DMA Military Sexual Trauma and the Disability
Examination Process
DMA Military Sexual Trauma and the Disability Examination Process......................................................... 1
Introduction.................................................................................................................................................... 2
Military Sexual Trauma (MST) ...................................................................................................................... 4
VA and DoD Policies and Programs ........................................................................................................... 16
MST Related Disability Claims.................................................................................................................... 22
MST and the Separation Health Assessment ............................................................................................. 31
Considerations for MST-Related PTSD Disability Examinations................................................................ 46
Course Summary ........................................................................................................................................ 58
References .................................................................................................................................................. 60
Glossary ...................................................................................................................................................... 63
Contact Us................................................................................................................................................... 67
Knowledge Check and Exercise Answers and Feedback .......................................................................... 68
Note:
This document has been created as a print version of the VA EES web-based DMA Military Sexual
Trauma and the Disability Examination Process course. For digital accessibility by users of assistive
technology, the document has a dynamic table of contents, electronic form fields and buttons in the
knowledge checks and exercises and links in the knowledge check and exercise feedback. Public-facing
URLs are hyperlinked as well, but VA intranet links are not active as they will not work outside of VA’s
network. No other interactivity exists in this document, even when referenced in the text.
Introduction
Welcome
The issue of sexual assault or sexual harassment (sexual trauma) in the military is of vast importance to
the Department of Veterans Affairs (VA) and the Department of Defense (DoD). DoD has programs to
provide safe and confidential methods for active duty Servicemembers to report sexual assault or sexual
harassment experiences. While VA does not have direct influence on DoD related programs, VA is in
communication with DoD about their programs and is committed to ensuring that Veterans who
experienced military sexual trauma (MST) have access to healthcare services and benefits that can
facilitate recovery.
Men and women who experience sexual trauma while in the military can be affected by their experiences
in a variety of ways. While many Servicemembers or Veterans who experience sexual trauma are quite
resilient, others may experience long-lasting physical and mental health conditions. In fact, some of the
men and women with whom you conduct disability examinations, including Separation Health
Assessments (SHAs), will have experienced sexual trauma while in the service.
You can assist Servicemembers and Veterans who may have experienced MST by conducting traumasensitive disability examinations with careful documentation, and by providing MST-related and other
resource information to the Servicemember and Veteran at the close of each SHA or at the close of each
disability examination.
The focus of this training is on the roles and responsibilities of VA disability examiners when interacting
with Servicemembers and Veterans who have experienced MST. Some information in this course may
not apply directly to your specific duties, but it will give you helpful background information to support your
role as a disability examiner.
IMPORTANT NOTE
The term MST will be used throughout this course to refer to experiences of sexual assault and/or sexual
harassment that occurred when an individual was on active duty. While the term MST is used in this
course since the audience will be VA and VA contract examiners, this is not a term used by DoD and it
may not be familiar to active-duty Servicemembers. DoD uses the terms sexual assault or sexual
harassment.
About This Course
Course Purposes
This training module has four purposes:
1. Provide information about potential effects on Servicemembers and Veterans of experiencing
MST
2. Provide information on policies and processes for documenting MST disclosures or evidence
during a disability examination
3. Inform you of procedures specific to the Separation Health Assessment (SHA) for providing MSTrelated and other resource information to Servicemembers transitioning from active duty to
Veteran status
4. Address issues specific to conducting Posttraumatic Stress Disorder (PTSD) disability
examinations that are related to MST
DMA Military Sexual Trauma and the Disability Examination Process
Page 2
Course Audience
This course is required for all VA and VA contract examiners who conduct disability examinations.
Course Length
This course will take you approximately 90 minutes to complete. If you must exit the course before
completion, your place will be bookmarked so you can continue where you left off. However, in order for
the bookmark to work, you must use the course Exit (x) button and not the browser’s close
button.
Please complete the lessons in the order presented so you can build on knowledge from one lesson to
the next. Each lesson includes knowledge checks or exercises designed to help you apply the knowledge
you gain along the way.
Assessments
When you complete the entire course, you will have access to the Final Assessment. A score of 80
percent or higher on the Final Assessment is required for accreditation purposes. The final page of this
course contains instructions for accessing a certificate of completion.
TACK NOTE
Servicemembers and Veterans portrayed in audio, video, and other presentations in this course are
fictitious and are not intended to resemble any Servicemember or Veteran, living or deceased.
Course Objectives
Terminal Learning Objective
The examiner who completes this course should be able to describe issues related to obtaining benefits
for physical and mental health conditions that may be secondary to MST.
Enabling Learning Objectives
To help you accomplish this objective, there are five enabling learning objectives:
1. Recognize the potential effects that experiencing sexual trauma or sexual harassment in the
military may have on a Servicemember’s or Veteran’s physical, mental, and emotional health.
2. Describe policies and programs implemented by DoD and VA to address the experiences of
sexual assault and sexual harassment in Servicemembers and Veterans.
3. Describe considerations for MST-related disability claims.
4. Recognize implications, requirements, and best practices for sharing information about MSTrelated resources with a Servicemember during a Separation Health Assessment.
5. Identify considerations and procedures for mental health examiners conducting MST-related
PTSD disability examinations.
The first lesson, Military Sexual Trauma, begins on the next page.
DMA Military Sexual Trauma and the Disability Examination Process
Page 3
Military Sexual Trauma (MST)
Lesson Objective
Some of the Servicemembers or Veterans that you examine experienced sexual trauma in the military.
This lesson defines military sexual trauma (MST), discusses the scope of MST, and explains how MST
affects Servicemembers and Veterans. When you finish this lesson, you should be able to recognize
potential effects of experiencing sexual trauma or sexual harassment in the military on a
Servicemember’s or Veteran’s physical, mental, and emotional health.
MST Defined
MST is an experience, not a diagnosis. Just like combat, MST experiences can result in a variety of
medical and mental health concerns. VA’s definition of MST comes from federal law, based on 38 U.S.C.
1720D.
38 U.S.C. 1720D(a)(1) refers to “psychological trauma, which in the judgment of a mental health
professional employed by the Department [VA], 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.”
MST refers to sexual assault or repeated, threatening sexual harassment experienced by a
Servicemember during military service, regardless of the geographic location, the gender of the
Servicemember, or the relationship to the perpetrator. Both men and women can experience MST.
Perpetrators may or may not be Servicemembers. Veterans from all eras of service have reported
experiencing MST.
Here are additional clarifications:



DoD uses different terminology to refer to these experiences, as DoD policies do not address
sexual harassment and sexual assault under the same umbrella.
MST can occur on or off base, while a Servicemember is on or off duty.
Perpetrators can be men or women, military personnel or civilians, superiors or subordinates in
the chain of command, strangers, friends, or intimate partners.
Statistics on the following pages will demonstrate that both men and women may experience sexual
harassment and sexual assault in the military. Please keep in mind that statistics regarding the
occurrences of MST may vary depending on the specific population screened, the time frame in question,
and even the terminology used.
DMA Military Sexual Trauma and the Disability Examination Process
Page 4
Department of Defense Study
DoD conducts a large annual study of unwanted sexual incidents among active-duty populations,
the Workplace and Gender Relations Survey of Active Duty Members (WGRA).
The 2012 WGRA study found that in the preceding twelve months, 23 percent of women and 4 percent of
men reported experiencing unwanted sexual attention, 8 percent of women and 2 percent of men
reported experiencing sexually coercive behavior, and 6.1 percent of women and 1.2 percent of men
reported experiencing unwanted sexual contact (sexual assault).
Frequency among Users of VA Healthcare
Data from VA’s universal MST screening program provides additional information about rates of MST.
Recognizing that many individuals that have experienced sexual trauma do not disclose their experiences
unless asked directly, it is VA policy that all Veterans seen for healthcare are screened for MST.
Screening is conducted in a private setting, by qualified health care providers trained to screen and
respond sensitively to disclosures. Data from Mental Health Services (2014) indicate that among
Veterans receiving VA outpatient healthcare services in Fiscal Year (FY) 2013:
77,681 or 24.3 percent of female Veterans screened positive for MST
57,856 or 1.3 percent of male Veterans screened positive for MST
IMPORTANT NOTE
MST includes both sexual assault and sexual harassment experiences. In addition, remember that not all
MST experiences have an associated diagnosis, and even those that do have a diagnosis may not have
a compensable disability based on Veterans Benefits Administration (VBA) regulations.
DMA Military Sexual Trauma and the Disability Examination Process
Page 5
Statistics for Veterans of Recent Deployments
VA also produces annual reports on MST screening and treatment among Operation Enduring Freedom
(OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans. Among VHA
OEF/OIF/OND outpatients in FY 2013:13,517 (21.6 percent) of women and 4,008 (1.0 percent) of men
reported MST when screened by a VA healthcare provider.
If you are interested in finding out more information about statistics regarding potential MST, a study by
Street, Gradus, Giasson, Vogt, and Resick (2013) sampled Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF) Veterans to gather data on sexual harassment. The complete reference
citation for this study can be accessed in the course Resources area.
Studies about physical and psychological conditions diagnosed more frequently in Veterans
who reported MST experiences are covered next.
Data from VA about Conditions Associated with MST
The physical and mental conditions most commonly found among VHA patients who report MST to their
providers are summarized below:
Physical Health
Mental Health
Liver disease
Posttraumatic Stress Disorder
Chronic pulmonary disease
Depression and other mood disorders
Women: Obesity, weight loss, hypothyroidism
Substance use disorders
Men: HIV/AIDS
Source: Kimerling, Gima, Smith, Street, and Frayne (2007)
IMPORTANT NOTE
Having these conditions does not mean that an individual has experienced MST.
DMA Military Sexual Trauma and the Disability Examination Process
Page 6
Physical Conditions Associated with Sexual Trauma
More information about the physical and mental health conditions that may be associated with sexual
trauma is detailed on the next pages. Given the associations between these conditions with MST, it is
critical for you to carefully assess and document them when conducting examinations. You will often be
the first clinician in VA to see a Veteran with an MST history and you may be the first person to whom
they are able to safely disclose having had an MST experience.
Research studies such as Frayne, et al., (1999) have found an association between the experience of
sexual trauma and these types of conditions:



Gastrointestinal problems, e.g., irritable bowel syndrome
Chronic pain, e.g., lower back pain, headaches
Gynecological problems, e.g., menstrual disorders, pelvic pain
Select Additional Medical Conditions to view more physical conditions associated with MST. It’s important
to remember, however, that even conditions that do not in general have a strong association with sexual
trauma or MST may still be MST-related for a given Servicemember or Veteran.
More Physical Conditions
A variety of studies indicate that medical conditions more likely to be diagnosed in Veterans who
experienced MST include these:
Arthritis
Chronic lung disease
Obesity
Thyroid disease (older men)
Diabetes
Endometriosis
Breast cancer (older women)
Miscarriage
Hypertension
Infertility
Hyperlipidemia
Sources: Frayne, et al. (1999); Frayne, Skinner, Sullivan, and Freund (2009); Kimerling,
Gima, Smith, Street, and Frayne (2007); Suris and Lind (2008)
MST and Psychological Health
A history of sexual assault has been shown to be associated with an increased risk for a number of
psychological disorders, including these:





Posttraumatic stress disorder (PTSD)*
Depression
Substance use disorders
Panic disorder
Generalized anxiety disorder
DMA Military Sexual Trauma and the Disability Examination Process
Page 7
Sources: Kimerling, Gima, Smith, Street, and Frayne (2007), and Suris and Lind (2007)
*A 2005 study of Gulf War Veterans indicated that Veterans who experienced MST had a higher
probability of developing PTSD than those who experienced combat but not MST, when compared to the
Gulf War Veteran population that did not experience MST or combat (Kang, et al., 2005).
Sexual trauma survivors frequently report problems including self-blame and shame, difficulty trusting
others, and low self-esteem. Select Self-Reported Problems to view additional self-reported problems.
Self-Reported Problems
Individuals who have experienced sexual trauma also frequently report these problems:










Issues with body image
Anger management issues
Impulsivity
Confusion about gender identity or sexual orientation
Intimacy and sexuality
Difficulties at work
Difficulties in relationships
Legal difficulties
Self-sabotage
Difficulties with medical and dental procedures (i.e., a rectal or vaginal exam, or any other
procedure that could feel invasive)
MST Experiences: Gender-Specific Issues for Women and Men
Issues for Women
Studies have documented some specific consequences for women who have experienced MST:


Women who experienced MST report more negative health consequences than women who
experienced childhood or civilian sexual assault.
MST has been shown to be more strongly associated with PTSD than pre- or post-military sexual
trauma.
Sources: Suris, et al. (2007); and Himmelfarb, Yaeger, and Mintz, (2006)
Issues for Men
MST presents a significant conflict with masculinity for many men. Sexual Trauma typically evokes
everything that masculinity rejects, such as:


Fear, shame, and other intense emotions
Vulnerability or helplessness
This can be associated with specific consequences for men who experienced MST, including:



Extreme homophobia
Attempts to “prove” heterosexuality to self and others
Impulsively getting married, or having increased unsafe or casual sex
DMA Military Sexual Trauma and the Disability Examination Process
Page 8


Confusion or worries about sexual identity or sexual orientation
Difficulties with intimacy, or avoidance of sexual activity
Additional Difficult Aspects Related to Experiencing MST
The following list describes aspects of MST that need to be considered, as they contribute to the negative
impact of the MST experience. Select each topic on this page to learn more. You may be asked questions
about this content.
Interpersonal Trauma
MST is an interpersonal trauma:





The perpetrator is often a friend, intimate partner, or other trusted individual.
MST may be particularly difficult in the military context, where the Servicemember relies
on others to be “Servicemembers in arms.”
MST may have significant implications on an individual’s subsequent relationships and on
their understanding of themselves.
Those who experience MST may continue to have interactions with their perpetrator(s):
o Eating, working, relaxing in the same areas as the perpetrator(s)
o No safe haven: sleeping quarters may be with the perpetrator(s) in situations of
same-gender assaults
o Ongoing potential for repeat victimization may exist
MST can increase feelings of helplessness and of being trapped.
Social Support
Social support may be limited after an experience of MST, which is problematic given research that
identifies social support as the most consistent and best predictor of recovery after trauma
(Charuvastra & Cloitre, 2008). The man or woman who experiences MST may:



Be far from friends and family which may limit supports
Not tell anyone due to shame or fear of retaliation, thus limiting his or her access to friends or
peers
Fear that his or her experiences aren’t as legitimate as combat trauma so decides to stay
quiet
Military Socialization and Values
The importance of strength and self-sufficiency are emphasized as part of the culture and training for
active-duty Servicemembers. These values can influence perceptions about MST for the man or
woman who experiences MST in the following ways:



He or she may have strong feelings of self-blame and feel “weak.”
He or she may try to “keep it together” and “be strong” to stay true to warrior values.
He or she may be reluctant to acknowledge the impact of MST experience(s) and pretend everything is okay.
DMA Military Sexual Trauma and the Disability Examination Process
Page 9
Other Complicating Factors
Many factors, including prior life experiences and/or current life circumstances can complicate an
individual’s response to and recovery from MST:




The individual may be young and/or lack a fully developed tool kit of coping strategies; he or
she may rely on substance abuse, behavioral acting out, or and cutting or other self-harm
behaviors to manage symptoms and reactions.
The individual may also be impacted by other traumatic experiences (e.g. exposure to
combat or prior experiences of abuse or assault).
Response and recovery can be negatively impacted by the number and severity of traumas
experienced by the individual.
Some individuals may struggle because the MST was committed by the perpetrator(s) to
punish or victimize them due to their perceived sexual orientation or gender identity.
Alternatively, MST can also cause individuals to worry about what MST means for their own
sexual orientation or gender identity.
Why Women May Not Report Unwanted Sexual Contact
Statistics for unreported rape and sexual assault are similar for military and civilian populations.
According to the Bureau of Justice Statistics report, Victimizations Not Reported to the Police, 2006-2010,
65 percent of rapes and sexual assaults in the United States went unreported.
Similarly, 2012 WGRA survey results showed that of the 6.1 percent of active-duty women who indicated
they experienced unwanted sexual contact in the preceding 12 months, only 33 percent reported it to a
military authority.
Of the 67 percent of active duty women who indicated they experienced unwanted sexual contact and not
reporting to a military authority, these were the top four reasons cited by respondents:




Discomfort that anyone would know
Discomfort around making a report
Fear that their report would not be kept confidential
Fear that nothing would be done
Other reasons provided by respondents for not reporting unwanted sexual contact included thoughts that
the unwanted contact was not important enough to report, thoughts that he/she would be labeled a
troublemaker, fears of retaliation or reprisals from the perpetrator or the perpetrator's friends, and fears
related to reports from others who had experienced negative consequences for reporting unwanted
sexual contact.
DMA Military Sexual Trauma and the Disability Examination Process
Page 10
Why Men May Not Report Unwanted Sexual Contact
Active duty men may report unwanted sexual experiences even less often than women. 2012 WGRA
survey responses indicated that only 19 percent of the 1.3 percent who experienced unwanted sexual
contact in the preceding 12 months reported it to a military authority.
The top four reasons given by male respondents who did not report unwanted sexual contact to military
authority were:




Concerns about being reprimanded or punished for infractions related to underage drinking or
other offenses
Concerns that others would not believe the report
Fear that performance evaluations and/or opportunities for promotion would suffer or be
negatively impacted
Fear of losing security clearance or personnel reliability certification
Other reasons given were hearing about negative experiences from others who reported or not knowing
how to report.
A Spectrum of MST Experiences: Marie
The four scenarios that follow will give you an idea of the spectrum of MST experiences, and how
repetition over time can impact the Servicemember who experiences MST.
Marie
Marie entered the service while in her early twenties. Marie was sexually harassed by a group of male
Servicemen on an ongoing basis. They made sexual comments, grabbed her buttocks on several
occasions, and asked Marie if she’d “ever been with a real man.”
Feeling uncomfortable and unsafe, Marie made efforts to avoid walking alone. However, on one occasion
she was cornered by one of the men. He stated that his friends were nearby and he forced her to perform
oral sex on him. Afterwards, Marie became increasingly distressed and isolated from others and lived in
constant fear of being assaulted again. She kept to herself at work, but for the most part her job
performance was fine.
Later in her service, Marie was returning home, having just parted with a close friend after a night out.
Alone, Marie was groped and digitally penetrated by the same man who forced her to perform oral sex.
The next day, this man interacted with Marie and he “acted like nothing had happened.” Marie never
talked to him again. Also, she felt numb most of the time and avoided social contact as much as possible.
DMA Military Sexual Trauma and the Disability Examination Process
Page 11
A Spectrum of MST Experiences: Tom
Tom
Tom is an African-American man who served between 1970 and 1972, when he was in his late twenties.
To begin with, Tom was surprised to encounter prejudiced and racist views about African-Americans on
the base.
One night, Tom went out to a bar with a friend from his barracks. Eventually, his friend met a woman and
left the bar with her. Later, Tom left the bar alone to return to the barracks. Just outside the bar, Tom was
attacked by three men. Tom tried to get away, but one of the attackers punched him in the face. Another
of his attackers had a bat or a stick that he threatened Tom with if Tom did not stay quiet. Two of the men
took turns holding Tom down while the other penetrated him anally. Tom was told repeatedly during the
attack that if he told anyone, his attackers would come back and kill him.
Tom did not report to duty the following day. When Tom was asked about his swollen eye, he stated that
he had been in a fight at the bar. As a result of this attack, Tom also developed painful hemorrhoids that
he never discussed with anyone.
A Spectrum of MST Experiences: Juan
Juan
Juan, a 25-year-old Latino man, was involved in heavy combat in Afghanistan. In one firefight, Juan
became disoriented. As a result, he was slow to keep up with other members of his unit as they moved
into some of the most dangerous fighting. Afterwards, some unit members made comments about being
unsure that they could trust him anymore.
The next night, Juan was grabbed by someone as he went to the latrine, and held down as another man
anally raped him. During the assault, his assailants said, “This should teach you to pull your weight
around here.” As a result of this assault, daily life and subsequent combat missions became even more
stressful and frightening for Juan. In addition, Juan contracted a sexually transmitted infection (STI) from
the assault in the form of human papillomavirus (HPV). Juan’s HPV has just manifested, although the
attack was three years ago.
Even today, Juan feels that others do not, in his own words, “have his back.” He fears that even the
slightest misstep on his part could be dangerous.
A Spectrum of MST Experiences: Amanda
Amanda
Amanda, now twenty-eight years old, is African-American and the single mother of a nine-year-old
daughter. Amanda was a truck driver in Iraq, where she was trained that she must not stop the truck even
if a civilian is in the road. Amanda was terrified at the thought that she might someday have to run over a
child, and talked to her colleagues about her fears.
While on active duty, Amanda was approached by a higher-ranking Servicemember, a man, who was
responsible for job assignments. He stated that he would change her assignment to staffing the truck
depot on the condition that Amanda would have sex with him. Although Amanda had no romantic or
sexual interest in him, she feared career consequences from refusing; and this concern, in combination
DMA Military Sexual Trauma and the Disability Examination Process
Page 12
with her great fear of having to run over a child, led her to have sex with the Servicemember on several
occasions. Amanda felt numb throughout the encounters. When she became pregnant from the
encounters, other Servicemembers found out and made comments about her being, in their words,
“easy.” In fact, Amanda was ostracized by her peers.
Common Myths about MST
Select Play to hear some common myths versus facts about MST. You may be asked questions about
this content.
COMMON MYTHS ABOUT MST
Man: Someone has to have been convicted of assault for a crime to have occurred.
Woman: Someone does not have to be convicted for a crime to have occurred. In fact, the majority of
perpetrators are never caught or convicted.
Man: MST doesn't happen to men.
Woman: MST can and does happen to both men and women
Man: Officers cannot experience MST
Woman: Sexual assault and chronic sexual harassment occur across all ranks
Man: If a person does not fight or refuse his or her perpetrator, he or she must have consented.
Woman: Compliance (or being unable to refuse, such as when intoxicated or asleep) does not equal consent.
Man: A person cannot have experienced MST if he or she was sexually active.
Woman: An individual's prior behavior and relationships cannot be used to blame him or her for an MST
experience or to discount the experience as MST. A Servicemember may have been sexually active, or
may even have even had a friendly relationship with a perpetrator prior to being assaulted or harassed,
but that doesn't mean that he or she wanted the MST to happen. Think instead about why the perpetrator
made a choice to assault or harass a Servicemember.
DMA Military Sexual Trauma and the Disability Examination Process
Page 13
Knowledge Check
Answers and feedback for this knowledge check can be found on page 68
1. True or false? The perpetrator of MST must be a stranger or a superior officer.
A. True
B. False
2. True or false? Recent research findings indicate that women who were sexually assaulted in the
military report more negative health consequences than women who experienced childhood or other
civilian sexual assault.
A. True
B. False
3. Which of the four following mental health conditions is less commonly found among VHA patients
who report MST to their providers?
A. Depression
B. Substance use disorders
C. Posttraumatic stress disorder
D. Bipolar disorder
4. True or false? MST is a diagnosis.
A. True
B. False
5. True or false? The 2012 WGRA survey showed that only 19 percent of men who indicated they
experienced unwanted sexual contact reported it to a military authority.
A. True
B. False
6. Which of the following three statements about MST is not correct? Select the incorrect answer.
A. VA’s definition of MST only includes sexual assault.
B. Not all MST experiences have an associated diagnosis.
C. Not all MST-related diagnoses have a compensable disability based on VBA regulations.
7. Which of the following four statements is not correct about VA's universal MST screening program?
Select the incorrect answer.
A. All Veterans seen for healthcare at VA facilities are screened for MST.
B. Screening is conducted using self-report forms.
C. Data from 2013 indicate that 24.3 percent of female Veterans screened positive for MST.
D. Data from 2013 indicate 1.3 percent of male Veterans screened positive for MST.
8. True or false? According to a recent Bureau of Justice Statistics report, most rapes and sexual
assaults that occurred in the United States between 2006 and 2010 were reported to authorities.
A. True
B. False
9. Which of the following four statements is true of MST? Select the correct answer.
A. Someone has to have been convicted of assault for a crime to have occurred.
B. MST doesn't happen to men.
C. Officers in the military can experience MST.
D. If a person does not fight or refuse his or her perpetrator, he or she must have consented.
DMA Military Sexual Trauma and the Disability Examination Process
Page 14
Lesson Summary
The content in this lesson was designed to help you gain a basic understanding of MST and its potential
effects for Servicemembers and Veterans. Now that you’ve completed this lesson, you should be able to
recognize the potential effects that experiencing sexual trauma or sexual harassment in the military may
have on a Servicemember's or Veteran's physical, mental, and emotional health.
The next lesson is an overview of VA and DoD Policies and Programs related to MST. It is intended to
give all disability examiners a general understanding of interagency collaboration and VA and
DoD programs to address MST-related issues.
DMA Military Sexual Trauma and the Disability Examination Process
Page 15
VA and DoD Policies and Programs
Lesson Objective
A lot of coordination goes into addressing MST-related concerns that may be present in the men and
women you examine. This lesson will cover VA and Department of Defense (DoD) coordination and
programs to address MST-related issues.
After completing this lesson, you should be able to describe policies and programs implemented by DoD
and VA to address the experiences of sexual assault and sexual harassment in Servicemembers and
Veterans.
Partnership between VA and DoD
Due to their commitment to effecting positive change in addressing MST related concerns in
Servicemembers and Veterans, leaders from the VA and DoD have regularly met to discuss MST-related
issues. Changes that have resulted from this collaboration include discussion of MST with
Servicemembers who are transitioning from active duty to Veteran status during the Transition Assistance
Program (TAP) as well as during the Separation Health Assessment (SHA). It is the hope of VA and DoD
leadership that by incorporating information about MST into the TAP and the SHA, active duty
Servicemembers will gain the information necessary for filing a claim for a condition secondary to MST.
DoD Programs
Three DoD programs assist Servicemembers who experience MST: The Safe Helpline, the Sexual
Assault Prevention and Response Office (SAPRO), and the Military Equal Opportunity (MEO) program.
DoD addresses sexual assault and harassment with separate reporting channels: SAPRO processes
sexual assault reports, while the MEO Program processes sexual harassment reports. Select each
program to view more information.
DMA Military Sexual Trauma and the Disability Examination Process
Page 16
The Safe Helpline
DoD has contracted with The Rape, Abuse & Incest National Network (RAINN) to
provide confidential, secure, and anonymous services for the DoD community via
the DoD Safe Helpline. The Helpine is available worldwide, 24/7 by click, call or
text–providing help anytime, anywhere, using multiple options:





Online Helpline
Telephone Helpline
Text for Info
Safe HelpRoom (Online chat room)
Safe helpline App
The Telephone Helpline staff can even transfer callers to local Sexual Assault Response
Coordinators (SARCs), if a Servicemember chooses. A complete description of services is found at
the following secure Safe Helpline website: https://www.safehelpline.org/
The Sexual Assault Prevention and Response Office
DoD created the Sexual Assault Prevention and Response Office (SAPRO) in 2005
as part of a comprehensive policy to address sexual assault in the military. SAPRO
provides oversight of the Department's sexual assault policy. SAPRO works handin-hand with all branches of service and the civilian community to develop and
implement innovative prevention and response programs. Sexual assault is
reported through SAPRO.
The Department of Defense Sexual Assault Prevention and Response Office (SAPRO) serves as
the single point of authority for program accountability and oversight, in order to enable military
readiness and reduce—with a goal to eliminate—sexual assault from the military. (SAPRO
Mission Statement)
— SAPRO Mission Statement
More details about SAPRO can be found on SAPRO’s website: http://www.sapr.mil/
MEO Program
The MEO program is charged with promoting equal opportunity and affirmative actions, and for
eliminating unlawful discrimination and sexual harassment within DoD. Sexual harassment is reported
through the MEO program.
DMA Military Sexual Trauma and the Disability Examination Process
Page 17
Partnership between VHA and VBA
VHA and VBA also continue to collaborate in efforts to address issues related to the examination of
disability claims for Veterans with MST claims. In keeping with these efforts, a satellite broadcast
sponsored jointly by VHA and VBA was released in April 2012. The training broadcast, entitled Military
Sexual Trauma: Disability Claims, addressed a wide range of topics related to MST claims and included
dialogue between a VBA adjudicator and a VHA mental health examiner to promote understanding of
VBA regulations and expectations in case adjudication as well as diagnostic concerns and considerations
of VHA providers. More importantly, the broadcast emphasized the need for collaboration between VHA
and VBA providers in addressing what are often complex claims involving MST.
Select Resources on the navigation bar for information on how to access a video of this broadcast.
VHA Policies and Programs for MST-Related Education and
Outreach
VHA has nationwide MST support programs and training initiatives to facilitate MST-related care,
including these:
MST Support Team
VHA’s Mental Health Services (MHS) has a national MST Support Team to perform national monitoring,
to coordinate MST-related education and training, and to promote best practices in the field.
MST Coordinators
Every VA healthcare system has an MST Coordinator who serves as a point person for MST issues at the
facility and who ensures that MST-related monitoring, treatment, and education and training occur there.
The MST Coordinator is your best point of contact for assistance in getting Veterans into MST-related
care or for answering any questions about local services. If you call your local VAMC, the operator should
be able to connect you to the MST coordinator.
Note: Veterans and Servicemembers needing assistance with benefits or claims should speak with a VBA
representative.
Mandatory and Optional Trainings on MST
In 2012, VHA established a mandatory training requirement on MST for all VHA mental health and
primary care providers. The mandatory trainings are intended to enhance awareness of and sensitivity to
issues related to MST. Many disability examiners may have also taken the course, Military Sexual
Trauma Sensitivity Training (VHA), if they conduct disability examinations as part of their collateral duties.
Select Educational and Training Resources to view additional resources for staff.
Educational and Training Resources


VA Mental Health Military Sexual Trauma public website: www.mentalhealth.va.gov/msthome.asp
VA internal MST Resource Homepage for staff at vaww.mst.va.gov, which includes:
o Educational handouts for staff
o Veteran outreach/informational materials
o Your local VA Medical Center’s MST Coordinator
DMA Military Sexual Trauma and the Disability Examination Process
Page 18
VHA Policies for MST-Related Treatment
VA has developed a range of services to assist Veterans and Servicemembers who experienced MST
with their recovery. All VHA treatment for physical and mental health conditions related to MST is
free of charge for enrolled Veterans. In addition:


Veterans do not need to have reported their experiences of MST at the time or have other
documentation that they occurred.
Service connection (VA disability compensation) is also not required.
Veterans may be able to receive free MST-related care even if they are not eligible for other VA care:


There are no length-of-service or income requirements to receive MST-related care.
Veterans with Other Than Honorable discharges may be able to receive MST-related care with
VBA Regional Office approval.
The Uniform Mental Health Services Handbook (VHA Handbook 1160.01) has detailed information on
which mental health services must be available for Veterans who have experienced MST.
IMPORTANT NOTE
Please remember these policies apply to all Veterans that you see as part of your disability evaluations.
VHA MST-Related Mental Health Treatment
As you learned earlier in this course, there are often mental health diagnoses that are associated with
MST. VHA offers a full continuum of mental health services for Veterans who have experienced MST:

Every VA medical center provides MST-related mental health outpatient services.
MST-Related Mental Health Outpatient Services
o Outpatient services are organized differently at different facilities—some have identified “MST
clinics,” while others provide services in a more distributed fashion.
o Services include formal psychological assessment and evaluation, psychotropic medications,
and individual and group psychotherapy; services are available to target problems such as
PTSD, substance use disorders, depression, and homelessness.

For Veterans who need more intensive treatment, many VHA facilities offer Mental Health
Residential Rehabilitation and Treatment Programs and some of these programs focus
specifically on MST or have specialized MST tracks. VHA also has inpatient programs available
for acute care needs (e.g., psychiatric emergencies and stabilization, medication adjustment).
Mental Health Residential Rehabilitation and Treatment Programs
o VA recognizes that some Veterans will benefit from treatment in an environment where all of
the Veterans are of one gender, so some facilities have separate programs for men and
women. All residential and inpatient MST programs have separate sleeping areas for men
and women.

