colonels and naval captains. that's a higher level. let me change this subject for a moment. you've talked eloquently about the deficiencies of the treatment system. would one solution be to allow military personnel to use their benefits in the civilian system? in other words, to go outside the military system, to get the counseling and those if there's more availability in the area that were wherever you live? for instance we have a program in northern maine under the va. it's a pilot program where veterans are able to get their services not by going four hours to the va hospital, but by accessing local civilian services. would that be something that might be helpful in this situation, by broadening the field of available treatment possibilities? mr. arbogast? >> thank you, senator. like i stated before, i already use my medicare for that purpose because where the va lacks. i think the va -- veterans would not have a problem traveling for good care. it's the fact that they need to -- you know, i emphasized on how good i get my spinal cord injury care in richmond virginia now. so, you know, that's a four-hour drive for us. so i would go there every day. >> if you were getting adequate care? >> well, i mean, i get adequate care there. i get superior care there. >> you mentioned the 90-mile drive. >> that would be within my va medical center, which i try to avoid at all costs, because they are just out of the loop. they don't have the resources. you know, they don't even have a doctor that specializes in spinal cord injury care. he he's just an md who thinks he just knows about it but really doesn't. but the thing is if every va had the resources to deal with every type of injury, illness, whatever, then it wouldn't be a problem to use the va system. it's a problem that each va medical center is different in that they're not being held accountable. >> do you have thoughts about that? >> i believe there are a lot of benefits, especially in the ability to test drive basically other counselors and caregivers to whom you feel comfortable, as well as being able to better specialize in what is actually affecting you. as well as there's the ptsd, prescription, overprescribing problems and there's also identity issues and other addiction that is don't fall under narcotics or alcohol, even like shopping kicks and things like that, that are not treated in the va. but if you went and sought outside help i think there's benefit to getting more specialized treatment. and i think it is -- i would say almost impossible for every va to have every service. and so with that knowledge, to have the ability to go outside of that would benefit them. >> but given the rise of this -- i don't want to imply that it hasn't existed before. i'm sure ptsd goes back to the beginning of time. but the increasing awareness of it, the volume of it that we're seeing in recent years, i suspect you would agree that this is something the va should be gearing up for in a very serious way. and i'm gathering from your testimony that you don't believe that they are. >> i don't believe the va has the ability to move three moves ahead, or to see that, where the need is coming until they have the problem. then they approach whomever. then the money comes in for the problem. by then it's two years down the road and the problem is even bigger. so, i don't see that there's an adequate system for the va to apply certain foresight in seeing where they need help and being able to justify it adequately to whoever they have to in order to get the funding for it. i would consider looking into that system, where you could encourage the individuals, the directors to think three moves ahead and say, you know -- >> what's coming? >> right. look what's coming. you don't necessarily have to prove it with the numbers in regards to, you know, you already have these. and this is what you're funded for. you don't have to have them on backup to justify the need. >> the va isn't within the purview of this committee but clearly it's a continuum of concern that we have about our military people, whether they're in service or veterans. thank you very much for your testimony. thank you very much for taking the time. yes, sir? >> there's a very big problem with the va's retention rate, too, with providers. >> retention rate? >> they can't keep doctors, especially where i'm at. their vboc or cboc, excuse me. i went through seeing a doctor, who i've seen for years. we're talking about like medical doctor. you know, i've seen for years. and then i come back in find out he quits. then it takes them six months to get a new doctor. so i'm left without care for six months. they finally get a new doctor, i have to explain everything all over again. and come to find out, well, i'll see you in a month, two weeks, whatever it may be. come to find out, he quits. so then i'm left without care for eight months. >> now do you have a choice in all this? do you have have to go to the va hospital or could you use tri-care to go anywhere? >> i could use tri-care to go anywhere. the fact is some civilian providers are just as bad as the va providers. it's the way -- >> are you suggesting our healthcare system in this country is screwed up? >> it is. it is, truthfully. it is. and, you know, it's quite disturbing that, you know, we more or less -- veterans have to go around and shop for, you know, is this doctor specialized in this care? what do they know? it is a very disturbing problem. >> thank you. thank