to review variations in 
approval rates in the near future. 

Finally, VBA does not electronically collect information about the 
number of MST-related claimants who receive medical exams, how often 
such exams are considered insufficient, and why claims are denied. 
[Footnote 40] As noted above, we found instances where VBA 
adjudicators may vary in how they interpret requirements for 
identifying markers and ordering an exam, and where VHA medical 
examiners may vary in how they conduct such exams. Without 
systematically collecting information about exams and why claims were 
ultimately denied, VBA cannot identify national or: 

regional trends in these areas. Officials acknowledged that MST has 
become a more prominent topic in recent years, particularly within 
Congress, and that VBA will collect and analyze more data as needed. 
[Footnote 41] 

Conclusions: 

In adjudicating claims related to sexual assault, VA faces the 
difficult task of assessing events for which there is often no 
concrete evidence. The difficulty of the task reveals the pernicious 
nature of MST: servicemembers may fear the repercussions of reporting 
an experience that was, itself, traumatic. This fear can be confounded 
if the perpetrator was a colleague or someone in a position of power, 
and this betrayal of trust can inflict profound confusion and pain. 

VA has taken a number of important steps to redress the dearth of 
evidence in a veteran's service record, both going forward with 
adjudicating new claims and acknowledging the potential for error in 
prior MST-related claim decisions. However, its decision to broaden 
the scope of allowable evidence--and thereby reduce inappropriate 
denials--brings its own challenges. Evaluating such a range of 
evidence requires expertise and a substantial degree of judgment by 
adjudicators and examiners, and some variation in determinations may 
be expected by virtue of the different circumstances surrounding each 
case. However, a level of inconsistency may occur that is not 
acceptable, especially if a veteran's chance of getting a claim 
approved is contingent on the particular adjudicator or medical 
examiner responsible for the review. Yet, to completely avoid such 
inconsistencies could require either a highly prescriptive set of 
rules for weighing the available evidence of sexual abuse, or, 
conversely, removing altogether the requirement for evidence of the 
assault--actions that carry their own risks and would require careful 
decision making. 

Even without sweeping changes to policy, there is substantial 
opportunity to make process changes that could better ensure benefits 
are appropriately awarded to veterans with valid MST-related claims. 
In contrast to VA's actions to date, which largely have been taken in 
response to external requests, a more proactive and systematic 
approach could further dispel confusion among adjudicators and 
examiners, identify errors, and inform veterans of opportunities to 
resubmit denied claims. Specifically, without more thorough and 
continuous training, some adjudicators and medical examiners are 
likely to remain confused about what qualifies as evidence. In 
addition, designing quality reviews to track trends over time, more 
fully analyzing data on MST-related claim decisions, and exploring 
options for collecting additional data could help VA flag potential 
areas of inconsistency for more careful review. Meanwhile, the limited 
outreach to veterans denied benefits for an MST-related claim could 
leave many unaware of new opportunities to have their claims 
reassessed under the broadened evidentiary requirements. 

Recommendations for Executive Action: 

The Acting Secretary of Veterans Affairs should direct the Under 
Secretary for Benefits to: 

* expand existing training and guidance to adjudicators responsible 
for MST-related claims by, for example, providing mandatory refresher 
courses or regularly distributing examples of relevant errors 
identified from quality assurance reviews. 

* develop a plan for conducting more comprehensive quality reviews of 
MST-related claims that allows the agency to identify problem areas, 
target improvement efforts, and track performance over time. 

* further analyze existing data on MST-related claim decisions by, for 
example, determining approval rates by regional office and veteran 
gender. 

* explore ways to systematically collect additional data on MST-
related claims that might allow the agency to better track 
consistency. Such data could include reasons for denials, whether 
claim evaluations included a medical exam, and how often related 
medical exam reports are returned to VHA for clarification or deemed 
insufficient. 

* expand outreach to veterans who are eligible to resubmit their 
previously denied PTSD claims related to MST. The agency should 
conduct this outreach in partnership with the Veterans Health 
Administration or external organizations, such as veteran service 
organizations. 

The Acting Secretary of Veterans Affairs should further direct the 
Under Secretary for Health to ensure that planned training on 
conducting MST-related exams is provided to all medical examiners who 
perform them, including contractors. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to VA for review and comment, and 
its written comments are reproduced as appendix III in this report. VA 
generally agreed with our conclusions and concurred with all of our 
recommendations. The agency outlined how it plans to address our 
recommendations as follows: 

* Regarding our recommendation to expand existing training and 
guidance to adjudicators, VA said that VBA is in the process of 
developing refresher training and anticipated that it will be 
available to staff by August 15, 2014. As VBA finalizes this training, 
it should consider making the training mandatory to all staff 
processing MST-related claims or to those whose claim decisions have 
been found to be in error. 

