Unwanted Sexual Behavior: Improved Guidance, Access to Care, and Training Needed to Better Address Victims' Behavioral Health Needs

Fast Facts

Service members who have experienced unwanted sexual behavior, such as harassment or assault, may suffer from chronic mental health problems.

These service members can get non-medical counseling through the Department of Veterans Affairs. But longer-term and psychiatric care are only available with a referral that would be shared with the Department of Defense as part of their patient record—which may deter some service members from seeking it.

DOD also doesn't always screen service members during routine medical exams to determine if they have experienced sexual trauma.

We recommended addressing these and other issues we found.

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Highlights

What GAO Found

The Department of Defense (DOD) and Department of Veterans Affairs (VA) offer behavioral health care to active-duty service members and veterans who experience unwanted sexual behavior. Unwanted sexual behavior includes sexual harassment, sexual assault, and domestic sexual abuse. However, several issues limit screening for and access to related care. For example:

VA requires clients in VA medical facilities to be screened for military sexual trauma; DOD screens for behavioral health conditions but not specifically for experiences with unwanted sexual behavior. Without developing guidance specifying how and when DOD medical providers should screen for such experiences, DOD cannot ensure consistent patient support or care.
Service members who have experienced unwanted sexual behavior may confidentially access non-medical counseling through VA. However, longer-term medical behavioral health care requires a referral from DOD, which may deter service members from seeking care. Until DOD considers how best to enable service members to access longer-term services through VA, without a referral, some service members may not seek needed care.

Analysis of separation data shows that service members who made unrestricted, formal, or some informal reports of experiences with unwanted sexual behavior left the military—voluntarily and involuntarily—at substantially higher rates than the overall active-duty population from fiscal years 2015 through 2021 (see fig.).

Separation Rates for All Active-Duty Service Members Compared to Those who Reported an Experience with Unwanted Sexual Behavior, Fiscal Years 2015–2021

However, multiple factors impede DOD's ability to determine if an experience with unwanted sexual behavior played a role in separation decisions. For example, certain processes related to medical examinations and higher-level reviews of involuntary separations are available only for victims of sexual assault, for specific time periods, and for certain behavioral health diagnoses. Until DOD considers potential modifications to these processes service members may be unable to benefit from actions that may affect eligibility for VA benefits.

Why GAO Did This Study

Service members who experience unwanted sexual behavior—sexual harassment, sexual assault, and domestic sexual abuse—during military service may suffer from chronic mental health conditions. Service members who have such experiences are also more likely to separate from the military, exacerbating DOD's critical recruitment and retention challenges.

GAO was asked to review service member mental health related to experiences with unwanted sexual behavior. This report examines, among other issues, the extent to which (1) DOD and VA screen for and provide access to behavioral health care services for such experiences, and (2) such experiences play a role in voluntary and involuntary separations of service members from the military. GAO reviewed guidance, analyzed DOD and VA behavioral health care data and DOD separation data, and interviewed DOD and VA officials at the headquarters level and at a nongeneralizable sample of military installations and VA medical facilities.

Recommendations

GAO is making 15 recommendations, 13 to DOD and two to VA, including that DOD develop guidance specifying how and when to screen for experiences with unwanted sexual behavior; consider how best to enable service members' access to care related to such experiences at any VA facility, without a referral; and consider modifying its guidance to help ensure it fully considers potential factors contributing to service member separations. DOD and VA concurred with the recommendations.

Recommendations for Executive Action

See All 15 Recommendations

Full Report

Highlights Page (1 page)

Full Report (174 pages)

Accessible PDF (218 pages)

GAO Contacts

Brenda S. Farrell

Former Director

FarrellB@gao.gov

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Sarah Kaczmarek

Managing Director

Office of Public Affairs

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Public Inquiries

Topics

Health Care

Confidential communicationsElectronic health recordsEmployee dismissalHealth careHealth care administrationHealth care providersHealth care standardsMedical recordsMental healthMilitary dischargesMilitary health carePost-traumatic stress disordersSexual abuseSexual assaultsSexual harassmentVeteransVeterans affairs