if you have military sexual trauma, the likelihood is four out of 10. we second chart shows the number of old who screened positive or military sexual trauma. the incident at ptsd is higher for men than women. ptsd as a man. charts, if you screened positive, yet they highlight incident rate of mental health condition. if you been sexually assaulted, your 70% likely to have a mental health condition as a man, slightly higher for a woman. two is that last charts. currently available data. 2002 - through 2008. do you wantt to put the charts up so people can see them? have a statement we are from to add to the record brian lewis. is there objection? is entered into the record. i invited you each to give a statement. good morning. thank you for the opportunity to discuss the intersection of two very important issues, mille military sexual trauma and suicide. we heard of veterans who struggled with the issues we are discussing today. i appreciate your willingness to come today and bring some of the data i'm about to speak about to life and make it more real for us today. stories underscored the issues i would like to speak of. ofis about the health impact sexual military trauma as well as the relationship between trauma and suicide specifically. mst is anexual trauma experience, not a diagnosis or condition and there are a variety of reactions of veterans can have after experiencing mst. the type and severity will all based on the nature of the experience, reactions of others at the time and whether the veteran had a prior history of trauma. although the struggles that men and women have after mst are similar and may overlap, there can be gender specific issues they may do with your the impact can also be affected i race, ethnicity, religion, sexual orientation and other cultural variables. remarkablys are resilient after experiencing trauma. send to go on to experience long-term difficulties. the data indicates that in fiscal year 2012 post about it trusts this order in depressive disorders were the mental health diagnoses most commonly associated with mst. were other inside he disorders, bipolar, substance use disorders, and schizophrenia and psychotic disorders. veterans often struggle with physical health conditions and other problems such as homelessness. with regard to suicide, research has shown that trauma in general is associated with suicide and suicidal behavior. this is true for civilian and military populations. if we focus on sexual trauma specifically, data from civilian studies have found an association between sexual victimization and suicidal mediation, attempted suicide and death by suicide. these relationships remain even after you control for additions or ptsd.ession although less work has been done examining the link between sexual trauma and suicide among veterans seven we, the data shows a pattern similar to the studies and civilians i just reviewed. studies and administrative data show sexual drama is associated with suicide attempts as well as step by suicide. this also holds even after accounting for mental health. approaches always need to be tailored to the specific needs of the individual veterans and take into account comorbid health conditions that also the treatment and broader psychosocial history, his or her current life context and his or her individual preferences. regarding treatment for veterans with ptsd significantly, a research base has accumulated, it is a fine exposure-based cognitive behavioral therapies. survivors and they have a particularly strong evidence base in this area. all those the therapy should be considered a first choice to treatment,rea some may focus on coping skill developments before. theiran help augment strategies for managing the emotional distress that may be brought up during completion of a cognitive behavioral treatment. va is committed to ensuring veterans get the help they needed to recover from mst. i appreciate the opportunity to speak at some of the research today as well as think he for your support of these important issues and empress. -- and am prepared to speak to any issues you may have. >> good morning. thank you for the opportunity to bears health care services for veterans who have experienced sexual trauma while serving on active duty or active duty for training which is known as military sexual trauma or mst . i would like to thank the veteran panel for the detailed testimony of their struggles and strength. end, v.a. has been executing initiatives to provide counseling and care to veterans who have experienced mst, monitor mst related screening and treatment, or by dba staff with training and inform veterans about our available services. recovery is possible after experiences of mst and the veterans health services has services spanning this full care. many survivors of sexual trauma do not disclose their experiences and must ask jarecki. policy are screened for experiences of mst. veterans who screened positive are offered a referral for mental health services. to v.a. health care related mst is provided free of charge. relatedof free mst services is entirely separate from the disability compensation process through the veterans benefits administration and service connection is not required. very medical center provides for physical and mental health conditions. complementing this, v.a. has residential rehabilitation treatment programs and inpatient programs to assist our veterans who need more intense treatment or support. we have mst