United States Government Accountability Office Report to Congressional Requesters UNWANTED SEXUAL August 2023 BEHAVIOR Improved Guidance, Access to Care, and Training Needed to Better Address Victims' Behavioral Health Needs GAO-23-105381 August 2023 UNWANTED SEXUAL BEHAVIOR Improved Guidance, Access to Care, and Training Needed to Better Address Victims' Behavioral Health Highlights of GAO-23-105381, a report to Needs congressional requesters Why GAO Did This Study What GAO Found Service members who experience The Department of Defense (DOD) and Department of Veterans Affairs (VA) unwanted sexual behavior-sexual offer behavioral health care to active-duty service members and veterans who harassment, sexual assault, and experience unwanted sexual behavior. Unwanted sexual behavior includes domestic sexual abuse-during military sexual harassment, sexual assault, and domestic sexual abuse. However, service may suffer from chronic mental several issues limit screening for and access to related care. For example: health conditions. Service members who have such experiences are also • VA requires clients in VA medical facilities to be screened for military sexual more likely to separate from the trauma; DOD screens for behavioral health conditions but not specifically for military, exacerbating DOD's critical experiences with unwanted sexual behavior. Without developing guidance recruitment and retention challenges. specifying how and when DOD medical providers should screen for such GAO was asked to review service experiences, DOD cannot ensure consistent patient support or care. member mental health related to • Service members who have experienced unwanted sexual behavior may experiences with unwanted sexual confidentially access non-medical counseling through VA. However, longer- behavior. This report examines, among term medical behavioral health care requires a referral from DOD, which may other issues, the extent to which (1) deter service members from seeking care. Until DOD considers how best to DOD and VA screen for and provide enable service members to access longer-term services through VA, without access to behavioral health care a referral, some service members may not seek needed care. services for such experiences, and (2) such experiences play a role in Analysis of separation data shows that service members who made unrestricted, voluntary and involuntary separations formal, or some informal reports of experiences with unwanted sexual behavior of service members from the military. left the military-voluntarily and involuntarily-at substantially higher rates than GAO reviewed guidance, analyzed the overall active-duty population from fiscal years 2015 through 2021 (see fig.). DOD and VA behavioral health care data and DOD separation data, and Separation Rates for All Active-Duty Service Members Compared to Those who Reported an interviewed DOD and VA officials at Experience with Unwanted Sexual Behavior, Fiscal Years 2015–2021 the headquarters level and at a nongeneralizable sample of military installations and VA medical facilities. What GAO Recommends GAO is making 15 recommendations, 13 to DOD and two to VA, including that DOD develop guidance specifying how and when to screen for experiences with unwanted sexual behavior; consider how best to enable service members' access to care related to such experiences at any VA facility, without a referral; and consider modifying its guidance to help ensure it fully considers potential factors contributing to service member However, multiple factors impede DOD's ability to determine if an experience separations. DOD and VA concurred with unwanted sexual behavior played a role in separation decisions. For with the recommendations. example, certain processes related to medical examinations and higher-level reviews of involuntary separations are available only for victims of sexual assault, View GAO-23-105381. For more information, for specific time periods, and for certain behavioral health diagnoses. Until DOD contact Brenda S. Farrell at (202) 512-3604 or farrellb@gao.gov. considers potential modifications to these processes service members may be unable to benefit from actions that may affect eligibility for VA benefits. United States Government Accountability Office Contents Letter 1 Background 5 DOD and VA Screening for Unwanted Sexual Behavior Experiences Differ and Several Challenges Hinder Access to Behavioral Health Care Offered by DOD and VA 16 VA and DOD Differ in Their Approach to Monitoring Data on Behavioral Health Care Related to Unwanted Sexual Behavior, and Cannot Ensure Confidentiality 55 DOD and VA Trainings Do Not Consistently Inform Service Members of VA Resources for Unwanted Sexual Behavior, but DOD Has Developed Medical Provider Training 70 DOD Does Not Know the Extent of the Role of Unwanted Sexual Behavior in Separation Decisions Due to Various Challenges 79 Conclusions 111 Recommendations for Executive Action 113 Agency Comments and Our Evaluation 116 Appendix I Objectives, Scope, and Methodology 120 Appendix II Additional DOD and VA Behavioral Health Data Analysis 134 Appendix III Character of Discharge and Reenlistment Eligibility Status of Separated Service Members 148 Appendix IV Comments from the Department of Defense 153 Appendix V Comments from the Department of Veterans Affairs 159 Appendix VI GAO Contact and Staff Acknowledgments 163 Related GAO Products 164 Page i GAO-23-105381 Unwanted Sexual Behavior Tables Table 1: Programs that Help Service Members Separating from the Military Transition Their Health Care Benefits from DOD to VA 53 Table 2: Types of Training that Identify Department of Veterans Affairs (VA) Resources for Active-Duty Service Members Who Experienced Unwanted Sexual Behavior, by Military Service 71 Table 3: Types of Behavioral Health Diagnoses Given to Service Members Who Received Medical Behavioral Health Care Related to Experiences with Unwanted Sexual Behavior, Fiscal Years 2015–2021 98 Table 4: Comparison of Misconduct and Disability Separations of Service Members who Reported an Experience With Unwanted Sexual Behavior, Fiscal Years 2015–2021 109 Table 5: DOD, VA, and Nongovernmental Organizations Contacted by GAO 122 Table 6: Number of Service Members Who Received Medical Behavioral Health Care Documented as Being for Experiences with Unwanted Sexual Behavior, by State and Territory, Fiscal Years 2015–2021 136 Figures Figure 1: Number of Veterans and Service Members Who Screened Positive for Military Sexual Trauma at a VA Vet Center, VA Medical Center, or VA Clinic, Fiscal Years 2015–2021 19 Figure 2: Percentage of Service Members, By Service, Who Received Department of Defense (DOD) Documented Medical Behavioral Health Care for Experiences with Unwanted Sexual Behavior, Fiscal Years 2015–2021 25 Figure 3: Number of Department of Defense (DOD) Military Treatment Facilities Worldwide That Documented Providing, and Number of Service Members Who Received, Medical Behavioral Health Care for Experiences with Unwanted Sexual Behavior, by Country, Fiscal Years 2015–2021 27 Figure 4: Number of Active-Duty Service Members Who Received Direct and Private Sector Medical Behavioral Health Care for Experiences with Unwanted Sexual Behavior, by Reporting Status, Fiscal Years 2015–2021 29 Page ii GAO-23-105381 Unwanted Sexual Behavior Figure 5: Percentage of Active-Duty Service Members Who Received Medical Behavioral Health Care for and Reported Experiences with Unwanted Sexual Behavior (by Gender, Military Service, Care Setting, and Care Location), Fiscal Years 2015–2021 31 Figure 6: Veterans and Service Members Who Received VA Behavioral Health Care for an Experience with Unwanted Sexual Behavior, by Care Source and Whether They Reported Experience to the Department of Defense, Fiscal Years 2015–2021 35 Figure 7: Number of Veterans and Service Members Who Received Department of Veterans Affairs (VA) Care for an Experience with Unwanted Sexual Behavior, by Type of Care Received, Fiscal Years 2015–2021 37 Figure 8: Number of Veterans and Service Members Who Received Documented Behavioral Health Care for Unwanted Sexual Behavior, by Care Provider and Reporting Status, Fiscal Years 2015–2021 39 Figure 9: Number of Service Members Who Reported an Experience with Unwanted Sexual Behavior to DOD and Received Behavioral Health Care that Was Documented by DOD or VA, Fiscal Years 2015–2021 58 Figure 10: Separation Rates of All Active-Duty Service Members Compared to Separation Rates of Service Members who Reported Experiences with Unwanted Sexual Behavior, Fiscal Years 2015–2021 81 Figure 11: Percentage of Reasons for Separation of All Separated Service Members Compared to Separated Service Members Who Reported an Experience with Unwanted Sexual Behavior, by Service and Gender, Fiscal Years 2015–2021 83 Figure 12: Time Period between a Service Member's Separation and Date that They Reported an Experience with Unwanted Sexual Behavior to the Department of Defense (DOD), Fiscal Years 2015–2021 93 Figure 13: Time Period between a Service Member's Separation and Date that They Reported an Experience with Unwanted Sexual Behavior to DOD, Fiscal Years 2015– 2021 96 Figure 14: Service Member Behavioral Health Diagnoses Associated with an Experience with Unwanted Sexual Page iii GAO-23-105381 Unwanted Sexual Behavior Behavior Overall and Among Those Who Reported Experiences, Fiscal Years 2015–2021 100 Figure 15: Number of Service Members Who Received Medical Behavioral Health Care Documented as Being for Experiences with Unwanted Sexual Behavior, by State and Territory, Fiscal Years 2015–2021 135 Figure 16: Number of Active-Duty Service Members Who Received Inpatient and Outpatient Medical Behavioral Health Care, by Reporting Status, Fiscal Years 2015– 2021 139 Figure 17: Percentage of Service Members Who Received Behavioral Health Treatment through the Military Health System Related to Unwanted Sexual Behavior, by Care Source and Race, Fiscal Years 2015–2021 140 Figure 18: Percentage of Service Members and Veterans Who Received VA Behavioral Health Care for Experiences with Unwanted Sexual Behavior, by Gender, Military Service, and Care Type, Fiscal Years 2015–2021 142 Figure 19: Percentage of Veterans and Service Members Who Received Behavioral Health Treatment Related to Unwanted Sexual Behavior at VA Medical Centers or Clinics, by Race, Fiscal Years 2015–2021 143 Figure 20: Percentage of Veterans and Currently Serving Service Members Who Reported an Experience with Unwanted Sexual Behavior and Received Related Behavioral Health Treatment at Department of Veterans Affairs Medical Centers or Clinics, by Race, Fiscal Years 2015– 2021 144 Figure 21: Percentage of VA Clients Who Received Vet Center Counseling Related to Unwanted Sexual Behavior, by Race, Fiscal Years 2015–2021 145 Figure 22: Percentage of Veterans and Service Members Who Screened Positive for Military Sexual Trauma, by Race and Facility Type, Fiscal Years 2015–2021 146 Figure 23: Percentage of Veterans and Service Members Who Screened Positive for Military Sexual Trauma, by Gender and Facility Type, Fiscal Years 2015–2021 147 Figure 24: Character of Discharge of All Separated Service Members Compared to Service Members Who Reported an Experience of Unwanted Sexual Behavior to the Department of Defense, Fiscal Years 2015–2021 149 Page iv GAO-23-105381 Unwanted Sexual Behavior Figure 25: Reenlistment Eligibility Status of All Separated Service Members Compared to Separated Service Members Who Reported an Experience of Unwanted Sexual Behavior to the Department of Defense, Fiscal Years 2015–2021 151 Figure 26: Separations of All Separated Service Members Compared to Separated Service Members Who Reported an Experience of Unwanted Sexual Behavior to the Department of Defense, by Gender, Fiscal Years 2015– 2021 152 Abbreviations DHA Defense Health Agency DOD Department of Defense MHS Military Health System PTSD Post-Traumatic Stress Disorder SHARP Sexual Harassment/Assault Response and Prevention TBI Traumatic Brain Injury VA Department of Veterans Affairs This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page v GAO-23-105381 Unwanted Sexual Behavior Letter 441 G St. N.W. Washington, DC 20548 August 2, 2023 Congressional Requesters Unwanted sexual behavior, which includes sexual harassment, sexual assault, and domestic sexual abuse, that occurs during military service undermines the core values of the Department of Defense (DOD) and the military services. 1 In addition, victims of such experiences may suffer from chronic behavioral health conditions that have the potential to degrade medical and force readiness. 2 Experiencing unwanted sexual behavior also increases the likelihood that service members separate from the military, which exacerbates the military services' critical recruitment and retention challenges. 3 Congress and DOD have taken steps to address the effects of unwanted sexual behavior on service members' behavioral health. For example, the Veterans Access, Choice, and Accountability Act of 2014 authorized the Department of Veterans Affairs (VA) to provide counseling and care and services to service members to treat a condition that resulted from an experience of unwanted sexual behavior that was suffered by the service member during military service. 4 In addition, in 2021, DOD's Independent 1For purposes of this report, we use the term "unwanted sexual behavior" as an umbrella term to collectively refer to sexual harassment, sexual assault, and domestic sexual abuse that occurs during military service. The Department of Veterans Affairs (VA) uses the term military sexual trauma to refer to incidents of sexual harassment and sexual assault that occurred during military service. We generally use the term "unwanted sexual behavior" in this report, but we use the term "military sexual trauma" when referring to VA screening or when the term "military sexual trauma" is used in agency guidance, documents, or position titles. 2We use the term "behavioral health conditions" to refer to mental, emotional, and substance use conditions. Examples of mental health conditions include anxiety disorders, mood disorders such as depression, post-traumatic stress disorder (PTSD), and schizophrenia. Examples of substance use conditions include alcohol use disorder and opioid use disorder. 3See RAND, Effects of Sexual Assault and Sexual Harassment on Separation from the U.S. Military (2021) and GAO, National Security Snapshot: DOD Active-Duty Recruitment and Retention Challenges, GAO-23-106551 (Washington, D.C.: Mar. 28, 2023). 4The Veterans Access, Choice, and Accountability Act of 2014 and subsequent legislation amended the statutory provision authorizing VA counseling and treatment for sexual trauma, and authorized the Secretary of Veterans Affairs, in consultation with the Secretary of Defense, to provide care to service members (including members of the National Guard and Reserves) to treat a condition which, in the judgment of a VA health care professional, resulted from a physical assault of a sexual nature, battery of a sexual Page 1 GAO-23-105381 Unwanted Sexual Behavior Review Commission on Sexual Assault in the Military made 18 recommendations specifically focused on service members' care and support following such experiences. 5 These recommendations include measures to optimize the response workforce, expand victim service options to meet the needs of all victims, and facilitate healing and restoration for victims. You asked us to conduct a review of service member behavioral health and experiences with unwanted sexual behavior. This report assesses the extent to which: 1. DOD and VA screen for and provide access to behavioral health care services to active-duty service members and veterans for experiences with unwanted sexual behavior during military service; 2. DOD and VA document and monitor the behavioral health care provided to active-duty service members and veterans who experience unwanted sexual behavior; 3. DOD and VA train service members on available VA resources for experiences with unwanted sexual behavior, and DOD trains its medical providers on trauma related to such experiences; and 4. experiences with unwanted sexual behavior play a role in voluntary and involuntary separations of service members from the military. nature, or sexual harassment that was suffered by the service member while serving on duty, regardless of duty status or line of duty determination. See 38 U.S.C. § 1720D(a)(2)(A). All service members (active-duty, reserve, and National Guard) and veterans (and certain other former service members who do not qualify as veterans) who experienced unwanted sexual behavior while serving in the military are eligible for counseling (referred to as military sexual trauma counseling) at VA Vet Centers without a referral, as well as services at VA Medical Centers and outpatient clinics with a referral. Pub. L. No. 113-146, § 402 (2014) (codified as amended at 38 U.S.C. § 1720D(a)(2)); and Department of Veterans Affairs Veterans Health Administration Directive 1115(1), Military Sexual Trauma (MST) Program (May 8, 2018) (amended Dec. 1, 2021). For purposes of this report, we use the term "veteran" to include any former service members who experienced or received care for unwanted sexual behavior. 5In February 2021, the Secretary of Defense issued a memorandum establishing a 90-day Independent Review Commission on Sexual Assault in the Military to report on and make recommendations to advance efforts to counter military sexual harassment and sexual assault in the areas of accountability, prevention, climate and culture, and victim care and support. The Commission made more than 80 recommendations as a result of its review. Independent Review Commission on Sexual Assault in the Military, Hard Truths and the Duty to Change: Recommendations from the Independent Review Commission on Sexual Assault in the Military (2021). Page 2 GAO-23-105381 Unwanted Sexual Behavior For all of our objectives, we reviewed relevant statutes and DOD, military service, and VA policies, guidance, and survey documents related to unwanted sexual behavior. We interviewed relevant DOD, military service, and VA officials at the headquarters levels, and we also conducted virtual site visits to selected installations in each of the military services and to selected VA medical facilities. 6 We also compared information with internal control standards, such as using quality information, communicating the necessary quality information to achieve an agency's objectives, and using separate evaluations to monitor the design and operating effectiveness of a specific function and obtain feedback on the effectiveness of ongoing monitoring. 7 For our first objective, we analyzed agency policies, guidance, and other documents and data on screening and behavioral health care to determine if, when, and how screening for experiences with unwanted sexual behavior and related behavioral health challenges should be conducted, what behavioral health services are available, and when they are offered. We also gathered and analyzed data that DOD and VA use to track the screening for and provision of behavioral health care related to experiences with unwanted sexual behavior. 8 For our second objective, we analyzed agency policies, guidance, and other information about documentation processes to determine if, when, and how behavioral health care for unwanted sexual behavior is documented and monitored. We interviewed agency officials and conducted one-on-one semi-structured interviews with health care 6On December 20, 2019, the National Defense Authorization Act for Fiscal Year 2020, Pub. L. No. 116-92, established the United States Space Force as a military service within DOD. We did not conduct a virtual site visit or gather separate data from the Space Force given its status as a new organization and because it followed Air Force policy and guidance for unwanted sexual behavior. For purposes of this report, any data for Space Force personnel were included in the Air Force data analyses. Throughout this report we refer to only four military services within DOD: the Army, the Navy, the Marine Corps, and the Air Force. 7GAO, Standards for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C.: Sept. 10, 2014). 8For purposes of this review, we focused on DOD medical behavioral health care, although DOD offers both medical and non-medical behavioral health care services. Medical behavioral health care services include specialty mental health care such as clinical therapy for mental health conditions, intensive outpatient programs, and residential treatment. Non-medical behavioral health care services include short-term therapeutic counseling that is supportive in nature and addresses general conditions of living, life skills, improving relationships, stress management, martial problems, parenting, and grief and loss. Page 3 GAO-23-105381 Unwanted Sexual Behavior personnel to gather illustrative examples of how DOD and VA guidance on documenting and monitoring services is operationalized, and the associated barriers or challenges to providing care for conditions related to experiences with unwanted sexual behavior. For our third objective, we analyzed the military services' annual or periodic training provided to all service members on sexual harassment, sexual assault, and domestic sexual abuse. Specifically, we analyzed the training to determine whether it provides information about VA resources for experiences with unwanted sexual behavior. We also reviewed VA courses provided to service members who are separating from the military and information about medical training provided to DOD medical providers. For our fourth objective, we analyzed statutes, agency guidance, and other information about separation processes to identify and analyze separation processes applicable to service members who had experienced unwanted sexual behavior. We reviewed reported results of DOD and military service surveys and DOD's processes for collecting information on whether service member experiences with unwanted sexual behavior were a motivating factor in separation decisions. We also analyzed separations data and reported incidents of unwanted sexual behavior to determine the extent that service members who made unrestricted or formal reports of unwanted sexual behavior to DOD separated from the military and the proportions of characteristics such as reason for separation, characterization of discharge, reenlistment eligibility status, and gender. We assessed the reliability of the data we analyzed by reviewing agency documentation and testing data completeness and accuracy, among other things, and found it reliable for the purposes presented in the report. 9 For a detailed description of our scope and methodology, see appendix I. We conducted this performance audit from August 2021 to August 2023 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that 9Figures and tables with results of our data analysis include a figure or table note that describes any caveats or limitations associated with a particular analysis. Page 4 GAO-23-105381 Unwanted Sexual Behavior the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Background DOD Definitions of DOD defines various types of unwanted sexual behavior, including sexual Unwanted Sexual harassment, sexual assault, and domestic sexual abuse. Behavior • Sexual harassment is conduct that involves unwelcome sexual advances, requests for sexual favors, and deliberate or repeated offensive comments or gestures of a sexual nature when (1) submission to such conduct is made either explicitly or implicitly a term or condition of a person's job, pay, or career; (2) submission to or rejection of such conduct by a person is used as a basis for career or employment decisions affecting that person; or (3) such conduct has the purpose or effect of unreasonably interfering with an individual's work performance or creates an intimidating, hostile, or offensive working environment. Such conduct constitutes sexual harassment when it is so severe or pervasive that a reasonable person would perceive, and the victim does perceive, the environment as hostile or offensive. 10 • Sexual assault is intentional sexual contact characterized by the use of force, threats, intimidation, or abuse of authority or when the victim does not or cannot consent. This includes a broad category of sexual offenses, including rape, sexual assault, aggravated sexual contact, abusive sexual contact, forcible sodomy (forced oral or anal sex), or attempts to commit these offenses. 11 • Domestic sexual abuse is a type of domestic abuse that involves a sexual act or sexual contact with the spouse or intimate partner 10DOD Instruction 1020.03, Harassment Prevention and Response in the Armed Forces (Feb. 8, 2018) (incorporating change 2, Dec. 20, 2022). 11DOD Directive 6495.01, Sexual Assault Prevention and Response (SAPR) Program (Jan. 23, 2012) (incorporating change 5, Nov. 10, 2021). Page 5 GAO-23-105381 Unwanted Sexual Behavior without the individual's consent or against the individual's expressed wishes. 12 DOD offers unrestricted and restricted reporting options to service members who disclose sexual assault and domestic sexual abuse. 13 If a victim of sexual assault discloses a sexual assault to a DOD health care provider, the provider must immediately notify a sexual assault response coordinator, who would then inform the victim of the reporting options. 14 The victim may then make an informed decision about which reporting option to elect and which services to request, or may decline to make a report or decline services. According to DOD officials, the requirement that health care providers notify the sexual assault response coordinator, victim advocate, or family advocacy program personnel if a service member discloses sexual assault or domestic abuse may serve as a 12While we refer to this as domestic sexual abuse, DOD uses the term "spouse or intimate partner sexual abuse." See DOD Manual 6400.01, Vol. 3, Family Advocacy Program: Clinical Case Staff Meeting and Incident Determination Committee (Aug. 11, 2016) (incorporating change 1, July 16, 2021). DOD defines domestic abuse as domestic violence, or a pattern of behavior resulting in emotional or psychological abuse, economic control, or interference with personal liberty that is directed toward a: current or former spouse, person with whom the alleged abuser shares a child in common, current or former intimate partner with whom the alleged abuser shares or has shared a common domicile, or person who is or has been in a social relationship of a romantic or intimate nature with the accused and determined to be an intimate partner. DOD Instruction 6400.06, DOD Coordinated Community Response to Domestic Abuse Involving DOD Military and Certain Affiliated Personnel (Dec. 15, 2021) (incorporating change 1, May 10, 2022). 13Restricted reporting allows victims to confidentially disclose sexual assault to specified individuals (e.g., sexual assault response coordinator, victim advocate, family advocacy program personnel, or health care provider) and receive services such as health care, counseling, and other support without triggering an investigation or notifying the service member's command. Unrestricted reporting allows a victim to access support services and triggers an investigation by law enforcement and command notification of the allegation. Victims who make an unrestricted report of sexual assault are also eligible for consideration for protection orders and expedited transfers, which are not available to victims filing restricted reports. A restricted report can be converted to an unrestricted report at a later date if the victim chooses, but an unrestricted report cannot be converted to a restricted report. Adult victims of domestic abuse who report the abuse to the military and are eligible to receive military medical treatment have the option to make a restricted report or unrestricted report. A restricted report does not require notification to the command or law enforcement, but allows the victim to receive support services from the military. An unrestricted report requires notification to the command and law enforcement and may trigger an investigation and administrative or disciplinary action. In some cases, a victim may not have the option to make a restricted report, such as if the command or law enforcement have otherwise been notified of the abuse or if Family Advocacy Program determines the victim is in immediate risk of serious harm. 14DOD Instruction 6495.02, Vol. 1, Sexual Assault Prevention and Response: Program Procedures (Mar. 28, 2013) (incorporating change 7, Sept. 6, 2022). Page 6 GAO-23-105381 Unwanted Sexual Behavior barrier for some service members, and could be a reason why some service members may not want to access care in a DOD military medical treatment facility for trauma related to unwanted sexual behavior. In addition to the reporting options related to sexual assault and domestic sexual abuse, DOD offers informal, formal, and anonymous complaint options to service members who disclose sexual harassment. 15 DOD Roles and Various offices and organizations within DOD have roles and Responsibilities for responsibilities for addressing unwanted sexual behavior in the military. Addressing Unwanted The Under Secretary of Defense for Personnel and Readiness is Sexual Behavior responsible for establishing and overseeing the department's policies and programs to prevent and respond to incidents of sexual harassment, sexual assault, and domestic sexual abuse. 16 • Sexual harassment. The Director of the Office for Diversity, Equity, and Inclusion is responsible for developing DOD Military Equal Opportunity policy, which includes policy on sexual harassment. The Director also oversees the military services' policies and programs for Military Equal Opportunity and harassment prevention and response. Each military service has established a Military Equal Opportunity 15Informal complaints are written or oral allegations of sexual harassment that are submitted to any entity authorized to receive Military Equal Opportunity complaints, but not submitted as formal complaints. See DOD Instruction 1350.02, DOD Military Equal Opportunity Program (Sept. 4, 2020) (incorporating Change 1, Dec. 20, 2022). Service members who initially elect to resolve their complaints informally may submit a formal complaint if they are dissatisfied with the outcome of the informal process. Formal complaints are written allegations of sexual harassment submitted to the staff designated to receive such complaints. Commanders are also able to elevate informal complaints they are handling to formal complaints if they determine an investigation is warranted. Sexual harassment command investigations must be conducted in accordance with 10 U.S.C. § 1561. Specifically, commanding officers are to commence an investigation (or cause the investigation to be commenced), to the extent practicable, within 72 hours of receipt of the initial complaint and complete the investigation within 14 days of the date it was commenced. Further, commanders are to take appropriate disciplinary or administrative action when a complaint is substantiated. DOD Instruction 1020.03. Anonymous complaints are allegations of sexual harassment that are submitted by an unknown or unidentified source. Actions taken in response to an anonymous complaint depend on the extent of the information provided. 16DOD Instruction 1020.03, DOD Directive 6495.01 and DOD Instruction 6400.06. Page 7 GAO-23-105381 Unwanted Sexual Behavior program to receive and respond to, among other things, complaints of harassment, including sexual harassment. 17 • Sexual assault. DOD's Sexual Assault Prevention and Response Office serves as the department's single point of authority, accountability, and oversight for DOD's sexual assault prevention and response program. Among other things, the office is responsible for implementing and monitoring compliance with DOD sexual assault policy and providing the DOD components, including the military departments, with technical assistance in addressing matters concerning sexual assault prevention and response. 18 Consistent with DOD policy, each military service has established policies and a sexual assault prevention and response program that specify, among other things, responsibilities of commanders, sexual assault response coordinators, and victim advocates, as well as training requirements for service members. 19 • Domestic sexual abuse. DOD's Family Advocacy Program serves as the policy proponent for, and a key element of, DOD's coordinated community response system to prevent and respond to reports of domestic abuse in military families, including domestic sexual abuse and child abuse. 20 The Family Advocacy Program sets uniform standards for all military service Family Advocacy Programs. Each military service Family Advocacy Program has a headquarters entity that develops and issues implementing guidance for the installation programs it oversees. Installation programs provide trauma-informed assessment, rehabilitation, and treatment generally 17The Army's Military Equal Opportunity program does not address sexual harassment complaints; sexual harassment complaints are addressed through the Army's Sexual Harassment/Assault Response and Prevention (SHARP) program. 18DOD Instruction 6495.02, Vol. 1, Sexual Assault Prevention and Response: Program Procedures (Mar. 28, 2013) (incorporating change 7, Sept. 6, 2022). 19The military services' Sexual Assault Prevention and Response programs include the Army's SHARP program. This program combines into a single program the Army's efforts to prevent and respond to incidents of sexual harassment and sexual assault. In May 2022, we reported on the Army's administration of this program, including the policies and programs, oversight mechanisms, and identification of reporting barriers. We made nine recommendations to improve the Army's administration of the program, and the Army concurred with those recommendations. See GAO, Sexual Harassment and Assault: The Army Should Take Steps to Enhance Program Oversight, Evaluate Effectiveness, and Identify Reporting Barriers, GAO-22-104673 (Washington, D.C.: May 27, 2022). 20The Family Advocacy Program is also responsible for preventing and responding to incidents of problematic sexual behavior in children and youth. Page 8 GAO-23-105381 Unwanted Sexual Behavior to persons who experience domestic sexual abuse and are eligible to receive treatment in a military medical treatment facility. 21 The Assistant Secretary of Defense for Health Affairs serves as the chief medical adviser to the Secretary of Defense and oversees health policy and budgeting across the Military Health System, including the health care management of service members who have experienced unwanted sexual behavior. 22 This Assistant Secretary also directs the activities of the Defense Health Agency. The Defense Health Agency (DHA) is a combat support agency that provides a host of shared health services across the Military Health System. Specifically, the agency operates the TRICARE health benefit, provides pharmacy and medical logistics, performs medical research and development, and operates health information technology systems. The Director of DHA is responsible for developing and issuing procedural guidance to ensure implementation of the department's sexual assault healthcare policy. The Director is also responsible for establishing guidelines and procedures to require that an adequate supply of resources is maintained in all locations where DOD conducts sexual assault forensic examinations, such as military medical treatment facilities. Each military department has a Surgeon General, who serves as its senior medical leader. VA Definition of Unwanted VA policy refers to unwanted sexual behavior experienced during military Sexual Behavior service-sexual harassment, physical assault of a sexual nature, and battery of a sexual nature-as military sexual trauma. 23 According to VA policy, these unwanted sexual behaviors are associated with a wide range of physical and behavioral health conditions, including: 21DOD Instruction 6400.01, Family Advocacy Program (FAP) (May 1, 2019). Intimate partner victims who are not eligible for treatment in a military medical treatment facility will receive domestic abuse advocate support and referrals for services in the local community. According to DOD officials, the military services establish their own procedures to determine eligibility for services. 22DOD Instruction 6310.09, Health Care Management for Patients Associated with a Sexual Assault (May 7, 2019). 23VA's Intimate Partner Violence Assistance Program also provides assistance to individuals experiencing domestic sexual abuse. For the purposes of this report, we refer to sexual harassment, sexual assault, and domestic sexual abuse experienced during military service as unwanted sexual behavior. As noted above, we generally use the term unwanted sexual behavior in this report, but we use the term military sexual trauma when referring to VA screening or when the term military sexual trauma is used in agency guidance, documents, or position names. Page 9 GAO-23-105381 Unwanted Sexual Behavior • physical injuries and conditions consistent with sexual assault, such as contusions, bone fractures, and sexually transmitted diseases; • medical conditions caused or exacerbated by physiological reactions to traumatic stress, such as chronic pain, gastrointestinal problems, and sleep disorders; • medical conditions caused or exacerbated by behavioral reactions or attempts to cope with traumatic stress, such as liver disease associated with drug or alcohol abuse, and obesity or extreme weight loss associated with disordered eating behaviors; and • behavioral health conditions and symptoms, such as PTSD, mood disorders, anxiety disorders, and substance use disorders. 