* Regarding our recommendation to develop a plan for conducting more 
comprehensive quality reviews, VA said that VBA plans to conduct 
special MST-related reviews twice each year and systematically analyze 
the results of each review within 4 months of completion. VA said that 
its current plans were sufficient to implement the recommendation. 
However, we would need additional information about the planned 
reviews--such as whether they will employ comparable methodologies and 
samples of claim files to allow VBA to track performance over time--
before considering this recommendation implemented. 

* Regarding our recommendation to further analyze existing data on MST-
related claim decisions, VA said VBA will review and analyze such data 
by October 2014 and conduct follow-up analyses every 6 months 
thereafter. 

* Regarding our recommendation to explore ways to systematically 
collect additional data on MST-related claims, VA said VBA has begun 
developing such an approach, particularly in terms of tracking reasons 
why claims are denied. VBA plans to conduct its first analysis in 
October 2014 with follow-up analyses every 6 months thereafter. VBA 
and VHA plan to use the information to identify areas where variations 
in approval rates may result from different interpretations of how to 
adjudicate claims or conduct medical exams. 

* Regarding our recommendation to expand outreach to veterans about 
the option to resubmit previously denied claims, VA said VBA will 
conduct additional outreach by September 30, 2014, working closely 
with VHA, veteran service organizations, and others. 

* Regarding our recommendation that planned training on conducting MST-
related exams be provided to all relevant medical examiners, VA 
outlined plans for ensuring that examiners participate in the 
training. Specifically, by April 30, 2015, all VHA medical examiners 
and contractors will be required to take the training and VA medical 
centers and vendors who employ contractors will be required to certify 
that examiners completed the training. 

VA also provided technical comments, which we incorporated into our 
report as appropriate. 

We are sending copies of this report to the appropriate congressional 
committees and the Acting Secretary of Veterans Affairs. In addition, 
the report is available at no charge on the GAO website at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7215 or bertonid@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made key contributions 
to this report are listed in appendix IV. 

Signed by: 

Daniel Bertoni: 
Director, Education, Workforce, and Income Security Issues: 

List of Requesters: 

The Honorable Patty Murray: 
Chairman: 
Committee on the Budget: 
United States Senate: 

The Honorable Bernard Sanders: 
Chairman: 
Committee on Veterans' Affairs: 
United States Senate: 

The Honorable Jon Runyan: 
Chairman: 
Subcommittee on Disability Assistance and Memorial Affairs: 
Committee on Veterans' Affairs: 
House of Representatives: 

The Honorable Mark Begich: 
United States Senate: 

The Honorable Richard Blumenthal: 
United States Senate: 

The Honorable Jon Tester: 
United States Senate: 

The Honorable Chellie Pingree: 
House of Representatives: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

The objectives of this report were to examine (1) the steps the 
Department of Veterans Affairs (VA) has taken to improve decisions for 
claims related to military sexual trauma (MST), (2) the results, to 
date, of VA's actions to improve such decisions, and (3) the extent to 
which the Veterans Benefits Administration (VBA) within VA is 
assessing the quality of its claim decisions related to MST. To 
address these objectives, we reviewed related federal laws and 
regulations as well as guidance, training materials, and planning 
documents for VA's improvement initiatives. We also reviewed GAO 
criteria on internal controls, program management, and good practices 
for implementing training. Further, for all three objectives, we 
interviewed VBA and Veterans Health Administration (VHA) officials, 
VBA and VHA regional staff, and national and local advocates. (See 
below for more information about our interviews). We also reviewed a 
small sample of completed claim files to obtain examples of the 
evidence available for establishing the occurrence of MST incidents 
and VBA and VHA processes to evaluate such evidence. (See below for 
more information about this claim file review.) To examine the results 
of the initiatives to date and the extent to which VBA is assessing 
the quality of claim decisions, we analyzed VBA administrative data on 
MST-related claim approval rates and spoke with relevant VBA staff. 
(See below for more information about our review of these data and our 
efforts to ensure their reliability.) We also reviewed VBA reports 
about their quality assurance reviews and the resubmission initiative 
for previously denied claimants. We assessed the reliability of these 
reports by reviewing related documentation and interviewing agency 
officials knowledgeable about how they were produced. We determined 
that the results presented in this report were sufficiently reliable 
for our purposes. 

Interviews: 

To obtain information relevant to all three objectives, we interviewed 
VBA officials responsible for developing and disseminating policy, 
training, and guidance on MST-related claims and quality assurance 
staff including officials responsible for the Systematic Technical 
Accuracy Review (STAR) and Quality Review and Consistency Programs. We 
also spoke with VHA officials responsible for overseeing medical 
examiners who conduct exams related to VBA disability claim decisions 
and VHA staff and officials responsible for developing and 
disseminating medical examiner training on MST-related exams. 