coordinators at every v.a. medical center he will assist veterans in accessing this service aired it can take tremendous -- service. it can take tremendous courage to seek out help. continuallyws increasing rate of veterans seeking care. has the training they need to work sensibly and effectively is a priority for ms mst v.a. all our required to complete a mandatory training on mst. the support team hosts monthly training calls open to all v.a. staff on topics related to mst. and sexualsuicide trauma has also been included. in addition, as part of the strong commitment to provide high-quality mental health care, specificlimited evidence-based psychotherapy for ptsd and other mental health conditions. because ptsd, depression, and anxiety are commonly associated with mst, these initiatives are very important means of expanding access to evidence-based treatment. recognizing the strong link between sexual trauma and risk for suicide, the national support team has an ongoing collaboration with the v.a. veterans crisis line. current efforts include the development of specialized materials to further enhance all crisis line staff knowledge of specific issues and facilitate sensitive and effective handling of calls from veterans who have experienced mst. complementing these efforts of a local level, coordinators have been encouraged to develop working relationship with the suicide prevention coordinators. these relationships will allow coordinators to ensure local suicide prevention initiatives and incorporate information target the unique needs of the survivors. this also facilitates adjusting the treatment means a specific veterans at their facilities who have experienced mst. the department of veterans affairs is committed to providing the highest quality care that our veterans have earned and deserve. i work to effectively treat veterans who have experienced mst and ensure eligible veterans have access to the care they need to recover from mst continues to be a top priority. i appreciate your support and am prepared to respond to any questions you may have. thank you. >> we bundled today. madam chairman, thank you for to speak on the relationship between sexual assault and the subsequent development of ptsd and suicide. sexual assault survivors are at an increased for developing transmittal he -- -- which is mended diseases, anxiety, and ptsd. conditions can have a and canting effect persist in pay -- precipitate suicidal thoughts. whether the survivor is male or female or the sexual assault occurred prior to joining the military burgeoning service -- service, the department of defense has policy and procedures in place to provide access to a structured and coordinated continuum of care and support for survivors of sexual trauma. this begins when the individual seeks care and extensive their transition from military service to the v.a. or care in their communities. guidance ford survivors of sexual assault on my treatment facilities and service for said now who provide or coordinate military care. included in this guidance is the requirement that the care is gender responsive, culturally competent and recovery oriented. provider thatault presents is treated as a medical emergency. treatment of any and all life-threatening conditions takes priority. survivors are offered testing and prophylactic treatment options. women are advised for the risk of pregnancy. to release from the emergency department, survivors are provided with referrals for additional medical services. patient's with the preferences for care. in locations where dod does not have the need for specialized care, including emergency care within a treatment facility. defense offered a memorandum regarding compliance with the standards. the services return detailed information plans and the first of a yearly reporting requirement is due this summer from each of them. of theg-term needs survivors of sexual assault extend the on the period a member remains on active duty. the health care needs provide -transition program. it bridges between health care systems and providers. you asked about the relationship between suicide and sexual abuse. we know from civilian population research that sexual assault is associated with suicide attempts and completions. it appears to be independent of gender. sexual assault is associated with depression, and zaidi, and ptsd. these mental health conditions are associated with suicidal ideation attempts. the evidence associating sexual assault and subsequent suicidal ideation is [indiscernible] 08, the 2011 and 20 number of individuals who attempted or completed suicide did and reported sexual abuse or from sixt in dod range 40 per year. only nine also had a diagnosis of ptsd. it shows an association that is similar with clinical aches greens and prior stories -- experience and prior stories with civilians. the department has a variety of initiatives directed to better understand the issues associated with suicide, including risk back roads, deployment, and possible precursors. tonk you for the opportunity discuss these very important issues. our policies are designed to ensure all trauma survivors, particularly those subjected to sexual assault, have access to a full range of grants to optimize recovery and that they are transitioned from military civilian life is supported. i would like to add my thanks to the witnesses. it is compelling testimony that makes us see ourselves in a better light. >> thank you for the near