24 VA Roles and Various offices and organizations within VA have roles and Responsibilities for responsibilities related to unwanted sexual behavior. Providing Services • Under Secretary for Health. The Under Secretary for Health directs Related to Unwanted the Veterans Health Administration-the largest integrated health care Sexual Behavior system in the United States, providing care at over 1,300 health care facilities, including 171 VA Medical Centers and 1,120 outpatient clinics. This Under Secretary, through the Office of Mental Health and Suicide Prevention, and Readjustment Counseling Service, oversees VA's support for veterans who have experienced unwanted sexual behavior. • Office of Mental Health and Suicide Prevention. This office has national program responsibility for and oversees the Veterans Health Administration's support for veterans who have experienced unwanted sexual behavior. The team assists with establishing, maintaining, and communicating national policy related to unwanted sexual behavior; identifying and promoting best practices for related care; conducting national monitoring; and expanding education and outreach events. The team also provides consultation, training, and resources to various VA personnel and staff. • Readjustment Counseling Service. This office, within the Veterans Health Administration, oversees 300 Vet Centers, which provide readjustment counseling as well as counseling for PTSD and military sexual trauma. The Chief Officer reports directly to VA's Under Secretary for Health and maintains direct authority over all Readjustment Counseling Service staff. The Chief Officer is also responsible for strategic planning for Vet Centers and for ensuring 24Veterans Health Administration Directive 1115(1). Page 10 GAO-23-105381 Unwanted Sexual Behavior coordination of readjustment counseling services with other programs within VA, including the Office of Mental Health and Suicide Prevention. • VA Medical Facility Directors. Facility Directors are responsible for ensuring that all former service members seen in VA medical facilities are screened for experiences with unwanted sexual behavior. They are also responsible for ensuring that all VA medical facilities have appropriate physical and mental health care services available to treat conditions related to such experiences. VA Medical Facility Directors also appoint a Coordinator at every VA facility to support the implementation of related policy and serve as the point person for care related to experiences with unwanted sexual behavior. 25 DOD and VA Behavioral DOD and VA offer a number of behavioral health care options to current Health Care Support and service members (active-duty, reserve, and National Guard) and veterans who experience unwanted sexual behavior. 26 Services for Experiences with Unwanted Sexual Military Health System. The Military Health System is a complex Behavior organization in which the military departments-the Army, the Navy, and the Air Force-and DHA share responsibility for health care delivery and receive oversight from the Office of the Assistant Secretary of Defense for Health Affairs and advice from the Joint Staff. The Military Health System exists to ensure that service members, including medical providers, are medically ready to deploy and accomplish missions. Further, the Military Health System offers a range of behavioral health care services to service members, such as counseling, crisis intervention, intensive outpatient programs, and residential treatment, and these services may be provided at DOD hospitals, medical centers, and clinics-referred to collectively as 25Veterans Health Administration Directive 1115(1) outlines six responsibilities of Coordinators (referred to by VA as Military Sexual Trauma Coordinators). An August 2021 VA Office of Inspector General report found that, based on a survey of 136 of VA's 158 Coordinators, several issues challenged coordinators' ability to fulfill roles and responsibilities, including insufficiently protected administrative time, role demands, insufficient support staff, and inadequate funding for outreach materials. VA Office of Inspector General, Veterans Health Administration Challenges for Military Sexual Trauma Coordinators and Culture of Safety Considerations, Report No. 20-01979-199 (Aug. 5, 2021). 26According to data provided by DOD, the Military Health System provided behavioral health care for unwanted sexual behavior to more than 5,300 active-duty service members from fiscal years 2015 through 2021. According to data provided by VA, VA medical centers and clinics have provided behavioral health care for unwanted sexual behavior to more than 316,600 service members and veterans from fiscal years 2015 through 2021. Page 11 GAO-23-105381 Unwanted Sexual Behavior military medical treatment facilities. 27 Military medical treatment facilities are the primary source of specialty mental healthcare for military personnel. Their services may include clinical therapy for mental health conditions, such as PTSD, major depression, and other conditions. The Military Health System also provides non-medical counseling and clinical therapy at military medical treatment facilities and through TRICARE. Behavioral health care is also available through network providers. 28 The Family Advocacy Program also provides clinical therapy, marital therapy, and support groups. In addition, DOD has non-medical counseling programs outside the Military Health System. For example, the Military One Source and the Military and Family Life Consultant programs provide non-medical, brief counseling support to augment counseling provided by the active and reserve components. 29 These programs provide non-medical, short-term, solution-focused counseling and briefings for circumstances amenable to brief intervention, including but not limited to stress and anger management, grief and loss, the deployment cycle, parent-child relationships, couples communication, marital issues, relationships, and relocations. This non-medical support is aimed at preventing the development or exacerbation of mental health conditions that may detract from military and family readiness. VA medical facilities. VA provides services to service members and former service members related to unwanted sexual behavior at VA medical facilities free of charge. 30 These services include counseling, 27Section 703(a) of the National Defense Authorization Act for Fiscal Year 2017 added section 1073d to title 10, United States Code, which set forth various requirements for medical treatment facilities (10 U.S.C. § 1073d). 28Outside the scope of medical services, service members who experience unwanted sexual behavior may also receive non-medical counseling or chaplain services. Chaplains may provide counseling to individuals, couples, families, and groups. 29DOD Instruction 6490.06, Counseling Services for DOD Military, Guard and Reserve, Certain Affiliated Personnel, and Their Family Members (Apr. 21, 2009, incorporating Change 2, Mar. 31, 2017). 30Such care is not subject to the minimum active-duty service requirement set forth in 38 U.S.C. § 5303A; veterans may therefore be able to receive this care even if they are not eligible for VA health care under other treatment authorities. Veterans may receive these services: (1) at any time after experiencing unwanted sexual behavior, (2) even if they are not enrolled in the VA health care system to receive other VA care, and (3) even if they did not file a Veterans Benefits Administration claim for unwanted sexual behavior. See Veterans Health Administration Directive 1115(1). Page 12 GAO-23-105381 Unwanted Sexual Behavior care, and other services to treat a condition which, in the judgement of a VA health care professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the individual was serving on duty, regardless of duty status or line of duty determination. 31 All VA medical facilities must provide outpatient care for mental health conditions related to unwanted sexual behavior on site, and must provide inpatient care for such conditions either on site or through a referral to other VA medical facilities. 32 VA facilities must ensure that there are a sufficient number of clinicians available to adequately meet the demand for treatment for mental health conditions related to unwanted sexual behavior in a timely fashion. 33 • A VA medical center is a facility that provides two or more categories of care: inpatient, outpatient, residential rehabilitation, or institutional extended care. 34 • VA Vet Centers are community-based counseling centers that provide a wide range of social and psychological services, including professional counseling to eligible veterans, service members, and their families. VA Vet Centers offer psychosocial counseling, called readjustment counseling, to assist veterans in overcoming barriers to achieving a successful readjustment from military to civilian life, specifically for military stressors such as unwanted sexual behavior. 35 31For the purposes of this report, we refer to VA clients as veterans. However, VA clients can include active-duty service members; certain, but not all, former service members; and veterans. 32There are 1,298 VA medical facilities nationwide, including medical centers and community-based outpatient clinics. Medical centers provide a wide range of services including traditional hospital-based mental health care. Community-based outpatient clinics provide the most common outpatient services, including health and wellness visits. 33Veterans Health Administration Directive 1115(1). 34As of March 2023, there were 171 VA medical centers across the United States. 35Vet Center counselors conduct a psychosocial assessment and military history, which allows them to identify veterans' readjustment problems. These problems are categorized as psychosocial focus areas. Psychosocial focus areas are descriptive, they are not medical diagnoses, and are used to identify the dominant focus point of a Vet Center visit. Unwanted sexual behavior is one of the psychosocial focus areas. Page 13 GAO-23-105381 Unwanted Sexual Behavior Separation from Military Service members may voluntarily separate from military service, for Service example, after completion of their service obligation or may be involuntarily separated if they are found to be unsuitable for continued military service. 36 A service member may be found unsuitable due to misconduct (including drug use, absence from the military without leave, and criminal behavior) or for medical reasons, such as a non-disability mental health condition that interferes with the service member's ability to function in the military. 37 In cases involving misconduct, the military may decide to prosecute the service member by court-martial if the conduct is serious enough, which could lead to a punitive discharge. Alternatively, and among other options, the relevant service might seek an involuntary administrative separation of the service member, which can be preceded by attempts to correct and rehabilitate behavior and to counsel service members on the impact of being separated for misconduct. Depending on the reason for separation, a number of processes may be followed. • Administrative separation for misconduct is an involuntary separation of a service member who is unqualified for further military service. Examples of the behaviors that can lead to an administrative separation for misconduct include behaviors ranging from a pattern of minor disciplinary infractions to the commission of a serious military or civilian offense. Depending on the circumstances, a service member generally is counseled about misconduct and may be given the opportunity to rehabilitate behavior prior to initiation of the separation process. Officials document the misconduct, and, if the separation process is initiated, a service member is formally notified of intent to separate. Service members are given a reasonable opportunity to consult with counsel and respond to the notice and may submit written 36In February 2023, we reported on the armed forces' use of administrative separation boards. We found that while the military services' policies and processes generally aligned with DOD policies and relevant laws, certain Air Force enlisted policy provisions regarding the required qualifications for noncommissioned officer board members contained conflicting requirements, and one of the provisions was inconsistent with DOD policy. We recommended that the Air Force clarify its guidance to be consistent with DOD policy. DOD did not provide comments on the draft report. GAO, Administrative Separation Boards: Air Force Should Clarify Member Qualifications, GAO-23-105780 (Washington, D.C.: Feb. 2, 2023). 37DOD Instruction 1332.14, Enlisted Administrative Separations (Jan. 27, 2014) (incorporating change 7, June 23, 2022) and DOD Instruction 1332.30, Commissioned Officer Administrative Separations (May 11, 2018) (incorporating change 3, Sept. 9, 2021). Page 14 GAO-23-105381 Unwanted Sexual Behavior or recorded matter for consideration, among other things. The separating official makes the final decision, including determining the service member's characterization of service. • Administrative separation in lieu of trial by court-martial is when a service member facing trial by court-martial voluntarily requests to be discharged from military service and, if approved, the separation case is then handled through the administrative process. • The Disability Evaluation System is a process DOD uses to determine fitness for duty because of disability, and whether a service member found unfit for duty due to disability will be separated or retired. 38 If found to be unfit, this process determines appropriate benefits for service members who are separated or retired for a service-connected disability. 39 When a service member separates from the military, DOD characterizes the nature of that service member's military service. Administrative separations generally result in one of three potential characterizations of service-honorable, general (under honorable conditions), and under other than honorable conditions-which determine a service member's eligibility for VA benefits and services. 40 Separated service members may appeal their separation to a discharge review board to request a change to the characterization within 15 years after separation from the military. Further, separated service members may appeal the discharge review board's decision by applying to a board for the correction of military records. Various DOD entities have roles and responsibilities related to the separation process. • Under the authority of the Under Secretary of Defense for Personnel and Readiness, the Assistant Secretary of Defense for Manpower 38DOD Instruction 1332.18, Disability Evaluation System (Nov. 10, 2022). 39VA generally determines entitlement to veterans' disability benefits. According to DOD officials, DOD examines and applies the VA disability ratings for a small portion (less than 2 percent) of cases. 40Service members who receive an honorable characterization of service are eligible for all VA benefits and services; service members who receive a general (under honorable conditions) characterization of service are eligible for most VA benefits and services, with the exception of some VA education assistance; and service members who receive an other than honorable characterization of service may not be eligible for any VA benefits and services, including health care. Page 15 GAO-23-105381 Unwanted Sexual Behavior and Reserve Affairs develops, maintains, and oversees procedural instructions for officer and enlisted administrative separations. This Assistant Secretary also establishes and delegates authority to establish appropriate separation reporting requirements. 41 • General Court-Martial Convening Authority is an individual designated by statute or a commanding officer designated by the Secretary of a military department with the authority to convene general courts-martial. The relevant General Court-Martial Convening Authority serves as the separation authority in certain administrative separations under specific circumstances, as specified in the separation guidance issued by the military departments. 42 • General or Flag Officer is the separation authority for service members who (1) submit an unrestricted report of sexual assault, (2) are recommended for involuntary separation within 1 year of the final disposition of the sexual assault case, and (3) request higher-level review of the separation action. 43 DOD and VA differ in how they screen for experiences with unwanted DOD and VA sexual behavior and offer various behavioral health care services to Screening for active-duty service members and veterans who experience unwanted sexual behavior. However, several challenges hinder access to care for Unwanted Sexual service members and veterans. VA requires all former service members Behavior Experiences seen in VA medical facilities to be screened for experiences with unwanted sexual behavior. However, DOD medical providers screen for Differ and Several behavioral health conditions but do not specifically screen for experiences Challenges Hinder with unwanted sexual behavior. 44 The following challenges limit access to behavioral health care for experiences with unwanted sexual behavior for Access to Behavioral some service members: Health Care Offered DOD providers do not consistently prioritize behavioral health care by DOD and VA • appointments for active-duty service members who disclose that they have been sexually assaulted and seek behavioral health care, and 41DOD Instruction 1332.14 and DOD Instruction 1332.30. 42DOD Instruction 1332.14. 43DOD Instruction 1332.14 and DOD Instruction 1332.30. The request for a higher-level review of the separation action is discussed later in this report. 44While many individuals are eligible to receive VA care for trauma related to unwanted sexual behavior, including active-duty service members, reservists, and members of the National Guard, the Veterans Health Administration guidance explicitly states that this screening requirement applies to former service members. See Veterans Health Administration Directive 1115(1), Military Sexual Trauma (MST) Program. Page 16 GAO-23-105381 Unwanted Sexual Behavior victims of sexual harassment are not required by DOD policy to receive priority access to care despite both types of unwanted sexual behaviors being on the same continuum of harm. • Active-duty service members who have experienced unwanted sexual behavior have limited confidential access to VA behavioral health care services at VA medical centers and clinics, which may pose an obstacle to some service members seeking necessary care. • Service members who qualify for VA care only related to an experience with unwanted sexual behavior may not be consistently informed about their eligibility for and how to access such care if they did not report their experience to DOD. DOD and VA Differ in Their VA providers routinely screen patients for experiences with unwanted Approach to Screening for sexual behavior, whereas DOD medical providers screen for behavioral health conditions but not specifically for experiences with unwanted Experiences with sexual behavior. Specifically, VA requires all former service members Unwanted Sexual seen in VA medical facilities to be screened at least once for military Behavior sexual trauma, and officials told us screening is encouraged at the time of intake for behavioral health care services. 45 VA officials told us that former service members will be screened again if they have a new period of military service or if a VA provider deems that an additional screening is in the interest of the patient. VA officials told us that they screen only former service members for trauma related to unwanted sexual behavior, not active-duty service members who receive VA care while on active- duty status. This is to maintain the active-duty service members' confidentiality because the Veterans Health Administration shares VA medical record data with the DOD electronic health record. Screenings 45Veterans Health Administration Directive 1115(1). VA officials told us that VA began systematically screening veterans for trauma related to unwanted sexual behavior in 1999 and 2000. VA providers use a clinical reminder in the Computerized Patient Record System to conduct screenings, which consists of two questions: (1) When you were in the military, did you ever receive unwanted sexual attention you found threatening (for example, touching, cornering, pressure for sexual favors, sexual texts or online messages, or inappropriate verbal remarks, etc.)? (2) When you were in the military, did you ever have sexual contact against your will or when you were unable to say no (for example, after being forced or threatened or to avoid other consequences)? The response options are "yes, patient reports experiencing military sexual trauma (MST);" "no, patient denies experiencing military sexual trauma (MST);" and "no response" for patients who decline to respond. If the patient responds yes, the clinical reminder prompts the provider to inform them that this type of experience is known as military sexual trauma, for which VA offers free treatment, and to inquire if they'd like to speak to a provider about such treatment. Each facility must decide how to process requests for care that result from a positive screening. Page 17 GAO-23-105381 Unwanted Sexual Behavior must take place in private clinical settings with clinical staff who are trained to screen sensitively for such trauma, respond to disclosures, and connect veterans with appropriate care or referrals. 46 Vet Centers screen every patient for trauma related to experiences of unwanted sexual behavior by gathering a full military history at the time of initial treatment. This full history includes both a basic set of questions, including a question about circumstances related to episodes of sexual assault or harassment experienced while serving on active military duty, as well as an expansion of these questions to gather a more detailed account of an individual's military experiences. 47 Our analysis of Veterans Health Administration and Office of Readjustment Counseling Service data show that more than 350,000 veterans and service members screened positive for trauma related to experiences with unwanted sexual behavior from fiscal years 2015 through 2021 (see fig. 1). 48 Of those who screened positive at a Vet 46According to VA officials, unwanted sexual behavior that occurs within the context of intimate relationships is routinely screened as part of the Relationship Health and Safety Screen. Historical sexual trauma is further assessed as part of the Relationship Health and Safety Assessment, under the Intimate Partner Violence Assistance Program. If it is discovered that unwanted sexual behavior occurred during military service, a referral is made to the military sexual trauma coordinator. 47Veterans Health Administration Directive 1500(2), Readjustment Counseling Service (Jan. 26, 2021) (amended Dec. 30, 2021). Vet Center counselors do not use the same clinical reminder screening questions that the VA medical facilities providers use. 48For the purposes of this analysis, screening positive for trauma related to unwanted sexual behavior at a Vet Center means the individual either self-identified as having such trauma when filling out paperwork on eligibility to receive Readjustment Counseling Services or told a counselor they had trauma from unwanted sexual behavior during the intake questionnaire. VA officials stated that these numbers for medical centers and clinics are slightly higher than what is seen in Veterans Health Administration reports on military sexual trauma screening. They stated that this is likely because the Veterans Health Administration reports exclude certain encounters, such as compensation and pension exams, and chart consults that may be included in this analysis. Page 18 GAO-23-105381 Unwanted Sexual Behavior Center, 748 (3 percent) were service members. 49 Of those who screened positive at a VA medical center or clinic, 7,450 (2 percent) were service members at the time of their screening. Figure 1: Number of Veterans and Service Members Who Screened Positive for Military Sexual Trauma at a VA Vet Center, VA Medical Center, or VA Clinic, Fiscal Years 2015–2021 Note: Veterans could be counted more than once across fiscal years and facility types. More than half of the veterans and service members who screened positive at a Department of Veterans Affairs (VA) medical center or clinic were screened every year from fiscal years 2015 through 2021 and almost 39 49Unlike medical facility providers, Vet Center counselors also screen active-duty service members on active-duty status in addition to former service members for trauma related to unwanted sexual behavior. Counselors record their response in their data system, Readjustment Counseling Services Net. This data system maintains confidentiality because it does not share data with the DOD electronic health record or the Veterans Health Administration Computerized Patient Record System. The Vet Center counselors we spoke with confirmed they screen all clients seeking care for experiences with unwanted sexual behavior. They said that not all clients who screen positive want to address those experiences at the moment of disclosure, or ever. They emphasized that veterans take the lead in decisions about whether a positive screening leads to treatment or not. Page 19 GAO-23-105381 Unwanted Sexual Behavior percent were screened in multiple years, although not every year. The term veteran includes any former service member who was screened by VA for unwanted sexual behavior. DOD medical providers have tools and methods they use to screen active-duty service members for various types of trauma, but they are not consistently used to identify trauma stemming from experiences with unwanted sexual behavior. 50 Specifically, during the course of mandatory medical appointments-such as the annual health assessment and pre- and post-deployment health assessments-active-duty service members are required to complete standardized DOD forms that include questions about stressors or upsetting experiences. 51 For example, one question asks about major life stressors someone has experienced that are a cause of significant concern, including legal, financial, spiritual, behavioral health, familial, employment, sleep, and substance abuse issues. However, we found that none of the five DOD forms used in these regular examinations specifically asks about experiences with unwanted sexual behavior. 52 According to DOD officials, the decision not to screen was deliberate to avoid putting service members in a precarious position, because if the service member does not want to disclose their experience at that time, this potentially creates an inconsistent record if the service member chooses to disclose the sexual trauma later. The officials said that if the service member did disclose, that information would be shared with the appropriate program office for unwanted sexual behavior, which 50According to the Department of Health and Human Services, screenings are medical tests that doctors use to check for diseases and health conditions before there are any signs or symptoms, when they may be easier to treat. A screening could be a blood test, physical exam, or a list of questions the doctor asks. For the purposes of this review, we considered screening to be a mechanism to check for experiences with unwanted sexual behavior or related behavioral health conditions in a proactive manner, for example, through a formal assessment tool used by a clinician or informal conversation with a service member. 51DOD Instruction 6200.06, Periodic Health Assessment (PHA) Program (Sept. 8, 2016); DOD Instruction 6490.03, Deployment Health (June 19, 2019). 52The five forms DOD uses to screen for other physical and behavioral health conditions are 1) the Annual Periodic Health Assessment DD Form 3024 (August 2021 version), 2) the Pre-Deployment Health Assessment DD Form 2795 (October 2015 version), 3) the Post-Deployment Health Assessment DD Form 2796 (October 2015 version), 4) the Post- Deployment Health Re-Assessment DD Form 2900 (October 2015 version), and 5) the Mental Health Assessment DD Form 2978 (July 2022 version). An updated Department of Army Form 3822 Report of Mental Status Evaluation includes a question that asks whether the service member was a victim of a sex-related, intimate partner violence, or spousal abuse offense during service. However, Army officials said the 2019 version of this form is still being used as the updated version has not yet been implemented. Page 20 GAO-23-105381 Unwanted Sexual Behavior may still be undesirable for a service member. The officials said that DOD seeks to make trauma-informed decisions that allow service members to have control over how or when their information is shared. Similarly, service members also are not screened for an experience with unwanted sexual behavior during the separation process and will not be screened under planned revisions to this process. VA officials stated that this is to protect service members' privacy and confidentiality. Since 2010, DOD and VA have worked together in a separation health assessment working group to revise and combine the DOD separation history and physical examination and the VA separation health assessment into one separation health assessment. 53 A VA official stated that VA and DOD jointly decided that the new separation health assessment will not include a screening question asking the service member whether they have experienced military sexual trauma or other forms of unwanted sexual behavior. DOD officials explained that placing screening questions on the separation health assessment would place service members in a difficult position of having to either disclose their experience or deny the experience, which could potentially affect their benefits claims should they choose to disclose their experience later. The officials said that the departments instead decided to provide a standardized handout to all separating service members on available resources, reporting options, and how to submit a military sexual trauma claim with VA. 54 The officials said that doing this ensures all separating service members are aware of the resources and how to get assistance, without facing the burden of determining whether to disclose their unwanted sexual behavior during the separation health assessment. DOD and VA officials told us that the new separation health assessment will include a standardized mental health screening. Specifically, DOD and VA officials stated that, similar to the current VA separation health assessment, the new separation health assessment will include standardized mental health screenings for depression, PTSD, alcohol 53A VA official stated that the new separation health assessment is a comprehensive health assessment that is designed to identify the presence of any health conditions that have occurred as the result of an injury, illness, or event (to include trauma from an experience with unwanted sexual behavior) experienced by the service member during military service. 54The development and content of this handout will be discussed in more detail later in this report. Page 21 GAO-23-105381 Unwanted Sexual Behavior use, suicide, and violence risk for all separating service members. VA officials said that if service members screen positive for these issues during the behavioral health section of the assessment, they are referred for behavioral health examinations, if indicated. As of February 2023, VA and DOD officials do not have an anticipated implementation date for the new separation health assessment. National guidance for health care providers recommends developing protocols that ensure consistent, effective practices for providing care to patients that experience sexual violence. 55 These protocols include screening all patients for sexual violence and asking direct questions in a non-judgmental way. However, DOD behavioral health care and primary care providers have inconsistent screening approaches because DOD does not have guidance that establishes protocols specifying how or under what circumstances DOD providers should ask patients about experiences with unwanted sexual behavior. 56 For example, although DOD's medical forms are generally not designed to screen for experiences with unwanted sexual behavior, some DOD care providers told us that they regularly ask active-duty service members about such experiences. Specifically, of the 20 DOD behavioral health care providers we spoke with, eight told us that they routinely screen active-duty service members for experiences with unwanted sexual behavior because, for example, they believe it will help the patient to feel more comfortable seeking care and treating the effects of trauma early, before unhealthy behaviors begin. Conversely, the remaining twelve providers stated that they do not ask about experiences with unwanted sexual behavior because they are concerned that active-duty service members might be reluctant to disclose such experiences if, for example, 55American College of Obstetricians and Gynecologists, Committee Opinion: Sexual Assault (2019); National Sexual Violence Resource Center, Assessing Patients for Sexual Violence: a Guide for Health Care Providers (2011). The Centers for Disease Control and Prevention also has guidance for all providers in intimate partner violence and sexual violence victimization assessment instruments. See Centers for Disease Control and Prevention, Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (2007). 56The Defense Health Agency guidance on primary care behavioral health standards does not include unwanted sexual behavior or sexual trauma in its discussion of required and optional assessment tools. Defense Health Agency Procedures Manual 6025.01, Primary Care Behavioral Health (PCBH) Standards (Dec. 20, 2019). Page 22 GAO-23-105381 Unwanted Sexual Behavior they are not ready to talk about the experience or are worried that receiving related care could hinder their career progression. 57 Although DHA has not issued guidance to providers to clarify how or when DOD medical providers should screen for experiences with unwanted sexual behaviors, DHA officials told us that they have discussed the development of such guidance. They said that all service members should complete questions posed on the behavioral health data portal, including a screen for trauma exposure. Without developing guidance that establishes protocols specifying how and when DOD medical providers to screen active-duty service members for experiences with unwanted sexual behavior, DHA cannot ensure that its providers are providing patients with a consistent level of support or care. DOD and VA Offer Behavioral Health Care to Treat Exposure to Unwanted Sexual Behavior DOD Offers Various Types of DOD has a variety of behavioral health care available at hundreds of Behavioral Health Care for installations throughout the world for active-duty service members who Treating Experiences with have experienced unwanted sexual behavior. According to DHA officials, Unwanted Sexual Behavior the traditional model of behavioral health treatment for exposure to trauma involves evidence-based outpatient care such as Cognitive Processing Therapy, Prolonged Exposure, and Eye Movement Desensitization and Reprocessing Therapy that takes place in 45-75 minute sessions that occur on a weekly, twice weekly, or biweekly basis. 58 DOD officials stated that, depending on the patient, ideally, some symptom improvement is seen within seven to eight sessions and treatment can end after 12 sessions. However, these officials stated that patients needing additional treatment may be referred to the Intensive 57Of these twelve providers, four were DOD behavioral health providers and eight were DOD primary care providers. 58According to the American Psychological Association's Dictionary of Psychology, Cognitive Processing Therapy (CPT) emphasizes cognitive strategies to help people alter erroneous thinking that has emerged because of a traumatic event, such as a person believing that the world is no longer safe. Eye Movement Desensitization and Reprocessing (EMDR) is a treatment methodology used to reduce the impact of trauma through simultaneous visualization of the traumatic event while concentrating on the rapid lateral movements of a therapist's finger. Page 23 GAO-23-105381 Unwanted Sexual Behavior Outpatient Program, which provides 3- to 4-hour treatment sessions up to 5 days per week for an additional period of time, depending on the program. 59 DOD officials stated that not all victims of unwanted sexual behavior experience trauma symptoms, and individuals with other diagnoses are provided treatments designed to address their presentation of symptoms. If a service member is determined to be actively suicidal, a DHA official stated that they may be referred to inpatient care. 60 According to our analysis of DHA data, DOD provided medical behavioral health care, such as intensive outpatient psychiatric services and crisis intervention behavioral health services, to 5,343 active-duty service members from fiscal years 2015 through 2021 (see fig. 2). 61 Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD 59DOD officials said that types of services, lengths, and days per week vary by program. 60DHA found significant barriers that limit the wide-scale implementation of using civilian partner Intensive Outpatient Programs to treat active-duty service members suffering from the psychological consequences of sexual trauma, outlined in their report on a congressionally-mandated pilot program. For example, there were challenges with referrals, information flow, lost duty-days, and cost of care. Department of Defense, Final Report To The Committees On Armed Services Of The Senate And The House Of Representatives: Pilot Program on Treatment of Members of the Armed Forces for Posttraumatic Stress Disorder Related to Sexual Trauma (April 2022). As of February 2023, DHA officials told us that the pilot has been completed and the results are still being analyzed which will inform what, if any, practice standards will be implemented as a permanent program. DHA officials said that, for the calendar years 2017-2021, there were 100,067 inpatient psychiatric admissions of which 43,510 (43.5%) included a diagnostic code for either suicidal ideation or a suicide attempt. Consequently, 56.5% of inpatient psychiatric stays during this period were not associated with suicidal ideation or attempts based on diagnostic coding. 