Agency Affected	Recommendation	Status
Department of Defense	The Secretary of Defense should ensure that the Director of the Defense Health Agency develops guidance that establishes protocols specifying how and when providers should screen patients for experiences with unwanted sexual behavior. (Recommendation 1)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, DOD needs to develop and issue guidance that establishes protocols specifying how and when providers should screen patients for experiences with unwanted sexual behavior.
Department of Defense	The Secretary of Defense should ensure that as the department revises its guidance on health care management for patients who have experiences with unwanted sexual behavior, it considers modifications to clarify (1) when and how medical care should be prioritized for victims of unwanted sexual behavior, and (2) whether to expand the provisions about prioritization of care to include service members who have experienced sexual harassment. Any such revisions to the guidance should specify how providers can prioritize care for victims of unwanted sexual behavior in a manner that is consistent with DOD policy while also allowing them to effectively care for victims of other types of trauma. (Recommendation 2)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, DOD needs to consider, when revising its health care management guidance, whether to clarify when and how medical care should be prioritized for victims of unwanted sexual behavior, and whether to expand the provisions about prioritization of care to include service members who have experienced sexual harassment.
Department of Defense	The Secretary of Defense should include, as part of the department's planned study to implement the Independent Review Commission's recommendation to authorize service members' access to the full spectrum of VA care related to unwanted sexual behavior, consideration of several factors to balance confidentiality with mission needs to better facilitate implementing the Commission's recommendation to the greatest extent feasible. Specifically, the department's study should consider how best to enable such access by assessing the following: the extent that permitting greater access to VA behavioral health resources would pose risks to DOD that would be different from the risks DOD faces from service members who confidentially obtain care in the private sector; whether access to VA care without a referral could be granted for service members who are not in certain populations or positions that require greater disclosure; potential revisions of or clarifications to service member disclosure requirements related to behavioral health; and mechanisms that could help facilitate confidential access to care, such as distinctions between treatments that do and do not require disclosure. (Recommendation 3)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, DOD needs to include, as part of its planned study about authorizing service members' access to the full spectrum of VA care related to unwanted sexual behavior, consideration of the several factors identified in our recommendation.
Department of Defense	The Secretary of Defense and the Secretary of Veterans Affairs should collaborate to take steps to ensure that service members who have experienced unwanted sexual behavior and are eligible for VA services related only to military sexual trauma are provided information about and connected to all programs that assist in the transition from DOD to VA care. (Recommendation 4)	Open DOD and VA concurred with this recommendation. In April 2024, VA noted a number of initiatives that DOD and VA have taken to inform current and former service members and key staff who assist in the transition process about available care and benefits. It stated that the VA-DOD Joint Executive Committee Sexual Trauma Working Group will continue to identify additional opportunities to ensure that current and former service members who have experienced unwanted sexual behavior are aware of and connected to services available to them. It estimated completion of this recommendation by the end of June 2024. To fully implement GAO's recommendation, DOD and VA need to take steps to ensure that service members who have experienced unwanted sexual behavior and are eligible for VA services related only to military sexual trauma are provided information about and connected to all programs that assist in the transition from DOD to VA care.
Department of Defense	The Secretary of Defense should ensure that the Director of the Defense Health Agency adopts information security best practices for MHS GENESIS to incorporate the principle of least privilege and limit health record access to those with an established provider-patient relationship or a need to know, and therefore better ensure victim confidentiality and privacy. (Recommendation 5)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, DOD needs to limit access to its electronic health record to those with an established provider-patient relationship or a need to know, and therefore better ensure victim confidentiality and privacy.
Department of Veterans Affairs	The Secretary of Veterans Affairs, in conjunction with the Secretary of Defense, should develop and evaluate options and make a determination of the best approach for incorporating a mechanism in its new electronic health record whereby VA providers can record unwanted sexual behavior care at medical centers and community-based outpatient clinics while limiting sharing that information to the greatest extent feasible. (Recommendation 6)	Open VA concurred with this recommendation. In April 2024, VA stated that it had completed an early draft of the Options Development and Evaluation plan that includes the core strategy required to develop and evaluate new options that includes goals, objectives, interim milestones, metrics, and timelines for each step of the project. It anticipated completion of the plan by June 2024 and full implementation of the plan by June 2026. To fully implement GAO's recommendation, VA needs to develop and evaluate options and determine the best approach for incorporating a mechanism in its new electronic health record whereby VA providers can record unwanted sexual behavior care at medical centers and community-based outpatient clinics while limiting sharing that information.
Department of Defense	The Secretary of Defense should ensure that the Director of the Defense Health Agency issues guidance that specifies how information about behavioral health care related to experiences with unwanted sexual behavior should be consistently documented in the electronic health record. (Recommendation 7)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, DOD needs to issue guidance specifying how information about behavioral health care related to experiences with unwanted sexual behavior should be documented in the electronic health record.