Community-based Vet Centers have MST-related services available.
DMA Military Sexual Trauma and the Disability Examination Process
Page 19
Recovery is Possible
MST-related treatment can help a Veteran move forward in his or her recovery. Select Play to hear a
story that is loosely based on the experience of a Veteran who disclosed an MST experience to her VA
provider and followed up on her provider’s suggestion to seek MST-related care from VHA.
I was raped by my superior several years ago, while I was on active duty. I reported the rape, and
he went to jail. I finished my active service and was discharged. I thought I could move on with
my life...
I was going to pursue work as a surgical technician after the service. I had the training and
experience for the job, and I enjoyed it. But I couldn’t because of a weird rash that was constantly
on my hands. I couldn’t tolerate wearing the surgical gloves. The itching and discomfort were
unbearable when I had the gloves on for even a few minutes.
So, I had been out of the service for a number of years when I decided to enroll in VHA for
healthcare. During the first visit to the VA facility, the provider asked me if I’d experienced sexual
trauma while I was in the service. I was surprised when he asked, but he explained that VA asked
this question of all Veterans who came to VA for healthcare. When I said yes I had been sexually
assaulted in the military, he told me that VA has free MST-related care services and he asked if I
wanted to talk to an MST Coordinator. “Why not,” I thought, and so he had the MST Coordinator
contact me.
The MST coordinator suggested that I receive mental health counseling from VA to address my
MST experience, and I agreed to do it. After a few weeks in counseling, the mysterious rash had
pretty well disappeared from my hands. Seems like wearing surgical gloves is something I could
do now! I would have never thought that mental health counseling would have helped with my
rash. But boy, am I glad that my provider asked me about MST to begin with!
DMA Military Sexual Trauma and the Disability Examination Process
Page 20
Knowledge Check
Answers and feedback for this knowledge check can be found on page 70
1. Match each kind of reporting with the correct DoD program.
Choose
A.
_____ one
Sexual harassment reporting
Option 1: SAPRO
Choose
_____ one
B.
Sexual assault reporting
Option 2: MEO program
2. True or false? Only select VA medical centers provide MST-related mental health outpatient services.
A. True
B. False
3. VHA established a mandatory MST training requirement in 2012 for all but one of the following three
kinds of clinicians. Select the clinicians who are not included.
A. Primary care providers
B. Mental health providers
C. Gynecologists
4. True or false? All VHA treatment for physical and mental health conditions related to MST is free of
charge for enrolled Veterans.
A. True
B. False
5. An MST Coordinator performs many functions at his or her facility. Select the function that is
generally not performed by an MST Coordinator. Select the incorrect answer.
A. Ensure that MST-related training and education occur
B. Serve as a point of contact for assistance in getting Veterans into MST-related care
C. Validate every diagnosis of an MST-related condition
D. Answer questions about MST-related care
6. Which of the following statements is not true for Veterans seeking MST-related healthcare from VA
facilities? Select the incorrect answer.
A. Veterans do not need to have reported their experiences of MST at the time or have other
documentation that they occurred.
B. There are income requirements.
C. Service connection (VA disability compensation) is not required.
D. There are no length-of-service requirements.
Lesson Summary
This lesson focused on policies and programs to address experiences of sexual assault and sexual
harassment in Servicemembers and Veterans. Now that you’ve finished this lesson, you should be able to
describe some important DoD and VA policies and programs related to MST.
The next lesson covers general information about MST-related disability claims.
DMA Military Sexual Trauma and the Disability Examination Process
Page 21
MST Related Disability Claims
Lesson Objective
This lesson will cover VBA processes for developing MST-related claims when evidence is not easily
developed because of underreporting of MST during service. As an examiner, you can assist Veterans
and Servicemembers who've experienced MST by conducting trauma-sensitive examinations and being
aware of best responses to MST disclosures.
Once you’ve completed this lesson, you should be able to describe considerations for MST-related
disability claims.
Considerations for Servicemembers and Veterans Filing a Claim
The issue of underreporting is important to consider, as many Veterans or Servicemembers will not have
any evidence in their Service Treatment Records or personnel files that a sexual trauma may have
occurred. Without direct evidence of an event, it is often difficult for VBA to grant benefits.
Moreover, Servicemembers and Veterans who experienced MST often have mixed feelings about
seeking service connection. The following table lists potential pros and cons for claimants.
PROS
CONS
Financial assistance
Requires disclosure to an unknown examiner
Potential for validation
Potential for feeling invalidated if a claim is denied
Acknowledgment of traumatic experience
Requires confronting painful memories
Requires admitting to having difficulties
Requires dealing with a government agency
May provoke feelings of dependency
Difficulty or inability to complete the PTSD
Statement in Support of Claim secondary to
Personal Assault
VBA Processes for MST-Related PTSD Claims
Diagnoses secondary to MST can be compensable regardless of whether the MST occurred outside
regular tours of duty, off military premises, or during peacetime, as long as Veterans Benefits
Administration (VBA) evidentiary requirements are met. In addition, please be aware that
Servicemembers and Veterans who suffered illness prior to military service, for example, as a result of
childhood trauma, may still file a successful claim for that condition if it can be credibly demonstrated that
the illness was aggravated by MST.
As Servicemembers often do not report MST for understandable reasons, a lack of evidence is a common
challenge for VBA adjudicators working on MST-related disability claims. As a result, VBA has assigned
DMA Military Sexual Trauma and the Disability Examination Process
Page 22
specially trained employees to handle these claims and process them in a “special operations” lane
where they receive added attention to evidence development and evaluation.
As VBA is very invested in assuring that all Veterans who have filed claims for conditions secondary to
MST receive the most fair ratings, VBA has also engaged in efforts beyond having specially trained
employees handle these claims. After VBA provided extensive training in 2011 for processing PTSD
disability claims due to MST, it engaged in outreach efforts to those Veterans whose claims were denied
prior to the training by sending them notification letters in 2013 and 2014 offering a re-evaluation of their
PTSD claim secondary to MST if they contacted the regional office of jurisdiction.
VBA Outreach
As part of the outreach to Veterans with previously denied MST-related PTSD claims, VBA also engages
in other outreach methods to inform eligible Veterans who may not have received the notification letter to
contact their regional office to reopen a claim. You may have an opportunity to assist in this effort. For
example, if you review records for a Veteran you examine and you notice a previously denied claim that
would be included in this outreach; you could follow the example in the audio presentation on this page.
Select Play to hear an examiner discuss this with a Veteran.
Examiner: I was looking at your C-file and noticed a denied PTSD claim from 2011. It was related to military sexual trauma. The Veterans Benefits Administration has been reviewing some of these denied claims. So, you may want to contact the Regional Office about possibly reopening your claim.
Veteran: Oh, I see. Thanks for letting me know. How do I reopen it?
Examiner: Okay, you can start by contacting your RO for more information. Or you can call the VBA
hotline. Let’s see...that number is: 800-827-1000.
The Importance of Conducting Trauma-Sensitive Examinations
Many of the Servicemembers or Veterans you examine will have experienced trauma. Since you will not
know who does and does not have a trauma history, it is good clinical practice to conduct all
examinations in a trauma-sensitive manner. This will help Veterans and Servicemembers feel more
comfortable and, in turn, help you to obtain the information you need.
The Veterans Health Administration (VHA) has encouraged practices that can benefit the Servicemember
or Veteran who has experienced MST. For example, VHA encourages the practice of allowing an
examinee to request an examiner of a specific gender, when feasible.
For this reason, simple ways you can conduct a trauma-sensitive examination are discussed on the next
page.
DMA Military Sexual Trauma and the Disability Examination Process
Page 23
IMPORTANT NOTE
VA C&P disability examiners should keep in mind that in many instances, a disability examination may be
the first interaction the Veteran or Servicemember has with VA. Leaving him or her with a good
impression may encourage him or her to return to VA for other services if needed.
Methods for a Trauma-Sensitive Examination
There are simple things you can do to help increase a Servicemember’s or Veteran’s comfort during the
disability examination. These are good things to do with all individuals to help them feel more comfortable
during examinations. When possible and consistent with appropriate professional boundaries, try to use
the following methods.
Reduce the Power Differential
Reduce the power differential and provide explanations:





Whenever possible, have conversations while the Servicemember or Veteran is fully dressed.
Sit at the same level as the Servicemember or Veteran preferably without a desk in between you.
Make eye contact.
Give the Servicemember or Veteran options and choices whenever possible.
Be transparent, explaining your reasoning for the questions you need to ask.
The Veteran or Servicemember Feels in Control
Ensure the Servicemember or Veteran feels in control:




Ask permission before touching
Let the Servicemember or Veteran know you will stop if he or she asks.
Keep a running commentary of exactly what you are doing and what you are about to do. For
example:
o “Okay, as you can see I am picking up an instrument now. This is for looking in your ears;
it shouldn’t hurt. I am going to move close to you and briefly touch your ears while I am
looking at your inner ear, is that okay?”
Check in periodically and ask how he or she is doing. Reactions
Respect Reactions
Respect a Servicemember’s or Veteran’s reactions:




View the Servicemember or Veteran as an expert on his or her own body and functioning.
Attend carefully to his or her identified concerns.
Respect the Servicemember’s or Veteran’s subjective experience, even if it seems extreme given
the objective circumstances.
Never ignore or dismiss a Servicemember’s or Veteran’s request or expression of distress.
DMA Military Sexual Trauma and the Disability Examination Process
Page 24
How to Respond Sensitively if a Veteran Discloses MST to You at
an Evaluation
There are many simple but effective things you can do during a disability exam to respond sensitively to a
disclosure of MST. These strategies can also work well when you are conducting an examination for a
claimed condition that a Servicemember or Veteran indicates is related to MST. Remember that you may
be the first person that he or she has ever told about his or her experiences. An empathetic, supportive
response has the power to be tremendously healing. For example, “I'm so sorry this happened to you.”
Select each of the items that follow to listen to an example.
Provide validation and empathy:
I’m very sorry this happened to you while you were serving our country. Thank you for deciding to
share this information today.
Provide education and normalization:
Other Veterans have had experiences like yours and for some, it can continue to affect them even
many years later. However, there are many services and treatments available to help you in your
recovery, if you need them.
Offer VA healthcare services:
Some of the Veterans I’ve met with have found it helpful to talk with someone about their
experiences. The VA offers free counseling related to MST. Would it be okay if I asked this facility’s
MST Coordinator to be in touch with you to tell you about the services available? After talking with
him or her about your options, you could decide if you wanted to take it any further.
Remember that not everyone needs counseling:
If you ever change your mind and want to speak to someone, just let me know.
DMA Military Sexual Trauma and the Disability Examination Process
Page 25
IMPORTANT NOTE
Remember to avoid phrases like this:




“Is there any proof?”
“Why didn’t you report it?”
“I’m not sure if anyone will believe you.”
“I’m not sure if I have to report this to the authorities.”
How to Respond Sensitively if a Veteran Discloses MST
(continued)
Except for mental health professionals providing psychotherapy, providers are discouraged from
requesting or recording a detailed account of what happened during the MST. The reason is that asking
the Veteran to recount the details of the assault can cause him or her to re-experience the trauma, much
as they would during exposure therapy. This should be left to mental health professionals with expertise
in these techniques, as the mental health clinician typically explores details of the trauma only after
multiple sessions to carefully lay the groundwork. However, it is helpful for providers to document basic
information that is spontaneously disclosed by the Veteran.
There are a few other suggestions for examiners that may be of interest to you.
Other Ways to Respond Sensitively
If the Veteran appears withdrawn or quiet, seems “out of it”, or provides minimal acknowledgement of
the information:


Say, “Take your time,” or, “Are you still here with me?”, or, “We can continue when you’re
ready.”
Give him or her a few moments if needed.
If the Veteran becomes tearful, angry, agitated, anxious, or “jumpy:”