today. survivors androm others that some are stopping therapy because they are afraid that their mental health records will be used against them during the court-martial. alleged victim and the navy academy case, she stopped going when she realized they could be provided to the accused. i understand this comes under standards.utional i am concerned about the negative impact on the mental health if they feel there is no confidentiality for their treatment. what might be the impact on survivors if they choose not to seek care because they are worried about their bb made public? are you seeing this happening? what do you think the risk is? a survivorim and does not report the case, they might not have access that they have not been willing to come forward. the risk of ptsd or suicide may be higher than it should. i would love your thoughts on that. out, i am start required to inform all patients seeking care with me that there are limitations to privacy and confidentiality in the military. that is part of the informed consent document that everybody that wants to come to see me as a provider has to understand. not only do i work through them with these limitations to privacy in one of the issues is if court perceiving might be a situation where the records might become available, i also give them a verbal counseling as well. concern that i think all therapy providers in the department of defense have. i have not seen this happen very often. it does happen. i am concerned. i've never had anyone treat -- quit treatment with me. i have seen other intuitions were that occurs. i am very careful about how i document care. i also teach others at the center for deployment psychology at the university. 60 to 70nywhere from different providers. we talk about these issues and how to best protect our patients care. this is something we are very concerned. of asked about the chances person's condition worsening if they do not get care. that is definitely a possibility. most people do tend to get better. what our research shows is that what we can do for most will is help them get better sooner with our therapy and care. for some people, they do not get better. they do without care. we want to have a number of different ways to provide them treatment. concerns, the dod has looked at a number of different ways to help people sample what is right for them. as you know, any victim of sexual assault has a number of different inks taken away. there health, their privacy, their sense of being. we want them to be able to sample at the rate they would like to. way of doingymous that is through our dod safe helpline. rateis run for as i the that four of five feet raped abuse group. -- that is run by the raped abuse group. they can get care and services they need from there. >> thank you. we have some information. i think this is for you. they gave us the numbers. we have raw numbers about restricted and nonrestricted report that had been made. reports. number of do we have the number of incidents so we can assess whether reporting has gone up or not? when we compare the earlier , the number of reported rapes went up but the incident rate went up. do we know if there is a higher incidence rate or if we really do have a higher reporting rate? >> ok. survey thisve a year for that. what i would offer to you is we know that even in 2006 when we have the highest rates of unwanted sexual contact reported, we only got about 2900 military servicemembers coming forward. this year with the 5400 we do assess that to increased victim confidence and more people hearing our message and understanding that we will take care of them. one piece of that at i would offer to you is that there are a portion of reports every year that come to us that occurred prior to military service. this year that percentage increased from 4% in 2012 to 11.5% in 2013. all the offenders in those cases are outside the military justice system. the only real reason for survivors to come forward is to get care and services that we offered through the sexual assault program. we feel that is -- an uptick inen reporting before prior to service. is that the difference between the two numbers? >> it is not the entire difference. laster we have a total of about 132 reports that were for incidents that occurred prior to service. this year the number is 621. >> that is a huge increase. they are eligible. a related question. we have heard from survivors that after they report the assault and the attempt to seek mental help treatment they were diagnosed with a personality disorder and are discharge. this is labeled as a pre-existing condition and cut off services for the survivor. many survivors have said after the assault they still wanted to stay in the military. because of the diagnoses of personality disorder, they work it out. what has your experience been with that issue? what is the best way to adjust this? what we have done is that no one can meet the military or be separated for a personality disorder without a complete medical review. we make sure that there is no underlying tbi that is causing the action or behavior or psychological health issue that needs to be addressed. we have put a mechanism in place to make sure we have safeguarded it and people are not leaving without a second look by medical professionals. >> if i could add to that. section 578 of the fy 13, you helped us out with that. we take your advice. we expended on it a little bit. , for any us to separation due to retaliation