61We based our analysis on information maintained in DOD's Military Health System Data Repository to identify behavioral health care records with International Classification of Diseases (ICD)-9 and ICD-10 diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Our analysis does not include behavioral health care that DOD does not track in its Military Health System Data Repository, such as the Family Advocacy Program's non-clinical counseling services. DHA uses ICD-10 codes related to sexual abuse to identify medical behavioral health care encounters related to unwanted sexual behavior. These codes' descriptions use the terms "sexual abuse" or "sexual harassment." The number of service members who received behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed later in this report. Page 24 GAO-23-105381 Unwanted Sexual Behavior officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. Figure 2: Percentage of Service Members, By Service, Who Received Department of Defense (DOD) Documented Medical Behavioral Health Care for Experiences with Unwanted Sexual Behavior, Fiscal Years 2015–2021 Note: We used the Department of Defense's (DOD) Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. An individual service member was counted only once in each fiscal year, regardless of the number of times they received care in that fiscal year. The same service member could have been counted in multiple fiscal years. The number of service members who received medical behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed later in this report. Page 25 GAO-23-105381 Unwanted Sexual Behavior These active-duty service members received care at 295 military treatment facilities across nine foreign countries and 42 U.S. states and territories (see fig. 3). 62 62See Appendix II for a breakdown of this analysis by U.S. states and territories. Page 26 GAO-23-105381 Unwanted Sexual Behavior Figure 3: Number of Department of Defense (DOD) Military Treatment Facilities Worldwide That Documented Providing, and Number of Service Members Who Received, Medical Behavioral Health Care for Experiences with Unwanted Sexual Behavior, by Country, Fiscal Years 2015–2021 Note: We used the Department of Defense's (DOD) Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Service members may have received behavioral health treatment related to unwanted sexual behaviors, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. An individual service member was counted only once in each facility in a country, regardless of the number of times they received care, but the same service member could have been counted in multiple facilities in a country or in multiple countries. The number of service members who received medical behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed later in this report. To protect privacy, we excluded values for countries that had fewer than 10 service members who received medical behavioral health care documented as being for experiences with unwanted sexual behavior. Page 27 GAO-23-105381 Unwanted Sexual Behavior From fiscal years 2015 through 2021, the proportion of care provided by DOD or purchased through TRICARE in the private sector varied from year to year for active-duty service members who received behavioral health care identified as being for an experience with unwanted sexual behavior. Our analysis of DOD data shows that there was a fairly uneven distribution during this time period in services provided to service members who did and did not make an unrestricted or formal report of an experience with unwanted sexual behavior to DOD, when isolating the data by source of care (direct or private sector) (see fig. 4). 63 63Service members may purchase care in the private sector themselves without using TRICARE, and those who did would not be counted in this figure. Figure 4 only presents data for those who received private sector care that was billed to TRICARE and paid in part or in full by TRICARE. Our analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. See Appendix II for analyses of DOD medical behavioral health care by race. Page 28 GAO-23-105381 Unwanted Sexual Behavior Figure 4: Number of Active-Duty Service Members Who Received Direct and Private Sector Medical Behavioral Health Care for Experiences with Unwanted Sexual Behavior, by Reporting Status, Fiscal Years 2015–2021 Notes: We used the Department of Defense's (DOD) Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. An individual service member was counted only once in each fiscal year, regardless of the number of times they received care in that fiscal year, but the same service member could have been counted in multiple fiscal years and in both direct and private sector care counts. The number of service members who received medical behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed later in this report. This analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. To protect privacy, we excluded values when the number of service members who received private sector care was less than 10. Page 29 GAO-23-105381 Unwanted Sexual Behavior Our analysis of DHA medical behavioral health data and reported incidents of unwanted sexual behavior generally shows that the proportion of active-duty service members who received behavioral health care from fiscal years 2015 through 2021 for an experience with unwanted sexual behavior and made an unrestricted or formal report about unwanted sexual behavior to DOD was similar to the proportion of those who did not make a report. 64 However, the rates of reporting for those who sought care through the Military Health System showed greater variability when broken out by more specific categories (see fig. 5). 65 64The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019-2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Service members who received non-medical counseling are not included in this analysis. DOD officials stated that not all victims of unwanted sexual behavior will need or want behavioral health care. See Appendix II for analyses of DOD medical behavioral health care by race. 65Unwanted sexual behavior has been found to be an underreported crime. For example, in 2021, DOD reported that an estimate 1 in 5 service members reported their experience of sexual assault to DOD authorities. Reasons for not reporting sexual assault were similar for men and women, and included thinking it was not serious enough to report, thinking no action would be taken, and worry about potential negative consequences from co-workers or peers. DOD, Department of Defense Annual Report on Sexual Assault in the Military: Fiscal Year 2021 (Aug. 29, 2022). The Independent Review Commission reported that the unique environment of the military exacerbates barriers to reporting sexual assault and sexual harassment. They said that service members who experienced sexual harassment reported experiencing negative actions for bringing their complaints to light. Some of those negative actions were being encouraged to drop the matter, and being treated worse by their co-workers, avoided, or even blamed for the problem. Independent Review Commission on Sexual Assault in the Military, Hard Truths and the Duty to Change. Page 30 GAO-23-105381 Unwanted Sexual Behavior Figure 5: Percentage of Active-Duty Service Members Who Received Medical Behavioral Health Care for and Reported Experiences with Unwanted Sexual Behavior (by Gender, Military Service, Care Setting, and Care Location), Fiscal Years 2015–2021 Note: We used the Department of Defense's (DOD) Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. An individual service member was counted only once, regardless of the number of times they received care, but the same service member could have been counted in both outpatient and inpatient or direct and private sector care counts. The number of service members who received medical behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed later in this report. This analysis includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or informal report, the report of unwanted sexual behavior would not be included in this analysis. In addition to medical services, DOD offers a range of non-clinical support services for active-duty service members who experience sexual assault or domestic sexual abuse. For example, the military services' Family Page 31 GAO-23-105381 Unwanted Sexual Behavior Advocacy Programs offer non-clinical counseling for victims of domestic sexual abuse, in addition to the clinical assessments used to determine the need for medical care and identify any needed care referrals. Further, sexual assault response coordinators assess the safety of sexual assault victims and offer mental health referrals, if desired. DOD's Military One Source and Military and Family Life Consultant programs also provide non-medical counseling aimed at preventing the development or exacerbation of mental health conditions. DOD is also beginning to provide a similar level of services for those who experience sexual harassment. For example, the Department of the Air Force issued policies in July and September 2022 expanding victim advocacy services to service members by allowing them to report sexual harassment through an unrestricted or restricted reporting option with the sexual assault prevention and response program office. 66 This update enhances existing Department of the Air Force policy requiring the Equal Opportunity program to conduct person-to-person hand-offs with the responsible commander or designee. The Marine Corps issued an interim policy that enables sexual assault prevention and response personnel to provide support to sexual harassment victims, and DOD officials said that the Navy also issued a similar policy. 67 In the Army, soldiers who experience sexual harassment have had access to certain sexual assault prevention and response services since its Sexual Harassment/Assault Response and Prevention (SHARP) program was established in 2009. Army officials stated that the Army's support to victims of sexual 66Assistant Secretary of the Air Force (Manpower and Reserve Affairs) Memorandum, Department of the Air Force Sexual Assault Prevention and Response Victim Advocacy Services and Confidential Reporting for Military Sexual Harassment (July 6, 2022); Department of the Air Force Instruction 36-2710, Equal Opportunity Program (June 18, 2020) (incorporating Department of the Air Force Guidance Memorandum 2022-02 (Sept. 30, 2022)); and Department of the Air Force Instruction 90-6001, Sexual Assault Prevention and Response (SAPR) Program (July 15, 2020) (incorporating Department of the Air Force Guidance Memorandum 2022-01 (Sept. 30, 2022)). These policies also implemented Section 532 of the William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021 regarding confidential reporting of sexual harassment to improve Airmen and Guardians' access to resources and support services. 67Marine Corps Administrative Message (MARADMIN) 629/22, Extension of Sexual Assault Prevention and Response Services to Sexual Harassment Claimants (Dec. 2, 2022). Page 32 GAO-23-105381 Unwanted Sexual Behavior harassment is codified in Army guidance and will also be included in the new SHARP regulation once it is published. 68 VA Offers Various Types of VA facilities offer counseling, care, and services to clients who Behavioral Health Care for experienced unwanted sexual behavior while serving on duty in the Experiences with Unwanted military. 69 VA requires that care for unwanted sexual behavior be Sexual Behavior consistent with the minimum clinical requirements of all Veterans Health Administration behavioral health services. 70 In its annual report for fiscal year 2019 on counseling, care, and services provided for military sexual trauma, VA reported that each of its health care facilities provided behavioral health services, such as formal psychological assessments and evaluation, psychiatry, and individual and group psychotherapy for experiences with unwanted sexual behavior. 71 VA medical centers and clinics and some VA Vet Centers offer treatments such as Cognitive Processing Therapy, Eye Movement Desensitization and Reprocessing therapy, and traditional talk therapies based on Acceptance and Commitment Therapy. 72 VA medical centers and community-based outpatient clinics may also offer whole health services such as yoga or lifestyle coaching as ways to help patients manage stress or limit alcohol consumption. According to our analysis of Veterans Health Administration data, VA medical centers and clinics provided behavioral health care to 316,666 68Army Regulation 600-20. Officials said that the Army has provided clarifying guidance subsequent to the effective date of the regulation, such as appointing an investigating officer from outside the victim's brigade to conduct sexual harassment complaint investigations. 69Veterans Health Administration Directive 1115(1). VA facilities include Veterans Health Administration medical centers and community-based outpatient clinics and Office of Readjustment Counseling Service Vet Centers. See Background for more information on facility types. 70VA uses the phrase "military sexual trauma-related care" to describe care for unwanted sexual behavior. The minimal clinical requirements are in Department of Veterans Affairs Veterans Health Administration Handbook 1160.01(1), Uniform Mental Health Services in VA Medical Centers and Clinics (Sept. 11, 2008) (amended Nov. 16, 2015). 71Department of Veterans Affairs, Annual Report for Fiscal Year 2019: Counseling, Care, and Services Provided to Veterans and Active Duty Servicemembers who Experienced Military Sexual Trauma (Dec. 2019). 72According to the American Psychological Association's Dictionary of Psychology, Acceptance and Commitment Therapy (ACT) is a form of cognitive behavioral therapy that helps individuals experience and accept their difficult thoughts and feelings and develop new ways of thinking about and responding to challenges. Page 33 GAO-23-105381 Unwanted Sexual Behavior veterans and service members for experiences with unwanted sexual behavior from fiscal years 2015 through 2021. 73 However, more than 95 percent of the veterans and more than 99 percent of those still serving who received this care did not make a formal or unrestricted report of the experience with unwanted sexual behavior to DOD prior to separation (see fig. 6). 74 73We identified these data using VA codes related to military sexual trauma. An individual was counted only once for each service category, regardless of the number of times they received care, but the same service member could have been counted as both a veteran and a currently serving service member if they received VA care in both capacities over our time period. Individuals also could have received care from DOD. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or informal report, the report of unwanted sexual behavior would not be included in this analysis. 74This analysis includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or informal report, the report of unwanted sexual behavior would not be included in this analysis. See Appendix II for analyses of VA behavioral health care by race. Page 34 GAO-23-105381 Unwanted Sexual Behavior Figure 6: Veterans and Service Members Who Received VA Behavioral Health Care for an Experience with Unwanted Sexual Behavior, by Care Source and Whether They Reported Experience to the Department of Defense, Fiscal Years 2015–2021 Note: We identified these data using Department of Veterans Affairs (VA) codes related to military sexual trauma. An individual was counted only once for each service category, regardless of the number of times they received care, but the same service member could have been counted as both a veteran and a currently serving service member if they received VA care in both capacities over our time period. Individuals also could have received care from the Department of Defense (DOD). The term veteran includes any former service member who received VA care for unwanted sexual behavior. This analysis includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or informal report, the report of unwanted sexual behavior would not be included in this analysis. According to VA officials, the number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. During this same period, VA separately provided behavioral health care related to unwanted sexual behavior to 38,882 veterans and service members at Vet Centers, where a referral is not needed for active-duty service members to obtain care (see fig. 6 above). More than 74 percent of those still serving when they got care and 97 percent of veterans who Page 35 GAO-23-105381 Unwanted Sexual Behavior received counseling at VA Vet Centers did not file a formal or unrestricted report with DOD for an experience with unwanted sexual behavior. 75 Based on available VA data, a substantially greater proportion of veterans than service members received behavioral health treatment or other military sexual trauma treatment at VA medical centers and clinics or received counseling at VA Vet Centers, as shown in figure 7. The number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. Further, the proportion of service members getting counseling at VA Vet Centers, which is confidential and does not require a referral, was generally greater than the proportion getting care at VA medical centers and clinics, where a referral is required. 76 75This analysis includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or informal report, the report of unwanted sexual behavior would not be included in this analysis. As discussed later in this report, active- duty service members may not be aware that they are able to get care at VA Vet Centers without a referral because information about active-duty service members' eligibility to receive these services is not included in the training that most service members receive. DOD officials also said that service members may choose to wait to receive care until after the investigation or court process has concluded, to avoid the potential for behavioral health records to be subpoenaed. See Appendix II for analyses of VA behavioral health care by race. 76As discussed above, Vet Centers offer counseling services only, while VA medical centers and clinics offer a wider range of behavioral health services. Page 36 GAO-23-105381 Unwanted Sexual Behavior Figure 7: Number of Veterans and Service Members Who Received Department of Veterans Affairs (VA) Care for an Experience with Unwanted Sexual Behavior, by Type of Care Received, Fiscal Years 2015–2021 Note: We identified these data using Department of Veterans Affairs (VA) codes related to military sexual trauma. An individual was counted only once in each fiscal year for each treatment type, regardless of the number of times they received care, but the same veteran or service member could have been counted in multiple fiscal years and in multiple treatment types. Individuals also could have received care from the Department of Defense. The term veteran includes any former service member who received VA care for unwanted sexual behavior. According to VA officials, the number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. To protect privacy, we excluded values when the number of service members who received non-behavioral health care at medical centers and clinics was less than 10. Of the more than 266,000 individual service members and veterans who received documented behavioral health care from either VA or DOD for experiences with unwanted sexual behavior from fiscal years 2015 through 2021, the majority, 88 percent, received such care only at VA Page 37 GAO-23-105381 Unwanted Sexual Behavior medical centers and clinics. 77 Of the same group, more than 7 percent received care from at least two sources, such as from DOD and a Vet Center or from a Vet Center and a VA medical center or clinic, and fewer than 1 percent received care from both DOD and VA. 78 Further, of the 7,264 service members and veterans who made an unrestricted or formal report of unwanted sexual behavior to DOD and received documented behavioral health care related to the experience from DOD or VA, almost 20 percent received care from at least two sources and almost 13 percent received care from both DOD and VA (see fig. 8). 79 77This total of more than 266,000 service members and veterans counts each individual only one time, regardless of where they received care or of their status as a service member or a veteran when they received care. This total is smaller than the 316,666 service members and veterans who got care at VA medical centers and clinics shown in figure 6 above because when calculating that total, the same service member could have been counted as both a veteran and a currently serving service member if they received VA care in both capacities over our time period. 78According to DOD officials, DOD behavioral health care documentation focuses on diagnosis, treatment plan, and safety rather than flagging precipitating or contributing stressors (which may include unwanted sexual behavior). 79The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. See Appendix II for additional analyses of DOD and VA behavioral health care. Page 38 GAO-23-105381 Unwanted Sexual Behavior Figure 8: Number of Veterans and Service Members Who Received Documented Behavioral Health Care for Unwanted Sexual Behavior, by Care Provider and Reporting Status, Fiscal Years 2015–2021 Note: We identified these data using Department of Veterans Affairs (VA) codes related to military sexual trauma in VA's Corporate Data Warehouse and Readjustment Counseling Services Net databases. We also used the Department of Defense's (DOD) Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non- medical counseling, without such treatment being identified in DOD or VA medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. An individual veteran or service member was counted only once in each care provider group, regardless of the number of times they received care. The number of service members who received medical behavioral health care from DOD that was identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed later in this report. According to VA officials, the number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted, because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. The term veteran includes any former service member who received VA care for unwanted sexual behavior. Areas in the figure are not to scale and are for illustrative purposes only. Page 39 GAO-23-105381 Unwanted Sexual Behavior Several Challenges Limit Access to Behavioral Health Care for Service Members Who Experience Unwanted Sexual Behavior Not All Service Members Who DOD providers do not consistently prioritize behavioral health care Experience Unwanted Sexual appointments for active-duty service members who disclose that they Behavior Receive Priority have been sexually assaulted and seek behavioral health care. None of Access to DOD Behavioral the eighteen DOD providers we spoke with knew of protocols requiring Health Care them to prioritize behavioral health care appointments for those sexually assaulted because DOD had not developed guidance on how to effectively apportion the limited number of behavioral health care appointments to meet the policy's intent while continuing to serve the acute needs of other patients. 80 DOD providers with whom we spoke described wait times for behavioral health appointments that ranged from 1 to 4 months. For example, DOD primary care providers at one installation told us that the wait time for behavioral health appointments can be 4 weeks, unless a patient is suicidal. DOD behavioral health providers at another installation told us that it can take service members 3 to 4 months to get a behavioral health appointment in the private sector. These providers stated that due to behavioral health provider shortages at the military treatment facility, they have to refer about 90 percent of service members to the private sector. 81 80While we spoke with 20 providers, two behavioral health providers did not discuss prioritization of care for those sexually assaulted. 81However, we heard of more than one instance where a service member was not allowed to seek care in the private sector. For example, an Army SHARP official described a case where a service member was sexually assaulted by a uniformed service member, and thus was not comfortable getting behavioral health treatment from a provider in uniform. However, this official stated that the DOD military treatment facility denied the victim's request to be treated by a private sector provider, because there was availability to provide behavioral health care using on-base resources. According to the official, even after Army SHARP officials elevated the request to the military treatment facility's commander and behavioral health chief, they continued to decline permission for behavioral health treatment off base, because DOD policy did not require them to authorize private sector treatment. DOD Instruction 6495.02, Vol. 1 states specialty care may be provided in the direct or civilian purchased care sectors, but does not require that such care be provided in the private sector at the service member's request. Page 40 GAO-23-105381 Unwanted Sexual Behavior DOD Health Affairs officials said that the Military Health System has an average wait time of 15 calendar days for the first specialty mental health appointment, which they said is below the system's access to care standard of 28 calendar days. They said that TRICARE network access to care averages 35.9 calendar days for psychological counseling and 34.1 calendar days for psychiatric care. The officials noted that DOD faces the same nationwide challenges as the private sector in that the demand for behavioral health services continues to outpace the supply of behavioral health professionals. DOD policy requires that active-duty service members who disclose a sexual assault be given priority and treated as emergency cases. It also states that victims of sexual assault shall receive timely access to comprehensive medical and behavioral health treatment, including emergency care treatment and services. 82 In addition, a different DOD policy states that patients who disclose that they were sexually assaulted and seek health care within DOD shall be given priority for appointments in DOD facilities and emergency care. 83 In the absence of DHA guidance about how providers are to prioritize services, DOD providers we spoke with have taken various approaches in how they prioritize patient care. For example, two providers told us that the speed at which a service member is able to secure a behavioral health appointment depends on the severity of the symptoms and availability of providers, and not on the trauma's precipitating event. 84 82DOD Instruction 6495.02, vol. 1, Sexual Assault Prevention and Response: Program Procedures (Mar. 28, 2013) (incorporating Change 7, Sept. 6, 2022). This guidance states that to provide comprehensive medical care, the surgeons general shall establish processes and procedures to coordinate timely access to emergency, follow-up, and specialty care that may be provided in the direct or civilian purchased care sectors for eligible beneficiaries of the Military Health System. The guidance defines medical care to include physical and psychological medical services. The guidance also states that priority treatment as emergency cases includes activities relating to access to healthcare, coding, and medical transfer or evacuation, and complete physical assessment, examination, and treatment of injuries, including immediate emergency interventions. 83DOD Instruction 6310.09, Health Care Management for Patients Associated with a Sexual Assault (May 7, 2019). 84DOD officials said that the intent of the DOD policy on prioritizing care for sexual assault victims is to ensure priority appointments in clinics or access to assessment, treatment, and care when service members present in an emergency department. The officials stated that for behavioral health appointments, that includes assessing the severity of symptoms and level of stress for service members requesting appointments for sexual harassment as well as sexual assault. Page 41 GAO-23-105381 Unwanted Sexual Behavior Three additional behavioral health providers told us that they try to give active-duty service members who disclose an experience with unwanted sexual behavior, such as a sexual assault, priority for behavioral health care appointments. In these cases, providers said that they give priority based on the reported precipitating event as opposed to the suspected symptoms of unwanted sexual behavior. 85 For example, providers told us they can unofficially prioritize care, such as by choosing to give active- duty service members the soonest available appointment. Providers also told us that they can "squeeze them in" the schedule at the request of another behavioral health provider, sexual assault prevention and response program personnel, or the service member's command. Moreover, these policies only require this prioritization of care for sexual assault survivors and do not include priority access to care for survivors of sexual harassment, despite both types of unwanted sexual behaviors being on the same continuum of harm. DOD recognizes that sexual harassment is one type of behavior on a continuum of harm that also includes sexual assault. 86 Further, DOD guidance outlines responsibilities of the military departments, including providing adequate protection and care to those who allege sexual harassment and informing them of available support services, such as public and private programs that 85Administrative staff confirmed this, stating that while there are no official protocols to prioritize these active-duty service members, implicitly some providers try to prioritize active-duty service members with sexual trauma if the individual discloses this trauma and their symptoms are severe enough to require prioritization. 86DOD has defined the continuum of harm as a range of interconnected, inappropriate behaviors that are connected to the occurrence of sexual assault and support an environment that tolerates these behaviors. DOD has reported that by increasing attention to lesser unwanted behaviors such as sexual harassment, DOD can reduce the prevalence of those behaviors as well as the prevalence of sexual assault. DOD Office of People Analytics Executive Note 2020-093, The Continuum of Harm: Examining the Correlates of Sexual Assault Victimization (September 2020). For example, the Sexual Assault Prevention and Response Office has reported that certain behaviors and activities, such as hazing, can lead to sexual assault. Of the four military services we reviewed, the Army was unique in that active-duty service members who file a complaint of sexual harassment have access to sexual assault response coordinators and victim advocates. Army SHARP personnel we interviewed indicated that although sexual harassment complainants have access to sexual assault response coordinators and victim advocates, it has been confusing for active-duty service members to have different processes for filing a complaint of sexual harassment and report of sexual assault. Army SHARP personnel explained that they need to ask questions to determine if an incident was sexual harassment or sexual assault, as a service member may not know which offense they experienced. Page 42 GAO-23-105381 Unwanted Sexual Behavior provide counseling, treatment, and other support. 87 As one behavioral health provider told us, the behavioral health support an individual needs depends on the trauma they experience from the behavior, not on whether the behavior they experienced was defined as sexual harassment or sexual assault. Similarly, the Independent Review Commission on Sexual Assault in the Military recognized that these behaviors are on the same continuum of harm, stating that to think of sexual harassment and sexual assault as two separate problem sets is to fundamentally misunderstand the challenge DOD faces. 88 Therefore, the commission made a cross-cutting recommendation in 2021 that DOD should immediately make sexual harassment victims eligible for sexual assault prevention and response services and undertake a review of all policies and structures tasked with addressing elements of the military's sexual harassment response. 89 To address the second part of this recommendation, DOD directed the Office for Diversity, Equity, and Inclusion and the DOD Diversity Management Operations Center to undertake a review of all policies and structures tasked with addressing elements of the military's sexual harassment response to identify gaps and ensure a smooth adaptation of new guidance and policy involving sexual assault response coordinators and sexual harassment complainants. 90 The department's implementation guidance for this recommendation directed that the review be completed by September 30, 2022. 91 According to officials from DOD's Office for Diversity, Equity, and Inclusion, they completed their review in January 87DOD Instruction 1020.03. 88The Independent Review Commission cited a RAND study that found that active-duty service members who experience sexual harassment suffer higher rates of sexual assault. Independent Review Commission, Hard Truths and the Duty to Change. See also GAO, Sexual Violence: Actions Needed to Improve DOD's Efforts to Address the Continuum of Unwanted Sexual Behaviors, GAO-18-33 (Dec. 18, 2017). 89Independent Review Commission, Hard Truths and the Duty to Change. DOD officials said that these findings are specific to the non-medical response, and not necessarily to the medical response. 90Under Secretary of Defense for Personnel and Readiness Memorandum, Guidance for Implementing Tier 1 Recommendations of the Independent Review Commission on Sexual Assault in the Military (Oct. 13, 2021). 91Under Secretary of Defense for Personnel and Readiness Memorandum, Revised Guidance for Implementing Cross Cutting Recommendation 1 of the Tier 1 Recommendations of the Independent Review Commission on Sexual Assault in the Military (Sept. 14, 2022). Page 43 GAO-23-105381 Unwanted Sexual Behavior 2022, but determined that an independent study would be needed. The officials said that this independent study should be completed in late 2023, and they plan to draft updates to relevant guidance based on the findings from this study by September 2024. DHA officials stated that they are revising their guidance on health care management for patients associated with sexual assault and estimated that the revised guidance would be issued by mid-2023. DHA officials told us that they have discussed the possibility of prioritizing behavioral health care appointments for those disclosing unwanted sexual behavior but that, given current behavioral health provider shortages, they are considering the practicality of such a recommendation. The officials stated that because DHA implements DOD policy, they also are considering whether such guidance should be a practice recommendation or policy. Until DHA considers modifying its guidance on health care management for patients who have experienced sexual assault to clarify when and how medical care appointments should be prioritized, while allowing them to effectively care for victims of all types of trauma, providers will continue to use ad-hoc approaches to prioritize patients' care that may not align with DOD policy. Further, without considering modifications to make service members who have experienced sexual harassment eligible for priority care, the department may be missing opportunities to more efficiently deliver care related to unwanted sexual behavior. Service Members Have Limited Active-duty service members who have experienced unwanted sexual Confidential Access to VA behavior have limited confidential access to VA behavioral health care Behavioral Health Care for services, which may prevent some service members from seeking Experiences with Unwanted necessary care. As previously discussed, in 2014, DOD and VA were Sexual Behavior authorized to work together to allow service members to obtain care for experiences with unwanted sexual behavior at any VA facility without a referral from DOD. 92 Using this authorization, DOD and VA established a process that allows service members (active-duty, Guard, and reserve) to obtain confidential, non-medical readjustment counseling services without 92Congress authorized VA provision of care for experiences with unwanted sexual behavior to current service members in 38 U.S.C. §1720D(a)(2). Page 44 GAO-23-105381 Unwanted Sexual Behavior a referral at VA Vet Centers for an experience with unwanted sexual behavior, which would not be shared with DOD. 93 However, a similar process was not established to allow these service members to access the longer-term medical behavioral health care administered by providers at VA medical centers and outpatient clinics without a referral. While active-duty service members may seek emergency care related to unwanted sexual behavior at any VA facility without a referral, they must obtain a referral that includes TRICARE authorization from a DOD provider in order to receive non-emergency care at a VA medical center or clinic for experiences with unwanted sexual behavior. According to DOD officials, this is consistent with the process for most non-emergent health care services that service members seek outside of direct care. Active-duty service members who have experienced unwanted sexual behavior and avail themselves of these services would have their patient records shared with DOD. 94 According to VA officials, service members seeking non-emergency VA care without a DOD referral may be doing so with the expectation of confidentiality, and VA's position is that this authority should be implemented in a way that fully protects confidentiality of the service member seeking care. VA officials said that this is crucial to maintaining patient trust and preserving service members' sense of VA as a source of help, not only during their service but also after transitioning to becoming a veteran. VA behavioral health providers emphasized that treating veterans who experienced unwanted sexual behavior requires alliance building with the veterans because such experiences cause individuals to 93According to the Independent Review Commission, there are 300 VA Vet Centers at which active-duty service members can currently seek non-medical care related to unwanted sexual behavior confidentially and without a referral. Independent Review Commission, Hard Truths and the Duty to Change. 