Say, “This can be a difficult experience for many Veterans. Would you like to take a break for
a few minutes?”, or, “Let me know when you are ready to continue.”
Listen empathically and acknowledge his or her distress.
Remind him or her that services are available if needed.
Behaviors such as these could indicate that he or she is considering disclosing an MST experience,
so be prepared to respond sensitively.
IMPORTANT NOTE
As an examiner, please remember that a variety of physical conditions may occur secondary to an
experience of MST. You should document not just the physical findings and the experience of MST, but
also document the relationship between the MST experience and the diagnosis.
DMA Military Sexual Trauma and the Disability Examination Process
Page 26
Responding to an MST Disclosure (Video)
You may remember an example fictional narrative of an MST experience earlier in this course for a
Veteran named Juan. In the video on this page, Juan Lopez discloses an MST experience to a disability
examiner in the context of a disability examination. The examiner is empathetic and she encourages Mr.
Lopez to consider VHA services that can help in his recovery.
Title: MST Disclosure to a Mental Health Disability Examiner
Examiner: So, those are all the questions I have for you today. Is there anything else I haven't asked you
about your depression that you think is important for me to know as part of this exam?
Mr. Lopez: Well I, I know I've been pretty vague as to how my depression started. But, I think I know why
it started. On my deployment, when something happened.
Examiner: Is that something you'd like to share with me today?
Mr. Lopez: I know that's not what this exam's about but... I haven't told anybody. I don't even think I should say anything now.
Examiner: What you decide to share is completely up to you.
[Veteran sighs]
Mr. Lopez: During my deployment, in Afghanistan, I was attacked... raped, going to the latrine one night.
It was a bunch of guys. They said I wasn't pulling my weight and that they couldn't trust me anymore. They were going to “teach me a lesson.” I didn't know what to do, who to trust. I thought they'd kill me or
do it again if I said anything. And then I find out I've got this HPV infection from the rape! I had never even
heard of that before this happened. It was just too much... too much...
[Examiner puts down clipboard, looks at Veteran] Examiner: I'm so sorry that happened to you, Mr. Lopez, and on your deployment. I can understand how
overwhelming that must have been.
Mr. Lopez: It was horrible.
Examiner: I'm glad that you felt comfortable enough sharing it with me today. Unfortunately, many
Veterans have had similar experiences, and for some, it can continue to affect them even years
DMA Military Sexual Trauma and the Disability Examination Process
Page 27
afterwards. People can recover though. Can I talk to you about VA services that are available that can
help you if you're still having problems that you think are related to that experience?
Mr. Lopez: I'd be open to it.
Examiner: Your VA offers free healthcare for medical and mental health conditions related to sexual
assault that occurred in the military. And every VA medical center has a Military Sexual Trauma
Coordinator, a person who can put you in touch with the medical and mental health professionals who are
experts in that area and who could help you. Do you think you would be interested in following up with
your VA's Military Sexual Trauma Coordinator after today's exam?
Mr. Lopez: Yeah, I think I need to do that.
Examiner: Let me get the name of that person for you before you leave today.
[Scene fades]
DMA Military Sexual Trauma and the Disability Examination Process
Page 28
Knowledge Check
Answers and feedback for this knowledge check can be found on page 71
1. True or false? Potential for validation is one reason Veterans or Servicemembers may be motivated
to file claims for MST-related conditions.
A. True
B. False
2. Which of the following suggestions applies if a Veteran discloses an MST experience during a
disability examination?
A. Prevent any disclosure altogether.
B. Solicit a detailed account of the experience or experiences.
C. Limit your documentation to the Veteran’s remarks.
D. Document and explain how physical findings are related to MST experience(s).
3. True or false? VHA does not encourage the practice of allowing an examinee to request a disability
examiner of a specific gender.
A. True
B. False
4. Examiners should follow one of the four suggestions below when conducting a trauma-sensitive
examination. Select the correct answer.
A. Have conversations while the Servicemember or Veteran is fully dressed.
B. Avoid eye contact with the Servicemember or Veteran
C. Don’t explain your reasons for questions you ask
D. Don’t provide the Veteran or Servicemember options and choices
5. Which of the following reasons can motivate Veterans to file disability claims? Select the correct
answer.
A. Disclosure to an unknown examiner
B. Financial assistance
C. Requires confronting painful memories
D. Requires admitting to having difficulties
6. True or false? VBA sent notification letters to Veterans in 2013 and 2014 that offered a re-evaluation,
under certain conditions, of previously denied MST-related PTSD claims.
A. True
B. False
7. VBA has implemented two of the three following policies and programs to address MST-related PTSD
claims from Veterans. Select the incorrect answer.
A. VBA has assigned specially trained employees to handle these claims with added attention to
evidence development and evaluation.
B. VBA reiterated the need to deny MST-related PTSD claims that lacked objective evidence
similar to evidence required for all disability claims.
C. VBA provided extensive training to VBA staff in 2011 for processing PTSD disability claims
due to MST.
DMA Military Sexual Trauma and the Disability Examination Process
Page 29
Lesson Summary
This lesson provided information about VBA processes to help adjudicators develop MST-related claims
and simple methods you can use for conducting trauma-sensitive examinations with all Veterans and
Servicemembers. You should now be able to describe considerations for MST-related disability
examinations.
The next lesson is specific to concerns about MST for Servicemembers and disability examiners during
the Separation Health Assessment (SHA). Some of the information will be background information for
disability examiners who do not conduct SHA examinations, but some information will be useful to all
examiners.
DMA Military Sexual Trauma and the Disability Examination Process
Page 30
MST and the Separation Health Assessment
Lesson Objective
The SHA will be administered to all Servicemembers as part of the process of separation from active
duty. When a Servicemember has filed a disability claim, a VA disability examiner will conduct the SHA
while the Servicemember is still on active duty. This lesson will explain how this context for the SHA
impacts the Servicemember and the disability examiner, particularly with respect to MST.
Once you have finished this lesson, you should be able to recognize implications, requirements, and best
practices for sharing information about MST-related resources with a Servicemember during an SHA.
The Separation Health Assessment
The SHA program was designed by VA and DoD as a program to help Servicemembers to engage in the
VA benefits process before separation from active military service. To accommodate the specific reporting
requirements for the SHA examination, the SHA General Medical Disability Benefits Questionnaire (DBQ)
was developed
General Medical Disability Benefits Questionnaire
The SHA General Medical Disability Benefits Questionnaire (DBQ) is a comprehensive examination
protocol and you must complete all sections. When you conduct an SHA, you are required to assess
and document all conditions during the examination. Your awareness of conditions that may be
associated with an MST experience can help you to document all potentially related conditions that
may be related to MST without soliciting a disclosure during the examination process.
The SHA DBQ will be administered to all Servicemembers as part of the process of separation from
active duty. Depending on whether the Servicemember has filed a disability claim, the SHA is conducted
by a DoD clinician or a VA disability examiner. Since the Servicemember is on active-duty, the
documentation of the SHA will be part of the Servicemember’s Service Treatment Records (STRs), which
will be shared with DoD.
For reasons that will be described in this lesson, you should not attempt to solicit a disclosure of MST
during the SHA. The SHA is a special case, and there are special considerations to which examiners
need to attend, given the risks of potential reprisal or compromising a restricted report if a Servicemember
were to disclose MST during an examination.
If a Servicemember chooses to disclose, the documentation of an MST event while on active duty may
be helpful for the Servicemember to receive VA benefits. However, as we will discuss later in this lesson,
it may be of greater benefit for the Servicemember to disclose to the proper authorities, if he or she
chooses to disclose.
Aspects of the SHA
Most processes to prepare for and conduct a Separation Health Assessment are similar to processes that
you use to prepare for a disability general medical examinations. Select each topic for details.
DMA Military Sexual Trauma and the Disability Examination Process
Page 31
Review of Records
Examiners are required to review Service Treatment Records (STRs). On the VA side, using the
electronic Veterans Benefits Management System (VBMS) makes it easier to access and review STRs
prior to the exam.
If the DD Form 2807-1, a self-reporting tool provided to the Servicemember, is available in the
Servicemember’s records, you are required to review this form as part of completing the SHA General
Medical DBQ.
To learn more about this form, you can access it by looking for DoD form DD 2807-1 at the public-facing
DoD Issuances website: http://www.dtic.mil/whs/directives/infomgt/forms/
Time Allotted
The minimum time requirement for conducting an SHA is one hour. Since the SHA is a general medical
examination in scope, the average time required is two hours—but this examination could require several
hours. In practice, the time allotted by VA for an SHA is determined by the individual examiner.
Additional Documentation Protocols
For the comprehensive SHA examination, additional DBQs or other appropriate documentation protocols
should be used to assess and document conditions as warranted. Currently, on average, 3.5 DBQs are
opened by disability examiners during an SHA.
Specialty Assessments
The majority of examinations that are part of the SHA can be conducted by a generalist. However, there
are certain claims, such as those related to hearing or tinnitus, mental health, eye disorders, and/or
traumatic brain injury that must be performed by specialists in those disciplines.
STICKY NOTE
The SHA may be complicated for a Servicemember who experienced MST. Please be sensitive to all
Servicemembers, including their preferences for an examiner of a specific gender or their desire to
decline certain exams. Remember, a Servicemember who experienced MST may have difficulties with
medical and dental procedures that might seem invasive, and this is why you should document if certain
exams are declined.
DoD Programs for Reporting Sexual Assault or Harassment
You may be unaware that the Servicemember you conduct an SHA with has reported sexual harassment
or assault to DoD, even after your thorough review of the Servicemember’s records provided you. A basic
knowledge of DoD reporting processes may be important should the Servicemember indicate he or she
wants to disclose to you. DoD addresses sexual assault and harassment with separate reporting
channels and programs. SAPRO processes sexual assault reports, while MEO processes formal reports
of sexual harassment. Select each topic to learn more.
DMA Military Sexual Trauma and the Disability Examination Process
Page 32
Reporting Sexual Assault
SAPRO serves as a single point of authority for sexual assault policy and provides oversight to all service
branches. Anyone who makes a report of sexual assault is assigned a sexual assault response
coordinator (SARC) or victim advocate who addresses safety needs, explains the reporting options
(Restricted or Unrestricted reporting), services available, and assists with navigating the military criminal
justice process. Additional details are found on this SAPRO web page:
http://www.sapr.mil/index.php/victim-assistance.
Restricted and Unrestricted Reporting
DoD has two options for reporting related to sexual assault. Unrestricted reports are shared with the
commander in the reporting location and with the Military Criminal Investigation Organization (MCIO).
Servicemembers can file a confidential “restricted” report with the proper DoD authorities. Restricted
reports are confidential but not anonymous and only specific individuals can access restricted reports. In
comparison, an unrestricted report lacks that protection or privacy.
Reporting Sexual Harassment
A Servicemember may choose to file an informal or formal report of sexual harassment.
Informal Reporting
Informal reporting is the preferred method of reporting, as DoD prefers to handle this with a
Servicemember’s immediate supervisor. In general, if there is an informal report, there may not be any
notes or documentation in a Servicemember’s personnel files and there may be no formal investigation.
Formal Reporting
For a formal report, a Servicemember must go through an MEO advisor. One advantage of a formal
report is that there will be a formal investigation and documentation. The formal report is often used by
Servicemembers who want to report to someone outside of their chain of command.
For more information on formal and informal reporting, See the Sexual Harassment/Assault Response
and Prevention (SHARP) website: http://www.preventsexualassault.army.mil/TemplateSexualHarassment.cfm?PAGE=what_is_harassment.cfm.
Implications for Servicemembers Disclosing MST
The Servicemember you examine during an SHA will soon be leaving active duty service. Generally, it is
more difficult to access evidence to support a disability claim for conditions related to MST experiences
once an individual has been discharged.
The Servicemember should be aware, but may not be, of the implications of disclosing MST during the
SHA. As previously discussed, the SHA examination report will become part of the Servicemember’s
STRs, including any report and documentation of in-service sexual trauma. Moreover, DoD has both
unrestricted and restricted reporting processes for sexual assault. If a Servicemember has already filed a
restricted report about a sexual assault and you document the assault in the SHA, the confidentiality of
the report may be compromised. If this is the case, he or she should file a claim for their MST-related
conditions after separating from the service, rather than disclosing at the SHA. It is thus in the
Servicemember’s best interest that you point out the information-sharing aspect of the SHA, especially if
he or she is reluctant to report MST experiences to a military authority.
DMA Military Sexual Trauma and the Disability Examination Process
Page 33
Even without an MST disclosure, you can be of assistance to all Servicemembers by carefully assessing
and documenting all conditions during this examination. If a Servicemember declines any assessment, it
is also important that you document the refusal.
It is possible to document an MST-related condition after an assessment but without a disclosure. This is
demonstrated on the next page.
An Example of Documenting an MST-Related Condition during
the SHA
Infertility is one example of an MST-related condition to document. Select Play to listen to dialog between
an examiner and a woman to determine the cause of infertility during an SHA.
AN EXAMPLE OF DOCUMENTING AN MST-RELATED CONDITION
Gynecologist: Hello Sergeant Smith, my name is Dr. Jones and I will be doing the gynecology portion of
your Separation Health Assessment. It says here that you are having a difficult time conceiving a child.
Can you tell me about that?
Sergeant Smith: Sure. My husband and I, we've been trying to have a baby for the last two years. I've
never been pregnant, but I've been on birth control up to the time we decided we wanted a baby.
Gynecologist: Your records show you to be a healthy 28-year-old lady; tell me about your menstrual
cycle.
Sergeant Smith: I've never had any problems with my menstrual cycle. They're always every twenty eight
days. I can set my watch by how regular they are. I don't have to take medication to control the cramps
like other women I know, and they—my periods—only last five days. I even did some ovulation predictor
kits and the kit showed that I ovulate on cycle day fourteen. So, I'm not sure why I can't get pregnant.
Gynecologist: Infertility has many possible etiologies. Does your husband have any children? Are you
aware of any chronic illnesses?
Sergeant Smith: He's 32, and in great health. He doesn't take any medications. I had him go to his doctor
to get checked out. His doctor said he's good to go and has a normal semen analysis. He has a son,
Cole, with his ex-wife. Cole is a wonderful, perfectly healthy four-year-old.
DMA Military Sexual Trauma and the Disability Examination Process
Page 34
Gynecologist: You ovulate and your husband is fine. Perhaps there is a problem with your fallopian tubes.
Have you had any sexually transmitted infections?
Sergeant Smith: I did have chlamydia about three years ago. The circumstances are very private... I'd
rather not go into that right now.
Gynecologist: You don't have to discuss anything you don't feel comfortable discussing. Just know that
there is a packet of information we will go over at the end of the visit that may be useful to you. In the
meantime, we need to do a G-Y-N exam. Are you OK with that?
Sergeant Smith: Yes, that'll be fine.
NARRATOR: Later, the examiner documents the exam.
Gynecologist (to herself): Hmmm, Sergeant Smith had a fixed uterus. I need to make sure I document
that important finding. A retroflexed, fixed uterus could mean that Sergeant Smith has pelvic adhesions.
Pelvic adhesions, possibly caused by the sexually transmitted infection, can cause scarring of fallopian
tubes. I wonder if Sergeant Smith has tubal factor infertility. Could Sergeant Smith have experienced MST
while she was on active duty? She said that she didn't want to disclose the circumstances of her STI. I
think I should document that she didn't want to discuss the circumstances.
Provide Handouts to Servicemembers
At the close of an SHA examination, you’ll give the Servicemember a packet of information that includes a
handout about MST-related resources, among others. You are asked to provide this information because
it informs the Servicemember about the importance of documenting or maintaining evidence related to
MST while on active duty for later benefits purposes, in addition to other useful information.
Two other handouts will provide information about the Veterans Crisis Line and VHA services. It is
important that all Servicemembers are aware of the Veterans Crisis Line as a free, easily accessible
resource if they are struggling, and of VHA services in case they ever need them.
We are now done with the exam. Before you leave, I want to provide you with a packet of handouts
that contain important information and resources for you. These include information about military
sexual trauma, resources you can use during a crisis, and healthcare resources available to you in
the VA after your discharge. Please review this information carefully. If you have questions, each of
the handouts directs you to the best resources to answer those questions. And even if this
information doesn’t apply to you now, it may be useful to you in the future, or to a fellow soldier, so
please take it with you. Thank you for coming in today and thank you for your service.
DMA Military Sexual Trauma and the Disability Examination Process
Page 35
MST Handout Contents
While you do not need to give specific, detailed information to the Servicemember about what is in the
handout, you should know that the MST handout provides guidance about:





Benefits and documentation related to MST, such as the importance of collecting and retaining
any evidence
MST and the benefits process, such as how to file a claim for a condition related to MST
The different types of evidence needed for a claim, and how to collect evidence
Information about the Safe Helpline and DoD points of contact for reporting sexual assault and
sexual harassment
The fact that healthcare for MST-related conditions is free and separate from the benefits process
If a Servicemember asks why they are getting the information, you can explain that VA wants all
Servicemembers to have this information, and that the handout offers guidance to protect their
confidentiality and their ability to apply for benefits. If they tell you they want to make a formal report about
MST, the handout directs them to the best resources and authorities. The MST handout will be available
early in 2015 at the DMA website: http://vaww.demo.va.gov.
The Veterans Crisis Line and VHA Services Handout Contents
Along with the MST-related resources handout, you'll provide handouts about the Veterans/Military Crisis
Line and VHA services. Select each handout name for a description of contents.
Veterans Crisis Line
The second handout in the packet is about the Veterans Crisis Line, which is sometimes known to the
Servicemember as the Military Crisis Line. Information available from the Centers for Disease Control and
VA indicates that Veterans and Servicemembers die by suicide at a higher rate than the general
population. In addition, Veterans or Servicemembers undergoing transitions, including the disability
examination process or the transition from active duty to Veteran status, also may be at higher risk for
suicide. The Veterans Crisis Line handout can be accessed at the DMA website:
http://vaww.demo.va.gov.
Select Play to hear information you can share with the Servicemember if they ask about why they are
receiving this handout.
This is the VA crisis hotline handout. We are providing all Servicemembers with this information. Any
Veteran or Servicemember can reach the Veterans Crisis Line by calling this number: 1-800-273TALK. Then you press “1” to identify yourself as a Servicemember or Veteran. You can also chat
online, or send a text message to this number—838255—to receive confidential support 24 hours a
day, 7 days a week.
DMA Military Sexual Trauma and the Disability Examination Process
Page 36
VHA Services
The third handout in the packet is about VHA healthcare. The VHA Services brochure can be accessed at
the DMA website: http://vaww.demo.va.gov. Once a Servicemember has been discharged, he or she can
enroll for healthcare at VHA. In fact, many Servicemembers that you see will be eligible as Veterans for
cost-free VHA healthcare based on the policy for all Operation Enduring Freedom (OEF), Operation Iraqi
Freedom (OIF), and Operation New Dawn (OND) combat Veterans (IB 10-438, Combat Veteran
Eligibility). The Combat Veteran Eligibility Fact Sheet can be accessed on VA's Health Benefits Reference
Library website at this address: http://www.va.gov/healthbenefits/resources/publications.asp.
An Examiner Provides Handouts during the SHA to a
Servicemember Who Asks Questions
Ms. Marie Karnes was introduced earlier in this course. At the close of an SHA, a disability examiner
introduces the three handouts to her. Select Play to watch as the examiner answers a few questions from
Ms. Karnes.
[Title: The Take-Home Information]
Examiner: I’d like to thank you for coming today. As I indicated earlier, I’ve documented all of the servicerelated injuries and complaints that you mentioned during the exam today. That’s an important and
necessary step in the claims process.
Ms. Karnes (Servicemember): Yes, we definitely covered a lot. You asked a lot of questions.
Examiner: I did ask a lot of questions, but I wanted to make sure we covered everything that was
important during the exam today.
Ms. Karnes (Servicemember): I would say we did!
Examiner: Now I want to give you some handouts that you can take with you and look over more carefully
after the exam today.
[Examiner touches packet]
Examiner: The first handout is about VA healthcare. It describes some of the services available when you
enroll in healthcare in VHA, the Veterans Health Administration. You may already be aware of some of
this information, but I wanted to remind you of some the benefits of enrolling in VHA for your healthcare
needs.
DMA Military Sexual Trauma and the Disability Examination Process
Page 37
Ms. Karnes (Servicemember): Yes, I’m aware of the services. I actually have a friend at the VA here, and
she said that the Women’s Clinic there is great. I actually wasn’t aware that VA had special clinics for
women, so it’s good thing she told me. I’m going to enroll.
Examiner: Yes, we have Women’s Clinics, as well as a variety of other physical and mental health
services available. I’m glad that you’re considering enrolling, especially given some of the concerns that
you brought up during the exam today. The other two handouts I’m going to give to you may not pertain to
you directly, but I like to give this information to all Servicemembers. If this information doesn’t pertain to
you directly, it may be useful to pass it on to another Servicemember.
Ms. Karnes (Servicemember): Okay.
Examiner: This handout is about the VA’s Crisis Line.
[Examiner holds up handout]
Examiner: The Crisis Line is a toll-free number that Veterans in crisis or their family members can call and
speak to a qualified professional who’s there to assist them. The toll-free number is right there on the
cover: 800-273-8255. There’s also information about online chat and texting options. The Crisis Line is
confidential and support is available 24 hours a day, 7 days a week, 365 days a year.
Ms. Karnes (Servicemember): Yeah. I’ve heard of the crisis hotline. They talked about it during the TAP
briefing. It’s good that the VA has something like this. I read in the newspaper and see all of the time
about suicide and soldiers. It’s sad. But, I mean I guess I’m lucky that I’ve never felt this way, but you’re
right; it’s useful to have information like this.
Examiner: The last handout I want to give you is about military sexual trauma, or MST. Unfortunately,
some Servicemembers have experienced military sexual trauma, which is defined as sexual assault or
repeated sexual harassment that occurred during military service. I know they cover this story in the TAP
briefing, but I wanted to make sure to provide you with information about MST and the benefits process.
Ms. Karnes (Servicemember): I didn’t know you could file a claim for MST.
Examiner: Let me clarify. You can’t file a claim for MST directly, but you can file a claim for a condition
you may have incurred as a result of experiencing military sexual trauma. The handout does a good job of
explaining that further. It also gives you information about some basic things about military sexual trauma
and the benefits process, such as how to go about filing a claim for a condition related to military sexual
trauma. The handout also explains the kind of evidence needed for a claim, and how to make sure that
there’s still some sort of evidence while you’re still on active duty.
Ms. Karnes (Servicemember): You mean I would have to report if I’d experienced MST?
Examiner: Not exactly. There are different regulations that pertain to certain conditions that can occur as
a result of military sexual trauma. For example, if someone is diagnosed with PTSD after experiencing a
sexual assault, there could be “markers” that count as evidence.
[Looks puzzled]
Ms. Karnes (Servicemember): Markers?
Examiner: Yes, markers. You can think of markers as indirect evidence that something likely occurred.
For example, a pregnancy test or a letter from a friend describing a change in behavior could be
considered markers. There is more information about that in the handout, and I encourage you to read it
DMA Military Sexual Trauma and the Disability Examination Process
Page 38
so you understand it more fully. The handout also offers guidance about how to protect confidentiality,
and does a really good job in giving information about how to apply for benefits. There’s also direction for
Servicemembers, directing them to the appropriate resources and authorities in the event that they
experience military sexual trauma and decide to file a report. We at VA want all Servicemembers to have
as much information about MST and possible benefits that you might be entitled to, before you leave the
military. The reason the resources are listed on the handout is that we want to make sure that any
Servicemember that has any questions can get to a trained expert.
Ms. Karnes (Servicemember): That makes sense.
Examiner: The final piece of information in the handout is just a reminder that that all healthcare for
conditions related to MST is free of charge.
Ms. Karnes (Servicemember): Really? How does that work?
Examiner: Once someone enrolls in VHA healthcare and chooses to disclose that they’ve experienced
MST, that ensures that all their healthcare for MST-related conditions is free of charge. Also, every VA
medical center has an MST Coordinator. You can contact your local VA and ask to speak to the MST
Coordinator. That coordinator can provide you with information about enrollment and treatment services
available to you.
Ms. Karnes (Servicemember): It’s good to know this. You know my friend that I mentioned before? The
one who’s getting care at the Women’s Clinic? Well, she experienced some stuff when we were
deployed. She’d kill me if she knew I was saying this.
Examiner: It sounds like you’re being a good friend to be concerned about her. As I mentioned earlier, I
give this information to everybody. And even if it may not be relevant to you, it could be relevant to
another Servicemember.
Ms. Karnes (Servicemember): Yes, it’s good you gave me all of this information to take with me. It gives
me a lot to think about.
[Scene fades]
How to Respond if a Servicemember Starts to Disclose during
the SHA
Despite the cautions in the handout and the cautions you may provide verbally, some Servicemembers
may still choose to disclose MST at the SHA. If appropriate, gently pause and remind the Servicemember
that it is his or her choice, but that disclosing during the SHA may risk his or her confidentiality. Take a
few moments to explain to the Servicemember the benefits of calling the Safe Helpline or reviewing the
handout before they choose.
If the Servicemember indicates that he or she does not want to call the Safe Helpline, or still wants to
speak to your or to someone from the VA, tell them you are glad they feel safe and ready, and offer to
schedule an appointment with a disability examiner who is specifically trained to address MST. Explain
that the specifically-trained examiner can spend the time with him or her that the Servicemember
deserves.
If a Servicemember does disclose, respond in a way that conveys empathy while at the same time
placing limits on time and depth of disclosure. If a Servicemember begins to disclose a detailed account
of the MST, or if the Servicemember appears distressed, it is helpful to gently limit the disclosure process.
DMA Military Sexual Trauma and the Disability Examination Process
Page 39
Distressed
After disclosing sensitive information, Servicemembers sometimes have feelings of shame and regret
about having exposed themselves. To address such reactions, at the end of the visit it may be helpful
to reassure the Servicemember that if any concerns arise he or she can contact the Safe Helpline or
the Military/Veteran Crisis Line, anonymously if he or she prefers. You can also thank them for taking
the brave step of disclosing and encourage good self-care after the exam.
Remind the Servicemember that this [limiting the disclosure process] is to maximize his or her claims
opportunity while at the same time maximizing his or her comfort and privacy. Assure the Servicemember
that you will refer him or her to someone who can provide support, if desired.
IMPORTANT NOTE
Avoid conveying that you don’t care or don’t want to listen.
An MST Disclosure Example (Video)
In the video on this page, Ms. Karnes discusses her readiness to disclose MST experiences with a
disability examiner during the SHA. You'll see how the examiner brings up potential privacy concerns for
Ms. Karnes's benefit. The examiner reminds Ms. Karnes that the local VA facility has an MST Coordinator
who can provide Ms. Karnes with information about services and treatments that are available, if needed.
Title: The Servicemember Starts to Disclose an MST Experience
Examiner: Well, Ms. Karnes, I want to thank you for coming in today, and speaking so candidly about
your experiences.
Ms. Karnes (Servicemember): You know... I haven't been totally candid about all of my experiences. And
when you showed me the handouts just now, it got me to thinking.
[She begins to cry]
Ms. Karnes (Servicemember): I've had some experiences I probably need to talk about that might be related to MST.
Examiner: I am sorry to hear that something might have happened to you while you were serving our
country. And I'm glad that you feel comfortable enough to share those experiences with me today. Know
that I'm very interested in hearing about your experiences, but I want to do everything I can to make sure I
DMA Military Sexual Trauma and the Disability Examination Process
Page 40
protect your confidentiality. If you do want to disclose something, you absolutely can, but I want to remind
you that if you disclose something, I can't guarantee that I can protect your confidentiality as everything
you say as part of this examination becomes part of your service treatment records.
Ms. Karnes (Servicemember): Okay.
Examiner: I know what you have to say is really important, and I'm glad you want to talk about it. If it's
okay with you, though, I would like to go over the information in the MST handout that talks about the best
resources for reporting that something may have happened. Please don't take this as me not caring about
you or not being interested in speaking about what you're sharing, but I just want to make sure that I do
everything I can to put you in touch with the people who are best able to help you.
Ms. Karnes (Servicemember): Okay.
Examiner: If you look at the MST handout that I gave you earlier, it provides information about privacy
and confidentiality issues in much greater detail. It also provides information about how to reach the
person who could best help you with the information you have, and best help you keep your information
private. For example, as an active-duty Servicemember, you can call the Safe Helpline right after our
exam today, and the staff there will be able to provide you with any information or assistance that you
might need.
Ms. Karnes (Servicemember): Yes, I'm familiar with the Safe Helpline. They mentioned it in the TAP
briefing.
Examiner: So what do you think is the best next step for you?
Ms. Karnes (Servicemember): Well, my confidentiality is really important to me.
Examiner: So you understand why I would recommend you call the Safe Helpline?
Ms. Karnes (Servicemember): Yes, I do. I really want to talk about it, but I don't want my commanders to
know.
Examiner: I appreciate what you may have experienced. Unfortunately, too many Servicemembers have
experienced military sexual trauma, and for some, it can continue to affect them even years later. Please
know that the VA has services and treatments available to you that could be helpful in your recovery, if
you need it.
Ms. Karnes (Servicemember): You mentioned an MST person at the VA before. How do I find that
person?
Examiner: That would be the MST Coordinator. I can ask the local VA MST Coordinator to get in touch
with you and provide you with information about services and treatments that are available, that could be
helpful in your recovery, if needed. Is that something you'd like me to do?
Ms. Karnes (Servicemember): That would be good.
Examiner: Great, I'll do that when we finish up here today. And I really want to thank you for even bringing
up the topic of MST. I know that took a lot of courage.
Ms. Karnes (Servicemember): Thank you for saying that, and thank you for making sure my confidentiality
is protected. I appreciate it.
DMA Military Sexual Trauma and the Disability Examination Process
Page 41
Examiner: Of course. I hope the information I gave you today was helpful.
[Scene fades]
Information Sharing between DoD and VA and Implications for
Confidentiality
It is important to note that VA and DoD share medical data to better coordinate care for Servicemembers
transitioning from the military to Veteran status. For example, when a C&P examiner performs the SHA,
he or she will use the electronic Compensation and Pension Records Interchange (CAPRI) system.
CAPRI feeds into VA’s Computerized Patient Record System (CPRS), and then into Veterans Health
Information Systems and Technology Architecture (VistA), where it can be shared with DoD for active
duty personnel. DoD uses a Bidirectional Health Information Exchange (BHIE) viewer to access the
Servicemember’s data. The SHA examination report becomes part of the Servicemember’s Service
Treatment Records.
Because of this sharing agreement, there are some special concerns about documenting MST on the
SHA. This will be discussed in more detail shortly.
Documenting MST
If a Servicemember discloses MST, follow these suggestions for documenting an MST incident on the
SHA documentation protocol. A legible, clear, objective medical record will facilitate the Servicemember’s
application for compensation.




Document the report in the Remarks section of the SHA DBQ, not the mental health section. For
example, “Assault happened on (date), no physical residuals.” If there are physical residuals,
please document those in the appropriate section of the DBQ and include a statement that
reflects how the residuals may be related to the MST experience.
If the Servicemember discloses and/or has not yet filed a report, it is important to be careful in
how you document this. You should attempt to document in a manner that still protects the
Servicemember’s privacy. For example, it may be better to document that the Servicemember
experienced a sexual assault while stationed at Ft. Bragg than stating that the service member
was sexually assaulted on May 8, 2011 by her commanding officer.
Documentation should include direct quotations from the Servicemember, where possible.
You should avoid using judgmental terms. Avoid blaming the Servicemember for behaviors at the
time of the assault such as alcohol consumption, and don’t point out other behaviors proximal to
the assault that did not contribute to the assault.
DMA Military Sexual Trauma and the Disability Examination Process
Page 42
Select Approaches to Avoid for examples of approaches to avoid.
Approaches to Avoid


Avoid judgmental statements such as, "The Servicemember did not fight off the perpetrator."
Avoid suggesting that the Servicemember may have encouraged the perpetrator(s) in some
way by his or her behavior.
TACK NOTE
You can be of assistance to all Servicemembers by carefully assessing and documenting all conditions
during this examination. If a Servicemember declines any assessment, it is also important that you
document the refusal.
Completing the SHA
Check Off
When you’ve finished providing the information and MST handout to the Servicemember, you’ll document
this by checking the checkbox at the end of the SHA documentation protocol DBQ.
Close the Examination
You can also thank the Servicemember for his or her service and let him or her know that the examination
is complete. When you conduct and close an SHA, remember that this may be the first encounter the
Servicemember has with VA. Leaving the Servicemember with a good impression will encourage him or
her to return to VA as a Veteran.
DMA Military Sexual Trauma and the Disability Examination Process
Page 43
Knowledge Check
Answers and feedback for this knowledge check can be found on page 72
1. Match the examiner who conducts a separation health assessment with the Servicemember
examined.
_______
A.
DoD examiner
Option 1.
A Servicemember who has filed a
disability claim with VA
_______
B.
VA disability examiner
Option 2
A Servicemember who has not
filed a disability claim with VA
2. True or false? The documentation from a Separation Health Assessment becomes part of a
Servicemember's Service Treatment Records.
A. True
B. False
3. True or false? If a Servicemember has filed a restricted report, and wants to assure his or her
confidentiality within DoD, it is in his or her best interest to file a claim for their MST-related conditions
after separating from the service rather than disclose an MST experience during the examination.
A. True
B. False
4. Match each kind of reporting with the point of contact at DoD
________ A. Formal reporting of
sexual harassment
Option 1.
________ B. Restricted reporting of
sexual assault
Option 2
SAPRO
MEO Advisor
________ C. Unrestricted reporting of
sexual assault
5. The disability examiner is required to give three of the following four handouts to Servicemembers
during the SHA. Select the handout that is not required.
A. VHA Services
B. Privacy policies
C. MST-related resource information
D. The Veterans' Crisis Line
6. Since the SHA can be complicated for a Servicemember who has experienced MST, you can assist
him or her during an SHA in all but one of the following four ways. Select the incorrect answer.
A. Carefully document all conditions present.
B. Document any assessments refused by the Servicemember.
C. Avoid any documentation of a potential MST-related condition
D. Be sensitive to a Servicemember's preference for an examiner of a specific gender.
DMA Military Sexual Trauma and the Disability Examination Process
Page 44
7. Although you express concerns for a Servicemember's confidentiality, a Servicemember may still
choose to disclose MST to you during an SHA. When this happens, which response is correct?
A. Demonstrate empathy but place limits on the depth of the disclosure
B. Refuse to hear the disclosure in order to protect the Servicemember’s confidentiality
C. Insist that only DoD personnel should hear the disclosure
D. Stop the examination and refer the Servicemember to a mental health provider
8. The handout for MST-related resources includes information on all but one of the following topics.
Select the incorrect answer.
A. The importance of collecting and retaining any evidence related to MST for benefits purposes
B. How to file a claim for a condition related to MST
C. The Veterans Crisis Line
D. The different types of evidence acceptable for a claim
9. True or false? A Servicemember who discloses sexual assault during an SHA may compromise a
restricted report with DoD if he or she has previously reported the assault.
A. True
B. False
10. If a Servicemember discloses MST during an SHA, which suggestion is correct for documenting MST
in the examination report?
A. Document the report in the mental health section of the SHA DBQ.
B. Explain how any physical residuals may be related to the MST experience.
C. Avoid using direct quotations from the Servicemember.
D. Describe other behaviors proximal to the assault that did not contribute to the assault.
Lesson Summary
This lesson focused on preserving a Servicemember’s confidentiality while conducting and reporting an
SHA, including how to respond to potential and actual disclosures of MST experiences. You’ll provide
every Servicemember examined with resources handouts at the end of the examination. You should now
be able to recognize implications, requirements, and best practices for sharing information about MSTrelated resources with a Servicemember during an SHA.
The next and final lesson of this course covers issues specific to MST-related PTSD examinations. This
information pertains most to mental health disability examiners, but all examiners will benefit from
knowing the requirements for evaluating and documenting MST-related conditions.
DMA Military Sexual Trauma and the Disability Examination Process
Page 45
Considerations for MST-Related PTSD Disability
Examinations
Lesson Objective
From fiscal year 2008 through fiscal year 2013, Veterans filed over 29,000 claims for disabilities related to
MST, according to the U.S. Government Accountability Office (2014). Furthermore, from fiscal year 2010
through fiscal year 2013, PTSD was the most common MST-related disability claimed, comprising about
94 percent of all MST-related claims (GAO, 2014). This lesson will cover how MST-related markers are
evaluated and documented for PTSD claims, and other considerations for the mental health disability
examiner who conducts PTSD examinations related to MST.
When you’ve completed this lesson, you should be able to identify considerations and procedures for
mental health examiners conducting MST-related PTSD disability examinations.
MST-Related Mental Health Claims
Veterans and Servicemembers may file a claim for a mental health condition related to MST, such as
depression or PTSD.
Exams for PTSD claims related to “personal traumas” such as MST are slightly different than for other
mental health conditions. These are governed by special regulations and VBA processes, so your role
may be a bit different when conducting examinations for PTSD claims secondary to MST. For PTSD
claims secondary to MST, VBA can accept “markers” as evidence to establish that the stressor occurred,
so your role may include considering and documenting markers as part of those exams. This lesson will
provide more information about your role as an examiner in considering markers.
What is a marker?
In the case of an MST-related PTSD evaluation, a marker can be “indirect evidence” that a Veteran or
Servicemember experienced MST. However, because markers are circumstantial rather than direct
evidence of an in-service stressful event, they are somewhat open to interpretation and can involve a
subjective evaluation.
As you go through this lesson, remember that although PTSD is the diagnosis most commonly associated
with MST, it is by no means the only one. There are a range of physical and mental health conditions that
may be associated with MST.
Myths about MST-Related Disability Claims
Select Play to hear myths versus facts about MST-related disability claims.
DMA Military Sexual Trauma and the Disability Examination Process
Page 46
MYTHS ABOUT MST-RELATED DISABILITY CLAIMS
Man: Objective evidence is not necessary for an MST claim.
Woman: Objective evidence is required for a claim of residuals secondary to MST, except in the case of
PTSD where markers can serve as evidence.
Man: MST equals PTSD
Woman: There can be a variety of sequelae secondary to MST to include physical and mental health disorders, or no sequelae at all.
Man: If someone carries a personality disorder diagnosis, they cannot have PTSD related to MST.
Woman: Individuals can be diagnosed with both personality disorders and PTSD.
MST-Related PTSD Claims
As discussed earlier in this course, there are high rates of PTSD among individuals who have
experienced MST. 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.
MST-Related PTSD Claims and Special Regulations
Since an MST experience may go undocumented during a Servicemember’s or Veteran’s time in service,
the available evidence is often insufficient for VBA to establish the occurrence of the stressor. Without the
DMA Military Sexual Trauma and the Disability Examination Process
Page 47
establishment of an event, it is often difficult for VBA to grant benefits. As a result, VA developed
regulations and procedures for evidentiary development and adjudication of MST-related PTSD claims,
based on Direct service connection; wartime and peacetime, 38 CFR 3.304(f)(5) (2014).
In 2002, VA revised its regulations for adjudicating PTSD claims related to in-service personal assault,
including MST. The revised regulation provides that evidence outside a Veteran’s service record may be
used to corroborate his or her account of MST. This information is addressed in VBA TL 11-05,
Adjudicating Posttraumatic Stress Disorder Claims Based on Military Sexual Trauma, which can be
accessed at this intranet URL: http://vbaw.vba.va.gov/bl/21/publicat/Letters/TrngLtrs/TL11-05.doc.
Three important considerations guide VBA in developing evidence to support a claim. These resulted
from a court case, Patton v. West, 12 Vet. App. 272 (1999):
1. Behavior changes occurring at the time of an incident may indicate the occurrence of an inservice stressor.
2. Evidence documenting such behavior changes may require interpretation by a qualified clinician
regarding its relationship to a medical diagnosis.
3. A qualified examiner’s opinion can be considered credible supporting evidence for occurrence of
the MST stressor. In other words, the general rule that an examiner’s post-service opinion cannot
be used as evidence for occurrence of the in-service stressor in PTSD claims does not apply to
PTSD claims involving MST.
Investigating a Marker Starts with VBA
In general when a Servicemember or Veteran files a claim and VBA obtains personnel and other records
identified by the Veteran or Servicemember, specially trained adjudicators look through the records to
identify markers. Once a marker is identified, a C&P examination is scheduled. However, there must be
some circumstantial or indirect evidence of the in-service MST event in order to go forward with
scheduling the C&P examination. If VBA adjudicators cannot locate a marker, a C&P examination will
generally not be scheduled.
When there is no direct documentation of the in-service MST event, the Veteran’s entire record must be
searched to locate any potential markers. This can be a time consuming task and involves an element of
subjective interpretation. What one individual interprets as a marker may not be interpreted as a marker
by someone else. To address this subjective element and promote consistency, VBA developers have
undergone extensive training to assist them with the development of MST claims and the identification of
markers.
IMPORTANT NOTE
As mandated by the PTSD personal assault regulation (38 CFR 3.304(f)(5)), VBA will not deny a PTSD
claim that is based on in-service personal assault without first advising the claimant that evidence from
sources other than the Veteran's service records or evidence of behavior changes may constitute credible
supporting evidence of the stressor, and allowing him or her the opportunity to furnish this type of
evidence or advise VBA of potential sources of such evidence. VBA may submit any evidence that it
receives to an appropriate mental health professional for an opinion as to whether this evidence may be
suggestive that a personal assault occurred.
Categories of Markers
For VBA purposes, 38 CFR 3.304(f)(5) established two categories of markers: markers involving records
other than service records, and behavior changes occurring during service or at some credible point after
service.
DMA Military Sexual Trauma and the Disability Examination Process
Page 48
Sources of records include,
but are not limited to:








Law enforcement authorities
Rape crisis centers
Mental health counseling centers
Hospitals
Physicians
Pregnancy tests
Tests for sexually transmitted diseases
Statements from:
o Family members
o Roommates
o Fellow service members
o Clergy members
Manifestations of behavior changes include,
but are not limited to:






Requests for transfer to another military
duty assignment
Deterioration in work performance
Substance abuse
Episodes of depression, panic attacks, or
anxiety without an identifiable cause
Unexplained economic or social behavior
changes
Other unexpected behavioral changes,
such as overly controlling or
perfectionistic behavior
On the next pages, you’ll have opportunities to check your understanding of record sources and behavior
changes that may be related to MST.
Marker Exercise
Answers and feedback for this exercise can be found on page 74
1. Lucinda filed a claim for PTSD 20 years after separation from the US Marine Corps, claiming that she
had interpersonal problems. She stated that, about six months before separation, she was at a bar
with other male and female Marines and had "a little too much" alcohol. Eventually she was there
alone with a male Marine who offered her a ride home. Lucinda went along but was driven to a
country road and sexually assaulted. The Marine was a top sergeant from a unit near hers and said
he would cause her much trouble if she told anyone about the incident. About six months before
separation, her performance evaluations showed problems performing her work with tardiness and
missed days. Her service records show no evidence of MST.
Which of the details of Lucinda’s story is a marker?
A. Which detail of Lucinda's story is a marker?
B. Lucinda filed a PTSD claim based on interpersonal problems.
C. Lucinda’s work performance deteriorated around the same time as the MST she described.
D. Lucinda drank alcohol on social occasions during service.
2
John filed a claim for PTSD ten years after separation from the US Navy, claiming that he had trouble
concentrating. He stated that he was aboard ship one night alone on watch duty when several other
sailors, who he had been in an argument with, approached him. They continued the argument, which
escalated into a fight. As John was trying to recover from a blow to the head, he was held down and
sexually assaulted. When he recovered, the men were gone, and John stayed away from them for the
remainder of his shipboard tour. He felt both angry and ashamed but never reported the incident.
There was no change in John's level of work during service. A note in his shipboard medical records
show that he attended sick call and was treated for a facial bruise and swollen nose. The note states
that John reported slipping and falling on deck during his night watch on the ship. John's service
records show no evidence of MST.
DMA Military Sexual Trauma and the Disability Examination Process
Page 49
Which detail of John's story is a marker?
A. John had trouble concentrating, even ten years after separation from service.
B. John did not report the MST experience he describes.
C. A note in John's shipboard medical records documents a visit for a facial bruise and swollen
nose.
Markers and the PTSD Examiner
What is the mental health examiner’s role in evaluating a marker? Once a C&P examination is scheduled,
the examiner will conduct an interview with the Veteran to assess whether (1) the Veteran has a
diagnosis of PTSD (2) whether there is a marker in the Veteran’s records or self-report that is indicative of
an MST-related incident (s) during service and (3) whether there is credible reason to believe that the
diagnosis of PTSD is related to the MST. Please be aware:


VBA personnel have been trained to identify markers and they should be tabbed in the claims file
for the examiner’s review. If the examiner agrees with the tabbed marker, a statement of
agreement should be included in the final examination report as part of the rationale for the
opinion.
However, a situation may arise where the examiner does not view the VBA marker as an
indication of an in-service MST event. Or, after a file review, the examiner may consider
something to be a marker that was not identified by VBA personnel. In these cases, the examiner
should also provide an explanation as to why something is or is not considered a marker and how
it may or may not be considered evidence of an in-service MST event.
It is important to note that some markers are more clear-cut than others, and at times, there may be some
subjectivity to whether or not something is a marker. For this reason, you, as an examiner,
must document not just the marker, but also your rationale for why the marker is indicative that MST may
have occurred. VBA requires a rationale or “reasons and bases” for the examiner’s opinion.
IMPORTANT NOTE
VBA will generally accept the examiner’s opinion statement as long as the weight of the available
evidence supports it. It strengthens the weight of the evidence if the Veteran provides consistent details
about an MST event over a period of time.
Potential Markers
A variety of things can be considered as markers for MST. For example, sometimes the Servicemember
or a Veteran develops relationship, self-image, or behavioral problems after an MST experience. Other
significant variations in behavior could also be markers, such as suddenly wanting no sexual contact, or
having increased sexual contact, or vacillations between both in the same individual over time. While the
MST experience or potential associated problems may not have been documented, any significant
change in behavior at the time of the event could be a marker, or indication, that he or she experienced
MST. These markers may already be found in documentation in the C-file or VBMS, or can be added to
the examination report by you, whether or not any MST experiences are known to have occurred. Select
each image to view more examples of potential markers.
IMPORTANT NOTE
If these “markers” are present, it does not necessarily mean that a Veteran or Servicemember
experienced MST.
DMA Military Sexual Trauma and the Disability Examination Process
Page 50
Self-Blame
Self-blame and shame: Did he or she suddenly become withdrawn or start to
avoid their peers?
Anger/Impulsivity
Anger: Was he or she ever mandated for anger management counseling?
Impulsivity: Is there evidence of treatment for self-injury? Are there speeding
tickets? Road rage incidents?
Legal or financial difficulties: Have there been bounced checks?
Trusting Others
Trusting others: Did they ask to be reassigned to another unit?
Difficulties at work: Is there documentation in personnel files?
Difficulties in relationships: Have there been marriage problems? Did the
Servicemember seek marriage counseling?
Intimacy
Intimacy and sexuality: Was there a sudden marriage? Are there suddenly
sexual functioning problems? Is there confusion about gender identity or sexual
orientation?
Avoiding Procedures
Difficulties with medical and dental procedures: e.g., refuses a rectal or vaginal
exam or anything that might seem invasive
Body Image
Did he or she start to neglect appearance or self-care for no apparent reason, or
undermine weight loss diets?
DMA Military Sexual Trauma and the Disability Examination Process
Page 51
Potential Markers Exercise
Instructions: You may recall Amanda’s story earlier in this course. This exercise gives you the
opportunity to explore potential markers in Amanda’s story. Review her story and think about the kinds of
evidence that might determine if a diagnosed disability for Amanda was related to experiencing MST.
Then, select each icon at the bottom of this page to view potential evidence.
Amanda, now twenty-eight years old, is African-American and the single mother of a nine-year-old
daughter. Amanda was a truck driver in Iraq, where she was trained that she must not stop the truck even
if a civilian is in the road. Amanda was terrified at the thought that she might someday have to run over a
child, and talks to her colleagues about her fears.
Amanda was then approached by a higher-ranking Servicemember, a man, who was responsible for job
assignments. He states that he will change her assignment to staffing the truck depot on the condition
that Amanda would have sex with him. Although Amanda had no romantic or sexual interest in him, she
feared career consequences from refusing; and this concern, in combination with her great fear of having
to run over a child, led her to have sex with the Servicemember on several occasions. Amanda felt numb
throughout the encounters. When she became pregnant from the encounters, other Servicemembers
found out and made comments about her being, in their words, “easy.” In fact, Amanda was ostracized by
her peers.
Pregnancy
The encounters resulted in a pregnancy
Messages
Emails or texts to friends or family, or to the perpetrator to meet
Social Media
Is there evidence from social media?
Chain of Command
What about the people in between Amanda and the perpetrator? Was she
moved without the chain of command input?
DMA Military Sexual Trauma and the Disability Examination Process
Page 52
An Example of a Marker and Appropriate Documentation
Here is an example of appropriate documentation of a marker. After reviewing the description of the
marker provided on the Request for Examination (VA 21-2507) or VERIS (Veterans Examination Request
Information System) form, the disability examiner evaluates the marker and records findings on a
documentation protocol.
Clear-cut example of a marker and appropriate documentation:
The 2507 indicates that the Veteran had a pregnancy test at the time that she was reportedly assaulted.
Documentation
The pregnancy test that Ms. Jones took and is documented in her Service Treatment Records is proximal
in time to when the reported MST event occurred (pregnancy test was taken on June 1, 2012 and MST
event was reported as occurring May 20th, 2012). This pregnancy test can be considered to be a marker
of an MST event.
Less clear-cut examples are shown on the next page.
Less Clear-Cut Examples of Markers with Appropriate
Documentation
After careful evaluation of a behavior change and its timing and context, the disability examiner
documents the findings and a rationale for whether or not each example below is a marker of an MST
event. Compare the examples for Ms. Smith to see very different findings for similar behavior changes.
See Mr. Johnson’s example for how to document the larger context of his history as part of the rationale.
Example 1: Ms. Smith got a belly button ring and a tattoo that says "strong"
The 2507 indicates that Ms. Smith got a belly button ring and a tattoo one year after she was reportedly
assaulted.
Documentation:
The belly button ring and tattoo that Ms. Smith obtained may be considered to be markers of a MST
event. Ms. Smith obtained a belly button ring and a tattoo one year after the reported date of the MST
event. The tattoo is of the word “strong.” While a belly button ring and tattoos would not serve as markers
in all cases of PTSD, in Ms. Smith’s case, it is believed that these are markers. Prior to 2008 (when the
reported MST event occurred), Ms. Smith presented herself in a very conservative fashion. She did not
have any body piercings or any tattoos. She indicated that she was raised in a strict, conservative home
and indicated that none of her family members had any piercings or tattoos. Ms. Smith indicated that after
she was assaulted, her feelings regarding body art began to change, and stated that she obtained both a
tattoo and a belly button ring to “prove” to her attacker (and to other men) that she was strong and that
she can be overtly desirable (which she interprets as having a belly button ring) without inviting unwanted
sexual overtures. Ms. Smith indicated that she does not wish to obtain other tattoos or piercings, but
stated that her tattoo and her piercing serve to remind her that she is a strong woman. Ms. Smith
obtained the belly button ring and tattoo at the time of the one-year anniversary of the MST event.
DMA Military Sexual Trauma and the Disability Examination Process
Page 53
Example 2: Ms. Smith got a belly button ring and a tattoo of a butterfly
The 2507 indicates that Ms. Smith got a belly button ring and a tattoo a year after she was reportedly
assaulted.
Documentation:
The belly button ring and tattoo that Ms. Smith obtained are not considered to be markers of a MST
event. Ms. Smith obtained a belly button ring and a tattoo one year after the reported date of the MST
event. The tattoo is of a butterfly. While a belly button ring and tattoos may serve as markers in some
cases of PTSD, in Ms. Smith’s case, it is believed as if this piercing and tattoo are not markers. Prior to
2008 (when the reported MST event occurred), Ms. Smith had numerous tattoos on a variety of body
parts. While Ms. Smith did not have any body piercings prior to 2008, she indicated that she had always
wanted piercings, but stated that she just had never obtained one. Ms. Smith was not able to articulate in
any fashion a relationship between her obtaining the tattoo and belly button ring and her reported assault.
There are also no other markers (behavior changes, information in personnel file, etc.) that are indicative
that a sexual assault occurred. However, this does not mean that MST did not occur.
Example 3: Mr. Johnson started having difficulties interacting with others
The 2507 indicates that Mr. Johnson started having difficulties interacting with others after he was
assaulted.
Documentation:
Mr. Johnson indicated that he had difficulties getting along with others in his unit. While Mr. Johnson
indicated that these difficulties began after he was sexually assaulted, Mr. Johnson appears to have a
long-standing history of having difficulties interacting with others, which seems to predate his reported
assault. Mr. Johnson reported that he was suspended from school on multiple occasions throughout his
youth for fighting. Additionally, he indicated that he “got in trouble” a lot during basic training for “mouthing
off” and just generally being a “hothead.” Mr. Johnson stated that he did not have friends prior to his
reported assault, as “no one is worth being friends with; they are all a bunch of assholes.” While Mr.
Johnson’s difficulties with getting along with others do not appear to be a marker of MST, this does not
indicate that MST did not occur. Additionally, it is important to note that Mr. Johnson’s results on a test of
symptom validity raises questions about the explanation for his reports. Mr. Johnson’s responses to the
questions on the scale suggest that he may be over-endorsing difficulties. Throughout the examination,
Mr. Johnson presented as a poor-historian and provided numerous conflicting statements.
Challenges for the Examiner in Providing an Opinion
Mental Health examiners face many challenges when asked to opine whether an event occurred, as it is
beyond the scope of an examiner to ascertain whether an event occurred without actually being a
witness.
However, VBA is not requesting an examiner’s opinion about whether or not an event occurred; this is a
factual issue and not appropriate for a psychological judgment. Instead, VBA is requesting an opinion
about the marker and its relationship to the claimed in-service MST event. Your opinion should address
whether the evidence, often in the form of markers, suggests that MST occurred, and whether that
experience would be sufficient to cause PTSD and the identified symptoms.
In other words, “Is what you see in the evidence/markers consistent with what you might expect to see
following a personal assault/MST of the type described, and if so, is there a reasonable chance that the
DMA Military Sexual Trauma and the Disability Examination Process
Page 54
PTSD symptoms could be related to that stressor?” The interview with the claimant should assist with this
judgment.
See VBA training letter TL 11 – 5 for additional details:
http://vbaw.vba.va.gov/bl/21/publicat/Letters/TrngLtrs/TL11-05.doc
Documenting Markers on the PTSD DBQ
There is a place on the PSTD Disability Benefits Questionnaire (DBQ) that asks the examiner to
document markers related to MST. This enables the rater to know if the markers are related to a Criterion
A stressor (according to DSM-5). Please see below for where this should be documented on the Initial
PTSD DBQ.
Please note that if there are markers related to sexual harassment, the sexual harassment needs to be of
significant enough magnitude to meet the definition of a Criterion A stressor.
DMA Military Sexual Trauma and the Disability Examination Process
Page 55
Knowledge Check
Answers and feedback for this knowledge check can be found on page 74
1. True or false? Objective evidence is required for a claim of residuals secondary to MST except in the
case of PTSD where markers can serve as evidence.
A. True
B. False
2. Resulting from the Patton v. West case, three of the following four considerations guide VBA in
developing evidence to support a claim for MST-related PTSD. Select the consideration that does not
apply.
A. Direct, objective evidence is required for MST-related PTSD claims.
B. Behavior changes occurring at the time of an incident may indicate the occurrence of an inservice stressor.
C. Evidence documenting behavior changes may require interpretation by a qualified examiner
regarding the relationship to a medical diagnosis.
D. A qualified examiner’s opinion can be considered credible supporting evidence for
occurrence of an MST stressor in PTSD claims.
3. One of the following statements is true regarding the VBA process for developing evidence for MSTrelated PTSD claims. Select the correct answer.
A. A Veteran’s or Servicemember’s record is not searched for markers.
B. VBA refuses records submitted by the Veteran or Servicemember.
C. Interpretation of potential markers can differ.
D. VBA has no responsibility to notify a claimant that sources outside of service-related records
can be used for evidence.
4. True or false? If after a file review, the mental health disability examiner considers something to be a
marker that was not identified by VBA personnel; the examiner should also provide an explanation as
to why this evidence is considered a marker and how it may be considered evidence of an in-service
MST event.
A. True
B. False
5. VBA is requesting a clinician's opinion about a marker and its relationship to the claimed in-service
MST event, not whether the examiner can be certain that the event occurred. To that end, two of the
following three statements about the examiner's opinion are correct. Select the statement that is not
correct.
A. An interview with the claimant is generally not helpful with the process of developing an
opinion based on markers.
B. The opinion should address whether the evidence, often in the form of markers, suggests that
the in-service personal assault occurred.
C. If the evidence suggests that an in-service personal assault occurred, the opinion should
address if, by extension, whether this experience was sufficient to cause PTSD and the
symptoms identified.
6. True or false? If documentation for an MST-related PTSD disability examination includes markers
related to sexual harassment, the sexual harassment needs to be of significant enough magnitude to
meet the definition of a Criterion A stressor.
A. True
B. False
DMA Military Sexual Trauma and the Disability Examination Process
Page 56
7. One of the following suggestions should be used by a mental health disability examiner for
documenting a marker in an MST-related PTSD claim. Select the correct answer.
A. The examiner should not state agreement with VBA’s designated marker, as this is assumed.
B. The examiner should ignore any potential marker that is different than VBA’s designated
marker.
C. The examiner should include a rationale that explains how any documented marker is
indicative that MST may have occurred.
D. The examiner should not search for and document different markers than VBA’s designated
markers.
8. Once a C&P examination is scheduled, the examiner will conduct an interview with the Veteran to
arrive at all but one of the following determinations. Select the incorrect answer.
A. Whether or not the Veteran reported the claimed personal assault prior to separation from
service
B. Whether or not the Veteran has a diagnosis of PTSD
C. Whether or not there is a marker in the Veteran’s records or self-report that is indicative of
MST during service
D. Whether or not there is credible reason to believe that the diagnosis of PTSD is related to the
MST
Lesson Summary
This lesson discussed VBA’s expectations of disability examiners conducting MST-related PTSD
examinations and covered discerning markers, documenting markers, and providing an opinion about the
relationship of a marker to a diagnosis of PTSD.
Now that you’ve completed this lesson, you should be able to identify considerations and procedures for
mental health examiners conducting MST-related PTSD disability examinations.
If you have completed all lessons, you may access the Course Summary on the next page and the Final
Assessment that follows.
DMA Military Sexual Trauma and the Disability Examination Process
Page 57
Course Summary
Congratulations! You’ve completed this DMA Military Sexual Trauma and the Disability Examination
Process course. You may use the course Menu to navigate any lesson as needed before you proceed to
the Final Assessment that follows this summary. This course provided information and examples in five
lessons to help you reach the terminal learning objective: describe issues related to obtaining benefits for
physical and mental health conditions that may be secondary to MST.
The first lesson
The first lesson, Military Sexual Trauma, defined MST and provided statistics about MST to help you
recognize its potential effects on a Servicemember’s or Veteran’s physical, mental, and emotional health.
The scope of and reasons for underreporting were also addressed, as well as various mental
and physical conditions diagnosed more frequently in Veterans who have experienced MST.
The second lesson
The second lesson, VA and DoD Policies and Programs, described policies and programs implemented
by DoD and VA to address the experiences of sexual assault and sexual harassment in Servicemembers
and Veterans. DoD programs include the Safe Helpline, SAPRO, and the MEO program. VA and DoD
implemented the Separation Health Assessment (SHA) to facilitate the transition from Servicemember to
Veteran. VHA policies and programs for MST-related education and outreach, and free and extensive
MST-related care were also covered.
The third lesson
The third lesson, MST-Related Disability Claims, provided background information on VBA’s extensive
training for VBA staff to develop MST-related PTSD claims based on available evidence. VBA’s outreach
to Veterans whose MST-related PTSD claims were denied prior to 2011 was also covered. This lesson
included suggestions for conducting trauma-sensitive examinations, and for responding sensitively if a
Veteran discloses MST during a disability examination.
The fourth lesson
MST and the Separation Health Assessment, the fourth lesson, started with details about the SHA and
how the report from an SHA becomes part of a Servicemember’s STRs. This lesson discussed possible
implications for the Servicemember who discloses MST during the SHA, suggestions for responding to a
potential disclosure, and considerations for documenting MST experiences on the SHA examination
report. This lesson also described three handouts that disability examiners must give to Servicemembers
at the close of the SHA.
The fifth lesson
Considerations for MST-Related PTSD Disability Examinations, the fifth lesson, covered indirect
evidence, used by VBA to develop MST-related claims. VBA and the examiner’s roles in discerning and
assessing markers used in MST-related PTSD claims were discussed. This lesson provided examples for
documenting markers and providing rationales to explain the examiner’s conclusions about the marker
and any connection to a possible MST experience.
DMA Military Sexual Trauma and the Disability Examination Process
Page 58
End of Course Activities
Congratulations!
You have completed the online learning module titled: “DMA Military Sexual Trauma and the Disability
Examination Process.”
Select the “Exit” link (please use the Exit link provided in the course rather than the browser’s close
button) and return to the Talent Management System (TMS) to access other content objects and/or
download your completion certificate once all requirements have been met.
If you've completed all requirements, such as completing an online evaluation, follow these steps to
review and print your course completion certificate:
1. Select the Exit link on this page to return to the TMS.
2. In the TMS, select the Completed Work pod located on the right side of your TMS home screen.
3. Select the course title, "DMA Military Sexual Trauma and the Disability Examination Process" to
review and print your course completion certificate.
DMA Military Sexual Trauma and the Disability Examination Process
Page 59
References
Books
American Psychiatric Association
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
ed.). Arlington, VA: American Psychiatric Association.
Department of Veterans Affairs, 2013
Department of Veterans Affairs. (2013). Uniform mental health services in VA medical centers and
clinics. Washington, DC: Department of Veterans Affairs.
This handbook, VHA Handbook 1160.01, can be accessed at this website:
http://www1.va.gov/vhapublications/publications.cfm?pub=2&order=asc&orderby=pub_Number
Code of Federal Regulations
Definitions, 38 CFR 3.1(y) (2014)
Definitions, 38 CFR 3.1(y) (2014). This regulation can be accessed on the U.S. Government Printing
Office website: http://www.gpo.gov/fdsys/pkg/CFR-2013-title38-vol1/xml/CFR-2013-title38-vol1-sec31.xml
Direct service connection; wartime and peacetime, 38 CFR 3.304(f)(5) (2014)
Direct service connection; wartime and peacetime, 38 CFR 3.304(f)(5) (2014). This regulation can be
accessed on the U.S. Government Printing Office website: http://www.gpo.gov/fdsys/pkg/CFR-2013title38-vol1/xml/CFR-2013-title38-vol1-sec3-304.xml
Court Cases
Patton v. West
Patton v. West, 12 Vet. App. 272 (1999).
Reports
U.S. Government Accountability Office
U.S. Government Accountability Office. (2014, June). Military sexual trauma: Improvements made,
but VA can do more to track and improve the consistency of disability claim decisions. (Publication
No. GAO-14-477). Retrieved on July 2, 2014, from http://www.gao.gov/assets/670/663964.pdf.
Studies
Charuvastra, A. and Cloitre, M.
DMA Military Sexual Trauma and the Disability Examination Process
Page 60
Charuvastra, A. and Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual
Review of Psychology, 59, 301-328.
Access to this article is available at the following DOI:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722782/
Defense Manpower Data Center
Defense Manpower Data Center. (2013). 2012 Workplace and gender relations survey of active duty
members. Arlington, VA: DMDC.
Department of Veterans Affairs, 2014
Department of Veterans Affairs (2014). Summary of military sexual trauma-related outpatient care,
Fiscal year 2013. Washington, DC: Department of Veterans Affairs, Office of Mental Health Services.
Frayne, S. M., Skinner, K. M., Sullivan, L. M., & Freund, K. M.
Frayne, S. M., Skinner, K. M., Sullivan, L. M., & Freund, K. M. (2003). Sexual assault while in the
military: violence as a predictor of cardiac risk? Violence and Victims, 18(2), 219-225.
Frayne, et al., 1999
Frayne, S. M., Skinner, K. M., Sullivan, L. M., Tripp, T. J., Hankin, C. S., Kressin, N. R., & Miller, D. R.
(1999). Medical profile of women Veterans Administration outpatients who report a history of sexual
assault occurring while in the military. Journal of Women's Health & Gender-Based Medicine, 8(6),
835-845.
Himmelfarb N., Yaeger D., and Mintz J.
Himmelfarb N., Yaeger D., and Mintz J. (2006). Posttraumatic stress disorder in female veterans with
military and civilian sexual trauma. Journal of Traumatic Stress, 19(6), pp. 837-46.
Kang, H., Dlager, N., Mahan, C., and Ishii, E.
Kang, H., Dlager, N., Mahan, C., and Ishii, E. (2005). The role of sexual assault on the risk of PTSD
among Gulf War veterans. Annals of Epidemiology, 15(3), pp. 191-195.
Kimerling, R., Gima, K., Smith, M.W., Street, A., Frayne, S.
Kimerling, R., Gima, K., Smith, M.W., Street, A., Frayne, S. (2007). The Veterans Health
Administration and military sexual trauma. American Journal of Public Health, (12), 2160-6.
Langton, L., Berzofsky, M., Krebs, C., Smiley-McDonald, H.
Langton, L., Berzofsky, M., Krebs, C., Smiley-McDonald, H. (2012). Victimizations not reported to the
police, 2006-2010. Washington, DC: United States Department of Justice. Retrieved April 10, 2014,
from http://www.bjs.gov/content/pub/pdf/vnrp0610.pdf
Street, A. E., Gradus, J. L., Giasson, H. L., Vogt, D., & Resick, P. A.
DMA Military Sexual Trauma and the Disability Examination Process
Page 61
Street, A. E., Gradus, J. L., Giasson, H. L., Vogt, D., & Resick, P. A. (2013). Gender differences
among veterans deployed in support of the Wars in Afghanistan and Iraq. Journal of General Internal
Medicine, 28, 556-562.
Suris A., Lind L., Kashner T.M., and Borman P.D., 2007
Suris A., Lind L., Kashner T.M., and Borman P.D. (2007). Mental health, quality of life, and health
functioning in women veterans: differential outcomes associated with military and civilian sexual
assault. Journal of Interpersonal Violence, 56 (2), pp. 126-30.
Suris, A., and Lind, L., 2008
Suris, A., and Lind, L. (2008). Military sexual trauma : A review of prevalence and associated health
consequences in veterans. Trauma, Violence, Abuse (9), 250-270.
Training Modules
Military Sexual Trauma Sensitivity Training (VHA)
This 90-minute web-based course is Item 1688383 on the VA Talent Management System (TMS) at
https://www.tms.va.gov
Military Sexual Trauma: Disability Claims
Use the URL below to access a video of this satellite broadcast from April, 2012.
Intended for a wide audience, this training covered a wide range of topics and included dialog
between VBA and VHA related to MST claims. Specifically, a VBA adjudicator and mental health
examiner conversed in order to help the VHA examiner better understand VBA regulations and
expectations for adjudicating cases, and to help the VBA adjudicator to better understand how
examiners come to conclusions about diagnoses.
1)
2)
3)
4)
go to https://vaees.blackboard.com
Log in, with user name: dmageneric and this password: password
In the My Courses pane, select the DMA C&P Training link
From the list of courses, play or download the video titled: Military Sexual Trauma (MST)
Disability Claims
United States Code
Counseling and treatment for sexual trauma, 38 U.S.C. 1720D(a)(1) (2013)
Counseling and treatment for sexual trauma, 38 U.S.C. 1720D(a)(1) (2013). This statute can be
accessed at on the U.S. Government Printing Office website:
http://www.gpo.gov/fdsys/pkg/USCODE-2012-title38/html/USCODE-2012-title38-partII-chap17subchapII-sec1720D.htm
DMA Military Sexual Trauma and the Disability Examination Process
Page 62
Glossary
A
Adjudicate
Adjudicate means to decide judicially. For the Veterans Benefits Administration (VBA), adjudication is the
process of weighing all evidence for a claim and determining the outcome.
C
C&P
Compensation and Pension
Compensation is a monthly tax-free monetary benefit paid to Veterans disabled by injury or illness
incurred in or aggravated during active military service. Disability compensation amounts vary with the
degree of disability and the number of the Veteran's dependents. Pension benefits are tax-free monetary
payments, specified by law, provided to wartime Veterans with limited or no income who are either aged
65 or older or who are permanently and totally disabled due to a non-service connected cause. Seriously
disabled or housebound Veterans receiving Pension may also qualify for an additional Aid and
Attendance or Housebound benefit.
Compensation and pension (C&P) also refers to the VHA entity that performs disability evaluations,
examinations, or opinions for Veterans and Servicemembers as part of the adjudication of a claim for VA
disability benefits, if an evaluation, examination, or opinion is necessary to decide the claim. A disability
evaluation is an assessment of the medical evidence, which may involve conducting an examination,
providing an opinion, or both. A disability examination is a medical professional’s personal observation
and evaluation of a claimant. It can be conducted in person or by means of telehealth technologies. An
opinion refers to a medical professional’s statement of findings and views, which may be based on review
of the claimant’s medical records or personal examination of the claimant, or both.
D
DBQ
A Disability Benefits Questionnaire (DBQ) is a documentation protocol used to record C&P examination
findings and pertinent history. DBQs are documentation tools tailored to the VA Schedule for Rating
Disabilities (Rating Schedule). A DBQ is more forensic than clinical as a medical report. DBQs enable VA
to access resources of the private medical community and streamline the disability examination process.
DoD
United States Department of Defense
M
MEO Program
DMA Military Sexual Trauma and the Disability Examination Process
Page 63
The Department of Defense Military Equal Opportunity (MEO) program is charged with promoting equal
opportunity and affirmative actions, and for eliminating unlawful discrimination and sexual harassment
within DoD. The MEO program handles sexual harassment investigations for DoD.
MST Coordinator
Every VA healthcare system has an MST Coordinator who serves as a point person for MST issues at the
facility and ensures that MST-related monitoring, treatment, and education and training occur there. The
MST Coordinator is a clinician’s best point of contact for assistance in getting Veterans into MST-related
care or for answering any questions about local services.
Marker
In the case of an MST-related PTSD evaluation a marker is “indirect evidence” that a Veteran or
Servicemember experienced MST. For VBA purposes, 38 CFR 3.304(f)(5) established two categories of
markers: markers involving records other than service records, and behavior changes occurring during
service or at some credible point after service.
Military Sexual Trauma (MST)
VA’s definition of military sexual trauma (MST) comes from federal law, based on 38 U.S.C. 1720D. In
general, MST is the term used by VA to refer to sexual assault or repeated, threatening sexual
harassment experienced by a Servicemember during military service, regardless of the geographic
location, the gender of the Servicemember, or the relationship to the perpetrator.
S
SAPRO
The Department of Defense (DoD) created the Sexual Assault Prevention and Response Office (SAPRO)
as part of a comprehensive policy to address sexual assault in the military. SAPRO provides oversight of
the Department's sexual assault policy. SAPRO works hand-in-hand with all branches of service and the
civilian community to develop and implement innovative prevention and response programs.
SARC
When a Servicemember makes a report of sexual assault to someone such as an individual in the
Department of Defense’s Sexual Assault Prevention and Response Office (SAPRO), law enforcement, or
a health care provider, the Servicemember is assigned a sexual assault response coordinator (SARC)
who serves as a victim advocate.
SHA
The Separation Health Assessment (SHA) refers to both a program and a documentation protocol that VA
developed in cooperation with DoD to improve the claims process for Servicemembers separating from
service.
The SHA General Medical Disability Benefits Questionnaire (DBQ) is a comprehensive examination
protocol.
STRs
DMA Military Sexual Trauma and the Disability Examination Process
Page 64
VBA defines Service Treatment Records (STRs) as the military health records for each Veteran. The
STRs typically include information such as:








Physical examinations and records, including entrance and discharge physical examinations, as
needed
The Veteran’s medical history
All dental examinations and records
Clinical record cover sheets and summaries
Entries from outpatient medical and dental treatments
Physical profiles
Medical board proceedings
Prescriptions for eyeglasses and orthopedic footwear
Safe Helpline
The DoD Safe Helpline provides live, one-on-one support and information to the DoD community. The
Telephone Helpline staff can even transfer callers to installation/base Sexual Assault Response
Coordinators (SARCs). The service is confidential, anonymous, secure, and available worldwide.
Servicemember
A Servicemember is a member of the uniformed services.
Sexual Assault
Based on 38 U.S.C. 1720D, VA defines sexual assault as physical assault of a sexual nature and/or
battery of a sexual nature.
Sexual Harassment
Based on 38 U.S.C. 1720D, VA defines sexual harrassment as repeated, unsolicited verbal or physical
contact of a sexual nature which is threatening in character.
T
Transition Assistance Program (TAP)
The Transition Assistance Program (TAP) was established to meet the needs of separating service
members during their period of transition into civilian life by offering job-search assistance and related
services. More information about TAP is found at: http://www.taonline.com/TapOffice/What-is-a-TAPoffice
U
U.S.C.
United States Code (U.S.C.)
DMA Military Sexual Trauma and the Disability Examination Process
Page 65
V
VBA
The Veterans Benefits Administration (VBA) is responsible for providing a wide variety of benefits and
services to Veterans and Servicemembers through Regional Offices. Major benefits provided by VBA and
authorized by Congress include service connected disability compensation, nonservice-connected
disability pension, burial assistance, survivors’ benefits, rehabilitation and employment assistance,
education and training assistance, home loan guarantees, and life insurance coverage.
VBMS
A VBA transformation initiative, the Veterans Benefits Management System (VBMS) is a web-based,
paperless claims processing solution that will assist VA in eliminating the claims backlog and enable fast,
accurate and integrated claims processing.
VHA
The Veterans Health Administration (VHA) governs the medical treatment facilities within the Department
of Veterans Affairs. With nationwide medical centers (VAMCs), VHA provides health care for Veterans.
VHA manages one of the largest healthcare systems in the United States. VAMCs within a Veterans
Integrated Service Network (VISN) work together to provide efficient, accessible health care to Veterans
in their areas.
Vet Center
The Vet Center Program was established by Congress in 1979 out of the recognition that a significant
number of Vietnam era Veterans (Vets) were still experiencing readjustment problems. Vet Centers are
community based and part of the U.S. Department of Veterans Affairs. Vet Centers across the country
provide a broad range of counseling, outreach, and referral services to combat-service Veterans and their
families. Vet Centers guide Veterans and their families through many of the major adjustments in lifestyle
that often occur after a Veteran returns from combat. Services for a Veteran may include individual and
group counseling in areas such as Posttraumatic Stress Disorder (PTSD), alcohol and drug assessment,
and suicide prevention referrals. All services are free of cost and are strictly confidential.
DMA Military Sexual Trauma and the Disability Examination Process
Page 66
Contact Us
VA TMS Help Desk
If you have technical problems while in the course, taking a self–exam, taking the evaluation or printing a
certificate of completion, please contact the VA TMS Help Desk via email at: [email protected] or
Monday through Friday between 8:00 AM and 10:00 PM EST toll free at: 1(866) 496–0463.
EES e-Learning Producer
Carole A. Bagley, Ph.D.
Department of Veterans Affairs, VHA/EES
Minneapolis Employee Education Resource Center
[email protected]
EES Project and Accreditation Manager
Antonio Bedford
Department of Veterans Affairs, VHA/EES
Crystal City, DC
[email protected]
DMA Military Sexual Trauma and the Disability Examination Process
Page 67
Knowledge Check and Exercise Answers and Feedback
Military Sexual Trauma (MST)
Knowledge Check
Knowledge Check is on page 14
1.
B
The statement is false. The perpetrator of MST is often a friend, intimate partner, or other trusted
individual. You may want to review the section titled: Additional Difficult Aspects of MST.
2.
A
This statement is true. According to studies, women report more negative health consequences after
being sexually assaulted in the military than women who experience childhood or other civilian sexual
assault. You may want to review the section titled: MST Experiences: Gender-Specific Issues for Women
and Men.
3.
D
In studies by Kimerling, et al. and Suris and Lind, a history of sexual assault has been most commonly
associated with increased risk for posttraumatic stress disorder, depression, substance use disorders,
panic disorder, and generalized anxiety disorder. Indications include an increased risk of bipolar disorder
too, but the incidence is much less frequent than the other disorders listed here. You may want to review
the section titled: MST and Psychological Health.
4.
B
MST is an experience, not a diagnosis. You may want to review the section titled: MST Defined.
5.
A
The statement is true. Only 19 percent of the 1.3 percent of men who indicated experiencing unwanted
sexual contact in the WGRA survey reported it to a military authority. You may want to review the section
titled: Why Men May Not Report Unwanted Sexual Contact.
6.
A
Option (A) is incorrect because VA's definition includes both sexual harassment and sexual assault. It is
true that not all MST experiences have an associated diagnosis and that not all MST-related diagnoses
have a compensable disability. You may want to review the section titled: Frequency among Users of VA
Healthcare.
7.
B
Option (B) is the incorrect answer because all MST screening is done by qualified clinicians in a private
setting. The other statements are true. You may want to review the section titled: Frequency among
Users of VA Healthcare.
DMA Military Sexual Trauma and the Disability Examination Process
Page 68
8.
B
The statement is false. According to the Bureau of Justice Statistics report, 65 percent of persons who
were assaulted did not report the assault to a police authority. You may want to review the section titled:
Why Women May Not Report Unwanted Sexual Contact.
9.
C
Option (C) is correct because MST can be experienced across all ranks. The other statements are
incorrect. You may want to review the section titled: Common Myths about MST.
DMA Military Sexual Trauma and the Disability Examination Process
Page 69
VA and DoD Policies and Programs
Knowledge Check
Knowledge Check is on page 21
1.
2, 1
DoD's MEO program is the point of contact for reporting sexual harassment, while SAPRO is the point of
contact for reporting sexual assault. You may want to review the section titled: DoD Programs.
2.
B
The statement is false. While many but not all VA medical centers offer inpatient mental health services,
all VA medical centers offer MST-related mental health outpatient services. You may want to review the
section titled: VHA MST-Related Mental Health Treatment.
3.
C
VHA established a mandatory training requirement for primary care providers and mental health
providers, but not for gynecologists. You may want to review the section titled: VHA Policies and
Programs for MST-Related Education and Outreach.
4.
A
The statement is true. All VHA treatment for physical and mental health conditions related to MST is free
of charge for enrolled Veterans. You may want to review the section titled: VHA Policies for MST-Related
Treatment.
5.
C
Option (C) is the incorrect answer. While the MST coordinator monitors and ensures that treatment for
MST-related conditions occurs, any diagnosis is established by clinicians. You may want to review the
section titled: VHA Policies and Programs for MST-Related Education and Outreach.
6.
B
Option (B) is the incorrect answer because there are no income requirements for Veterans to be eligible
for MST-related healthcare at VA facilities. You may want to review the section titled: VHA Policies for
MST-Related Treatment.
DMA Military Sexual Trauma and the Disability Examination Process
Page 70
MST-Related Disability Claims
Knowledge Check
Knowledge Check is on page 29
1.
A
Potential for validation can motivate Veterans or Servicemembers to file claims for MST-related
conditions. You may want to review the section titled: Considerations for Servicemembers and Veterans
Filing a Claim.
2.
D
Option (D) is the correct answer. In fact, it is important that you document not just the physical findings
and the experience of MST, but that you document the relationship between the MST experience and the
diagnosis. You may want to review the section titled: How to Respond Sensitively if a Veteran Discloses
MST (continued).
3.
B
The statement is false because VHA encourages the practice of allowing an examinee to request an
examiner of a specific gender, when feasible. This practice can benefit the Servicemember or Veteran
who has experienced MST. You may want to review the section titled: The Importance of Conducting
Trauma-Sensitive Examinations.
4.
A
Option (A) is correct because conversing with the fully dressed Servicemember or Veteran when possible
is one way of reducing the power differential as part of a trauma-sensitive examination. Other traumasensitive practices include making eye contact, explaining why you are asking some questions, and
providing Veteran or Servicemember with options and choices. You may want to review the section titled:
Methods for a Trauma-Sensitive Examination.
5.
B
Option (B) is the correct answer because financial assistance can motivate Veterans to file disability
claims while the other reasons can deter them. You may want to review the section titled: VBA
Processes for MST-Related PTSD Claims.
6.
A
The statement is true. VBA sent notification letters to Veterans in 2013 and 2014, after extensive training
of VBA staff, to offer a re-evaluation of previously denied MST-related PTSD claims. You may want to
review the section titled: VBA Processes for MST-Related PTSD Claims.
7.
B
Option (B) is the incorrect answer. Because of the lack of direct evidence for many MST-related PTSD
claims, VBA provided extensive training to VBA staff and assigned specially trained employees to handle
these claims. You may want to review the section titled: VBA Processes for MST-Related PTSD Claims.
DMA Military Sexual Trauma and the Disability Examination Process
Page 71
MST and the Separation Health Assessment
Knowledge Check
Knowledge Check is on page 44
1.
2,1
A C&P disability examiner will conduct the separation health assessment with a Servicemember when the
Servicemember has filed a disability claim with VA. Otherwise, a DoD examiner will conduct this
assessment. You may want to review the section titled: The Separation Health Assessment.
2.
A
The statement is true; the SHA examination report becomes part of the Servicemember's Service
Treatment Records. You may want to review the section titled: The Separation Health Assessment.
3.
A
The statement is true. If a Servicemember has already filed a restricted report about a sexual assault and
you document this in the SHA, the confidentiality of the report may be compromised. If a Servicemember
has filed a restricted report, and wants to assure his or her confidentiality within DoD, he or she should file
a claim for their MST-related conditions after separating from the service. You may want to review the
sections titled: Aspects of the SHA and DoD Programs for Reporting Sexual Assault or Harassment.
4.
2, 1, 1
SAPRO is the DoD point of contact for restricted and unrestricted reports of sexual assault, while an MEO
Advisor is the point of contact for a formal report of sexual harassment. You may want to review the
section titled: DoD Programs for Reporting Sexual Assault or Harassment.
5.
B
This answer is incorrect. Option (B) is the incorrect answer. Privacy concerns may be discussed in the
MST-related resource information, but no privacy policies handout is included. The three handouts are:
VHA Services, MST-related resource information, and the Veterans Crisis Line. You may want to review
the section titled: Provide Handouts to Servicemembers.
6.
C
Option (C) is the incorrect answer. You should document all conditions present, including any potential
MST-related conditions. You may want to review the sections titled Aspects of the SHA and Implications
for Servicemembers Disclosing MST
7.
A
Option (A) is correct because you should respond with empathy but limit the disclosure because giving
you a detailed account may distress the Servicemember. While you should caution the Servicemember
about confidentiality concerns, you do not need to refuse a disclosure and you should not insist that the
Servicemember disclose to DoD. If the Servicemember prefers not to call the Safe Helpline for support,
you can offer to make a referral to a VA mental health counselor. However, this referral is not a reason to
DMA Military Sexual Trauma and the Disability Examination Process
Page 72
stop the examination. You may want to review the sections titled Aspects of the SHA and Implications for
Servicemembers Disclosing MST.
8.
C
Option (C) is the incorrect answer. There is a separate handout for the Veterans Crisis Line; it's not
included in the MST-related resources handout. You may want to review the section titled: Provide
Handouts to Servicemembers.
9.
A
The statement is true. If a Servicemember has filed a restricted report of sexual assault with DoD,
disclosure during the SHA may compromise this report. You may want to review the section titled: DoD
Programs for Reporting Sexual Assault or Harassment.
10.
B
Option (B) is correct; if you document any physical residuals, you should explain how they may be related
to the reported MST experience. Also, you should document the report of MST in the Remarks section of
the DBQ and include direct quotations from the Servicemember where possible. Avoid pointing out other
behaviors proximal to an assault that did not contribute to it. You may want to review the section titled:
Information Sharing between DoD and VA and Implications for Confidentiality.
DMA Military Sexual Trauma and the Disability Examination Process
Page 73
Considerations for MST-Related PTSD Disability Examinations
Exercise
Exercise is on page 49
1.
B
The deterioration in Lucinda's work performance at the same time as the MST experience she describes,
shown in tardiness and missed days, is a marker showing behavior change. This marker indicates the
possibility that she was sexually assaulted
2.
C
A note in John's shipboard medical records show that he was treated for a facial bruise and swollen nose,
which he stated were due to slipping and falling on deck.
Knowledge Check
Knowledge Check is on page 56
1.
A
The statement is true because in the case where MST-related PTSD is being claimed, markers can serve
as evidence. Other kinds of MST-related claims will require objective evidence. You may want to review
the section titled: Myths about MST-Related Disability Claims.
2.
A
Option (A) is not a consideration that guides VBA in developing evidence to support a claim for MSTrelated PTSD. As a result of the Patton v. West case, VBA will consider behavior changes occurring at
the time of an incident, and this evidence may require interpretation by a qualified examiner regarding the
relationship to a medical diagnosis. Moreover, an examiner's post-service opinion can be used as
evidence for occurrence of an in-service stressor in MST-related PTSD claims. You may want to review
the section titled: MST-Related PTSD Claims and Special Regulations.
3.
C
Answer option (C) is correct because interpretation of potential markers can differ. Also, VBA will search
all records for markers, including records submitted by the claimant only when VBA cannot find direct
evidence of an MST event in records. As part of searching for a marker, no MST-related PTSD claim will
be denied without VBA advising the claimant that evidence from sources other than the Veteran's service
records and that evidence of behavior changes may constitute credible supporting evidence of a stressor.
You may want to review the section titled: Investigating a Marker Starts with VBA.
4.
A
This statement is true. The mental health disability examiner may discern a marker not identified by VBA.
In this case, the disability examiner should provide an explanation as to why this evidence is considered a
marker and how it may be considered evidence of an in-service MST event. You may want to review the
section titled: Markers and the PTSD Examiner.
DMA Military Sexual Trauma and the Disability Examination Process
Page 74
5.
A
Option (A) is not correct. In fact, the opposite is true: an interview with the claimant is generally helpful
with the process of developing an opinion based on markers. You may want to review the section titled:
Markers and the PTSD Examiner.
6.
A
The statement is true. Markers for sexual harassment need to be of significant magnitude to meet the
definition of a Criterion A stressor. You may want to review the section titled: Documenting Markers on
the PTSD DBQ.
7.
C
Option (C) is correct. In the documentation for an MST-related PTSD claim, the examiner should always
state if he or she agrees with VBA's designated marker and the examiner should examine and document
a marker if he or she determines one. In either case, the examiner should include a rationale that explains
how any documented marker is indicative that MST may have occurred. There is no need for the
examiner to search for different markers than VBA's designated markers. You may want to review the
section titled: Markers and the PTSD Examiner.
8.
A
Option (A) is the incorrect answer because the examiner is not tasked with determining if the claimant
reported the claimed personal assault prior to separation from service. All other determinations must be
made and reported. You may want to review the section titled: Markers and the PTSD Examiner.
DMA Military Sexual Trauma and the Disability Examination Process
Page 75