within a year of the report, it had to be reviewed by a general officer. that was the nature of the law. i checked in our military instructions. that has an incorporated into the separation instruction. we have expanded it just a little. instead of a year from the date of report, we took it from a year that date it was made. it is much longer. incident just retaliations, we have any separation administratively can be heard in this process and be reviewed. in addition, incident the first general officer in the chain, we took it to the first general officer in the chain of that administrative separation authority chain of command. it goes beyond that one person. we took your good idea and put it into our instruction. >> thank you. >> can i follow up on that? a personality disorder would make one subject to involuntary discharge. is that right? >> yes. >> if you are a victim of an assault, one of the consequences would be people would be disturbed and it would show but we do not want to cut off treatment. we do not want it to be anything other than an honorable discharge and we want to make sure that the person is not denied treatment for what happened to them in the military. is that correct? >> that is correct. disorder is often used as a way to separate. we want to make sure that we do not deny people treatment but not deny the military the ability to separate someone for a cause. this chart, it makes perfect sense to me that ptsd candidates from a sexual assault would have a-city to have posttraumatic stress syndrome simply because of the nature of the attack. compared to anything else. the one category we left out was combat related action. cases i'me ptsd familiar with, people who were involved in a combat related experience. i would argue that if sexual saltlt is -- that sexual is every bit as to magic if not more. .- as dramatic if not more the military system is being scrutinized and that is fair. we have a problem. the question is how to fix it. i want to also highlight some of the things about the military that are worth noting. question if one of our staff members were assaulted at be entitled toy medical disability as a result of that assault? i have been told that is not the case. i want people to understand that in the workplace in the civilian world, sexual assaults occur. bet employers not going to held liable for compensation claims for the acts of a third party. that is the general proposition of law. in the military, when the assault occurs, you are treated quite differently. i think that is a positive thing. if somebody in your own office were assaulted, a federal employee, under the law, all the things available to a military member will not be available to the staff here that is probably true in a civilian population. let's focus on the fact that if you get assaulted sexually in the military, there is an array of benefits made available to in unlike anything i know of the private sector. i think that is very much appropriate because of your willingness to serve your country. how we make that better is the to subject --is the subject of the discussion. our military members have access to health care, to treatment, not available to the average person who goes through similar experience in the work p lace. we want to make it better. we should be proud that occurs in our military. we want to make it better. about expanding treatment options, both witnesses testified that they believed that services available in the civilian tour could supplement -- sector could supplement or increase the likelihood of a better outcome. tri-careentleman is eligible. the other lady is not. how do we deal with that dilemma? we do as a congress to make sure that someone who goes to the disability evaluation claim that iake a was in the military and sexually resulted dutch assaulted as a result of having these problems, once you are eligible for compensation based on your evaluation. this gentleman is eligible for tri-care. the other lady was not. how do we correct that problem? cannot speak to the compensation process. that falls under the veterans benefit administration. as for our veterans who screen positive or sexual trauma, and every veteran is a screened, these are questions that occurred while you are on active duty in the set and is sexual harassment. if you answer yes to one or both of the questions, or you are considered to have screened positive. then foru eligible treatment out of the v.a.? v.a. care is always an option. >> do they know that? she's shaking her head no. how can that be? coordinator atst every facility. >> is part of the screening process of making it aware that you are available for treatment outside the v.a.? >> you are given a referral to mental health. we can always connect you with the mst coordinator and that person can explore options for you. if for some reason there is a access issue for you as far as like 90 miles to get to treatment. toboth of the witnesses seem indicate while they appreciate the services, they were limited. every problem you have in the military you have in the civilian world. people are afraid to report. some of these problems we will never solve because the accused has the right to defend themselves. it is always subject to debate. both witnesses seem to be very that they had access to help care outside of the traditional be a system. do you agree with that? if so, how can we improve that? and all of our outreach materials would ask them to coordinate this. they