94Department of Veterans Affairs and Department of Defense Joint Executive Committee Fiscal Year 2020 Annual Report, Military Sexual Trauma: Transition of Health Care and Assistance with Disability Claims. Page 45 GAO-23-105381 Unwanted Sexual Behavior distrust people who should have helped them, such as their chain of command or fellow active-duty service members. 95 DOD guidance states that DOD's Sexual Assault Prevention and Response program shall focus on doing what is necessary and appropriate to support victim recovery. Moreover, it states that Surgeons General of the military departments shall establish processes and procedures to coordinate timely access to emergency, follow-up, and specialty care that may be provided in the direct or civilian purchased care sectors for eligible beneficiaries of the Military Health System. 96 Additionally, the Independent Review Commission on Sexual Assault in the Military recommended in 2021 that DOD authorize service members who have experienced unwanted sexual behavior confidential access to the full spectrum of VA care without a referral. 97 The Commission also stated that any risks to mission and deployment readiness could be mitigated by ensuring service members are aware of their responsibility to proactively communicate about these potential concerns with their sexual assault response coordinator, victim advocate, commander, or DOD provider as necessary when determinations about fitness for duty or 95According to one director, veterans who experienced unwanted sexual behavior express the feeling that they do not know who they can trust, and they tend to express feelings of isolation from people they should have been able to trust. This is because individuals who experienced unwanted sexual behavior in the military say they do not know who the enemy is-it could be a fellow service member who should have been their teammate who committed the assault or leadership who turned the other way instead of supporting them when they disclosed an experience with unwanted sexual behavior. 96DOD Instruction 6495.02, Vol. 1. DOD Instruction 6310.09, which DOD officials said is the overarching guidance for the health care management of sexual assault, does not address obtaining care in the private sector, other than access to sexual assault medical forensic examinations. DOD Instruction 6310.09, Health Care Management for Patients Associated with a Sexual Assault (May 7, 2019). 97Independent Review Commission, Hard Truths and the Duty to Change. Access to behavioral health services at the VA is not the only possible option to provide confidential care opportunities to service members, as options like private sector care are also available. However, if DOD implements this recommendation, there would be 171 VA medical centers and 1,112 community-based outpatient clinics nationwide at which active- duty service members could confidentially seek higher-level medical behavioral health care and other care related to unwanted sexual behavior without a referral. The Independent Review Commission also highlighted that a benefit of increased access to VA care could also offer active-duty service members enhanced opportunities to receive needed care virtually, which can help address barriers to seeking care. Page 46 GAO-23-105381 Unwanted Sexual Behavior deployability must be made. 98 Moreover, the Commission stated that victims need options outside of the military community where they can obtain support, services, and, privacy that they may be unable to preserve through sexual assault prevention and response program services. 99 According to DOD officials, the Sexual Assault Advisory Group created a Plan of Actions and Milestones in January 2022 that was approved by the Under Secretary of Defense for Personnel and Readiness to explore the Commission's recommendation. Specifically, the officials stated that the department would explore the feasibility of allowing active-duty service members full access to VA services without a referral, whether such access mitigates stigma associated with help-seeking, and the extent to which such access would adversely impact the military services' ability to receive readiness-impacting feedback from VA health care providers. 100 The officials said that they have completed three of the seven milestones as they work toward an established deadline of January 31, 2026. However, the remaining steps in the plan are to conduct focus groups and draft and submit a report with recommendations for reducing stigma and facilitating metal health help seeking and retention. The plan ends with the January 2026 deadline for the creation of another plan of actions and milestones to execute recommendations from the report. Officials told us that this would not be the date for completing actions to address the 98Independent Review Commission, Hard Truths and the Duty to Change. DOD guidance states that service members have a responsibility to report medical issues (including physical, dental, and mental/behavioral health) that may affect their readiness to deploy, ability to perform their assigned mission, or fitness for retention in military service to their chain of command. DOD Instruction 6025.19, Individual Medical Readiness Program (July 13, 2022). Additionally, a recent RAND Corporation study suggested that retention might be higher when care is delivered in a way that is in line with patient preferences. The RAND study also reported that developing a trusting relationship with providers was important for service members both accessing and remaining in care, with individuals expressing concerns about the sensitivity, compassion, and reactions of providers. RAND Corporation, Sexual Harassment and Sexual Assault in Military Settings: A Review of Associated Mental Health Conditions, Treatments, and Access to Care (Santa Monica, CA: 2023). 99Independent Review Commission, Hard Truths and the Duty to Change. 100The Sexual Assault Advisory Group consists of senior psychological health and sexual assault subject matter experts from the Office of the Assistant Secretary of Defense for Health Affairs, DHA, the Sexual Assault Prevention and Response Office, and the military services. It advises senior DOD leaders on matters related to the mental health needs of service members who disclose sexual assault. Page 47 GAO-23-105381 Unwanted Sexual Behavior Commission's recommendation and providing service members with access to VA services without a referral. 101 Although the Commission's recommendation is under consideration, DOD officials stated that they do not believe that allowing service members access to the full spectrum of VA care without a referral is the best option to facilitate help-seeking or address stigma, because they believe this avenue was thoroughly explored previously and resulted in the current process. 102 As a result, it is unlikely that DOD will implement the Independent Review Commission's recommendation as written. Instead, the officials said that DOD is completing a thorough study, as described in its plan of actions and milestones, that will ensure an appropriate course of action is identified. DOD officials also raised concerns generally about service members accessing care at VA. According to DOD officials, there is a distinction between DOD's and VA's missions, in that the Veterans Health Administration is a health care organization while DOD is a security organization with a health care component that has to balance fitness for duty, deployability, and readiness. For example, the officials said that allowing active-duty service members to confidentially obtain more extensive care provided at VA medical centers and outpatient clinics, which may include the administration of prescription medicine, limits commanders' awareness of psychological or medical conditions and treatments that may affect mission and deployment readiness. 103 However, a 2021 RAND study found that access to high-quality, effective behavioral care is essential because behavioral health conditions are the 101According to DHA officials, a number of milestones have already been completed ahead of schedule, including identifying key stakeholders and completing a literature review on barriers to seeking mental health care for sexual assault victims. However, other milestones-such as organizing focus groups, producing a report with findings and recommendations, submitting the report to senior leadership for approval, and creating the second Plan of Actions and Milestones for execution-will not all be completed until January 31, 2026. 102As part of the prior exploration of this issue, DOD and VA officials said that they considered three compromise options, and that these options were found to insufficiently address each department's concerns. 103Activeduty service members are required to receive preauthorization for all non- emergent care provided outside the military medical treatment facility, except for cases of medical emergency or for service members assigned to remote locations. 32 CFR §199.16(d)(2) and (e). Page 48 GAO-23-105381 Unwanted Sexual Behavior second most common medical reason for service members not being ready to deploy. 104 In addition, the Independent Review Commission stated that when the stigma of behavioral health impedes a victim's ability to get care, their mental health may worsen to the point where it negatively impacts their careers, relationships, and their physical health, not to mention military readiness. Readiness could be improved if service members had more opportunities to access care. DOD officials further explained their concerns about allowing service members to obtain care at VA medical centers and clinics without a referral, stating that medical providers would also be unaware of care provided, and this would create risks for individual patient safety. DOD officials stated that VA providers are not trained in assessing fitness for duty and that VA does not provide feedback to DOD regarding symptom severity and functioning that directly affects readiness. DOD officials also said that service members can always access VA care with a referral, consistent with current processes for most non-emergent care outside a military medical treatment facility. However, DOD's concerns about its medical providers being unaware of care provided would be just as applicable to care provided by civilian providers where service members did not obtain a referral through DOD. Moreover, even when DOD provides a referral to private sector care, we have previously reported that DOD's information about specialty care referrals is not always complete or accurate. 105 Further, service members may not want to seek care at a DOD facility or get a referral from DOD to get care at VA because of confidentiality concerns. For example, a 2018 Defense Personnel and Security 104RAND, Readiness of Soldiers and their Adult Family Members Who Receive Behavioral Health Care (Santa Monica, CA: 2021). 105We made two recommendations to DOD, and DOD concurred with both of these recommendations. DOD had not yet taken action to implement these recommendations as of April 2023. GAO, DOD Health Care: Improvements Needed for Tracking Coordination of Specialty Care Referrals for TRICARE Prime Beneficiaries, GAO-19-488 (Washington, D.C.: June 12, 2019). Similarly, an Army SHARP official stated that DOD does not receive follow up information from those private sector providers to know what treatment was provided to the service member. According to DHA officials, managed care support contractors are not required to obtain clinical information from private sector care network providers or provide clinical information to the military medical treatment facility. Instead, they facilitate transfer of clinical information from private sector network providers to direct care system facilities by educating the private sector providers on the need to return clinical information whenever there is a referral from the military medical treatment facility. Page 49 GAO-23-105381 Unwanted Sexual Behavior Research Center report found that service members' lack of confidentiality in some of the behavioral health programs currently available was a common barrier to care. 106 While the content of an individual's appointment is protected by the Health Insurance Portability and Accountability Act, the fact that someone is scheduling and attending appointments generally would not be. The report explained that this presents a barrier because service members may not want their command to know that they have appointments scheduled with a behavioral health provider. The Independent Review Commission reported that seeking services within the installation gates introduces the potential for loss of privacy, making access to civilian services a critical option. The Commission stated that many victims wanted access to services but did not seek them out for fear that others might discover what happened to them. Service members concerned about confidentiality who do not choose to seek treatment through DOD may choose to obtain care in the private sector, and some may choose to do so without any referral from DOD. For example, DOD's 2014 Survivor Experience Survey found that 11 percent of respondents sought care at a civilian mental health treatment facility. 107 Based on our analysis and the work of the Independent Review Commission, we believe that modifications to DOD's planned study as it is currently envisioned may better position it to produce an alternative. Such an alternative that would provide confidential access to behavioral health resources with an existing large network of providers qualified to treat trauma associated with unwanted sexual behavior in the military environment. As a result, adjustments to the study's scope could help DOD consider how best to enable service members to confidentially access services and better facilitate implementation of the Commission's recommendation to the maximum extent feasible. For those circumstances or populations in which complete confidentiality would not 106Defense Personnel and Security Research Center, Mental Health and Help-Seeking in the U.S. Military: Survey and Focus Group Findings (July 2018). DOD officials said that DOD and VA are working to address requirements in the James M. Inhofe National Defense Authorization Act for Fiscal Year 2023 to help eliminate stigma associated with obtaining mental health care services and to further encourage service members to seek help. Among other things, the Act establishes requirements related to confidentiality regarding the request and receipt of mental health care services by service members. Pub. L. No. 117-263 § 704 (2022). 107Defense Research, Surveys, and Statistics Center, 2014 Survivor Experience Survey (October 2014). Page 50 GAO-23-105381 Unwanted Sexual Behavior be feasible, the study could help identify and consider approaches that would balance confidentiality with competing mission needs, such as guidelines for sharing information about service members' medications and treatment with appropriate DOD officials in the event that their treatment is deemed as compromising their ability to carry out responsibilities or poses a credible risk to their individual safety or the safety of others, or could otherwise affect readiness. 108 Removing as many potential barriers to care as possible will provide service members with more choices and options to access confidential care, to the greatest extent feasible. Until DOD implements the Commission's recommendation allowing service members to access care at all VA facilities without a referral, some service members may not seek behavioral health care for experiences related to unwanted sexual behavior, which could negatively affect their mental and physical health, and readiness. Programs that Transition Service members who qualify for VA care solely related to an experience Service Members to VA Care with unwanted sexual behavior after they separate from the military may May Miss Opportunities to Help not be consistently informed through transition programs about their Those Solely Eligible for VA eligibility for, and access to, such care after they separate from the Care Related to Unwanted military if they did not report their experience to DOD. Service members Sexual Behavior who are generally ineligible for VA care after separating from the military may still receive care from VA for an experience with unwanted sexual behavior. 109 However, these service members do not consistently receive the transition assistance that is provided to those eligible for all types of VA care. This is due to coordination challenges between DOD and VA personnel when implementing established transition programs that may 108See, e.g., DOD Instruction 6490.08, Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members (Aug. 17, 2011). This instruction establishes DOD policy that health care providers shall follow a presumption they are not to notify a service member's commander when the service member obtains mental health care or substance abuse education services, unless the presumption is overcome by one of the notification standards listed in the instruction. 109According to Veterans Health Administration Directive 1115(1), 38 U.S.C. § 1720D(a)(1) authorizes VA to provide care related to unwanted sexual behavior to certain former members of the Armed Forces. Care related to unwanted sexual behavior is not subject to the minimum active-duty service requirement set forth in 38 U.S.C. § 5303A; veterans may therefore be able to receive care related to unwanted sexual behavior even if they are not eligible for VA health care under other treatment authorities. Page 51 GAO-23-105381 Unwanted Sexual Behavior not ensure that service members with more limited VA care eligibility receive similar levels of transition assistance. VA policy specifies that ill or injured active-duty service members and veterans transitioning into the VA health care system receive transition assistance and care coordination. Specifically, VA guidance requires VA Liaisons for Healthcare, among other responsibilities, to identify active- duty service members and veterans ready for discharge to VA and to obtain clear referral information and authorization for VA to treat those still on active-duty. The guidance also requires VA Liaisons for Healthcare to link active-duty service members and veterans with appropriate providers and resources across the care setting, and to ensure that VA and DOD facility points of contact are connected and able to communicate and collaborate regarding the transition. 110 Three programs are available to help transition active-duty service members from DOD to VA care: (1) DOD inTransition Program, (2) DOD Transition Assistance Program, and (3) VA Liaisons for Healthcare. Each of these programs is generally tasked with connecting service members with available VA resources, such as behavioral health care services. However, we identified missed opportunities to connect those service members with more limited VA care eligibility to available behavioral health care services, as described in table 1. 110VA Veterans Health Administration Directive 1011, Department of Veterans Affairs Liaison for Healthcare Serving Military Treatment Facilities and Public-Private Partnerships (May 9, 2022). Page 52 GAO-23-105381 Unwanted Sexual Behavior Table 1: Programs that Help Service Members Separating from the Military Transition Their Health Care Benefits from DOD to VA Program Description Missed opportunity inTransition Defense Health Agency program that is free, inTransition officials said that coaches do voluntary, and confidential for all active-duty service not regularly include resources on the DOD members and veterans and assists in transitioning Family Advocacy Program, sexual assault behavioral health care between the Military Health prevention and response program, and System, VA providers, or community programs. Equal Opportunity program in their outreach According to officials, inTransition program coaches to service members. are trained to recognize trauma related to unwanted sexual behavior and understand what DOD and VA resources are available. Transition Assistance Program DOD program that prepares separating active-duty DOD and VA personnel informed us that service members for post-military life. According to active-duty service members may not seek officials, this program provides a mandatory 1-day VA VA care even after receiving the mandatory benefits briefing that includes information on VA care one-day VA benefits briefing because they related to unwanted sexual behavior. do not fully understand their eligibility for care or documentation required to receive such care, which could be addressed through the briefing.a VA Liaisons for Healthcare VA program placing liaisons at designated DOD Some VA Liaisons for Healthcare said they installations, military treatment facilities, or public- do not regularly coordinate with DOD sexual private partnerships that coordinate the transition of assault prevention and response, Family health care of wounded, ill, or injured active-duty Advocacy, or Equal Opportunity program service members or veterans into the VA health care personnel. system Source: GAO analysis of Department of Defense (DOD) and Department of Veterans Affairs (VA) documentation and interviews. | GAO-23-105381 a Service members may not seek VA care for a variety of reasons, including active-duty service members who may believe they cannot seek VA care related to unwanted sexual behavior without proof of the incident or prior related care received; and active-duty service members may believe they are ineligible for VA care related to unwanted sexual behavior because they are ineligible for other VA benefits. For example, sexual assault prevention and response program personnel at some of the installations in our review reported differing levels of coordination with Veterans Health Administration military sexual trauma coordinators when transitioning care for separating active-duty service members. Specifically, sexual assault prevention and response program personnel stated that they developed good relationships with the local VA facility and military sexual trauma coordinators. DOD officials said that not all service members may want or need to transition care related to experiences with unwanted sexual behavior from DOD to VA. However, only one of the DOD sexual assault prevention and response program personnel we spoke with had any experience working with a VA military sexual trauma coordinator in transitioning care for separating active-duty service members, which could indicate that not all service members receive the same level of assistance and care coordination. Page 53 GAO-23-105381 Unwanted Sexual Behavior At another installation, sexual assault prevention and response personnel noted that there is significant turnover among military sexual trauma coordinators, which affects their ability to maintain current contact information for those serving in these positions. As a result, these personnel stated that it can be difficult to connect a service member with a coordinator, thus potentially delaying critical care. VA officials told us that the degree of coordination between sexual assault response coordinators and VA military sexual trauma coordinators varies, and VA officials have tried to encourage those links. The officials stated that the referral process is a challenge they are addressing with DOD, and they are working to better publicize the VA Liaisons for Healthcare. The officials said that if no one knows the liaisons exist, then it is hard to go to the next step to engage personnel in the right services. According to DOD officials, DOD and VA are already working to increase collaboration through the Joint Executive Committee Sexual Trauma Working Group, and they identified two initiatives that are underway. First, the officials said that DOD and VA have completed collaboration on posters that will be posted throughout DOD installations and will contain information on available VA services. Second, the officials discussed a handout that DOD and VA are developing with information about VA medical and mental health care for experiences with unwanted sexual behavior, which will be provided to all service members at the separation health assessment. 111 These are steps that could help address this need once they are completed. However, until such steps are completed to help ensure that service members who are only eligible for VA care for an experience with unwanted sexual behavior receive the appropriate information as they transition from DOD to VA care, some service members may not be aware of or receive critical care for which they are eligible. Further, given that some DOD personnel told us that active-duty service members who experience unwanted sexual behavior are at higher risk for suicide during the transition period following separation from the military, it is essential that DOD and VA work to connect all interested active-duty service members with available resources. 111This handout is discussed in more detail later in this report. Page 54 GAO-23-105381 Unwanted Sexual Behavior VA and DOD differ in their approach to monitoring data on behavioral VA and DOD Differ in health care related to experiences with unwanted sexual behavior, and Their Approach to neither can ensure that the care they provide for such experiences is confidential. Specifically, service members' health records are not Monitoring Data on sufficiently controlled in the Military Health System's (MHS) GENESIS- Behavioral Health DOD's electronic health record-to ensure confidentiality and privacy. In addition, providers at VA medical centers and community-based Care Related to outpatient clinics cannot provide care to active-duty service members for Unwanted Sexual experiences with unwanted sexual behavior that is confidential from DOD because those facilities use an electronic health records system that Behavior, and Cannot shares data with DOD. Finally, active-duty service members who Ensure Confidentiality experience trauma from experiences with unwanted sexual behavior may face challenges filing a VA disability claim or receiving benefits due to inconsistent documentation in MHS GENESIS, which can make it difficult to connect behavioral health care and experiences with unwanted sexual behavior. VA and DOD Differ in Their VA's and DOD's approaches to monitoring data on behavioral health care Approach to Monitoring for experiences with unwanted sexual behavior differ. Specifically, VA monitors behavioral health care data related to experiences with Data on Behavioral Health unwanted sexual behavior and generally knows how many former service Care for Experiences with members receive these services. DOD monitors all behavioral health Unwanted Sexual outcomes, but does not specifically analyze behavioral health care for Behavior conditions related to experiences with unwanted sexual behavior. VA monitors data on screening, referrals, and services provided at medical centers and community-based outpatient clinics to former service members who have experienced unwanted sexual behavior. VA program guidance for addressing unwanted sexual behavior, which covers VA medical facilities and community-based outpatient clinics, states that the Office of Mental Health and Suicide Prevention is to assist with program monitoring nation-wide. 112 This office produces several reports that it uses to monitor care provided for experiences with unwanted sexual behavior at medical centers and community-based outpatient clinics. These reports include the following: • Patients who Received Outpatient Care in Most Recent 12 Months and Were Ever Screened for Military Sexual Trauma. Updated weekly, this report provides information, broken out by region and facility, on the total number and percentage of patients seen who 112Veterans Health Administration Directive 1115(1). Page 55 GAO-23-105381 Unwanted Sexual Behavior have ever been screened for trauma related to unwanted sexual behavior in a fiscal year. It also shows the total number and overall percentage of patients who have been screened for experiences with unwanted sexual behavior whose most recent screen is positive. • Follow-up for Patients Requesting a Referral to Military Sexual Trauma-Related Care. Updated daily, this report provides information, broken out by region and facility, on the patients who did and did not complete a behavioral health visit related to unwanted sexual behavior after being positively screened for related trauma and requesting a referral for services. • Military Sexual Trauma-Related Outpatient Care Report. Updated weekly, this report provides information, broken out by region and facility, on patients who screened positively for an experience with unwanted sexual behavior and received related outpatient care. The report includes the number and percentage of patients who received outpatient care for exposure to unwanted sexual behavior, as well as the outpatient encounters these patients received for these experiences during the reporting timeframe. While DOD monitors a variety of behavioral health issues to identify trends and assess patient outcomes, it does not regularly monitor behavioral health care trend or outcome data for experiences with unwanted sexual behavior because such monitoring is not required. DOD officials said that all behavioral health outcomes are monitored, but they do not flag or analyze separately behavioral health care specific to experiences with unwanted sexual behavior. Specifically, DOD officials said that DHA uses a behavioral health data portal to monitor certain outcomes data, and these data are reported in a dashboard. The officials said that DHA also has a survey to monitor patient satisfaction with care. The officials stated that these tools do not identify trends or assess patient outcomes specific to experiences with unwanted sexual behavior. DOD officials expressed concerns that collecting data regarding a highly underreported crime would be difficult and could give an inaccurate or incomplete picture due to the number of people who choose not to disclose an incident. Moreover, officials expressed concerns over data collection potentially creating barriers to those seeking care if service members are worried about privacy and see such an effort as surveillance. As discussed later in this report, DOD providers do not consistently document that the behavioral health care they have provided to an active- duty service member is related to an experience with unwanted sexual Page 56 GAO-23-105381 Unwanted Sexual Behavior behavior. According to our analysis of documented care in the DOD and VA electronic health records and DOD incident data, of the 28,328 active- duty service members who filed at least one unrestricted or formal report to DOD of unwanted sexual behavior during fiscal years 2015 to 2021, 26 percent (7,264) received related behavioral health care through DOD or VA during that time period (see fig. 9). 113 DOD and VA electronic health records did not indicate any behavioral health care documented as related to unwanted sexual behavior during these fiscal years that DOD or VA may have provided to the other 21,064 (74 percent) active-duty service members who made unrestricted or formal reports of an experience of unwanted sexual behavior to DOD. 114 The number of service members who received DOD behavioral health care documented as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed later in this report. 113The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. 114The Independent Review Commission reported that victims of unwanted sexual behavior have noted barriers to accessing behavioral health care, including but not limited to difficulty getting time off work, stigma about attending mental health appointments on base in uniform, fear about career repercussions, lack of knowledge about available resources, feeling overwhelmed by the process of having to seek appropriate care, and challenges in maintaining continuity of care during transitions such as permanent changes of station. Independent Review Commission on Sexual Assault in the Military, Hard Truths and the Duty to Change. Page 57 GAO-23-105381 Unwanted Sexual Behavior Figure 9: Number of Service Members Who Reported an Experience with Unwanted Sexual Behavior to DOD and Received Behavioral Health Care that Was Documented by DOD or VA, Fiscal Years 2015–2021 Note: Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without such treatment being identified in Department of Defense (DOD) medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. The number of service members who received medical behavioral health care identified as related to unwanted sexual behavior is likely undercounted, because of DOD's inconsistent care documentation practices, discussed later in this report. According to Department of Veterans Affairs (VA) officials, the number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. DOD and VA Cannot Ensure Confidential Care for All Victims of Unwanted Sexual Behavior DOD's Electronic Health Access controls for service members' health records in MHS GENESIS- Record System Does Not DOD's electronic health record system-do not ensure confidentiality and Ensure Information privacy of all sensitive information, such as allowing confidential Confidentiality and Privacy for designations or allowing access restrictions for care provided for Victims of Unwanted Sexual Behavior Page 58 GAO-23-105381 Unwanted Sexual Behavior unwanted sexual behavior. 115 MHS GENESIS has the capability for DOD to establish up to seven different levels of access as a way to limit access to service members' medical records and to protect their confidentiality. For example, level two access, "restrictive: assault/abuse," was assigned to certain users, such as behavioral health and emergency department staff, and level three access, "legal," was assigned to information management and legal personnel. However, in 2020, a working group made up of DOD and VA personnel agreed to an "Open Chart Access" policy. According to DHA officials, this policy allows all DOD users of MHS GENESIS, except for the Health Information Manager, to have the same access to all service members' medical records in MHS GENESIS-regardless of whether the user has an established provider- patient relationship or a need to know. The memorandum related to this agreement noted that maintaining all encounters at the same level of access regardless of sensitivity would ensure that clinically relevant data are available to all clinicians at the point of care. 116 Despite the agreement for broad access rights for patient records, DOD providers also stated that privacy concerns influence how comprehensively they document care. 117 Specifically, 12 DOD care providers told us that concerns about the confidentiality of medical records in MHS GENESIS affect how they document care that they provide or recommend for active-duty service members who experience unwanted sexual behavior. For example, two behavioral health providers 115DOD began the deployment of MHS GENESIS in 2017 and is expected to complete deployment in December 2023. We have previously reported about DOD's implementation of MHS GENESIS. See GAO, Electronic Health Records: Additional DOD Actions Could Improve Cost and Schedule Estimating for New System, GAO-22-104521 (June 8, 2022). We made two recommendations to DOD in this report, and DOD concurred with both of these recommendations. DOD had not yet taken action to implement these recommendations as of April 2023. See also GAO, Electronic Health Records: DOD Has Made Progress in Implementing a New System, but Challenges Persist, GAO-21-571 (Sept. 20, 2021). In this report, we made three recommendations to DOD, and DOD concurred with these recommendations. As of April 2023, DOD had not yet taken action to implement these recommendations. 116DOD and VA Memorandum for Record, Access and Restrictions to Information within the Joint Electronic Health Record (EHR) of the Department of Veterans Affairs (VA) and the Department of Defense (DOD) (Aug. 12, 2020). 117According to DOD officials, MHS GENESIS has a form with specific pages for behavioral health providers to identify and document (1) trauma and abuse, (2) military trauma, and (3) domestic violence. These pages include both check boxes, radio buttons, and free text comment fields that support the documentation of physical, sexual, emotional, neglect, and exploitation issues, among others. Page 59 GAO-23-105381 Unwanted Sexual Behavior said that due to their concerns over patient confidentiality in MHS GENESIS, they feel the need to use generic code words, such as "interpersonal," to document care provided for experiences with unwanted sexual behavior. A primary care provider said that some military treatment facilities rely on paper charts when it comes to reported cases of sexual assault due to providers' privacy and confidentiality concerns with MHS GENESIS privacy, which likely reduces the amount and detail of documentation regarding sexual assault that providers include in the electronic medical record. In addition, some DOD providers told us they have concerns about the effect such access may have on a patient's ability to receive confidential and private care-in particular, those who had experienced unwanted sexual behavior. 118 For example, four providers explained that medical personnel who may not have a need to know, such as corpsmen, have the same access to medical records of the enlisted peers with whom they live and work as do specialists such as a clinical psychiatrist, who would be more likely to have a need to know. These providers further described a scenario in which a medical provider or health care staff member could subject a fellow service member to unwanted sexual behavior and then easily look up that member's medical record to see if they had disclosed the incident. According to DHA officials, removing restrictions on provider access to service members' records in MHS GENESIS helps balance continuity of care and service member privacy, while restricting it would limit a provider's access to information needed to provide timely treatment to a patient and thus potentially pose a risk to their safety and health. For example, these officials stated that if service members' records were completely private, a provider may not have access to the patient's current list of medications and could inadvertently prescribe medication that produces a negative interaction. DHA officials also cited providers' compliance with the Health Insurance Portability and Accountability Act of 1996 as another way that they minimize the risk of providers inappropriately accessing active-duty service members' medical records, stating that unauthorized access of medical records is a medical provider 118Arecent RAND Corporation study reported that service members expressed concerns about the confidentiality of military health records, how the information might be used, and whether it could have a negative impact on a service member's career. RAND Corporation, Sexual Harassment and Sexual Assault in Military Settings. Page 60 GAO-23-105381 Unwanted Sexual Behavior issue of compliance with this act and not an issue with how MHS GENESIS functions. 