In addition, we interviewed managers and staff at the regional level 
to better understand how MST-related policies and initiatives were 
implemented. We selected 5 of VBA's 57 regional offices for review. 
The offices were selected to reflect a variety of characteristics 
related to (1) performance on VA accuracy and consistency reviews, 
[Footnote 42] (2) efficiency of claim processing,[Footnote 43] (3) 
number of MST-related claims received,[Footnote 44] (4) time elapsed 
since certain VA initiatives were adopted,[Footnote 45] and (5) 
geographical region.[Footnote 46] We visited 3 of the selected offices 
in person (Nashville, Portland, and San Diego) and conducted 
interviews with the remaining 2 over the phone (Milwaukee and 
Pittsburgh). The information obtained during these interviews is not 
generalizable to all VBA regional offices. 

For all 5 regional offices, we spoke with managers, adjudicators who 
specialize in MST-related claims, quality review team members who 
review MST-related claims, and personnel who conduct veteran outreach 
related to MST. For the 3 offices that we visited in person, we 
interviewed one or more VHA psychologists who conduct medical exams 
for MST-related claims or provide clarification to VBA adjudicators 
regarding MST-related exams completed by others. We also spoke with 
local veteran service organization representatives in each of these 3 
offices who had previously worked on MST-related claims. 

Outside of VA, we spoke with representatives from national veteran 
service organizations and other advocacy groups. These included 
representatives from the Disabled American Veterans, Iraq and 
Afghanistan Veterans of America, National Veterans Legal Services 
Program, Service Women's' Action Network, and Veterans of Foreign 
Wars. We selected interviewees based on the size of the organization 
and recommendations from other stakeholders. 

Claim File Review: 

For each of the 3 VBA regional offices we visited in person, we 
reviewed a non-generalizable sample of 6 claim files that were 
completed in 2013 (18 total) to provide illustrative examples of how 
VBA adjudicates MST-related claims. These claim files included the 
evidence collected by adjudicators, correspondence with the veteran on 
the status of their claim, and the decision made on the claim. We 
selected claim files from among those recently completed at the time 
of our visit to each regional office. We chose files that provided 
variation in terms of the claimed disability, decision made on the 
claim (approval or denial), and veteran gender. Our sample also 
included two PTSD claims related to other stressors for comparison 
purposes. For each claim file, we documented the disability, evidence 
provided to support the claim, key findings from the medical exam, 
nature and frequency of correspondence with the veteran, and decision 
on whether to approve or deny the claim. 

Analysis of VBA Data on Claim Decisions: 

We obtained and analyzed data from VBA's RBA2000 database for the 
following types of disability claim decisions: 

* MST-related claims. We obtained data on the number of all MST-
related claims that were received, completed, and approved or denied 
for each fiscal year from 2008--the earliest year for which VBA has 
data--through 2013. We also obtained breakouts for these data by 
disability claimed, veteran gender, and regional office. 

* PTSD claims related to other non-MST stressors. Similar to the data 
for MST-related claims, we obtained data on the number PTSD claims 
related to other stressors that were received, completed, and approved 
or denied for each fiscal year from 2008 through 2013 for comparison 
purposes. We also obtained breakouts for these data by veteran gender 
and regional office. 

In requesting data from VBA, we chose to exclude data on decisions 
made regarding re-evaluation requests for a higher disability rating 
percentage because such decisions are based largely on the diagnoses, 
not on whether the claim is MST-related. We chose to report approval 
rates by MST-related disability or "claim" rather than unique case or 
unique veteran. Each unique case can include claims for multiple 
disabilities, and each unique veteran may have multiple cases with 
claims for multiple disabilities. Therefore, we determined that 
analysis at the level of individual disabilities provided the most 
accurate and nuanced information about MST-related decision making. 

We assessed the reliability of the data obtained by (1) performing 
electronic testing for obvious errors in accuracy and completeness, 
(2) reviewing existing information about the data and the system that 
produced them, and (3) interviewing agency officials knowledgeable 
about the data. We determined that the data were sufficiently reliable 
for purposes of providing information on trends in claim decisions. 
However, there were several limitations to the data obtained: 

* The data obtained may under-represent the number of MST-related 
claims completed because VBA does not have procedures in place to 
verify whether adjudicators appropriately flag MST-related claims in 
the system. 

* We chose to report on claim decisions made since fiscal year 2010 
due to data reliability concerns about older decisions. Although VBA 
databases have allowed the agency to track MST-related claims since 
fiscal year 2008, its tracking system became more accurate in fiscal 
year 2010. Prior to that time, the codes used to identify MST-related 
claims only referred to PTSD, and officials expressed concern that 
adjudicators applied the codes inconsistently. In fiscal year 2010, 
VBA developed more detailed codes for identifying MST-related claims, 
including codes that identified claims for both PTSD and other 
disabilities. The agency also provided more guidance to adjudicators 
about appropriately applying the codes. 