are in a perfect position to help them. we are finding every year we have been tracking the treatment it is increasing every year. we are seeing more veterans for service. ms v.a. >> i appreciate the gains made in the focus and attention. the right track. we can learn from these experiences. this has been a good hearing. i really appreciate the scrutiny. i do think there is a gap. seems to be disconnect between what is actually available to them and what they perceive to be available to them. let's try to fix that. >> i just want to follow-up. when did the military sexual trauma coordinators be placed at every v.a. in the country? >> 2000. >> there is been a military nader in the core united states since then? is that person busy? in the united states since then? is that person busy? >> yes. educating staff. >> do they meet with trauma survivors? >> as part of their clinical work, yes. they do provide treatment. the core donators are predominantly a sky colleges -- a psychologist or social worker. they will be giving therapy as well as looking and monitoring their screening treatment rates. make a formalo request afterward to get data on all the military sexual trauma core donators and how many patients they see a year and what their workload is. maybe it is not even known that they exist. i would like to know what they actually do. we can work on that later. thank you for the work you do on this important area. i want to start with this. concern.the we do not have a group for men and feeling like the services were not at the same level. you are the health director. it says [indiscernible] is that the name of a department? like that is a good question. is three areas of our responsibility i hold in my position. i have a colleague who is the national drug or for psycho geriatrics. it just happened to be that this was a special area. my title in no way implies that as a women's issue. we have worked very hard to show it as gender-neutral. the primary responsibility was removed and women's health services to be placed in mental health services in 2006. >> that is helpful. let me ask your reactions about the discussions in both of our earlier witnesses and their concerns about this over medication phenomenon. what could you tell me about that? start.ll i cannot speak to that. i have no firsthand knowledge of as far asis doing analyzing the use of medication. i would need to take that for the record. i am sorry. the degree know with of specificity you need to have for this answer. what i will do as we will try to submit a precise question in writing rather than had you guess what we mean. that may be a little easier. we will take that under advisement. had, and i dohave not know if it is regional or more general is in the suicide prevention area, you do a good job of trying to publicize to active duty veterans suicide prevention hotline. i have had an experience where there are a lot of veterans. somebody saying they were doing a great job of putting this out. they're always use only there to deal with you. he said they did not do with me right away. he said i contacted them right away. there is an individual who had e-mailed this. it turns out the hot leg really was a 24-hour hotline if you called on the home. if you e-mailed it was a cold line. he made the point that if you are an extremist in a mental health area, even the act of talking to someone can be tough. it can be easier just to write an e-mail. he felt like his cry for help was ignored. that maybe it was treated there because it was an e-mail. i would recommend that to your attention. it might have been fixed or an aberration or one v.a. hospital. i can see why somebody made you'll were comfortable reaching out there in e-mail than a phone call. >> we know that suicide is complex. we like to think the way in which we deal with suicide also take a multifaceted approach. when somebody reaches out for help, our options and how they even initiate that contact. veteransdepartment of affairs has, the dod uses it as well. we branded as the military crisis line. it is the same crisis line. warriors program we have funded in the department of defense. it is a peer support program. a gives you an option if you just want to talk to a peer and get a referral. resilientprovided case management so that they can track and stay with you over the course of your military career. the goal is to make sure that regardless of whether you do a home call, e-mail, text, chat, that when you look for help there are different options and ways for you to find that help. >> i would offer that you can and or call or text 24/7 there is someone live there to answer any kind of reach out on the individual. would like to go back to the testimony. when asked about the analogy -- incestd military and military sexual assault, we have tackled to some degree the issue of suicide of active duty and veterans. has an reallyy focused on this. arecall some testimony about number of military witnesses in the it isalking about less the people have come back seeing warbled things and the horrible things are waiting on them and driving them to suicide. involvedhat people are in such a close support network and the came back network was no more. networks, theyd did not understand what they had been through. that experience of going through a support network of colleagues to a feeling of disconnection, that has been a factor earlier before the full committee. it had been suggested there was some research that really tied back into this problem and military suicide. am i remembering it or describing it correctly? is that one of the factors? the causes and associated factors was suicide do tend to be very complex. factorsthe primary associated our relationship issues, financial issues and legal issues. when we look at relationship issues, it you are describing the loss of a relationship issue. we think about that as an intimate relationship issue. it does extend beyond. mostly youngis by ormales who have died attempted suicide. from exitcome and go duty or change units, we have seen the majority of our suicide are among those that in their first year of enlistment who have never deployed and have not been in combat. 