119 Further, DHA officials told us that there are two MHS GENESIS functionalities intended to protect active-duty service members' privacy: an audit log that tracks access to service member medical records, and a behavioral health note type. However, the officials said that the agency does not use the audit log to regularly monitor whether active-duty service members' medical records are being inappropriately accessed. Additionally, they stated that while the behavioral health note type does not publicize information on the patient portal or health information exchange, it does not restrict other providers' access. 120 DOD guidance states that DOD must foster the development and expansion of health information system interoperability, the electronic exchange of protected health information, and electronic health record system development and policy in a manner that provides reasonable safeguards for the confidentiality, integrity, and availability of protected health information created, received, maintained, or transmitted through electronic media. 121 In addition, the National Institute of Standards and Technology's Security and Privacy Controls for Information Systems and Organizations states that federal information security programs are responsible for protecting information and information systems from unauthorized access, use, disclosure, disruption, modification, or 119Pub. L. No. 104-191 (Aug. 21, 1996) (codified as amended in scattered sections of the United States Code). In commenting on a draft of this report, DOD officials noted that MHS GENESIS system end users are required to abide by the Health Insurance Portability and Accountability Act Privacy Rule, which addresses the use and disclosure of protected health information. Among other things, the privacy rule and associated guidance discussing the rule states that the covered entity's policies and procedures must identify the persons or classes of persons within the covered entity who need access to the information to carry out their job duties, the categories or types of protected health information needed, and conditions appropriate to such access. The guidance provides as an example that hospitals may implement policies that permit doctors, nurses, or others involved in treatment to have access to the entire medical record, as needed, but that where the entire medical record is necessary, the covered entity's policies and procedures must state so explicitly and include a justification. 120Accordingto DHA officials, this is a note that behavioral health providers can use to document patient information in MHS GENESIS. 121DOD Instruction 6025.18, Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule Compliance in DOD Health Care Programs (Mar. 13, 2019). Page 61 GAO-23-105381 Unwanted Sexual Behavior destruction to provide confidentiality, integrity, and availability. 122 These standards also provide that organizations should employ the principle of least privilege, allowing only authorized accesses for users that are necessary for accomplishing assigned organizational tasks. The standards state that organizations consider the creation of additional processes, roles, and accounts as necessary to achieve least privilege, and apply least privilege to the development, implementation and operation of organizational systems. However, MHS GENESIS, as currently implemented by DOD, does not effectively balance service member privacy with the timely provision of care because DOD has not adopted information security best practices to limit health record access to those with a provider-patient relationship or a need to know. Specifically, the decision to allow all DOD users of MHS GENESIS to have the same level access to all service members' medical records appears to be contrary to the principle of least privilege. The 2020 memorandum related to the access decision states that level two access, "restrictive: assault/abuse," would be inactivated. However, in a prior agreement reached by a DOD and VA working group that evaluated policy related to the joint electronic health record, the group noted concerns about documentation of treatment for unwanted sexual behavior, stating that this information was particularly sensitive and should have heightened access control. 123 Without adopting information security best practices, such as the principle of least privilege, for MHS GENESIS to limit health record access to those with an established provider-patient relationship or a need to know, DOD cannot ensure the confidentiality of active-duty service members' data and provide assurance that those who have experienced unwanted sexual behavior are afforded privacy and protection from offenders. 122National Institute of Standards and Technology, Security and Privacy Controls for Information Systems and Organizations, Special Publication 800-53, Revision 5 (Gaithersburg, MD: September 2020). 123DOD and VA Memorandum for Record, Access and Restrictions to Information within the Joint Electronic Health Record (EHR) of the Department of Veterans Affairs (VA) and the Department of Defense (DOD) (Aug. 12, 2020), and DOD and VA Memorandum for Record, Access and Restrictions to Information within the Joint Electronic Health Record (EHR) of the Department of Veterans Affairs (VA) and the Department of Defense (DOD) (June 21, 2019). Page 62 GAO-23-105381 Unwanted Sexual Behavior VA Cannot Ensure the Providers at VA medical centers and community-based outpatient clinics Confidentiality of Active-Duty cannot provide care to active-duty service members for experiences with Service Members Seen in unwanted sexual behavior that is confidential from DOD, because those Medical Centers and facilities use an electronic health records system that shares data with Community-Based Outpatient DOD. 124 Conversely, VA Vet Centers offer confidential care to all clients Clinics and utilize an electronic health record system that does not share data with DOD. 125 VA providers we spoke with noted that the extent to which care is confidential can be a barrier to seeking treatment for an experience with unwanted sexual behavior. Specifically, these providers stated that service members worry that VA will share information with DOD that could jeopardize their career, such as being removed from their position or separated from the military. VA military sexual trauma coordinators also noted confidentiality concerns as a barrier to care. They said that to provide care that is truly confidential to active-duty service members who 124VA relies on patient data from DOD to help ensure that it has access to necessary health information that could assist clinicians in making informed decisions to provide care to service members transitioning from DOD to VA's health care system. VA's old electronic health records system and its new system both share data with DOD. VA's old system, the Veterans Health Information Systems and Technology Architecture, shares information with DOD through the Joint Legacy Viewer, which allows Veterans Health Administration and Veterans Benefits Administration users to view the records of DOD- only patients, although VA requires that such actions be audited. Department of Veterans Affairs Office of Information and Technology, Joint Legacy Viewer (JLV) 2.9 User Guide, Version 1.3 (September 2020). VA began the process of replacing its old electronic health record system in 2017 with the same system as DOD. VA decided to acquire the same system as DOD because it would allow all of VA's and DOD's patient data to reside in one system, thus assisting the departments in their goals of enabling seamless care between VA and DOD. We have previously reported about VA's implementation of its new electronic health record system. See GAO, Electronic Health Record Modernization: VA Needs to Address Change Management Challenges, User Satisfaction, and System Issues, GAO-23-106685 (Mar. 15, 2023). We made ten recommendations to VA, and VA concurred with these recommendations. See also GAO, Electronic Health Records: VA Has Made Progress in Preparing for New System, but Subsequent Test Findings Will Need to Be Addressed, GAO-21-224 (Feb. 11, 2021). We made two recommendations to VA in this report, and VA concurred with both of these recommendations. As of April 2023, VA had not taken steps to implement these recommendations. See also GAO, Electronic Health Records: Ongoing Stakeholder Involvement Needed in the Department of Veterans Affairs' Modernization Effort, GAO-20-473 (June 5, 2020). In this report, we made one recommendation to VA, and VA concurred with the recommendation. VA had not taken steps to implement this recommendation as of April 2023. 125As discussed above, Vet Centers provide psychosocial counseling, called readjustment counseling, which is non-medical care. According to DOD officials, the non-medical counseling that DOD provides also offers confidential care to clients and does not share data with DOD electronic health records. Page 63 GAO-23-105381 Unwanted Sexual Behavior have experienced unwanted sexual behavior, they need to ensure that DOD cannot view those patient records. 126 As previously discussed, in 2021, DOD's Independent Review Commission recommended that DOD authorize all active-duty service members who have experienced unwanted sexual behavior confidential access to the full spectrum of VA care without a referral. In making the recommendation, the Commission noted that confidentiality is required in order to offer victim-centered, trauma-informed care, and that ensuring confidentiality should be a primary consideration. According to the Commission, by opening up multiple avenues by which service members are able to access confidential care and support, service members will be better able to survive and thrive. The Commission further stated that care should be provided confidentially to the fullest extent possible. This may include pursuing IT solutions in the joint VA-DOD electronic health record that can maximize confidentiality and enforcing accountability mechanisms that have been established to preserve patient privacy. 127 Regulations implementing the Health Insurance Portability and Accountability Act of 1996 include the Health Insurance Portability and Accountability Act Privacy Rule. 128 That rule establishes the minimum necessary standard, which is based on the premise that protected health information not be disclosed when it is not necessary to satisfy a particular purpose or carry out a function. The minimum necessary standard requires covered entities to evaluate their practices and enhance safeguards as needed to limit unnecessary or inappropriate access to and disclosure of protected health information. 129 However, VA providers will be unable to document care provided at VA medical centers or community-based outpatient clinics without sharing it 126VAofficials said that veterans' safety with respect to open records access, such as MyHealtheVet, is another concern. They stated that some unwanted sexual behavior happens in the context of intimate relationships with a partner who has access to the medical record, and care should be taken to ensure privacy and enhance safety. 127Independent Review Commission, Hard Truths and the Duty to Change. The Commission also noted that VA providers are more likely to have military cultural competence and training in evidence-based therapies for PTSD and other conditions that are highly prevalent among sexual assault victims. 12845 C.F.R. §§ 164.500-164.534 (2021). 12945 C.F.R. §§ 164.502(b) and 164.514(d) (2021). Page 64 GAO-23-105381 Unwanted Sexual Behavior with DOD in the future, because VA and DOD officials decided not to implement a mechanism in VA's new electronic health records system that would enable VA providers to designate information as confidential. Specifically, as discussed above, in 2020, DOD and VA agreed to an "Open Chart Access" policy, which DHA officials said allowed all DOD and VA users of MHS GENESIS to have the same access to all service members' medical records in the joint electronic health record. 130 VA officials said that VA will be transitioning to its new electronic health record system over the next 8 or more years. VA officials stated that confidentiality of care has been, and continues to be, an extensive point of discussion with DOD. They said that the outcome of these discussions is the current data sharing agreement. According to DOD officials, DOD requires knowledge of service members' medical treatment that could affect readiness, and blocking access to critical medical data could adversely impact future treatment for service members. However, the Independent Review Commission noted that these risks can be mitigated by ensuring service members are aware of their responsibility to proactively communicate about these potential concerns with their sexual assault response coordinator, sexual assault prevention and response victim advocate, commander, or military health care provider as necessary when determinations about fitness for duty or deployability must be made. 131 Under the current open access approach in the joint electronic health records systems, active-duty service members who have experienced unwanted sexual behavior will potentially be unable to obtain confidential care at any VA medical center or clinic, regardless of whether a referral from DOD is required. According to VA officials responsible for its implementation, the new system does not currently have the functionality to flag as confidential an encounter between a VA provider and a patient, or elements of an encounter, such as certain provider notes or treatment codes, because the two departments jointly determined that data sharing would improve care for service members and veterans. 132 As a result, the 130DOD and VA Memorandum for Record, Access and Restrictions to Information within the Joint Electronic Health Record (EHR) of the Department of Veterans Affairs (VA) and the Department of Defense (DOD) (Aug. 12, 2020). 131Independent Review Commission, Hard Truths and the Duty to Change. 132DOD and VA Memorandum, Access and Restrictions to Information within the Joint Electronic Health Record (EHR) of the Department of Veterans Affairs (VA) and the Department of Defense (DOD) (Aug. 12, 2020). Page 65 GAO-23-105381 Unwanted Sexual Behavior officials said that incorporating such a capability into the system would require reconsidering that foundational decision and then implementing a significant redesign. Developing and evaluating options and making a determination of the best approach for ensuring patient confidentiality in these situations will enable DOD to implement the Independent Review Commission's recommendation to authorize confidential access to all VA care without a referral. Including guidelines in these options to ensure that medications and treatment that could affect readiness would continue to be shared with DOD would help mitigate DOD's concerns about readiness. Additionally, by addressing the Commission's recommendation, DOD would increase the number and range of non-uniformed behavioral health providers available to provide confidential care to service members in person and virtually. 133 Victims of Unwanted Active-duty service members who experience trauma from experiences Sexual Behavior May with unwanted sexual behavior may face challenges filing a disability claim or receiving benefits in a timely manner due to inconsistent Face Challenges documentation in the DOD electronic health record, MHS GENESIS. Receiving Trauma-Related Active-duty service members and veterans can generally file a claim for Disability Benefits Due to disability compensation prior to or following separation from military Inconsistent service. According to the Veterans Benefits Administration's Disability Documentation of Compensation for Conditions Related to Military Sexual Trauma Fact Sheet, there are three criteria for any VA disability compensation claim to Behavioral Health Care be successful: • a current physical or mental condition that affects the body or mind; • an event, injury, or illness that happened while an individual was serving in the military; and • a link between the current disability and the event, injury, or disease that happened during an individual's military service. 133According to the Independent Review Commission, VA has 300 VA Vet Centers at which active-duty service members can currently seek non-medical care related to unwanted sexual behavior confidentially and without a referral. If DOD implements their recommendation, there would be an addition of 171 VA medical centers and 1,112 community-based outpatient clinics nationwide at which active-duty service members could confidentially seek higher-level medical behavioral health care and other care related to unwanted sexual behavior without a referral. The Independent Review Commission also highlighted that increased access to VA care could also offer active-duty service members enhanced opportunities to receive needed care virtually. Page 66 GAO-23-105381 Unwanted Sexual Behavior According to Veterans Benefits Administration officials, their internal reports comparing PTSD claims for service members and veterans who file a claim based on trauma from experiences with unwanted sexual behavior show that such claims are more likely to receive higher than average VA benefits than disability claims not based on experiences with unwanted sexual behavior. According to VA officials, Veterans Service Representatives are tasked with weighing the totality of the evidence submitted when validating a claim. However, these representatives can face challenges obtaining adequate records on behalf of the individual filing the claim. We have previously reported that processing veterans' disability claims related to an experience with unwanted sexual behavior poses challenges for VA, because many sexual assaults are not officially reported when they happen during military service. 134 In addition, officials from the Army Discharge Review Board stated that some provider encounter notes are vague, which can make it difficult for the behavioral health support to link the care to experiences with unwanted sexual behavior. 135 These officials said that it is better for providers to be thorough in their encounter notes as opposed to withholding information so that the board can make an informed decision about any connection between service member behavior and an experience with unwanted sexual behavior. Similarly, officials from the Air Force Discharge Review Board said that if a service member's military record or medical record does not contain any historical information about experiences with unwanted sexual behavior, the case 134GAO, VA Disability Benefits: Compensation Program Could Be Strengthened by Consistently Following Leading Reform Practices, GAO-22-104488 (Washington, D.C.: July 18, 2022). We made eight recommendations to VA in this report, and VA generally concurred with these recommendations. As of April 2023, VA had not taken steps to implement these recommendations. DOD and VA officials stated that, to assist VA decision makers in developing claims, they are working on a memorandum of agreement to allow VA access to DOD data on whether a victim reported an incident of unwanted sexual behavior to DOD. However, DOD officials indicated that this agreement will not provide documentation for service members who chose not to report an incident to DOD. 135Each of the military services maintains a discharge review board with authority to change, correct, or modify discharges or dismissals that are not issued by a sentence of a general court-martial. These boards may consider requests by veterans for modifications of their discharges due in whole or in part to mental health conditions, including PTSD, TBI, sexual assault, or sexual harassment. See Office of the Under Secretary of Defense for Personnel and Readiness Memorandum, Clarifying Guidance to Military Discharge Review Boards and Boards for Correction of Military/Naval Records Considering Requests by Veterans for Modification of their Discharge Due to Mental Health Conditions, Sexual Assault, or Sexual Harassment (Aug. 25, 2017). Page 67 GAO-23-105381 Unwanted Sexual Behavior can involve a lot more work because the board would need to do more research to find other pertinent evidence. DHA guidance states that it must provide standardized guidance across the military health system, including a clinical documentation improvement program, to ensure that DOD health records are relevant and complete, among other things. 136 In addition, Standards for Internal Control in the Federal Government states that management should internally communicate necessary quality information that is current, complete, accurate, accessible, and timely. 137 These standards also state that management should implement control activities through policies that include responsibilities for objectives and related risks, implementation, and operating effectiveness. DHA has issued guidance on topics related to behavioral health treatment outcomes, data analytics and evaluation, and primary care behavioral health standards. 138 While DHA officials said that they are working towards providing guidance for standardization within the electronic health record, DHA has not published guidance on how to document behavioral health care provided for experiences with unwanted sexual behavior. 139 DHA officials have stated that there is value in providing guidance on documentation of unwanted sexual behavior. Absent such guidance and given the concerns we previously discussed regarding patient confidentiality, DOD providers have taken various approaches to 136Defense Health Agency Procedural Instruction 6040.07, Medical Coding of the DOD Health Record (Mar. 8, 2021). 137GAO-14-704G. 138Defense Health Agency Procedural Instruction 6490.02, Behavioral Health (BH) Treatment and Outcomes Monitoring (July 12, 2018); Defense Health Agency Administrative Instruction 3000.01, Analytics and Evaluation (A&E) (Aug. 3, 2020); Defense Health Agency Procedures Manual 6025.01, Primary Care Behavioral Health (PCBH) Standards (Dec. 20, 2019). None of the behavioral health providers we spoke with received DOD guidance on how to document behavioral health care related to unwanted sexual behavior in active-duty service members' medical record in MHS GENESIS. 139As of February 2023, DHA officials said that the draft DOD Instruction 6310.09, Health Care Management of Patients Associated with Interpersonal Violence, proposes language on minimum documentation requirements for mental health records. According to DHA officials, this draft guidance is expected to be finalized in late 2023. However, DHA officials said that DHA is responsible for providing implementing guidance for this instruction, which it has not issued. Page 68 GAO-23-105381 Unwanted Sexual Behavior documenting such care. As discussed above, these inconsistent practices include • using code words to indicate that care is related to a "traumatic" or "interpersonal" event without specifying more detail; • not indicating at all that care is related to trauma from an experience with unwanted sexual behavior; and • using a separate, unofficial system outside MHS GENESIS to document care (e.g. compiling a separate paper file with handwritten notes). Furthermore, MHS GENESIS does not offer providers a consistent way to "tag" care provided as related to an experience with unwanted sexual behavior. DOD officials said that unwanted sexual behavior is an underreported crime in both the military and civilian populations, and that "tagging" medical records for such care could be a barrier to seeking help. DHA officials also told us that the use of flags is a legacy approach that can produce multiple flags, resulting in those flags potentially being missed or overlooked. Instead, they said that DOD's approach has been to utilize a "problem list" that includes sexual assault and associated trauma disorders. Specifically, providers may choose from dozens of pre- populated codes in MHS GENESIS to document a specific diagnosis in a standardized manner. These codes enable providers to more efficiently identify an individual with a particular diagnosis, among other things. However, not all treatments related to unwanted sexual behavior are represented in the list of available codes. For example, MHS GENESIS has a code that allows providers to document care for a confirmed initial case of adult sexual abuse. However, there are no codes to document more general or ongoing treatment provided for an experience with unwanted sexual behavior that is not associated with a specific and related behavioral health diagnosis. Officials said that DOD has no current plans to change the existing mechanism for identification of unwanted sexual behavior experiences in medical records, citing concerns related to the underreported nature of the crime, risks of identifying victims, and creating barriers to care. Without guidance on how to document behavioral health care provided for all types of unwanted sexual behavior, DOD cannot be sure that its providers are recording the information a patient would need to potentially qualify for disability benefits through VA. Moreover, incomplete or Page 69 GAO-23-105381 Unwanted Sexual Behavior imprecise health records-such as what can result from using code words, not indicating that care is related to unwanted sexual behavior, or using an unofficial system outside MHS GENESIS-could have negative implications for service members' continuity of care and transition to VA care. While DOD and VA provide some information to service members on DOD and VA unwanted sexual behavior, their trainings do not consistently provide Trainings Do Not service members with information on available VA resources. Specifically, most of the military services' annual trainings on unwanted sexual Consistently Inform behavior do not provide information about available VA resources for Service Members of active-duty service members with related experiences. In addition, DOD's Transition Assistance Program provides inconsistent information about VA Resources for VA resources for experiences with unwanted sexual behavior to Unwanted Sexual separating service members. DOD has developed sexual assault training for health care providers as well as documentation, and is developing Behavior, but DOD additional training for behavioral health care providers. This additional Has Developed training includes information on providing trauma-informed care to service members who experience unwanted sexual behavior. Medical Provider Training Most Military Service DOD has taken steps to improve the availability of information about VA Trainings Do Not Provide resources for active-duty service members who have experienced unwanted sexual behavior during military service, but this information is Information about VA not consistently communicated to all service members in military service- Unwanted Sexual level training. As previously discussed, any service member and most Behavior Resources to former service members who experienced unwanted sexual behavior Service Members while serving in the military are eligible for counseling (referred to as military sexual trauma counseling) at VA Vet Centers without a referral, as well as services at VA medical centers and outpatient clinics with a referral. 140 These resources are available even if the service member did not report the unwanted sexual behavior to DOD. DOD guidance requires training for all service members on sexual harassment, sexual assault, and domestic sexual abuse on an annual or 140Such counseling may include individual or group counseling, marital and family counseling, referral for benefits assistance, liaison with community agencies, or substance abuse information and referral. Page 70 GAO-23-105381 Unwanted Sexual Behavior other periodic basis. 141 DOD guidance for sexual assault prevention and response education and training states that, at a minimum, annual refresher training must include information about available resources for victims on and off base. 142 Similarly, DOD guidance for domestic sexual abuse states that the military departments are to provide annual mandatory training to all military personnel that discusses, among other things, information about military and civilian domestic sexual abuse resources. 143 However, as shown in table 2, three of the military services do not provide this information during required annual training for all service members. Only the Air Force's annual sexual assault prevention and response training includes information about VA resources for active-duty service members who experience unwanted sexual behavior. 144 Table 2: Types of Training that Identify Department of Veterans Affairs (VA) Resources for Active-Duty Service Members Who Experienced Unwanted Sexual Behavior, by Military Service Military Sexual harassment Sexual assault Domestic sexual service training training abuse training Army    Navy    Marine Corps    Air Force    Source: GAO analysis of service training materials. | GAO-23-105381 Note: According to Army and Air Force officials, the Departments of the Army and the Air Force do not have enterprise-wide training on domestic abuse. Army officials said that specific domestic abuse training content varies at each installation; however, the training content listed in Army guidance does not include any mention of Department of Veterans Affairs (VA) resources. Air Force officials provided a copy of the domestic abuse training provided to installation commanders and senior enlisted advisers; this training does not discuss VA resources for active-duty service members who experience unwanted sexual behavior. 141DOD Instruction 1020.03; DOD Instruction 6495.02, Vol. 2, Sexual Assault Prevention and Response: Education and Training (Apr. 9, 2021); and DOD Instruction 6400.06, DOD Coordinated Community Response to Domestic Abuse Involving DOD Military and Certain Affiliated Personnel (Dec. 15, 2021) (incorporating change 1, May 10, 2022). 142DOD Instruction 6495.02, Vol. 2. 143DOD Instruction 6400.06. 144The Department of the Air Force provides training to all service members in the Air Force and the Space Force. Page 71 GAO-23-105381 Unwanted Sexual Behavior • Air Force. The Air Force's annual sexual assault prevention and response training includes a handout that discusses VA resources for current and former service members (active-duty, reserve, and National Guard) who experience unwanted sexual behavior. • Army. The Army's annual Sexual Harassment/Assault Response and Prevention training discusses VA resources for veterans for experiences with unwanted sexual behavior, but does not mention available resources for active-duty service members. • Navy. The Navy's sexual assault training lists VA as a resource for unwanted sexual behavior, but it does not discuss what resources are available or make clear that VA resources are available to active-duty service members. The training also includes a link to VA's website for unwanted sexual behavior, but the page that is linked does not mention services available to active-duty service members. The facilitator's guide does not provide additional detail. • Marine Corps. Marine Corps trainings on sexual harassment, sexual assault, and domestic sexual abuse do not discuss available VA resources for experiences with unwanted sexual behavior. DOD's 2021 Independent Review Commission on Sexual Assault in the Military identified barriers to accessing behavioral health care. Barriers identified include getting time off work, stigma about attending mental health appointments on base in uniform, fear about career repercussions, lack of knowledge about available resources, feeling overwhelmed by the process of having to seek appropriate care, and challenges in maintaining continuity of care during transitions. Military service sexual assault prevention and response personnel we spoke with during our virtual site visits echoed many of these barriers. The Commission met with multiple victims of unwanted sexual behavior who expressed that they had struggled with suicidal ideation, and it noted in its report that suffering in silence and isolation adds weight to the heavy burden these individuals are already carrying. 145 The Commission further stated that it is important that the full range of DOD support personnel are made aware of VA's ability to serve those who have experienced both 145The Independent Review Commission recommended that DOD authorize all active- duty service members to access the full spectrum of VA services for conditions related to military sexual harassment and sexual assault confidentially and without a referral. In implementing guidance for this recommendation, DOD stated that it would explore whether allowing service members full access to VA services without a referral is feasible, mitigates stigma associated with help seeking, and does not adversely impact the military services' ability to receive readiness-impacting feedback from VA health care providers. Page 72 GAO-23-105381 Unwanted Sexual Behavior sexual harassment and sexual assault in the military, and that the information be included in online, training, and outreach materials. Section 538 of the William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021 requires the Secretary of Defense to ensure that sexual assault prevention and response personnel receive annual training on VA resources for experiences with unwanted sexual behavior, and that information about such resources be provided to victims of unwanted sexual behavior and posted in a number of DOD facilities. 146 DOD Sexual Assault Prevention and Response Office officials described efforts to address these provisions and to help ensure service members are aware of available VA resources. Specifically, they noted that the Safe Helpline-DOD's 24/7 anonymous hotline for sexual assault support-has a section on VA services and that pamphlets advertising available resources are located at VA and DOD clinics. These officials further stated that they added a training requirement for sexual assault prevention and response personnel on VA resources available to transitioning service members. In addition, in November 2021, DOD revised the DD Form 2910 Victim Reporting Preference Statement-which eligible individuals must sign to make a restricted or unrestricted report of sexual assault-to include a required attestation that the individual was advised of eligibility for VA services for unwanted sexual behavior experienced as a service member. The revised form provides further details on how VA can help with medical and mental health care as well as filing a disability claim, including that every VA health care facility has a military sexual trauma coordinator. For additional information, the form includes a link to the VA's military sexual trauma website. If the service member is retiring or separating, the relevant sexual assault prevention and response personnel are to include contact information for the nearest Veterans Health Administration military sexual trauma coordinator, according to DOD officials. Further, in February 2023, DOD and VA officials told us that they were jointly developing a standardized fact sheet that contains information on available VA resources for such experiences, including those available to active-duty service members to be distributed by both departments during health assessments when service members separate from the military. DOD officials anticipated that the fact sheet would be implemented by late 146Pub. L. No. 116-283, § 538 (2021). Page 73 GAO-23-105381 Unwanted Sexual Behavior spring or early summer 2023. DOD officials also said that they are developing a poster that will be posted in high traffic locations on all military installations to publicize information about VA resources. While these are positive steps to help ensure service members are aware of available VA resources, a service member generally must separate from the military or proactively seek information or support to receive this information. As such, the thousands of service members who DOD annually estimates have experienced, but chose not to report, sexual assault may not know about available care resources offered through VA. Standards for Internal Control in the Federal Government states that quality information is current, complete, accurate, accessible, and timely. The Standards further state that management should internally communicate the necessary quality information to enable personnel to perform key roles in achieving objectives and addressing risks. Information should be communicated internally in such a way as to ensure that it is readily available to its intended audience when needed. 147 However, the military services do not provide information about VA resources in their annual training because DOD has not updated its guidance on unwanted sexual behavior training to require that the services do so. Specifically, although DOD guidance for sexual assault and domestic sexual abuse requires the military services to discuss available resources, it does not explicitly require the military services to include information about VA resources for experiences with unwanted sexual behavior. Further, DOD guidance for harassment prevention and response outlines required training content, but providing information about available resources is not a required topic. 