We analyzed VBA data to determine the most common disabilities 
associated with MST-related claims and examined trends in approval 
rates. We calculated approval rates by dividing the number of claims 
approved by the number completed for each type of claim. We examined 
trends in approval rates nationally as well as by veteran gender and 
regional office. We chose to include all 57 regional offices in our 
analyses. To assess whether any individual decision could unduly 
impact the approval rates in offices with fewer claims, we also 
conducted an analysis that excluded offices with 20 or fewer claims in 
fiscal year 2013. We ultimately decided to include the results from 
these offices after determining that both analyses resulted in the 
same range of approval rates. 

We were unable to determine the causes for variation among regional 
office rates due to the absence of data on factors that could impact 
claim decisions--such as the reasons for denial--and the limited 
number of MST-related claims in each regional office. Trends in 
approval rates do not necessarily attest to the accuracy of claim 
decisions, and could be attributed to actual differences among claims 
and their levels of evidence. 

Our analyses focused on completed claims by fiscal year. Since claims 
may take awhile to complete, sometimes more than a year, in any given 
year, a large number of cases may be pending and therefore not 
captured in our analyses for one or more years. Given limitations with 
the administrative data, we could not analyze whether completed claims 
differed significantly from pending claims and whether including 
pending claims would alter the results of our analysis of potential 
trends in MST-related claim decisions. Figure 9 provides the number of 
MST-related claims completed, received, and pending in each fiscal 
year from 2010 through 2013. Information on pending claims was 
obtained from VBA's MAP-D database, which tracks information on claims 
still in process. VBA officials said the number of pending MST-related 
claims may be under-represented. They explained that an adjudicator 
may not know a claim is related to MST until later on in the process 
and thus, would not flag it as an MST-related claim in MAP-D.[Footnote 
47] 

Figure 9: The Number of Claims Related to Military Sexual Trauma 
Completed, Received, and Pending, Fiscal Year 2010 through Fiscal Year 
2013: 

[Refer to PDF for image: multiple line graph] 

Fiscal year: 2010; 
Completed: 5,057; 
Received: 6,136; 
Pending: 4,261. 

Fiscal year: 2011; 
Completed: 3,654; 
Received: 6,541; 
Pending: 7,122. 

Fiscal year: 2012; 
Completed: 5,170; 
Received: 7,232; 
Pending: 8,706. 

Fiscal year: 2013; 
Completed: 8,749; 
Received: 7,689; 
Pending: 5,935. 

[End of figure] 

Source: GAO analysis of Veterans Benefits Administration data. 

[End of figure] 

[End of section] 

Appendix II: Text of Notification Letter Sent to Previously Denied 
Claimants: 

Veteran XXX, 

The Department of Veterans Affairs (VA) records show that you 
previously filed a disability claim for posttraumatic stress disorder 
(PTSD) and stated that the stressor was related to sexual trauma 
experienced in the military. 

Although your claim was denied, in VA's continued efforts to assist 
Veterans, claims for PTSD based on military sexual trauma (MST) are 
being reviewed. A new review will determine if any evidence was 
overlooked. Participation in a VA examination may be required. 

Please contact your local VA regional office if you would like your 
PTSD claim reviewed to determine entitlement to service connection. 

For convenience, submit the enclosed VA Form 21-4138 (Statement in 
Support of Claim) and indicate that you would like to have your PTSD 
claim based on MST reviewed. 

If you have any additional evidence to support your claim, including 
statements from family members or fellow service members, please 
advise the regional office. 

Sincerely, 

Thomas J. Murphy: 
Director, Compensation Service: 

[End of section] 

Appendix III: Comments from the Department of Veterans Affairs: 

Department of Veterans Affairs: 
Office of the Secretary: 

May 15, 2014: 

Mr. Daniel Bertoni: 
Director, Education, Workforce, and Income Security Issues: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Mr. Bertoni: 

The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "MILITARY SEXUAL TRAUMA:
Improvements Made, but VA Can Do More to Track and Improve the 
Consistency of Disability Claim Decisions" (GAO-14-477). VA generally 
agrees with GAO's conclusions and concurs with GAO's recommendations 
to the Department. 

The enclosure specifically addresses GAO's recommendations and provides
technical comments to the draft report. VA appreciates the opportunity 
to comment on your draft report. 

Sincerely, 

Signed, by: 

Jose D. Riojas: 
Chief of Staff: 

Enclosure: 

Department of Veterans Affairs (VA) Response to Government 
Accountability Office (GAO) Draft Report: Military Sexual Trauma: 
Improvements Made, but VA Can Do More to Track and Improve the 
Consistency of Disability Claim Decisions (GAO-14-477): 

GAO Recommendation: The Secretary of Veterans Affairs should direct the
Under Secretary for Benefits to: 

Recommendation 1: expand existing training and guidance to adjudicators
responsible for MST-related claims by, for example, providing mandatory
refresher courses or regularly distributing examples of relevant 
errors identified from quality assurance reviews. 