89% have not in combat. some serious issues we feel we try to look at. peer support and providing community-based care is so important. we see the relationship issues are such a driving after in relationship to suicide and self harm. that would then lead back to the point about the patrol phenomenon. if there is a close connection ,etween cali and your superior sexual assault within your unit is the sundering of a relationship that you had an expectation based on trust. but atggests a little the connection between sexual trauma in the military and this risk of suicide. defense suicide , we areon office working on a study right now looking at some of the intersections between suicide prevention and sexual assault response so that we can get a better understanding of how we can move or word providing support and services to this population. i cannot agree more. it really is tantamount to an incest type situation. >> is in the betrayal also that they have to tell their dad or the decision-maker? it is not just the betrayal. it is the second the trail that makes it intense. >> depending on who the perpetrator is, yes. i am saying the second thing about reporting. i have heard one victim said it is like being raped by your father -- your brother and your father decides the case. it goes beyond to the rapist is. it is also decided as a family matter. person deciding has to decide between two people they love. that lack of objectivity, knowing the perpetrator, that was the second the trail. -- second themp betrayal. >> it is so important. >> we are talking about the decision-maker. your dad decides. >> no question. i was just clarifying. i would just clarifying i understood what i understood the testimony to be. the incestuous reference is not just about who reads too. it's also about who decides your future and your fate. one i heard but i understand what you said. thank you very much. i wanted to follow up just to clarify one point. i think is important for people listening at home to understand that in terms of sure numbers, there are nor -- there are more male victims in the military of sexual assault and e-mail big dems. isn't that right in terms of sheer numbers? that was correct about maybe three or four years ago. right now there is more women who screen positive for military sexual trauma who choose to come to the v.a. have more women victims with the recent numbers that have come forward? year, we last fiscal had a little over 77,000 women who have screened positive. for the men it is over 57,000. >> this is not a male or a e-mail id. situation. as this issue has come up in our committee and people talk to me about it, they make it an issue of this is an issue of women or there are fewer women in the military and think lee they're taking on greater roles which is a wonderful thing. thatt people to understand our home that there are a lot of men that are big dems as well and who are watching this. this is not a male or a female crime. as well andvictims two are watching this. this is not a male or a female crime. people need to understand that the address for everyone. one of the questions i wanted to follow-up with you. how long on average does it take for, once the referral is entered, for someone to actually see a mental health provider? >> i am sorry. i do not have that data with me as far as from screen to treatment. i will have to take that for the record. >> i think that is an important question. immediacy is really important. people are waiting too long to see mental health providers. i hear this from people at home. i can only imagine that this could be exacerbated for someone he was a victim of sexual -- who is a victim of sexual assault. i think the other challenge we face is what is the situation in terms of providers? are we facing a shortage of providers? one of the things i was certainly glad to hear the reports of is that more people are coming forward. we wanted to feel that people would be able to come forward. we want more to come forward. need to make sure we have the providers should give treatment and support. i wanted to get your answer on that one, what is our situation on having enough dividers in the mental health area? my experience has been that even at my state, taking it outside of the military context we have a shortage of mental health providers within our state. i would imagine that you have similar challenges. i wanted to get your thoughts. required to produce a report on capacity to provide mst related mental health care. all centers do have that capacity. that is something we do track. >> on the follow-up, if you can let me know how long does an average person weight once the referral is made. also, if you could answer to me what you think the provider challenges are in