148 Until DOD revises its sexual harassment, sexual assault, and domestic sexual abuse guidance to require that information about available VA resources for experiences with unwanted sexual behavior be included in annual or periodic training that is administered to all service members, service members may be unaware that these resources exist. This would be particularly applicable to service members who experience unwanted sexual behavior but do not report it. Further, without taking steps to ensure that the military services implement the revised guidance, service 147GAO-14-704G. 148DOD Instruction 1020.03. Page 74 GAO-23-105381 Unwanted Sexual Behavior members may experience delays in receiving or fail to receive critical support to help them overcome their traumatic experiences. DOD's Transition Men separating from the military may receive less information than some Assistance Program women about available VA resources for service members who experienced unwanted sexual behavior during military service. DOD's Provides Inconsistent Transition Assistance Program includes a required VA benefits and Information about VA services course as well as an optional online course on women's health. Resources for Both of these courses include information about VA resources for those Experiences with who have experienced unwanted sexual behavior. However, the optional Unwanted Sexual women's health course includes more detailed information about these VA resources than the VA benefits course required for all separating Behavior service members. Specifically, a VA benefits course is provided to all eligible separating service members as part of the Transition Assistance Program. The participant guide for the course includes a section entitled "maintaining your mental health" that includes a page of information about unwanted sexual behavior. It defines unwanted sexual behavior (referred to as military sexual trauma), discusses eligibility and acceptable evidence to support disability compensation claims, and provides website and app links and a phone number for more information. 149 It also notes that both men and women can experience unwanted sexual behavior. The participant guide includes a separate section entitled "women veterans' health care," which notes that women who qualify for VA health care can access treatment for conditions related to experiences with unwanted sexual behavior. Although the guide does not discuss specific services that are available, VA officials told us that the benefits advisors who teach the course can connect participants with the appropriate resources if requested. In comparison, the participant guide for the optional women's health course includes more detailed information about VA resources for experiences with unwanted sexual behavior. Specifically, it discusses free counseling and treatment provided by VA for mental and physical health conditions stemming from experiences with unwanted sexual behavior. It states that such care is available in every VA health care system, and that services include outpatient, inpatient, and residential treatment. 150 The 149VA, VA Benefits and Services Participant Guide Active Duty, Version 5.0 (January 2023). 150VA, Women's Health Transition Training Participant Handbook (May 2021). Page 75 GAO-23-105381 Unwanted Sexual Behavior guide also notes that counseling related to such experiences is also available at VA's community-based Vet Centers and that individuals may meet with a female or male clinician. In addition, it states that every VA health care system has a Coordinator to help access services and programs related to unwanted sexual behavior. DOD is statutorily required to provide separating service members with information about the availability of health care following separation from active-duty service, including information on the availability of mental health services and the treatment of PTSD, anxiety disorders, depression, suicidal ideations, or other mental health conditions associated with service in the armed forces. 151 In addition, Standards for Internal Control in the Federal Government states that management should internally communicate quality information down and across reporting lines to enable personnel to perform key roles in achieving objectives, addressing risks, and supporting the internal control system. 152 The VA benefits course was developed by VA officials with the assistance of contractors, according to VA officials. These officials stated that a DOD-VA workgroup reviews the entire Transition Assistance Program curriculum, including the VA benefits course, at least annually. They further noted that the workgroup meets monthly and, as part of those meetings, reviews the curriculum to identify any needed updates in response to stakeholder feedback and to ensure compliance with program guidelines. However, VA officials did not identify any plans to address the inconsistencies in the information provided to men and women about available VA resources for experiences with unwanted sexual behavior. 153 DOD has reported that while women are at higher risk for sexual assault, a substantial number of men also experience some kind of sexual assault each year. 154 As of fiscal year 2021, about 83 percent of active-duty service members were male. DOD further reported that support services 15110 U.S.C. §1142(b)(7) and (11). 152GAO-14-704G. 153VAofficials said that the Intimate Partner Violence Assistance Program produces gender-inclusive materials on intimate and sexual violence. 154DOD, Plan to Prevent and Respond to Sexual Assault of Military Men (October 2016) and DOD Office of People Analytics, 2021 Workplace and Gender Relations Survey of Military Members Active Component Results and Trends (October 2022). Page 76 GAO-23-105381 Unwanted Sexual Behavior and research pertaining to male sexual assault have historically lagged behind those for female victims in both the civilian and military contexts. In its fiscal year 2021 annual report on sexual assault in the military, DOD reported that 10 percent of men who experienced unwanted sexual behavior reported it to a DOD authority compared to 29 percent of women. DOD outlined efforts it has taken to update its plan to prevent and respond to sexual assault of military men. 155 In March 2015, we reported that while DOD had taken steps to address sexual assaults of service members generally, it had not used data on male victims to inform program development or systematically evaluated and provided guidance on gender-specific health care needs. 156 We made six recommendations to improve DOD's ability to prevent sexual assaults of male service members and increase its responsiveness to male service members who are sexually assaulted, two of which DOD has implemented. 157 In response to those recommendations, in 2016 DOD issued its plan to address male sexual assault, which established four objectives to address male victims. 158 DOD also developed the Men's 155DOD, Department of Defense Annual Report on Sexual Assault in the Military: Fiscal Year 2021 (Aug. 29, 2022). 156GAO, Military Personnel: Actions Needed to Address Sexual Assaults of Male Servicemembers, GAO-15-284 (Washington, D.C.: Mar. 19, 2015). 157As of March 2023, four recommendations had not yet been implemented; specifically, our recommendations to DOD to (1) develop a plan for data-driven decision making to prioritize program efforts, (2) develop and issue guidance for the department's medical and mental health providers that delineates gender-specific distinctions and the care regimen that is recommended to most effectively meet those needs, (3) develop clear goals with associated metrics to drive the changes needed to address sexual assaults of males and articulate these goals, for example in the department's next sexual assault prevention strategy, and (4) revise its sexual assault prevention and response training to more comprehensively and directly address the incidence of male service members being sexually assaulted and how certain behavior and activities-like hazing-can constitute a sexual assault. GAO-15-284. 158DOD, Plan to Prevent and Respond to Sexual Assault of Military Men (October 2016). Page 77 GAO-23-105381 Unwanted Sexual Behavior Sexual Assault Prevention and Response Campaign to provide education and access to important resources. 159 By revising the Transition Assistance Program participant guide for the veterans benefits and services course to include information similar to what is included in the optional women's health course, DOD can further its efforts to support all victims. Specifically, VA and DOD can better ensure that all separating service members receive similar levels of important information on VA resources for experiences with unwanted sexual behavior regardless of gender. DOD Has Developed DOD has developed sexual assault response training for health care Sexual Assault Training for providers and is developing additional training for behavioral health providers. This additional training includes information on providing Health Care Providers and trauma-informed care to service members who experience unwanted Is Developing Training for sexual behavior during military service. DOD guidance on sexual assault Behavioral Health health care management requires that all health care personnel who may Providers that Addresses encounter patients who disclose that they were sexually assaulted Trauma-Informed Care receive initial and annual training. Among other things, the training is to include basic information on sexual assault and trauma-informed approaches for responding to patients, including how the experience of sexual assault and treatment needs vary by gender. 160 In February 2023, a DHA official stated that a training entitled "Sexual Assault First Contact-First Responder Training" was available for all health care personnel as of January 2023. The official said that this training will be assigned as mandatory training at some time during fiscal year 2023. The training includes information on patient responses to trauma after sexual assault, sexual assault reporting methods, roles of 159According to DOD Sexual Assault Prevention and Response Office officials, the campaign provides an opportunity for effective individual-level interventions for men who may be at higher risk of sexual violence. The officials said that in December 2022, the DOD Sexual Assault Prevention and Response Office finalized its evaluation plan. Among other things, this evaluation plan attempts to quantify the effects of the Men's Campaign by reviewing sample data from the DOD Safe Helpline from fiscal years 2021 and 2022 and comparing use of the resource by gender before and after the launch of the campaign. An analysis of the data found a measurable increase in a sampling of Safe Helpline users following the launch of the campaign, according to the officials. 160DOD Instruction 6310.09. According to DHA officials, they are revising this guidance and expect to issue the revised guidance in late 2023. There are additional, specialized training requirements for medical providers who conduct sexual assault forensic examinations. Page 78 GAO-23-105381 Unwanted Sexual Behavior first responders, the sexual assault medical forensic examination, patient follow-up care, and patient care during deployments. In addition to this first responder training for all health care personnel, DHA officials stated that the agency was in the process of revising guidance on sexual assault health care management to update requirements for medical provider training. Specifically, these officials stated that the guidance will require all behavioral health providers to take training specific to the provision of behavioral health care to sexual trauma patients. DHA officials further stated that the agency is concurrently developing training for behavioral health providers. These officials stated that the training will include information on providing trauma-informed care to Military Health System beneficiaries who have experienced unwanted sexual behavior, to include all forms of sexual trauma, not only sexual assault, as well as appropriate medical records documentation. DHA officials estimated that the revised guidance would be issued by late 2023 and that the behavioral health provider training would be available to providers in fall 2023. We will continue to monitor the implementation of this training through follow-up work on this report and the recommendations made in it. DOD collects some information about service members when they leave DOD Does Not Know the military, but it does not know the extent to which an experience with the Extent of the Role unwanted sexual behavior plays a role in voluntary or involuntary separations from active-duty service. Multiple factors limit DOD's of Unwanted Sexual understanding of an active-duty service member's experience with Behavior in unwanted sexual behavior, and thus the department's ability to consider whether such an experience contributed to a proposed involuntary Separation Decisions separation. Further, the military services have established guidance on Due to Various how to manage concurrent disability evaluation system and administrative separation cases, but their varying approaches to resolving such cases Challenges could negatively affect separation outcomes for service members who have experienced unwanted sexual behavior. DOD and the Military DOD and the military services collect some information about service Services Are Unable to members when they leave military service, including the basis for the separation. However, they do not collect information consistently about Identify when Service whether an experience with unwanted sexual behavior contributed to a Members' Separations Are service member's decision to voluntarily separate, or on the Related to Unwanted circumstances leading to an involuntary separation. Specifically, DOD Sexual Behavior and the military services have established more than 350 separation program designator codes that include an explanatory narrative describing the basis for a service member's separation from the military. Page 79 GAO-23-105381 Unwanted Sexual Behavior For example, there are codes used to indicate that a service member separated due to completion of required active service, failure to meet established weight control standards, substandard performance, or a pattern of minor disciplinary infractions. Per DOD guidance, separation program designator codes are to be used internally by DOD and the military services to collect and analyze data on separations and to identify any statistical reporting trends. 161 RAND has reported that experiencing sexual assault or sexual harassment appears to be strongly associated with separation from military service. 162 The RAND study found that while the exact costs of the personnel losses were unclear, the services were losing years worth of staff days prematurely, and recruitment and training costs associated with replacing service members earlier placed greater administrative and financial burdens on the military. 163 This is consistent with our analysis of DOD separation data, as shown in figure 10. Specifically, we found that about 12 percent of active-duty service members who served from fiscal years 2015 through 2021 separated from service. However, the separation rates of service members who made unrestricted or formal reports of an experience with unwanted sexual behavior to DOD were substantially higher, ranging from a 37 percent separation rate in the Air Force to a 60 percent separation rate in the Marine Corps. 164 161DOD Instruction 1336.01, Certificate of Uniformed Service (DD Form 214/5 Series) (Feb. 17, 2022). 162RAND, Effects of Sexual Assault and Sexual Harassment on Separation. The study also found that service members who were sexually harassed but not sexually assaulted also had an elevated risk of separation. The study highlighted that sexual harassment is a serious threat to readiness independently of its frequent association with sexual assault. 163For example, in December 2022, we reported that it cost DOD $220,000 to $500,000 to train some cyber professionals over a period of 1 to 3 years. We made six recommendations to DOD in this report, and DOD concurred with these recommendations. As of April 2023, DOD had not taken steps to implement these recommendations. GAO, Military Cyber Personnel: Opportunities Exist to Improve Service Obligation Guidance and Data Tracking, GAO-23-105423 (Washington, D.C.: Dec. 21, 2022). 164The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Page 80 GAO-23-105381 Unwanted Sexual Behavior Figure 10: Separation Rates of All Active-Duty Service Members Compared to Separation Rates of Service Members who Reported Experiences with Unwanted Sexual Behavior, Fiscal Years 2015–2021 Note: The analysis of those who reported unwanted sexual behavior to the Department of Defense (DOD) includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. However, separation program designator codes do not allow the department to document whether a service member is separating as a result of an experience with unwanted sexual behavior (or other crimes), or a behavioral health condition stemming from such an experience. A DOD official with whom we spoke stated that DOD has not made any efforts to consider developing a separation program designator code to track whether a service member has separated as a result of unwanted sexual behavior. The official told us that to establish such a code, a subject matter expert would need to articulate the reason for establishing that code, and provide a basis for the code's establishment in policy. Furthermore, the DOD official stated that separation program designator codes previously specified several different behavioral health conditions, Page 81 GAO-23-105381 Unwanted Sexual Behavior but these codes were discontinued because they contributed to stigmatization surrounding certain medical conditions. Experiences with sexual assault and sexual harassment during military service may potentially lead to service members' misconduct that is the basis for their separation. 165 However, there are no separation program designator codes that could be used to represent this occurrence. The separation program designator code is linked to the narrative reason for separation, which appears on the DD Form 214. 166 DOD officials said that it would be inappropriate to use separation program designator codes for specific information that may inadvertently bring attention to or stigmatize an individual. Our analysis of separation program designator codes, separations data, and unrestricted and formal reports of unwanted sexual behavior during fiscal years 2015 through 2021 found that larger proportions of service members who made unrestricted or formal reports to DOD of experiences with unwanted sexual behavior were separated for misconduct or disability versus the proportion of the overall active-duty population who were separated for these reasons, as shown in figure 11. 167 165For example, DOD's memo on the safe-to-report policy (about collateral misconduct by victims of sexual assault) includes as a possible mitigating factor a victim engaging in misconduct after the sexual assault, which may be related to symptoms of exposure to trauma. It provides an example of a victim engaging in underage drinking as a coping mechanism to alleviate sexual assault trauma symptoms. Under Secretary for Defense for Personnel and Readiness, Safe-to-Report Policy for Service Member Victims of Sexual Assault (Oct. 25, 2021). 166The DD Form 214 is the Certificate of Uniformed Service. DOD Instruction 1336.01, Certificate of Uniformed Service (DD Form 214/5 Series) (Feb. 17, 2022). 167The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. See appendix III for similar analyses of the characterization of discharge and reenlistment eligibility status for all service members compared to those who reported experiences with unwanted sexual behavior. Page 82 GAO-23-105381 Unwanted Sexual Behavior Figure 11: Percentage of Reasons for Separation of All Separated Service Members Compared to Separated Service Members Who Reported an Experience with Unwanted Sexual Behavior, by Service and Gender, Fiscal Years 2015–2021 Note: For purposes of this analysis, we created these five groups and organized all of the separation program designator codes into these groups. The service-initiated group includes separations that correspond to separation program designator codes with meanings such as failure to meet weight control standards, retention inconsistent with national security standards, erroneous entry or reenlistment, and failure to meet minimum retention standards, among others. The analysis of those who reported unwanted sexual behavior to the Department of Defense (DOD) includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. In addition to the separation program designator codes, DOD and the military services administer various surveys to collect information about service members who separate from the military. For example, DOD Page 83 GAO-23-105381 Unwanted Sexual Behavior biennially administers a Workplace and Gender Relations Survey to all active-duty service members to monitor the estimated prevalence of gender discrimination, sexual harassment, and sexual assault as well as to identify the factors that contribute to risk. 168 DOD also uses this survey to gauge service members' intentions to separate because of an experience with unwanted sexual behavior, among other things. 169 DOD's report on the results of the 2021 survey found that service members who experienced sexual harassment or unwanted sexual contact had significantly lower retention intentions compared to service members who did not have these experiences. 170 According to DOD officials, this survey has been used to estimate separation rates for sexual assault victims. Each of the military departments also administers an exit survey to separating service members, or a similar type of survey, but only the Army's survey asks about experiences with unwanted sexual behavior. The Army's survey-the Department of the Army Career Engagement Survey-launched in May 2020 and includes questions regarding whether an experience with unwanted sexual behavior was a motivating factor in service members' decisions to leave the military. 171 Army officials stated they administer this survey annually to all active-duty service members regardless of their rank or time in service to measure retention intentions. The survey includes questions that allow service members to document whether concerns about sexual assault or sexual harassment were a 168According to DOD officials, the survey is conducted biennially for both active-duty and reserve component service members. The officials said that until 2021, the active and reserve component surveys were conducted in opposite years, but beginning in 2021 and going forward, the surveys are conducted simultaneously. 169DOD did not conduct the planned survey of the active component in 2020 due to the COVID-19 pandemic. DOD also administers a survey of individuals serving in the reserve component, which was due in 2021. As a result, the 2021 survey was administered to both the active and reserve components simultaneously. DOD also conducts a similar survey administered to cadets and midshipmen at the DOD service academies. The most recent of those is the 2022 Service Academy Gender Relations Survey. 170DOD Office of People Analytics, Climate Related to Sexual Violence and Gender Discrimination in the Active Component: Findings from the 2021 Workplace and Gender Relations Survey of Military Members (Sept. 2022). The report also stated that retention intentions were also lower among service members who experienced hostility in the workplace or perceived their workplace as tolerant of sexual harassment. 171The Army's survey is not a traditional exit survey that is administered only to separating service members. Instead, Army officials said this survey is sent to all active-duty service members to measure retention intentions. Page 84 GAO-23-105381 Unwanted Sexual Behavior reason for separating from the military, but it does not ask whether they have experienced such an incident. 172 According to Army officials, the Army comprehensively analyzes the survey data when stakeholders request it. However, the officials stated that the typical response rate for the survey has been about 10 percent. The officials said that as of February 2023, the Army has not analyzed any responses to questions related to experiences with unwanted sexual behavior, and that they had no future plans to do so. Surveys administered by the Departments of the Navy and the Air Force do not include questions regarding whether unwanted sexual behavior was a motivating factor in service members' decisions to leave the military. Multiple Factors Limit Multiple factors limit DOD's understanding of an active-duty service DOD's Ability to Determine member's experience with unwanted sexual behavior and DOD's ability to determine whether such an experience contributed to a proposed the Role of Unwanted involuntary separation. While DOD guidance is consistent with statutory Sexual Behavior in requirements, there are ways in which victims of different types of Involuntary Separations unwanted sexual behavior are treated differently. Specifically, • Certain statutorily mandated medical examinations and higher-level general or flag officer reviews of involuntary separation cases are limited to sexual assault victims and are not available to victims of sexual harassment. • Though eligible for these considerations, sexual assault victims must avail themselves of these options within a specific time. • The medical examination is only for those victims diagnosed with PTSD or traumatic brain injury (TBI). This further decreases DOD's awareness of, and the population eligible for consideration of, such experiences during separation proceedings. • A process related to higher-level reviews in instances in which service members filed an unrestricted report of sexual assault does not allow service members who file a restricted report of sexual assault to 172In the 2022 survey, respondents were given a list of items and asked to select a response that reflected the degree to which the item influenced their decision to leave or stay in the Army. The response options were: (1) Extremely important reason to leave; (2) Somewhat important reason to leave; (3) Not an important reason to leave or stay; (4) Somewhat important reason to stay; and (5) Extremely important reason to stay. Question 56 asked respondents to select one of those response options to concerns of sexual assault or sexual harassment. Page 85 GAO-23-105381 Unwanted Sexual Behavior request a higher-level general or flag officer review of their involuntary separation case. • The Army, the Navy, and the Marine Corps have not incorporated mechanisms into their separation procedures to notify a service member of their right to request a higher-level general or flag officer review. • DOD guidance related to documentation of the separation health assessment given to all separating service members could limit a service member's ability to obtain future VA benefits for conditions related to unwanted sexual behavior. Medical Examinations and Service members who have experienced sexual harassment and are Higher-Level General or Flag being involuntarily separated from the military are not eligible for the Officer Reviews for Involuntary same medical examination and the higher-level general or flag officer Separations Are Not Available review of their case that are available to victims of sexual assault. 173 to All Victims of Unwanted Specifically, to implement a statutory requirement, DOD's officer and Sexual Behavior enlisted administrative separation guidance requires a medical examination to assess whether the effects of PTSD or TBI relate to the basis for administrative separation if four criteria are met. 174 These criteria include that a service member was sexually assaulted during the previous 24 months and was diagnosed with or reasonably alleges the influence of PTSD or TBI based on sexual assault during the past 24 months. 175 The DOD guidance also provides that these examinations determine any 173Victims of domestic sexual abuse are also eligible for these processes under DOD guidance. DOD Instruction 6400.06, DOD Coordinated Community Response to Domestic Abuse Involving DOD Military and Certain Affiliated Personnel (Dec. 15, 2021) (Incorporating change 2, May 16, 2023). 174DOD Instruction 1332.14, Enlisted Administrative Separations (Jan. 27, 2014) (Incorporating Change 7, June 23, 2022); DOD Instruction 1332.30, Commissioned Officer Administrative Separations (May 11, 2018) (Incorporating Change 3, Sept. 9, 2021); 10 U.S.C. § 1177. 175For the medical examination requirement to apply, the four criteria are that a service member (1) is being administratively separated under a characterization that is not either Honorable or General (Under Honorable Conditions); (2) was deployed overseas to a contingency operation or was sexually assaulted during the previous 24 months; (3) is diagnosed by a physician, clinical psychologist, psychiatrist, licensed clinical social worker, or psychiatric advanced practice registered nurse as experiencing PTSD or TBI, or reasonably alleges the influence of PTSD or TBI based on deployed service to a contingency operation or sexual assault during the previous 24 months; and (4) is not being separated pursuant to a court-martial or other proceeding under the uniform code of military justice. For further discussion of the differences in the characterization of discharge between the population of all separated service members and those who reported experiences with unwanted sexual behavior, see appendix III. Page 86 GAO-23-105381 Unwanted Sexual Behavior existing medical condition incurred during active-duty service, provide baseline information for future care, and provide a final opportunity before separation to document any health concerns, exposures, or risk factors associated with active-duty service. This information would then be considered in assessing whether the effects of PTSD or TBI based on sexual assault relate to the basis for administrative separation. In addition, to implement a different statutory requirement, the guidance states that service members who made an unrestricted report of sexual assault and are recommended for involuntary separation within 1 year of the final disposition of their sexual assault case may request a review by senior military officials-referred to as general or flag officers. 176 These higher-level general or flag officer reviews are conducted to determine the circumstances of, and grounds for, the involuntary separation, and the involuntary discharge may not be approved without the concurrence of the higher level authority. 177 This review was established to help ensure 176DOD Instruction 1332.14; DOD Instruction 1332.30; Pub. L. No. 112-239, § 578 (10 U.S.C. § 1561 note). In accordance with DOD guidance: (1) A service member requesting this review must submit their written request to the first general or flag officer in the separation authority's chain of command before the separation authority approves the member's final separation action; (2) Requests submitted after the final separation action is complete will not be reviewed by a general or flag officer, but the separated service member may apply to the appropriate service Discharge Review Board or Board of Correction of Military/Naval Records for consideration; and (3) A service member who submits a timely request will not be separated until the general or flag officer conducting the review concurs with the circumstances of and the grounds for the involuntary separation. A general officer is an officer of the Army, Air Force, or Marine Corps in the grades of general, lieutenant general, major general, or brigadier general. A flag officer is an officer of the Navy in the grades of admiral, vice admiral, rear admiral, or rear admiral (lower half). This review is separate from administrative separation boards or discharge review boards. For additional information about these boards, see GAO-23-105780. 177Involuntary separations are separations in which a service member is denied reenlistment or denied continuation on active duty or in an active status. The officer guidance specifies that this review requirement expands the relevant statutory requirement to ensure that an involuntary separation is not initiated in retaliation for making an unrestricted report of sexual assault. DOD Instruction 1332.30. Additionally, see appendix III for analyses of the characterization of discharge and reenlistment eligibility status for all service members compared to those who reported experiences with unwanted sexual behavior. Page 87 GAO-23-105381 Unwanted Sexual Behavior that an involuntary separation was not initiated in retaliation for making an unrestricted report of sexual assault. 178 However, in cases of sexual harassment, a medical examination is not required to assess whether the effects of resulting PTSD or TBI relate to the basis for administrative separation. Nor is an opportunity provided to request a higher level general or flag officer review, despite sexual harassment being on the same continuum of harm as sexual assault. 179 RAND's research on separations of active-duty personnel has shown multiple negative health consequences of in-service sexual harassment, such as lower health satisfaction and psychological well-being. RAND has also reported that among veterans, the experience with in-service sexual harassment is associated with various negative psychological effects, including depression, PTSD symptoms, and poorer general mental health, as well as a greater number of medical conditions. 180 Military attorneys and commanders we spoke with had varying perspectives on whether involuntary separation cases involving sexual harassment should receive a similar medical examination. For example, some of the Army commanders with whom we spoke told us that they could see the benefit in applying the provisions to sexual harassment cases, so that medical providers could provide input and higher-level commanders with more experience could make more informed decisions when taking actions. Some Air Force commanders with whom we spoke told us that applying the separation provisions to sexual harassment 178DOD officials noted that relatedly, in accordance with DOD Instruction 6495.02, volume 1, all Sexual Assault Response Coordinators and Victim Advocates are required to advise adult victims who reported a sexual assault or sought mental health treatment for sexual assault of the opportunity to communicate with a general or flag officer regarding issues related to their military career that the victim believes are associated with the sexual assault. 179Alladministratively separating service members receive a separation health physical examination at a military medical treatment facility or by DOD-contracted services. If the service member is within 90-180 days of separation, the service member may instead choose to receive a separation health assessment administered by VA. This medical examination to assess whether the effects of PTSD or TBI relate to the basis for administrative separation is a separate requirement from the separation health physical examination. As discussed earlier in this report, DOD defines the continuum of harm as a range of interconnected, inappropriate behaviors that are connected to the occurrence of sexual assault and support an environment that tolerates these behaviors. For example, the Sexual Assault Prevention and Response Office has reported that certain behavior and activities, such as hazing, can lead to sexual assault. 180RAND, Effects of Sexual Assault and Sexual Harassment on Separation. Page 88 GAO-23-105381 Unwanted Sexual Behavior cases would not be an undue burden. Further, an Air Force staff judge advocate told us that such changes would be beneficial for victims. However, other military officials expressed uncertainty or a negative opinion about the benefits of applying these separation provisions to other types of unwanted sexual behavior beyond sexual assault. For example, Army staff judge advocates with whom we spoke told us that sexual assault is uniquely egregious and that including additional unwanted sexual behaviors would minimize the seriousness of that offense. A group of Navy commanders stated that while sexual harassment is on the same continuum of harm as sexual assault, they do not need to be treated equally with regards to separation provisions. Additionally, these Navy commanders told us that raising sexual harassment cases to a higher separation authority could diminish the influence the lower-level commander has on the unit. These commanders explained that the Navy treats sexual assault and sexual harassment differently; for example, the Naval Criminal Investigative Service is required to investigate all sexual assault cases. A Marine Corps commander with general court-martial convening authority and Marine Corps staff judge advocates said that it would not be beneficial or necessary to apply the separation provisions related to sexual assault to sexual harassment cases. They stated that this is, in part, due to workload issues or because they believed that sexual harassment cases were being appropriately handled. Performance Goal 3.2.2 of DOD's Strategic Management Plan is to promote military readiness by decreasing the prevalence of sexual assault and readiness detracting behavior. 181 To implement this goal, DOD's Strategic Management Plan states that DOD will work to increase protective factors and enhance the provision of care for all service members. In addition, DOD's Independent Review Commission on Sexual Assault in the Military stated that victim care and support must center on the needs of the victim, and that service members who have experienced sexual assault and sexual harassment have suffered a profound moral injury, which must be acknowledged and redressed. 182 The Secretary of Defense's memo providing implementation guidance for 181DOD, DOD Strategic Management Plan: Fiscal Years 2022-2026. 182Independent Review Commission on Sexual Assault in the Military, Hard Truths and the Duty to Change. Page 89 GAO-23-105381 Unwanted Sexual Behavior the recommendations from the Commission's report stated that solving this problem requires significant and enduring changes to DOD's approach to victim care and support. 183 Further, Standards for Internal Control in the Federal Government states that management should implement control activities through policies that include responsibilities for objectives and related risks, implementation, and operating effectiveness. 