VA Comment: Concur. The Veterans Benefits Administration (VBA) is in 
the process of creating an eLearning product for Military Sexual 
Trauma (MST) refresher training for MST-related claims. The course 
will consist of four separate eLearning lessons, which may be assigned 
individually or as a group. VBA expects to have the following lessons
completely developed and available to field personnel by August 15, 
2014: 

Course Title: Posttraumatic Stress Disorder Due to Military Sexual 
Trauma. 

* Lesson 1: Introduction: Target audience is Claims Assistants, 
Veterans Service Representatives (VSR) and Rating Veterans Service 
Representatives (RVSR). Course duration is 20 minutes. 

* Lesson 2: Rules and Regulations: Target audience is VSRs and RVSRs.
Course duration is 30 minutes. 

* Lesson 3: Development: Target audience is VSRs and RVSRs. Course
duration is 40 minutes. 

* Lesson 4: Rating: Target audience is RVSRs. Course duration 
undetermined. 

Recommendation 2: develop a plan for conducting more comprehensive 
quality reviews of MST-related claims that allows the agency to 
identify problem areas, target improvement efforts, and track 
performance over time. 

VA Comment: Concur. MST claims continue to be part of each regional 
office's monthly quality sample. In addition, VBA has established and 
implemented a plan for the Systematic Technical Accuracy Review (STAR) 
staff to conduct special focused reviews for MST claims twice each 
year. These recurring, focused reviews will help identify problem 
areas, target improvement efforts, and track performance over time. 
The first review began in May 2014 and will focus on the root cause of 
why MST claims are denied, as well as to assess whether the claims 
have been denied in error. The second review will be conducted in the 
first quarter of fiscal year 2015 to analyze regional office grant 
rates that are outside of the national statistical norm to determine
whether these types of claims receive an accurate decision. Within 4 
months of completion of each review, results will be updated in the 
systematic analysis identified in Recommendation 4. VBA considers this 
recommendation fully implemented. 

Recommendation 3: further analyze existing data on MST-related claim 
decisions by, for example, determining approval rates by regional 
office and veteran gender. 

VA Comment: Concur. VBA pulled data to compare many claims processing 
metrics and outcome measures for MST-related cases and is in the early 
stages of review. The data produced include a review of approval rates 
by regional office and Veteran gender. Additionally, VBA will continue 
to conduct consistency studies of the claims processing personnel 
responsible for MST-related cases based on the results of the STAR 
special review and data analysis. As noted in the response to 
Recommendation 2, VBA will continue to look for opportunities to 
enhance its quality review program to allow us to monitor the quality 
of claims processing over time. VBA's first analysis will be complete
by October 2014, with follow-up analyses every 6 months thereafter. 
Target Completion Date: October 31, 2014. 

Recommendation 4: explore ways to systematically collect additional 
data on MST-related claims that might allow the agency to better track 
consistency. Such data could include reasons for denials, whether 
claim evaluations included a medical exam, and how often related 
medical exam reports are returned to VHA for clarification or deemed 
insufficient. 

VA Comment: Concur. VBA agrees with GAO that variations in the 
approval rates do not necessarily mean that decisions were inaccurate. 
In conjunction with GAO's review, VBA began to explore new ways to 
systematically collect additional data on MST-related claims to 
promote improved consistency. VBA has commenced analyses of claims 
processing metrics and outcomes for MST-related claims in order to 
compare data. VBA looks for methods to identify whether MST claim 
denials were based on the results of a medical examination or based on 
the claims processor's determination that there was insufficient 
evidence to support an examination request, among other factors. 

Working with the Veterans Health Administration (VHA), VBA will use 
the data from these analyses to identify areas where variations in 
approval rates may result from different interpretations of 
identifying markers, when to order exams, or how examiners conduct the 
exams. The data will assist in the identification and implementation of
additional training to improve the development and rating processes 
for MST-related claims. VBA's first analysis will be complete by 
October 2014, with follow-up analyses every 6 months thereafter. 
Target Completion Date: October 31, 2014. 

Recommendation 5: expand outreach to veterans who are eligible to 
resubmit their previously denied PTSD claims related to MST. The 
agency should conduct this outreach in partnership with the Veteran 
Health Administration or external organizations, such as Veterans 
Service Organizations. 

VA Comment: Concur. VBA has completed proactive outreach to Veterans 
who were eligible to resubmit their previously denied posttraumatic 
stress disorder (PTSD) claims related to MST. Over 2,600 letters were 
mailed to those Veterans who had previously been denied claims related 
to MST. VBA is attempting to expand outreach to the population of 
previously denied PTSD claims related to MST who filed prior to 2010. In
addition, VBA will continue to work closely with VHA, Veterans Service 
Organizations, and other external partners to ensure this information 
is disseminated to Veterans so that they may submit or resubmit a 
claim for PTSD related to MST. Target Completion Date: September 30, 
2014. 