terms of going forward if he will have more people report to make sure we we will have --if more people report to make sure we have adequacy. i want to follow up on this of where we are with regard to the reports and the increase that we have seen in the reports. what do you think that says in you have talked fairly positively about that as an indicator that we're certainly glad more people are feeling that they can come forward. what do you think in terms of the role of the commander? one of the pieces of legislation we will be looking at is how do the decision in terms of whether the charge will go forward? example thatfor senator mccaskill and i have is one that would go if there is a difference of opinion between the lawyer and commander it would go up all the way to the civilian secretary in instances where the decision is to not bring a case. if we were, what effect or what role do you believe the commander should have in terms of involvement in addressing this issue? if you have thoughts on this. >> i am a clinical psychologist. clearly, my perspective would come from treating big m's. -- victims. >> i am only asking from your own background. >> i believe that commanders need to be more involved, not less involved. we know that they are going to be critical to setting the climate of unity and respect. shat is a unit we know victim can heal and floors. every victim's experience influences other victims. until we make sure commanders are held responsible to create a climate of dignity we really do believe that will allow us to move forward on this and increased even more reports of sexual assault every year. you.ank i appreciate that. can you give us an update? we talked a lot about the victimsut them's --victi counsel. i also worked with senator who is very involved in these issues. how are things going? i know this is a very important undertaking. just as an initial report of what your thoughts are of implementing this important initiative that will give every that is thereil to advocate for them and no one else. >> very briefly, all the services were supposed to have initial operating capability last october. they stepped of the full capability in january. to be air force has the greatest number, had this program going about a year. >> they started it as a pilot. >> yes, ma'am. >> the information we have got back from the survivors is overwhelmingly favorable. this is a deal sexual for victims of assault in the military. having that person to represent you increases the confidence, allows them to understand what the options are even more. although it is a small number, i would offer to you that what we have heard is that of the restricted reporters that have engaged the special but them's counsel, their conversion rate from restricted to unrestricted cases that would bring them into the justice system, their conversion rate is at about 50%. are about 14% we or 15%. we do think this is perceived promising. psychologist perspective, it is great. it boost their abilities and gives them a greater understanding of the legal system. >> thank you. one of the things we will be watching carefully is making sure that we are updated on how it is a supplement to -- how it is being implemented. brief.going to be very i want to associate myself with your request for the data on the backlog. that is really important. do not sugarcoat it. we want the straight data from the day somebody on the average applies to the time they get accepted. treatment delayed his treatment denied in many of these cases. is treatment denied in many of these cases. tri-care is only available to retirees 20 years or more. if you cannot get service at the v.a. for your service related trauma, you do not have any choices. i think that is something we need to be thinking about. it is not like they could turn around and use tri-care with their local provider. i just want to make a statement. i do not understand why anyone would go to you for counseling if they understand the record can be made available at a later proceeding. makes no sense whatsoever. i want to visit that. thank you. >> thank you. i just want to go back over a little of your testimony. i agree that we have to set a climate of dignity and be more involved and not less involved. takingmanders need to be responsibility for setting the command climate, making sure there's no retaliation, aching to the victim feel safe to come forward. is actually suggesting they become less involved. when they do so, they actually distorted the debate. the only commanders today that authority to be a convening authority are very senior-level commanders. it it is less than 3% of commanders. the 97% of commanders are as involved as they ever have been involved. what we are trying to do is make them more responsible by actually reviewing their record on creating a command climate that is consistent with no rape, no assault. the commanders will never have the right to make legal decisions. whether or not we take that away from the 3% of commanders, the purpose is to instill confidence by the victims. if you listen to the victims panel, one was retaliated against by all the senior-level commanders. her hope that a senior-level commander would have her back does not exist. her perception is that all the others in the chain of command will and want you to focus on that. theyyou say i don't think should be less responsible, no one is arguing for them to be

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