184 The standards also provide that management periodically use separate evaluations to monitor the design and operating effectiveness of a specific function and obtain feedback on the effectiveness of ongoing monitoring. Service members who have experienced sexual harassment cannot receive a medical examination to assess whether the effects of certain behavioral health conditions relate to the basis for administrative separation or a general or flag officer review of their involuntary separation cases because eligibility for this benefit does not extend to sexual harassment. 185 Because sexual harassment and sexual assault are on the same continuum of harm, it may be beneficial for DOD to evaluate where similarities in the effects of sexual harassment and sexual assault should be considered and assess whether similar benefits should be afforded. While DOD guidance reflects the statutory requirements, limiting medical examinations and higher-level general or flag officer reviews to victims of sexual assault constrains DOD's understanding of the range of behavioral health problems faced by victims of sexual harassment and domestic sexual abuse as well as potential factors contributing to their separation from military service. Further, by evaluating an expansion of the benefit to provide all victims of unwanted sexual behavior facing involuntary separation the opportunity to obtain a medical examination to assess whether the effects of certain behavioral 183Secretary of Defense Memorandum, Department of Defense Actions and Implementation Guidance to Address Sexual Assault and Sexual Harassment in the Military (July 2, 2021). 184GAO-14-704G. 185The medical examination could benefit service members by providing an opportunity to identify and document any behavioral health concerns associated with unwanted sexual behavior, and could better enable service members to get the treatment they need or potentially lead to a disability separation as an alternative to an administrative separation. The higher-level general or flag officer review could benefit a service member by providing an opportunity for a senior officer to ensure no retaliation was involved in a proposed involuntary separation or to consider the potential for retention, suspension of the separation, or the appropriateness of the character of discharge. As discussed above, the character of discharge affects a service member's eligibility for VA benefits and services. Page 90 GAO-23-105381 Unwanted Sexual Behavior health conditions relate to the basis for administrative separation and a higher-level general or flag officer review, DOD could determine the advantages of further empowering service members to identify and address behavioral health treatment needs. Medical Examinations and The medical examination and higher-level general or flag officer review Higher-Level Reviews Include provisions also specify particular timeframes in which they may be Specific Time Limits obtained. Specifically, in accordance with statute, DOD's officer and enlisted administrative separation guidance requires a medical examination to assess whether the effects of PTSD or TBI based on sexual assault during the past 24 months relate to the basis for administrative separation. 186 The guidance also indicates that higher-level general or flag officer reviews of involuntary separation cases for service members who experienced sexual assault are available only if the final disposition of the case occurred within 1 year of the separation notification. 187 However, the behavioral health effects from these experiences can develop after and last longer than 2 years following the traumatic event. 188 For example, a report by the Department of Veterans Affairs and Department of Defense Joint Executive Committee stated that sexual assault and sexual harassment during military service can affect a 186DOD Instruction 1332.14; DOD Instruction 1332.30; 10 U.S.C. § 1177. The guidance also states that a service member must receive a medical examination if the service member is diagnosed by a physician, clinical psychologist, psychiatrist, licensed clinical social worker, or psychiatric advanced practice registered nurse as experiencing PTSD or TBI, or reasonably alleges the influence of PTSD or TBI based on deployed service to a contingency operation or sexual assault during the previous 24 months. As noted above, victims of domestic sexual abuse are eligible for these processes under DOD guidance, as their incidents will be recorded in DOD's Defense Sexual Assault Incident Database. Specifically, DOD Instruction 6400.06 provides that information on official unrestricted reports of adult sexual abuse will be entered into DOD's Defense Sexual Assault Incident Database and that all allegations of sexual abuse or sexual assault must be reported to the appropriate military criminal investigative organization. DOD Instruction 6400.06, DOD Coordinated Community Response to Domestic Abuse Involving DOD Military and Certain Affiliated Personnel (Dec. 15, 2021, change 1 effective May 10, 2022). 187DOD Instruction 1332.14 and DOD Instruction 1332.30. This provision implements section 578 of Public Law 112-239 (codified at 10 U.S.C. § 1561 note). 188Department of Veterans Affairs and Department of Defense Joint Executive Committee Fiscal Year 2020 Annual Report, Military Sexual Trauma: Transition of Health Care and Assistance with Disability Claims. Page 91 GAO-23-105381 Unwanted Sexual Behavior victim's mental and physical health, even many years later. 189 As noted above, experiences with sexual assault and sexual harassment during military service may potentially lead to service members' misconduct that is the basis for their separations. 190 The eligibility criteria for the medical examination are limited to service members being administratively separated under a characterization that is not either Honorable or General (Under Honorable Conditions), among other things. 191 We analyzed DOD separations data and unrestricted and formal reports of unwanted sexual behavior from fiscal years 2015 through 2021 for individuals who separated for misconduct or another involuntary reason and had a character of discharge that was not Honorable or General (Under Honorable Conditions) and thus could be eligible for this medical examination if they meet the criteria. We found that 11 percent of service members who made unrestricted reports of experiences with sexual assault to DOD and subsequently involuntarily separated from military service with other than an Honorable or General (Under Honorable Conditions) discharge did so more than 2 years after the experience (see fig. 12). 192 Therefore, per DOD guidance, they were not eligible to receive a medical examination to consider whether specific behavioral health conditions related to the basis for the separation. 189The report further noted that victims differ in their reactions to these traumatic experiences based on previous life experiences and other background factors. 190For example, DOD's memo on the safe-to-report policy (about collateral misconduct by victims of sexual assault) includes as a possible mitigating factor a victim engaging in misconduct after the sexual assault, which may be related to symptoms of exposure to trauma. It provides an example of a victim engaging in underage drinking as a coping mechanism to alleviate sexual assault trauma symptoms. Under Secretary for Defense for Personnel and Readiness, Safe-to-Report Policy for Service Member Victims of Sexual Assault (Oct. 25, 2021). 191DOD Instruction 1332.14 and DOD Instruction 1332.30. 192This analysis includes only unrestricted reports of sexual assault made to DOD in fiscal years 2015 through 2021. For purposes of this analysis, we analyzed reports of sexual assault separately from reports of domestic sexual abuse and sexual harassment. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted report, the report would not be included in this analysis. Page 92 GAO-23-105381 Unwanted Sexual Behavior Figure 12: Time Period between a Service Member's Separation and Date that They Reported an Experience with Unwanted Sexual Behavior to the Department of Defense (DOD), Fiscal Years 2015–2021 Note: The analysis of those who reported unwanted sexual behavior to the Department of Defense (DOD) includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For purposes of this figure, we analyzed reports of sexual assault separately from reports of domestic sexual abuse and sexual harassment. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Data for service members who separated under any circumstances includes voluntary and involuntary separations with any character of discharge. Data for service members who reported unwanted sexual behavior and involuntarily separated under other-than-honorable conditions includes separations for misconduct or other involuntary reasons with a character of discharge other than honorable or general (under honorable conditions). The counts for those who reported unwanted sexual behavior and involuntarily separated under other than honorable conditions were less than 10 for those who experienced other or multiple types of unwanted sexual behavior and separated from 1 to less than 2 years or 2 or more years after making a report. a Service members who separated more than 2 years after reporting sexual assault and service members who reported other types of unwanted sexual behavior would not be eligible for the medical examination. This data is shown for comparison purposes. However, the number of service members who met these eligibility criteria was just 3 percent of the population of service members who made unrestricted reports of sexual assault to DOD and subsequently Page 93 GAO-23-105381 Unwanted Sexual Behavior separated from military under any circumstances-voluntary or involuntary. 193 Considering a possible expansion of the eligibility criteria to include more types of separations and characters of discharge would potentially enable thousands more service members who experienced unwanted sexual behavior to benefit from having a medical examination to assess whether the effects of a behavioral health condition related to the basis for their separation and thus would be considered in their separation proceedings (see fig. 12 above). The medical examination could benefit service members by providing an opportunity to identify and document any behavioral health concerns associated with unwanted sexual behavior, and could better enable service members to get the treatment they need. As a result, this examination may provide an opportunity for the separating official to consider whether previously undiagnosed or untreated behavioral health issues may have led to the conduct that is the basis for the proposed separation, which could affect the separation decision or potentially lead to a disability separation as an alternative to an administrative separation. Service members face similar limitations in their ability to request a review of their separation by a higher-level deciding official. The higher-level general or flag officer review could benefit a service member by providing an opportunity for a senior officer to ensure no retaliation was involved in a proposed involuntary separation or to consider mitigating actions, such as the potential for retention, suspension of the separation, or the appropriateness of the character of discharge. 194 As discussed above, a service member who made an unrestricted report of sexual assault and who is recommended for involuntary separation within 1 year of final disposition of their sexual assault case may request a general office review of the circumstances of and grounds for the involuntary separation. While the length of time for a sexual assault case to reach final disposition will vary depending on the type and complexity of the case, cases that involve a court-martial-the most serious of 193We analyzed reports of sexual assault separately from reports of domestic sexual abuse and sexual harassment for this analysis of separations for misconduct or other involuntary reasons with a character of discharge other than honorable or general (under honorable conditions). 194As discussed above, the character of discharge affects a service member's eligibility for VA benefits and services. Page 94 GAO-23-105381 Unwanted Sexual Behavior military judicial proceedings that is generally reserved for more serious misconduct and crimes-would generally take the longest amount of time. DOD's fiscal year 2021 annual report on sexual assault in the military states that it took, on average, nearly 11 months for a case to reach final disposition in a court-martial. 195 Our analysis of DOD separations data and reports of unwanted sexual behavior shows that when this period is combined with the 1 year time limitation given to request a higher-level general or flag officer review of a separation case, a number of service members would be disqualified from the potential benefit of this review. Specifically, as shown in figure 13 below, all of the service members who separated for misconduct or other involuntary reasons and who separated 2 or more years after reporting unwanted sexual behavior-approximately 17 percent of such service members who made an unrestricted report of sexual assault to DOD and separated from the military from fiscal years 2015 through 2021-would have been ineligible for the higher-level general or flag officer review. 196 195According to DOD, in fiscal year 2021, the average length of time from the date a person reported a sexual assault to the date that court-martial proceedings concluded was 325 days (10.7 months). The average length of time from the date a person reported a sexual assault to the date a nonjudicial punishment was imposed was 161 days. DOD, Department of Defense Annual Report on Sexual Assault in the Military: Fiscal Year 2021 Appendix B: Metrics and Non-Metrics on Sexual Assault (Aug. 29, 2022). 196For purposes of this analysis of separations for misconduct or other involuntary reasons, we analyzed reports of sexual assault separately from reports of domestic sexual abuse and sexual harassment. According to a DOD official, there could be other avenues for establishing a connection between an experience with unwanted sexual behavior and the reason for a proposed separation, such as a review by an administrative separation board. In February 2023, we reported on the armed forces' use of administrative separation boards. GAO, Administrative Separation Boards: Air Force Policy Should Clarify Member Qualifications, GAO-23-105780 (Washington, D.C.: Feb. 2, 2023). Page 95 GAO-23-105381 Unwanted Sexual Behavior Figure 13: Time Period between a Service Member's Separation and Date that They Reported an Experience with Unwanted Sexual Behavior to DOD, Fiscal Years 2015–2021 Note: The analysis of those who reported unwanted sexual behavior to the Department of Defense (DOD) includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For purposes of this figure, we analyzed reports of sexual assault separately from reports of domestic sexual abuse and sexual harassment. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Data for service members who separated under any circumstances includes voluntary and involuntary separations with any character of discharge. a Service members who separated more than 1 year after disposition of their sexual assault allegation and service members who reported other types of unwanted sexual behavior would not be eligible for the higher-level review. This data is shown for comparison purposes. Performance Goal 3.2.2 of DOD's Strategic Management Plan is to promote military readiness by decreasing the prevalence of sexual assault and readiness detracting behavior. 197 To implement this goal, DOD's Strategic Management Plan states that DOD will work to increase protective factors and enhance the provision of care for all service members. Further, Standards for Internal Control in the Federal Government states that management should implement control activities through policies that include responsibilities for objectives and related risks, implementation, and operating effectiveness. 198 In addition, internal 197DOD, DOD Strategic Management Plan Fiscal Years 2022-2026. 198GAO-14-704G. Page 96 GAO-23-105381 Unwanted Sexual Behavior control principles provide that management periodically use separate evaluations to monitor the design and operating effectiveness of a specific function and obtain feedback on the effectiveness of ongoing monitoring. According to DOD officials, the medical examination and higher-level general or flag officer review is not offered to all separating service members who have reported an experience with unwanted sexual behavior because current officer and enlisted administrative separation guidance limits the time period for obtaining the examination and the review. DOD officials said that they were unaware of any concerns with the current policy, which is based on statute. 199 We recognize that the time limitations reflected in DOD's guidance are in line with statutory requirements. However, if DOD were to evaluate the possibility of expanding these timeframes as well as other eligibility restrictions for obtaining a medical examination related to the type of separation and character of discharge, it would likely increase its ability to fully consider how all factors, including an experience with unwanted sexual behavior, may have contributed to a service member's proposed involuntary separation from military service. Furthermore, it could help to ensure that the amount of time it takes victims to process trauma does not disqualify them from having all factors potentially contributing to their proposed separation considered. DOD Recognizes a Limited Experiences with unwanted sexual behavior may result in a variety of Number of Behavioral Health behavioral health diagnoses, but the military services consider only the Conditions as Potentially effects of PTSD and TBI in administrative separation decisions. Our Contributing to a Service analysis of DHA data show that experiences with unwanted sexual Member's Involuntary behavior may result in a variety of diagnoses. For example, in cases Separation where an experience with unwanted sexual behavior resulted in service members seeking treatment from fiscal years 2015 through 2021, ultimate behavioral health diagnoses spanned 11 different categories, as shown in table 3. 200 The behavioral health disorder categories with the highest number of service member diagnoses are PTSD, anxiety disorders other than PTSD, other behavioral health disorders, and depressive 19910 U.S.C. §1177 and Pub. L. No. 112-239, §578 (10 U.S.C. §1561 note). 200We used the Centers for Medicare and Medicaid Services reference guide to group behavioral health diagnoses, which includes behavioral health and substance use disorders. Page 97 GAO-23-105381 Unwanted Sexual Behavior disorders. 201 Most active-duty service members with a substance use disorder were diagnosed with either an alcohol or tobacco use disorder. Table 3: Types of Behavioral Health Diagnoses Given to Service Members Who Received Medical Behavioral Health Care Related to Experiences with Unwanted Sexual Behavior, Fiscal Years 2015–2021 Diagnosis category Total Behavioral Health Disorders Post-Traumatic Stress Disorder (PTSD) 2,291 Other Behavioral health disorders 2,199 Anxiety disorders (other than PTSD) 1,191 Depressive disorders 1,116 Personality disorders 168 ADHD, conduct disorders, and hyperkinetic syndrome 106 Bipolar disorder 97 Schizophrenia and other psychotic disorders 36 Substance Use Disorders Alcohol use disorder 334 Tobacco use disorders 60 Drug use disorders 22 Source: GAO analysis of Defense Health Agency data. | GAO-23-105381 Notes: We identified these data using diagnostic codes related to unwanted sexual behavior in the Department of Defense's (DOD) Military Health System Data Repository, which includes medical care provided by DOD providers and care provided by private sector providers with a TRICARE referral. Service members may be counted in more than one category if they had more than one diagnosis. Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. Further, not all active-duty service members receiving behavioral health care related to experiences with unwanted sexual behavior during the time period may have received a diagnosis that was documented as being related to unwanted sexual behavior. The number of service members who received medical behavioral health care diagnoses identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed earlier in this report. Similarly, VA also has reported that experiences with unwanted sexual behavior are associated with a range of mental health problems, stating that VA's services for PTSD, depression, anxiety, and substance abuse, 201Specific diagnoses within these categories include generalized anxiety disorder (anxiety disorders other than PTSD), adjustment disorder and bulimia (other behavioral health disorders), and major depressive disorder single episode or recurrent (depressive disorders). Page 98 GAO-23-105381 Unwanted Sexual Behavior among others, are important resources for victims of unwanted sexual behavior. 202 Despite the range of diagnoses that medical professionals assign to experiences with unwanted sexual behavior, many service members are not able to use the results of a medical examination because the current process only recognizes PTSD and TBI diagnoses as potentially contributing to an involuntary separation. 203 Our analysis of DHA data found that the majority of service members with a documented behavioral health diagnosis related to an experience with unwanted sexual behavior received a diagnosis other than PTSD or TBI. Specifically, from fiscal years 2015 through 2021, 70 percent of service members with a behavioral health diagnosis related to an experience with unwanted sexual behavior would have been ineligible for a medical examination to determine if their behavioral health condition contributed to their separation. 204 In contrast, service members diagnosed with PTSD and potentially eligible for a medical examination (if they met other eligibility criteria) accounted for 30 percent of service members with a diagnosis related to an experience with unwanted sexual behavior. There were no TBI cases documented as being related to such experiences. The proportions were similar for service members who made unrestricted or formal reports of an experience with unwanted sexual behavior to DOD and received a related behavioral health diagnosis. Specifically, our analysis showed that 19 percent of these service members were 202VA, Annual Report for Fiscal Year 2019: Counseling, Care, and Services Provided to Veterans and Active Duty Servicemembers Who Experienced Military Sexual Trauma (Dec. 2019). 203DOD Instruction 1332.14 and DOD Instruction 1332.30 only specify diagnoses of PTSD or TBI for this purpose. The medical examination could potentially benefit service members by providing an opportunity to identify and document any behavioral health concerns associated with unwanted sexual behavior, and could better enable service members to get the treatment they need or potentially lead to a disability separation as an alternative to an administrative separation. 204To be eligible for the medical examination, individuals would also have to meet the other eligibility criteria, such as being sexually assaulted during the previous 24 months and being administratively separated under a characterization that is not either Honorable or General (Under Honorable Conditions), among other things. Page 99 GAO-23-105381 Unwanted Sexual Behavior diagnosed with PTSD while 81 percent were diagnosed with other behavioral health conditions (see fig. 14). 205 Figure 14: Service Member Behavioral Health Diagnoses Associated with an Experience with Unwanted Sexual Behavior Overall and Among Those Who Reported Experiences, Fiscal Years 2015–2021 Note: We used the Department of Defense's (DOD) Military Health System Data Repository to identify behavioral health care records with International Classification of Diseases (ICD)-9 and ICD- 10 diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active- duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. The number of service members who received behavioral health diagnoses that were identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed earlier in this report. Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without receiving a diagnosis related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. There were no diagnoses of traumatic brain injury that were identified as related to an experience with unwanted sexual behavior. The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an 205The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a confidential informal report or a restricted report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Page 100 GAO-23-105381 Unwanted Sexual Behavior experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Performance Goal 3.2.2 of DOD's Strategic Management Plan is to promote military readiness by decreasing the prevalence of sexual assault and readiness detracting behavior. 206 To implement this goal, DOD's Strategic Management Plan states that DOD will work to increase protective factors and enhance the provision of care for all service members. Further, Standards for Internal Control in the Federal Government states that management should implement control activities through policies that include responsibilities for objectives and related risks, implementation, and operating effectiveness. 207 In addition, internal control principles provide that management should periodically use separate evaluations to monitor the design and operating effectiveness of a specific function and obtain feedback on the effectiveness of ongoing monitoring. DOD officials said that current research indicates that PTSD, depressive disorders, substance use disorders, and anxiety disorders are associated with sexual assault. However, they said that not all service members who experience sexual assault experience mental health concerns and warrant a medical examination. We recognize that DOD's guidance is consistent with statutory requirements. 208 However, expanding the medical examination requirement could help DOD better support those service members who have mental health concerns other than PTSD and TBI. By evaluating modifications to these processes to recognize the range of potential diagnoses that could result from an experience with unwanted sexual behavior, DOD would help to ensure that it more fully considers factors potentially contributing to a service member's proposed involuntary separation. Further, it could better enable service members to get the treatment they need, and could potentially lead, for example, to a disability separation as an alternative to an administrative separation. 206DOD, DOD Strategic Management Plan Fiscal Years 2022-2026. 207GAO-14-704G. 20810 U.S.C. §1177 and Pub. L. No. 112-239 §578 (codified at 10 U.S.C. §1561 note). Page 101 GAO-23-105381 Unwanted Sexual Behavior Service Members Cannot Service members who file a restricted report of sexual assault cannot Request a Higher-Level request a general or flag officer review of their involuntary separation General or Flag Officer Review case under the process discussed above. DOD offers active-duty service of Involuntary Separation if members who are victims of sexual assault two reporting options. The They Filed a Restricted Report first is an unrestricted option, which involves notifying the service member's command and results in the initiation of an investigation. The second is a restricted option, which allows a service member to confidentially disclose the assault to specified individuals and to obtain any necessary care without notifying their command or triggering an investigation. 209 Since instituting its sexual assault prevention and response program, DOD has taken various steps to help ensure that a service member who files a restricted report of sexual assault has access to a comparable level of services as someone who files an unrestricted report, while preserving their confidentiality. However, victims who file restricted reports remain ineligible to request a higher-level general or flag officer review because this right is limited solely to those who file unrestricted reports. 210 Performance Goal 3.2.2 of DOD's Strategic Management Plan is to promote military readiness by decreasing the prevalence of sexual assault and readiness detracting behavior. 211 To implement this goal, DOD's Strategic Management Plan states that DOD will work to increase protective factors and enhance the provision of care for all service members. Standards for Internal Control in the Federal Government states that management should implement control activities through policies that include responsibilities for objectives and related risks, implementation, and operating effectiveness. 212 In addition, internal 209DOD Directive 6495.01. 210DOD Instruction 1332.14; DOD Instruction 1332.30; Pub. L. No. 112-239, § 578. The provisions about the medical examination requirement do not specify restricted or unrestricted reports; instead, the provision applies to any service member who was sexually assaulted in the past 24 months and who meets the other specified criteria. As a result, a service member who filed a restricted report would be eligible for this medical examination without converting the report from restricted to unrestricted. The medical examination could benefit service members by providing an opportunity to identify and document any behavioral health concerns associated with unwanted sexual behavior, and could better enable service members to get the treatment they need or potentially lead to a disability separation as an alternative to an administrative separation. 211DOD, DOD Strategic Management Plan Fiscal Years 2022-2026. 212GAO-14-704G. Page 102 GAO-23-105381 Unwanted Sexual Behavior control principles provide that management periodically use separate evaluations to monitor the design and operating effectiveness of a specific function and obtain feedback on the effectiveness of ongoing monitoring. While the limited applicability to unrestricted reports in DOD guidance is consistent with statutory requirements, the department may want to evaluate the benefits and feasibility of modifications that would allow victims who filed restricted reports to request a higher-level general or flag officer review of their separation. Including both restricted and unrestricted reports would likely increase commanders' ability to fully consider how all factors, including a restricted sexual assault report, may have contributed to a service member's proposed involuntary separation from military service. 213 Further, it would help to ensure these victims have access to all options available to defend themselves when facing an involuntary separation from military service. Military Services Do Not Some, but not all, military services have incorporated mechanisms into Consistently Inform Service their separation procedures to notify a service member of their right to Members of Their Right to a request a higher-level general or flag officer review when an involuntarily Higher-Level General or Flag separating service member has filed an unrestricted report of sexual Officer Review assault within 1 year of being notified they are being recommended for discharge. The military services vary in how they provide a review by a higher-level commander for involuntary separation cases involving service members who have experienced sexual assault. 214 Specifically, the Army, the Navy, and the Marine Corps automatically elevate the deciding official, or separation authority, to a general or flag officer for enlisted service members who filed an unrestricted report of sexual assault whose final disposition was within the previous 12 months. 213For example, the separating official can review the case to ensure no retaliation was involved in a proposed involuntary separation and possibly retain the service member if retaliation was identified. The separating official also can consider mitigations such as the potential for rehabilitation and retention, suspension of the separation, or the appropriateness of the character of discharge. As discussed above, the character of discharge affects a service member's eligibility for VA benefits and services. 214Army Regulation 635-200, Active Duty Enlisted Administrative Separations (June 28, 2021); Army Regulation 600-8-24, Officer Transfers and Discharges (Feb. 8, 2020); Naval Military Personnel Manual (MILPERSMAN) Article 1910 (series), Enlisted Administrative Separations; SECNAV Instruction 1920. 6D, Administrative Separation of Officers (July 24, 2019); Marine Corps Order 1900.16, Separation and Retirement Manual (Change 2, Feb. 15, 2019); Department of the Air Force Instruction 36-3211, Military Separations (June 24, 2022). Page 103 GAO-23-105381 Unwanted Sexual Behavior Defense counsel from the Army, the Navy, and the Marine Corps all told us that involuntary separation cases involving sexual assault victims are automatically elevated to the relevant general or flag officers for final separation decision. 215 Navy defense counsel stated that staff judge advocates have to know the service member is a victim of sexual assault to elevate the separation authority. The military services' separation notification correspondence does not consistently include a method for notifying service members about their right to request a higher-level general or flag officer review if a separating service member has experienced unwanted sexual behavior. Air Force guidance requires the Air Force to notify service members of their right to request a general officer review in a standardized separation notification letter. 216 However, the Army, the Navy, and the Marine Corps guidance does not provide for information about the right to request a higher-level general or flag officer review to be included in their standard separation notification correspondence. 217 Instead, the Army's standard correspondence included in its guidance directly asks separating enlisted service members if they have filed an unrestricted report of sexual assault within the past 24 months. 218 The correspondence does not explain the reason for asking this question, or mention that responding yes would allow a higher-level general officer review of the separation. The Army guidance also states that if a service member has reported a sexual assault, the separation action is required to have a higher-level general or flag officer review prior to separation. The guidance for the Navy and the Marine Corps does not require them to ask service members if they reported sexual assault in their similar separation correspondence. 219 215The separating official can review the case to ensure no retaliation was involved in a proposed involuntary separation and possibly retain the service member if retaliation was identified. The separating official also can consider mitigations such as the potential for rehabilitation and retention, suspension of the separation, or the appropriateness of the character of discharge. The character of discharge determines a service member's eligibility for VA benefits and services. 216Air Force Instruction 36-3211. 217Army Regulation 635-200; Army Regulation 600-8-24; MILPERSMAN Article 1910 (series); SECNAV Instruction 1920.6D, Administrative Separation of Officers (July 24, 2019); Marine Corps Order 1900.16. 218Army Regulation 635-200; Army Regulation 600-8-24. 219MILPERSMAN 1910-600; Marine Corps Order 1900.16. Page 104 GAO-23-105381 Unwanted Sexual Behavior Standards for Internal Control in the Federal Government states that management should internally communicate quality information down and across reporting lines to enable personnel to perform key roles in achieving objectives, addressing risks, and supporting the internal control system. 220 Service members may not know that they may be eligible to request a higher-level general or flag officer review of a proposed separation because the guidance of most of the military services does not require them to include that information in their separation correspondence. DOD officials from the Office of Military Personnel Policy told us that if service members were not being informed about such eligibility, then this may be a worthwhile recommendation specific to the services or military departments that are not providing such information. Without modifying their guidance to require separation notification correspondence to inform service members who have experienced unwanted sexual behavior about their right to request a higher-level review, the military services cannot ensure that all service members who experience unwanted sexual behavior are aware that they may be eligible to have their involuntary separation reviewed by a general or flag officer. DOD Separation Health DOD guidance related to the separation health assessment given to all Assessment Documentation separating service members could limit a service member's ability to Guidance May Hinder Ability to obtain future VA benefits for conditions related to an experience with Obtain VA Benefits unwanted sexual behavior. DOD guidance states that all separating service members must receive a complete medical history and examination. 221 Administratively separating service members receive a separation health physical examination at a military medical treatment facility or by DOD-contracted services. If the service member is within 90 to 180 days of separation, the service member may instead choose to receive a separation health assessment administered by VA. Both health assessments are a component of the service member's separation package pending separation from military service and are used to determine their eligibility for disability compensation from VA. However, current DOD guidance prohibits providers from documenting a sexual assault disclosed by a service member during a separation exam 220GAO-14-704G. 221DODInstruction 6040.46, The Separation History and Physical Examination (SHPE) for The DOD Separation Health Assessment (SHA) Program (Apr. 14, 2016). Page 105 GAO-23-105381 Unwanted Sexual Behavior in their health record. 222 Specifically, this guidance states that regardless of whether the service member elects for restricted or unrestricted reporting, documentation of the alleged sexual assault will not be included in the report of the separation history and physical examination, which becomes part of the service treatment record. 