Recommendation 6: The Secretary for Veterans Affairs should further 
direct the Under Secretary for Health to ensure that planned training 
on conducting MST-related exams is provided to all medical examiners 
who perform them, including contractors. 

VA Comment: Concur. VHA is in the process of developing a training 
course focused on training examiners to conduct trauma sensitive 
examinations for disability claims that are filed secondary to an 
individual having experienced MST. The training course has been 
approved and funded by the Office of Disability and Medical Assessment 
(DMA) and the Employee Education System (EES). 

The course will have a specific focus on training examiners who are 
conducting Separation Health Examinations as individuals transition 
from active duty to Veteran status. 

The training course will be available to contracted examiners through 
VHA EES online Talent Management System. The course will be 
electronically distributed to the four contract vendors associated 
with DMA's Disability Exam Management Contract: 

1. Quality. Timeliness. Customer Service.
2. Logistics Health Incorporated.
3. Veterans Evaluation Services.
4. Medical Support Los Angeles. 

Target Completion Date: January 1, 2015. 

Training will be completed by all medical examiners that perform MST-
related exams. 

Each Veterans Integrated Service Network (VISN) or vendor will be 
required to certify that those examiners within their VISN or under a 
specific contract, who conduct MST-related disability exams, have 
completed the training course. Target Completion Date: April 30, 2015. 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Daniel Bertoni, (202) 512-7215, or bertonid@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Michele Grgich (Assistant 
Director), Carl Barden, James Bennett, Susan Bernstein, Bianca Capone, 
William Colvin, Helen Desaulniers, Joel Green, Jonathan McMurray, Jean 
McSween, Nhi Nguyen, Almeta Spencer, Barbara Steel-Lowney, Walter 
Vance, Kathleen Van Gelder, and Craig Winslow made contributions to 
this report. 

[End of section] 

Footnotes: 

[1] In the survey DOD used to generate these estimates, the agency 
defined the term "unwanted sexual contact" as sexual crimes between 
adults prohibited by military law, ranging from rape to abusive sexual 
contact. It involves intentional sexual contact that was against a 
person's will or occurred when the person did not or could not 
consent. Unlike VA's definition of military sexual trauma (see below), 
DOD's definition of unwanted sexual contact does not specifically 
include verbal sexual harassment. 

[2] Although rates of MST are higher among women, large numbers of men 
are also estimated to have experienced sexual abuse. 

[3] 38 U.S.C. §§ 1110 and 1131. This does not include disabilities 
caused by a veteran's own willful misconduct or abuse of alcohol or 
drugs. 

[4] According to DOD, 2,949 servicemembers filed formal sexual abuse 
complaints in fiscal year 2012, which represents about 11 percent of 
the 26,000 servicemembers who were estimated to have experienced 
unwanted sexual contact during that fiscal year. In fiscal year 2013, 
DOD reported that 4,113 servicemembers filed formal reports. DOD does 
not plan to update its estimate of the overall prevalence of unwanted 
sexual contact until the end of fiscal year 2014. 

[5] Patton v. West, 12 Vet. App. 272 (1999). 

[6] Post-Traumatic Stress Disorder Claims Based on Personal Assault, 
67 Fed. Reg. 10,330 (Mar. 7, 2002). While MST-related claims were an 
impetus for these regulatory changes, those changes apply to in-
service personal assaults generally and not just those that are sexual 
in nature. They are also specific to PSTD claims and do not impact the 
standard of evidence for other types of claims related to MST, such as 
depression or anxiety disorders. 

[7] 38 C.F.R. § 3.304(f)(5). The regulation also provides that VA will 
not deny a PTSD claim based on in-service personal assault without 
advising the veteran that evidence outside the service record or 
evidence of behavior changes may be considered and allowing the 
veteran to furnish it or advise VA of its existence. 

[8] These data are collected through VBA's RBA2000 database. When 
discussing data on MST-related "claims" for the purposes of this 
report, we are referring to the number of disability claims for 
medical conditions related to MST filed by veterans. A veteran may 
have filed multiple cases with the VBA, and these cases may contain 
multiple claims for physical or mental health conditions related to 
MST. 

[9] We visited the Nashville, Portland, and San Diego VBA regional 
offices and conducted telephone interviews with Milwaukee and 
Pittsburgh staff. We selected these offices based on a range of 
criteria, including performance on VA accuracy and consistency 
reviews, claims processing time, the number of MST-related claims 
received, and geographic location, among other things. Staff we spoke 
with in each office included managers, adjudicators responsible for 
making MST-related claim decisions, quality review team members who 
review MST-related claims, and personnel who conduct veteran outreach 
related to MST. 