Department of Defense	The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Director of the Office for Diversity, Equity, and Inclusion, revises harassment prevention and response training guidance to require that information about Department of Veterans Affairs resources for experiences with unwanted sexual behavior be included in annual or periodic training that is administered to all service members, and takes steps to ensure that the military services implement the revised guidance. (Recommendation 8)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, DOD needs to revise its harassment training guidance to require that information about Department of Veterans Affairs resources for experiences with unwanted sexual behavior be included in training that is administered to all service members, and take steps to ensure that the military services implement the revised guidance.
Department of Defense	The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Director of the Sexual Assault Prevention and Response Office, revises sexual assault prevention and response training guidance to require that information about Department of Veterans Affairs resources for experiences with unwanted sexual behavior be included in annual or periodic training that is administered to all service members, and takes steps to ensure that the military services implement the revised guidance. (Recommendation 9)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, DOD needs to revise its sexual assault training guidance to require that information about Department of Veterans Affairs resources for experiences with unwanted sexual behavior be included in training that is administered to all service members, and take steps to ensure that the military services implement the revised guidance.
Department of Defense	The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Deputy Assistant Secretary of Defense for Military Community and Family Policy, revises domestic sexual abuse training guidance to require that information about Department of Veterans Affairs resources for experiences with unwanted sexual behavior be included in annual or periodic training that is administered to all service members, and takes steps to ensure that the military services implement the revised guidance. (Recommendation 10)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, DOD needs to revise its domestic sexual abuse training guidance to require that information about Department of Veterans Affairs resources for experiences with unwanted sexual behavior be included in training that is administered to all service members, and take steps to ensure that the military services implement the revised guidance.
Department of Veterans Affairs	The Secretary of Veterans Affairs, in coordination with the Secretary of Defense, should revise the participant guide for the Transition Assistance Program's Department of Veterans Affairs benefits and services course taken by all separating service members to include information about available Department of Veterans Affairs resources for experiences with unwanted sexual behavior, similar to what is included in the Transition Assistance Program's optional course on women's health. (Recommendation 11)	Closed – Implemented VA concurred with this recommendation. In January 2024, VA issued an updated version of the VA Benefits and Services Participant Guide that includes more detailed information on VA resources for experiences with unwanted sexual behavior. Specifically, it includes a section on unwanted sexual behavior (which VA refers to as military sexual trauma) that discusses eligibility, disability compensation, and access to care as well as links to relevant websites for additional information. It also includes a related appendix that discusses information on counseling and treatment options, and the availability of such care, similar to the optional women's health course. According to VA officials, VA and DOD worked collaboratively to publish the updated guide. These actions meet the intent of the recommendation.
Department of Defense	The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness conducts a comprehensive evaluation to consider whether to modify DOD guidance on involuntary officer and enlisted administrative separations concerning medical examinations and higher-level general or flag officer reviews, including proposing changes to relevant statutes, as necessary. This evaluation should assess the following areas: (a) whether the eligible population should be service members who experienced any type of unwanted sexual behavior; (b) the appropriate timeframes between when an incident is reported and when a separation is proposed, and other eligibility restrictions for obtaining a medical examination or higher-level review; (c) which behavioral health conditions or diagnoses should determine eligibility for a behavioral health examination; (d) whether service members who file restricted reports should be eligible to request a general or flag officer review; and (e) whether to permit documentation of the alleged sexual assault in the report of the separation health assessment. (Recommendation 12)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, DOD needs to conduct a comprehensive evaluation about whether to modify DOD guidance on involuntary officer and enlisted administrative separations concerning medical examinations and higher-level general or flag officer reviews. This evaluation should consider the several factors identified in our recommendation, and should include proposing changes to relevant statutes, as necessary.
Department of the Army	The Secretary of the Army should ensure that Army guidance on involuntary officer and enlisted administrative separations is modified to require that the Army's standardized separation notification correspondence includes information about the general or flag officer review for victims of sexual assault. (Recommendation 13)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, the Army needs to modify its guidance on involuntary officer and enlisted administrative separations to require that the Army's standardized separation notification correspondence includes information about the general or flag officer review for victims of sexual assault.
Department of the Navy	The Secretary of the Navy should ensure that Navy guidance on involuntary officer and enlisted administrative separations is modified to require that the Navy's standardized separation notification correspondence includes information about the general or flag officer review for victims of sexual assault. (Recommendation 14)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, the Navy needs to modify its guidance on involuntary officer and enlisted administrative separations to require that the Navy's standardized separation notification correspondence includes information about the general or flag officer review for victims of sexual assault.
Department of the Navy	The Secretary of the Navy should ensure that the Marine Corps guidance on involuntary officer and enlisted administrative separations is modified to require that the Marine Corps's standardized separation notification correspondence includes information about the general or flag officer review for victims of sexual assault. (Recommendation 15)	Open DOD concurred with this recommendation. To fully implement GAO's recommendation, the Marine Corps needs to modify its guidance on involuntary officer and enlisted administrative separations to require that the Marine Corps's standardized separation notification correspondence includes information about the general or flag officer review for victims of sexual assault.