[10] Veteran service organization representatives assist many veterans 
with filing disability claims. As claimant representatives, veteran 
service organizations must be accredited by VA and are tasked with 
providing information on benefits and assistance in applying for them. 
For more information on VA's accreditation program, see GAO, VA 
Benefits: Improvements Needed to Ensure Claimants Receive Appropriate 
Representation, [hyperlink, http://www.gao.gov/products/GAO-13-643] 
(Washington, D.C.: Aug. 1, 2013). 

[11] Although VBA has collected data on MST-related claims since 
fiscal year 2008, we used data since fiscal year 2010 because the 
codes in VBA's data system used to flag MST-related claims were more 
accurate beginning at that time. 

[12] 38 U.S.C. § 1720D requires that VA operate a program of 
counseling and other services for veterans needing them to overcome 
sexual trauma. VBA has indicated that the definition in this statute 
should be used for purposes of disability claims. See Department of 
Veterans Affairs, Adjudicating Posttraumatic Stress Disorder (PTSD) 
Claims Based on Military Sexual Trauma (MST), Training Letter 11-05 
(Washington D.C.: June 17, 2013), Attachment. While we use the term 
"military sexual trauma," which VA uses in some of its guidance, VA 
regulations generally refer to "in-service personal assault" or 
"personal assault." 38 C.F.R. § 3.304(f)(5). In addition, the term MST 
is sometimes used to refer to the precipitating incident or incidents 
as well as any resulting trauma it causes. 

[13] Through VHA, veterans may also receive medical treatment for 
conditions related to MST. 

[14] VBA adjudicators include veterans service representatives who 
assist veterans during the initial data collection steps in the 
process and ratings veterans service representatives who work with 
veterans service representatives to evaluate the evidence and order 
medical exams, and ultimately decide whether to approve or deny a 
claim. 

[15] 38 C.F.R. § 3.304(f). The regulation refers to an "in-service 
stressor," and in the MST context, that in-service stressor would be 
the personal sexual assault. 

[16] VA's regulatory changes do not apply to claims other than PTSD, 
such as those for depression or anxiety disorders. 

[17] 38 C.F.R. § 3.304(f)(5). 

[18] A diagnosis of PTSD must be based on criteria contained in the 
American Psychiatric Association's Diagnostic and Statistical Manual 
of Mental Disorders, 5th edition. 

[19] A veteran may appeal, in succession, to the Board of Veterans' 
Appeals, the U.S. Court of Appeals for Veterans Claims, the Court of 
Appeals for the Federal Circuit, and finally the Supreme Court of the 
United States. A veteran can also reopen a claim that was denied based 
on new and material evidence, file a claim for an increase in a 
service-connected disability, or file a claim for a new disability. A 
veteran can also file a claim alleging clear and unmistakable error in 
a prior final regional office or board decision. 

[20] VBA officials described the sample as nationally representative, 
although they could not provide documentation that would allow us to 
verify the accuracy of this statement. 

[21] VBA began to phase in specialization for MST-related claims in 
2011, and it was later incorporated into VA's larger claims 
restructuring initiative. This larger initiative directed regional 
offices to divide claims and adjudicators into three segmented lanes, 
based on the type and complexity of the claims. VA considers MST-
related claims to be among the most complex, and processes them 
through the "special operations" lane. The first phase of regional 
offices implemented the new structure in early 2012, and all regional 
offices had implemented it by March 2013. 

[22] Medical examiners specialize in conducting exams for certain 
types of conditions, such as PTSD, but do not further specialize by 
the type of traumatic event that may have caused the PTSD, such as MST 
or combat. 

[23] VA regulations outline evidentiary requirements for PTSD claims 
and special evidentiary rules for PTSD claims based on: 1) PTSD 
diagnosed in-service, 2) combat, 3) fear of hostile military or 
terrorist activity, 4) status as prisoner of war, and 5) in-service 
personal assault, which would include MST. 38 C.F.R. § 3.304(f). 

[24] GAO, Human Capital: A Guide for Assessing Strategic Training and 
Development Efforts in the Federal Government, [hyperlink, 
http://www.gao.gov/products/GAO-04-546G] (Washington, D.C.: Mar. 1, 
2004). GAO developed this guide through consultations with government 
officials and experts in the private sector, academia, and nonprofit 
organizations; examinations of laws and regulations related to 
training and development in the federal government; and reviewing the 
sizable body of literature on training and development issues, 
including previous GAO products on a range of human capital topics. 

[25] The results are not specific to PTSD claims, although nationally, 
94 percent of MST-related claims are for PTSD. These results reflect 
all 57 regional offices. When we excluded offices with fewer than 20 
MST-related claims, we found that the range of approval rates remained 
the same. 

[26] See GAO, Veterans' Disability Benefits: VA Has Improved Its 
Programs for Measuring Accuracy and Consistency, but Challenges 
Remain, [hyperlink, http://www.gao.gov/products/GAO-10-530T] 
(Washington, D.C,: Mar. 24, 2010) and Institute for Defense Analyses, 
Independent Assessment of the Quality Assurance Program in the 
Department of Veterans Affairs, IDA Paper P-4744 (Washington, D.C.: 
July 2011). 

[27] Office of Personnel Management, Training Evaluation Field Guide: 
Demonstrating the Value of Training at Every Level (Washington, D.C.: 
January 2011) and [hyperlink, http://www.gao.gov/products/GAO-04-546G]. 

[28] We did not explicitly ask the other two examiners about their 
threshold for providing a positive opinion about whether the MST 
incident occurred. 

[29] VBA officials said that veterans resubmitting claims may 
experience some delays because adjudicators are currently prioritizing 
claims that have been pending for a year or more. 

[30] GAO, Standards for Internal Control in the Federal Government, 
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] 
(Washington, D.C.: Nov. 1, 1999). 

[31] The fifth organization did not have a position on this issue. 

[32] 38 C.F.R. § 3.304(f)(3). 

[33] Legislation pending in Congress would address the evidentiary 
requirements for PTSD claims related to MST. On June 4, 2013, the 
House of Representatives passed H.R. 671, the Ruth Moore Act of 2013, 
which includes a statement of the sense of the Congress that the VA 
should update and improve its regulations related to MST. In the 
Senate, S. 294, also entitled the Ruth Moore Act of 2013, would amend 
current law to provide, for example, that under certain conditions a 
veteran's lay testimony alone may establish the occurrence of MST. S. 
294 was introduced and referred to the Committee on Veterans' Affairs 
on February 13, 2013. 

[34] While our analysis of VBA data suggests similar approval rates 
for PTSD and non-PTSD mental health claims attributed to MST, VBA data 
do not allow for comparisons of approval rates by whether non-PTSD 
mental health conditions were diagnosed in or post-service. 

[35] The review included one questionnaire for adjudicators who gather 
evidence (veterans service representatives and related quality review 
staff) and one questionnaire for adjudicators who determine whether to 
approve the claim (ratings veterans service representatives and 
related quality review staff.) The 755 adjudicators who answered the 
question were from 53 of 57 regional offices. 

[36] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] and 
Office of Personnel Management, Training Evaluation Field Guide: 
Demonstrating the Value of Training at Every Level. 

[37] Specifically, the 2011 and 2012 reviews of denied claims both 
focused on different types of denied claims--all denied claims versus 
those that were denied after receiving an exam--that were completed 
between 2008 and the time that each review was conducted, and thus 
cannot show change in quality over time. 

[38] Results from national STAR and local quality reviews are used to 
track performance trends within and/or among all regional offices. 

[39] Between fiscal years 2010 and 2013, about 63 percent of MST-
related claims completed were filed by females, 36 percent were filed 
by males, and 1 percent was filed by veterans who did not specify 
their gender. 

[40] VBA does collect some high-level data on reasons for claim 
denials, but VBA officials said it provides very limited information 
on actual reasons for each claim. Current codes to capture reasons for 
denials in VBA's data system include, for example, "not in the line of 
duty," "not aggravated by service," "no diagnosis," and "not incurred/ 
caused by service." 

[41] Both House and Senate versions of pending legislation, the Ruth 
Moore Act of 2013 (H.R. 671 and S. 294), would require VA to report 
data on MST-related claims as well as information on employee training 
related to MST. 

[42] We used data from VBA's ASPIRE Dashboard to rank regional office 
performance on VA's national accuracy and consistency reviews of 
disability and compensation claim decisions for May 2013, the most 
recent data at the time of our selection. 

[43] We used data from VBA's ASPIRE Dashboard to rank regional office 
performance on the efficiency of claim processing in May 2013. 
Regional offices were ranked based on the percentage of backlogged 
claims, average days of processing time for claims, and average days 
pending for claims. 

[44] We used data requested from VBA's Office of Field Operations to 
rank regional offices on the number of MST-related claims received in 
fiscal year 2012, the most recent data at the time of our selection. 
For this criterion, we focused on selecting regional offices with a 
higher number of MST-related claims received, since these types of 
claims are the focus of our study. 

[45] We used data requested from the Office of Field Operations to 
rank regional offices based on the date of adoption of the special 
operations lanes initiative, which uses specialized staff to 
adjudicate MST-related claims. 

[46] We used VBA's regional office structure, which categorizes 
regional offices into eastern, western, southern, and central regions. 

[47] They stated that adjudicators are more likely to have accurate 
information about a claim's relationship to MST by the time the claim 
is completed and documented in the RBA2000 database. 

[End of section] 

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