223 This could contribute to the inconsistent documentation of care related to unwanted sexual behavior, as discussed above. The separation health assessment process could thereby limit a service member's ability to obtain future VA benefits. Standards for Internal Control in the Federal Government states that management should internally communicate quality information down and across reporting lines to enable personnel to perform key roles in achieving objectives, addressing risks, and supporting the internal control system. 224 However, information about unwanted sexual behavior may not be communicated in DOD medical records because DOD guidance prohibits it. DOD officials said that their concerns around documentation are that they do not want service members to go on record saying they did not experience an incident when they actually had. As discussed above, DOD officials explained that if service members deny having had such an experience, the denial could potentially affect their benefits claims should they choose to disclose their experience later. VA officials said permitting such documentation should not be a problem because if an examination is done by a VA provider, there is no such prohibition. The VA officials also stated that if DOD changed its guidance to permit such 222DOD Instruction 6040.46. The guidance is applicable to both restricted and unrestricted reports of sexual assault. 223DOD officials told us that if they updated the guidance to require documentation of such disclosures, they were concerned that providers would think that they were required to ask service members questions about whether they had experienced unwanted sexual behavior. As discussed above, service members are not screened for an experience with unwanted sexual behavior during the separation process to protect service members' privacy and confidentiality. DOD officials said that if a service member did disclose an experience during the separation health assessment, that information would be shared with the appropriate program office for unwanted sexual behavior, which may be undesirable for a service member. 224GAO-14-704G. Page 106 GAO-23-105381 Unwanted Sexual Behavior documentation, this change should not impact the separation health assessment form. 225 We have previously reported that processing veterans' disability claims related to unwanted sexual behavior poses challenges for VA because many sexual assaults are not officially reported when they happen during military service. 226 We also said that evidence of the trauma related to experiences with unwanted sexual behavior can be difficult to produce or validate. DHA officials said that there is value in providing guidance on documentation of unwanted sexual behavior. The officials also stated that consideration must be given to the reason sexual trauma disclosure is necessary, balancing patient privacy and victim control over who is privy to their disclosure. DOD officials were willing to explore a change to the documentation policy for the separation health assessment, but they raised concerns that providers may think they are required to ask about sexual trauma. Until DOD evaluates whether to permit documentation of disclosure of reports of unwanted sexual behavior during the separation health assessment, victims may continue to face challenges in obtaining VA benefits for conditions related to unwanted sexual behavior. Allowing disclosure of unwanted sexual behavior incidents and allowing documentation of such disclosures in the service treatment record or the separation health assessment, with the service member's permission, could help facilitate claims processing for VA. Military Departments Vary The military departments each have guidance on how to manage in How They Manage concurrent disability evaluation system and administrative separation cases, which occur when a service member is notified of a proposal for Concurrent Involuntary administrative separation while they are also separately being evaluated Separation and Disability for separation on the basis of a disability. However, their approaches to Evaluation System Cases 225As discussed above, VA and DOD jointly decided that the new separation health assessment will not include a screening question asking the service member whether they have experienced military sexual trauma or other forms of unwanted sexual behavior. DOD officials said that the departments instead decided to provide a standardized handout to all separating service members on available resources, reporting options, and how to submit a military sexual trauma claim with VA. 226GAO, VA Disability Benefits: Compensation Program Could Be Strengthened by Consistently Following Leading Reform Practice, GAO-22-104488 (Washington, D.C.: July 18, 2022). Page 107 GAO-23-105381 Unwanted Sexual Behavior resolving concurrent cases differ in a manner that could negatively affect separation outcomes for victims of unwanted sexual behavior. The Army and the Air Force generally require the official making the separation decision to decide between the disability separation or the administrative separation after both processes are complete, while the Navy and the Marine Corps separating officials may approve an administrative separation before completion of the disability separation process. For example, Department of the Army guidance on disability separations states that enlisted service members being processed for an administrative separation for misconduct as well as a disability separation will have the results of their medical evaluation board sent to the official making the separation decision, who must decide which action to pursue. 227 Similarly, Department of the Air Force guidance states that in a dual process case, both processes run independently and final disposition is withheld for decision by the Secretary of the Air Force Personnel Council or the general court-martial convening authority, as appropriate. 228 In contrast, Department of the Navy disability evaluation system guidance on dual process cases allows the Navy and the Marine Corps to administratively separate service members before the disability evaluation system process is complete. The deciding official may direct separation prior to completion of the disability evaluation system process if the separation authority determines and documents, in writing, that the member should be separated for the misconduct despite the medical 227The official making the separation decision is referred to in Army guidance as the general court-martial convening authority. Army Regulation 635-40, Disability Evaluation for Retention, Retirement, or Separation (Jan. 19, 2017). Army administrative separations guidance provides that disability separations processing takes precedence, regardless of whether the medical determination is made before, during or after initiation of an administrative separation, except under certain circumstances. Army Regulation 635-200. Army disability evaluation system guidance specifies than an exception to the separating authority deciding between the disability separation and the administrative separation would be if an enlisted service member is approved to be administratively separated instead of being subject to a court-martial, which could result in their being separated before a medical evaluation board has been completed. Under the Army guidance, if an officer was referred to the medical evaluation board prior to the approval of the resignation in lieu of court-martial, then the case would continue to be dual-processed. An officer is not eligible to be referred to the medical evaluation board after approval to resign in lieu of trial by court-martial. Army Regulation 635-40. 228Ifthe conclusion of the disability evaluation system referral is that the service member is determined fit and returned to duty, then the administrative separation process may continue. Page 108 GAO-23-105381 Unwanted Sexual Behavior condition. 229 Navy disability evaluation system counsel with whom we spoke stated service members who have dual processed cases could be administratively separated before the disability evaluation system case is complete, which can negatively impact factors such as the service member's characterization of discharge and being discharged without a VA disability ratings decision. 230 A DOD official said that there are reasons why every case should not go through the disability evaluation system process, such as situations where a disruptive service member may cause disciplinary problems if they have to remain in service while a decision is pending. Although the effect of the different service policies regarding concurrent separations on the proportion of separations is unknown, as the facts and circumstances of each case is unique, our analysis of DOD separations data and reports of unwanted sexual behavior showed that the percentage of disability separations was higher in the Army and the Air Force than it was in the Navy and the Marine Corps, as shown in table 4. We also found that there were more misconduct separations than disability separations involving male service members who made unrestricted or formal reports of unwanted sexual behavior in all of the military services from fiscal years 2015 through 2021, while there were more disability separations than misconduct separations for female service members in all of the military services. Table 4: Comparison of Misconduct and Disability Separations of Service Members who Reported an Experience With Unwanted Sexual Behavior, Fiscal Years 2015– 2021 Army Navy Marine Corps Air Force Misconduct Men 30% 28% 26% 22% Women 13% 13% 9% 11% Disability Men 24% 18% 9% 19% Women 39% 29% 27% 33% 229SECNAV M-1850.1, Department of the Navy Disability Evaluation System Manual (Sept. 2019). This guidance provides that the separation authority for enlisted dual processing cases shall be the first general or flag officer in the service member's chain of command, unless a higher authority is required. 230See appendix III for similar analyses of the characterization of discharge and reenlistment eligibility status for all service members compared to those who reported experiences with unwanted sexual behavior. Page 109 GAO-23-105381 Unwanted Sexual Behavior Source: GAO analysis of Department of Defense data. | GAO-23-105381 Note: Our analysis of those who reported unwanted sexual behavior to the Department of Defense (DOD) includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Navy disability evaluation system counsel we spoke with told us that the timeline for the disability evaluation system is very long compared to the timeline for an administrative separation case. 231 As a result, they said that it is likely that an administrative separation case would complete processing before the disability case is complete. The Navy disability evaluation system counsel expressed concerns about the Navy's approach, and told us that disability evaluation system cases should be concluded before the decision to administratively separate a service member is executed. The counsel believed that it is important to allow the physical evaluation board to decide the service member's fitness for continued military service and VA to make a disability ratings decision because they provide third party opinions about the effect of the service member's condition on their ability to do their job and about the severity of the service member's condition. Further, the counsel stated that without allowing the disability evaluation system process to finish, commands that separate service members administratively do not have complete information about the effect of the service member's condition on their job or the severity of their condition. In addition, members of the Navy Physical Evaluation Board explained why the lengthy period associated with processing a disability evaluation system might result in a service member who is going through the disability evaluation system process also facing a concurrent administrative separation case based on misconduct. These officials said that service members who are referred to the disability evaluation system for a behavioral health condition that is exacerbated by staying in the military environment often have their condition continue to deteriorate while they wait. The officials said that service members with behavioral health conditions may get into trouble while they wait for this process because there is a high co-morbidity of substance use and, for example, conditions like PTSD. For example, smoking marijuana to relieve their 231Navy Physical Evaluation Board officials told us that completion of the disability process can take as long as 1.5 years. The Navy Physical Evaluation Board adjudicates disability cases for the Navy and the Marine Corps. Page 110 GAO-23-105381 Unwanted Sexual Behavior symptoms would incur disciplinary action and trigger dual processing with an administrative separation case for misconduct. We raised the differences among the services and the concerns about the Navy policy to DOD in a draft of this report. In response, DOD indicated that it has determined that flexibility is important to ensuring good order and discipline. Therefore, it opted to maintain its existing minimum guidance, which has resulted in the differences among the military departments. DOD officials stated that officials making separation decisions balance consideration of a medical impairment or disability as a matter of equity or good conscience. Furthermore, these officials stated that imposing additional requirements on this process would not be in the best interests of service members or in maintaining good order and discipline. Unwanted sexual behavior-sexual harassment, sexual assault, and Conclusions domestic sexual abuse- undermines the core values of DOD and the military services. In addition, some victims of experiences with unwanted sexual behavior may suffer from chronic mental health conditions and are more likely to separate from the military. This decreases medical and force readiness and exacerbates the military services' critical recruitment and retention challenges. The behavioral health aspects of unwanted sexual behavior during military service have multiple facets, such as screening, reporting, and training, and addressing these issues will require DOD to take actions in multiple areas. Specifically, we identified challenges in the following areas: (1) accessing behavioral health care at DOD and VA facilities, (2) improving data and information sharing in DOD and VA electronic health record systems, (3) providing information about VA behavioral health care resources to service members, and (4) improving the separations decision process. DOD and VA provide behavioral health care for many active-duty service members and veterans who experienced unwanted sexual behavior, but several challenges exist in accessing care at DOD and VA facilities. Specifically, we identified challenges in how: (1) DOD screens for trauma stemming from experiences, (2) DOD prioritizes providing care to victims, (3) DOD enables service members to access care at VA medical centers and outpatient clinics, and (4) DOD and VA programs assist active-duty service members to transition from DOD to VA care. Without addressing these challenges, DOD and VA cannot ensure service members will be aware of, or will receive, the critical care for which they are eligible. Page 111 GAO-23-105381 Unwanted Sexual Behavior We also identified challenges associated with service members' privacy and confidentiality associated with data and information sharing in DOD and VA electronic health record systems. Specifically, we identified challenges in access controls in DOD's electronic health record, confidentiality of records in VA's electronic health record, and documentation of care for unwanted sexual behavior in DOD's electronic health record. By adopting information security best practices, determining an approach for confidentiality in the VA health record system to the maximum extent feasible, and developing guidance on documenting care, DOD and VA can better protect victims' data privacy while providing the best care possible. DOD has increased the availability of information about VA resources for active-duty service members who have experienced unwanted sexual behavior during military service, but DOD has not consistently communicated this information to all service members. Until DOD requires information about available VA resources be included in annual or periodic training, service members who experience unwanted sexual behavior, but do not report it, may be unaware that these resources exist. Moreover, by revising the participant guide for the transition assistance program's veterans benefits and services course to include information similar to what is included in the optional women's health course, VA and DOD can better ensure that all separating service members receive similar levels of important information on VA resources for experiences with unwanted sexual behavior. While DOD guidance on involuntary separation is consistent with statutory requirements, the processes pertaining to certain medical examinations and higher-level general or flag officer reviews related to involuntary separation cases treats victims of unwanted sexual behavior differently in some cases. Specifically: (1) these options are not available to victims of sexual harassment; (2) sexual assault victims are given limited time to avail themselves of these options and face other eligibility restrictions; (3) the medical examination process assesses only whether PTSD or traumatic brain injury-not other behavioral health diagnoses- could be related to the basis for involuntary separation; (4) service members who file a restricted report are not eligible to request the higher- level review; and (5) not all military services have incorporated mechanisms to notify service members that they may be eligible to request a higher-level review. Without addressing these issues, DOD will not fully consider how additional factors, including sexual harassment, may have contributed to a service member's proposed involuntary separation from military service. As a result, service members may not Page 112 GAO-23-105381 Unwanted Sexual Behavior get the treatment they need or may be unable to benefit from higher-level reviews, which could lead to mitigating actions such as the rehabilitation and retention, suspension of the separation, or a review of the character of discharge. Finally, DOD documentation guidance related to the separation health assessment given to all separating service members could limit a service member's ability to obtain future VA benefits for conditions related to unwanted sexual behavior. Considering modifications to the separation guidance to permit documentation of reports of unwanted sexual behavior that are disclosed during the separation health assessment could help decrease challenges faced by victims in obtaining VA benefits. We are making a total of 15 recommendations, including 10 to the Recommendations for Secretary of Defense, one to the Secretary of the Army, two to the Executive Action Secretary of the Navy, and two to the Secretary of Veterans Affairs. The Secretary of Defense should ensure that the Director of the Defense Health Agency develops guidance that establishes protocols specifying how and when providers should screen patients for experiences with unwanted sexual behavior. (Recommendation 1) The Secretary of Defense should ensure that as the department revises its guidance on health care management for patients who have experiences with unwanted sexual behavior, it considers modifications to clarify (1) when and how medical care should be prioritized for victims of unwanted sexual behavior, and (2) whether to expand the provisions about prioritization of care to include service members who have experienced sexual harassment. Any such revisions to the guidance should specify how providers can prioritize care for victims of unwanted sexual behavior in a manner that is consistent with DOD policy while also allowing them to effectively care for victims of other types of trauma. (Recommendation 2) The Secretary of Defense should include, as part of the department's planned study to implement the Independent Review Commission's recommendation to authorize service members' access to the full spectrum of VA care related to unwanted sexual behavior, consideration of several factors to balance confidentiality with mission needs to better facilitate implementing the Commission's recommendation to the greatest extent feasible. Specifically, the department's study should consider how best to enable such access by assessing the following: the extent that permitting greater access to VA behavioral health resources would pose Page 113 GAO-23-105381 Unwanted Sexual Behavior risks to DOD that would be different from the risks DOD faces from service members who confidentially obtain care in the private sector; whether access to VA care without a referral could be granted for service members who are not in certain populations or positions that require greater disclosure; potential revisions of or clarifications to service member disclosure requirements related to behavioral health; and mechanisms that could help facilitate confidential access to care, such as distinctions between treatments that do and do not require disclosure. (Recommendation 3) The Secretary of Defense and the Secretary of Veterans Affairs should collaborate to take steps to ensure that service members who have experienced unwanted sexual behavior and are eligible for VA services related only to military sexual trauma are provided information about and connected to all programs that assist in the transition from DOD to VA care. (Recommendation 4) The Secretary of Defense should ensure that the Director of the Defense Health Agency adopts information security best practices for MHS GENESIS to incorporate the principle of least privilege and limit health record access to those with an established provider-patient relationship or a need to know, and therefore better ensure victim confidentiality and privacy. (Recommendation 5) The Secretary of Veterans Affairs, in conjunction with the Secretary of Defense, should develop and evaluate options and make a determination of the best approach for incorporating a mechanism in its new electronic health record whereby VA providers can record unwanted sexual behavior care at medical centers and community-based outpatient clinics while limiting sharing that information to the greatest extent feasible. (Recommendation 6) The Secretary of Defense should ensure that the Director of the Defense Health Agency issues guidance that specifies how information about behavioral health care related to experiences with unwanted sexual behavior should be consistently documented in the electronic health record. (Recommendation 7) The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Director of the Office for Diversity, Equity, and Inclusion, revises harassment prevention and response training guidance to require that information about Department of Veterans Affairs resources for experiences with Page 114 GAO-23-105381 Unwanted Sexual Behavior unwanted sexual behavior be included in annual or periodic training that is administered to all service members, and takes steps to ensure that the military services implement the revised guidance. (Recommendation 8) The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Director of the Sexual Assault Prevention and Response Office, revises sexual assault prevention and response training guidance to require that information about Department of Veterans Affairs resources for experiences with unwanted sexual behavior be included in annual or periodic training that is administered to all service members, and takes steps to ensure that the military services implement the revised guidance. (Recommendation 9) The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Deputy Assistant Secretary of Defense for Military Community and Family Policy, revises domestic sexual abuse training guidance to require that information about Department of Veterans Affairs resources for experiences with unwanted sexual behavior be included in annual or periodic training that is administered to all service members, and takes steps to ensure that the military services implement the revised guidance. (Recommendation 10) The Secretary of Veterans Affairs, in coordination with the Secretary of Defense, should revise the participant guide for the Transition Assistance Program's Department of Veterans Affairs benefits and services course taken by all separating service members to include information about available Department of Veterans Affairs resources for experiences with unwanted sexual behavior, similar to what is included in the Transition Assistance Program's optional course on women's health. (Recommendation 11) The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness conducts a comprehensive evaluation to consider whether to modify DOD guidance on involuntary officer and enlisted administrative separations concerning medical examinations and higher-level general or flag officer reviews, including proposing changes to relevant statutes, as necessary. This evaluation should assess the following areas: (a) whether the eligible population should be service members who experienced any type of unwanted sexual behavior; (b) the appropriate timeframes between when an incident is reported and when a separation is proposed, and other Page 115 GAO-23-105381 Unwanted Sexual Behavior eligibility restrictions for obtaining a medical examination or higher-level review; (c) which behavioral health conditions or diagnoses should determine eligibility for a behavioral health examination; (d) whether service members who file restricted reports should be eligible to request a general or flag officer review; and (e) whether to permit documentation of the alleged sexual assault in the report of the separation health assessment. (Recommendation 12) The Secretary of the Army should ensure that Army guidance on involuntary officer and enlisted administrative separations is modified to require that the Army's standardized separation notification correspondence includes information about the general or flag officer review for victims of sexual assault. (Recommendation 13) The Secretary of the Navy should ensure that Navy guidance on involuntary officer and enlisted administrative separations is modified to require that the Navy's standardized separation notification correspondence includes information about the general or flag officer review for victims of sexual assault. (Recommendation 14) The Secretary of the Navy should ensure that the Marine Corps guidance on involuntary officer and enlisted administrative separations is modified to require that the Marine Corps's standardized separation notification correspondence includes information about the general or flag officer review for victims of sexual assault. (Recommendation 15) We provided a draft of this report to DOD and VA for review and Agency Comments comment. DOD concurred with 15 recommendations. VA concurred with and Our Evaluation recommendations 6 and 11 that were directed to the Secretary of Veterans Affairs, and with recommendation 4 directed to the Secretary of Defense in collaboration with the Secretary of Veterans Affairs. Both departments noted a number of actions they planned to take to address these recommendations. VA also noted completion dates for its planned actions. Both departments provided additional technical comments, which we incorporated in the report, as appropriate. Written comments from DOD and VA are reprinted in their entirety in appendix IV and V respectively. With respect to recommendation 5 that DOD incorporate the principle of least privilege and limit health record access to those with an established provider-patient relationship or a need to know and therefore better ensure victim confidentiality and privacy, DOD concurred but stated that all MHS GENESIS system end users are required to abide by rules and Page 116 GAO-23-105381 Unwanted Sexual Behavior regulations established pursuant to the Health Insurance Portability and Accountability Act of 1996. DOD noted that this includes the Health Insurance Portability and Accountability Act Privacy Rule, which addresses the use and disclosure of protected health information. DOD also stated that MHS GENESIS leverages an auditing tool designed to monitor inappropriate behavior by system users. However, a requirement alone for users to comply with the rules and regulations does not ensure that the privacy requirements of the principle of least privilege are met. For example, as we noted in our report, DOD's decision to allow all DOD users of MHS GENESIS to have the same level of access to all service members' medical records may not help to ensure the principle is implemented. As we noted, without adopting information security best practices to limit health record access to those with an established provider-patient relationship or a need to know, DOD cannot ensure the confidentiality of active-duty service members' data and provide assurance that those who have experienced unwanted sexual behavior are afforded privacy and protection from offenders. We also noted in our report that DHA officials said that the agency does not use the audit log to regularly monitor whether active-duty service members' medical records are being inappropriately accessed. As a result, we believe that additional actions are needed for DOD to further refine and limit access to health records in MHS GENESIS. In our draft report, we made a recommendation that the Under Secretary of Defense for Personnel and Readiness update the DOD guidance on administrative and disability separations to specify how the military services should address concurrent disability evaluation system and non- disability separation cases. In its comments, DOD did not concur. DOD stated that its existing guidance is sufficient to allow both the administrative non-judicial and military judicial systems to operate in parallel with the disability evaluation system until such time as one system concludes. 232 We noted in the report the different approaches among the services in how such concurrent cases are handled due to the lack of overarching DOD guidance on this issue. Specifically, we found that the Army and the Air Force generally require the official making the separation decision to decide between the disability separation or the administrative separation after both processes are complete, while the Navy and the Marine Corps separating officials may approve an 232DOD referenced DOD Instruction 1332.18, Disability Evaluation System (Nov. 10, 2022). Page 117 GAO-23-105381 Unwanted Sexual Behavior administrative separation before completion of the disability separation process. We made our recommendation in the draft report in part because we wanted to ensure that DOD was fully aware of the differences among the military departments and the potential for different outcomes that we identified in that section of the report. Based upon DOD's formal comments, it is evident that DOD is aware of and accepts the different approaches undertaken by the military departments, even when they lead to different outcomes for service members who are facing concurrent disability evaluation system and administrative separation cases in different military services. Specifically, DOD stated that it has determined that additional restrictions are not in the best interest of a service member nor good order and discipline. As a result, we have dropped this recommendation from our report. We are sending copies of this report to the appropriate congressional committees, the Secretary of Defense, the Secretary of Veterans Affairs, the Secretary of the Army, the Secretary of the Navy, and the Secretary of the Air Force. In addition, this report is available at no charge on the GAO website at https://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-3604 or farrellb@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix VI. Brenda S. Farrell Director, Defense Capabilities and Management Page 118 GAO-23-105381 Unwanted Sexual Behavior List of Requesters The Honorable Mark Takano Ranking Member Committee on Veterans' Affairs House of Representatives The Honorable Jack Bergman House of Representatives The Honorable Julia Brownley House of Representatives The Honorable Neal P. Dunn House of Representatives The Honorable Rick Larsen House of Representatives Page 119 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Appendix I: Objectives, Scope, and Methodology Methodology This report assesses the extent to which (1) the Department of Defense (DOD) and the Department of Veterans Affairs (VA) screen for and provide access to behavioral health care services to active-duty service members and veterans for experiences with unwanted sexual behavior during military service; (2) DOD and VA document and monitor the behavioral health care provided to active-duty service members and veterans who experience unwanted sexual behavior; (3) DOD and VA train service members on available VA resources for experiences with unwanted sexual behavior, and DOD trains its medical providers on trauma related to such experiences; and (4) experiences with unwanted sexual behavior play a role in voluntary and involuntary separations of service members from the military. For purposes of this report, we use the term "unwanted sexual behavior" as an umbrella term to collectively refer to sexual harassment, sexual assault, and domestic sexual abuse. VA uses the term military sexual trauma to refer to incidents of sexual harassment and sexual assault that occurred during military service. See the background section of this report for the DOD and VA definitions of these terms. Virtual Site Visits to For all of our objectives, we interviewed relevant military service officials Selected Military and VA medical providers at a nongeneralizable sample of four military installations and three VA medical facilities in the United States. 1 For Installations and VA military installations, we selected one installation per military service and Medical Facilities selected the installations based on a number of factors, including sexual harassment and sexual assault risk levels as determined by a 2018 RAND report, 2 presence of a military medical treatment facility, the number of personnel on the installation, the number of expected military separations, distance from a VA facility, and geographic location. 3 At each installation, we conducted semi-structured interviews with equal 1We conducted virtual site visits at one installation in each of the military services, as well as one VA community-based outpatient clinic, one VA vet center, and one VA medical center. 2RAND, Sexual Assault and Sexual Harassment in the U.S. Military: Volume 5. Estimates for Installation- and Command-Level Risk of Sexual Assault and Sexual Harassment from the 2014 RAND Military Workplace Study (2018). 3On December 20, 2019, the National Defense Authorization Act for Fiscal Year 2020 established the United States Space Force as a military service within DOD. Pub. L. No. 116-92, § 952(b)(2) (codified at 10 U.S.C. § 9081(a)). We did not conduct a Space Force virtual site visit given its status as a new organization and because it still followed Air Force policy and guidance for unwanted sexual behavior. Throughout this report we refer to only four military services within DOD: the Army, the Navy, the Marine Corps, and the Air Force. Page 120 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology opportunity personnel, sexual assault prevention and response personnel, Family Advocacy Program personnel, primary care and behavioral health providers, military attorneys, Transition Assistance Program counselors, O-4 through O-6 commanders, and commanders with general court-martial convening authority to discuss issues such as available behavioral health care services, training and information about such services, and separation processes for service members who have experienced unwanted sexual behavior. For VA medical facilities, we selected three facilities based on type of facility, number of patients served, available behavioral health services, and proximity to a military installation. At the VA medical facilities, we interviewed facility leadership, military sexual trauma coordinators, care management personnel, behavioral health providers, primary care providers, liaisons, and management staff about available behavioral health care and the provision of such care to service members and veterans who have experienced unwanted sexual behavior. Because we did not select locations using a statistically representative sampling method, the comments provided during our interviews with military service and VA medical providers are nongeneralizable and therefore cannot be projected across DOD, a military service, any other installations, VA, or any other VA medical facilities. While the information obtained was not generalizable, these visits provided perspectives from installation officials who have assisted with the response to or provided behavioral health services to service members who have experienced unwanted sexual behavior. It also provided perspectives from VA medical providers who have assisted with the provision of or provided behavioral health services to service members and veterans who have experienced unwanted sexual behavior. In addition to the site visit locations, we also met with a variety of officials in DOD and VA. Table 5 presents the DOD, VA, and nongovernmental organizations we contacted during our review to address our four objectives. Page 121 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology Table 5: DOD, VA, and Nongovernmental Organizations Contacted by GAO Organization Office contacted Department of Defense (DOD) • Defense Health Agency • Defense Manpower Data Center • Department of Defense Inspector General • Defense Sexual Assault Prevention and Response Office • Family Advocacy Program • Office for Diversity, Equity, and Inclusion • Office of People Analytics • Office of the Assistant Secretary of Defense for Health Affairs • Office of the Under Secretary of Defense for Personnel and Readiness • TRICARE • VA-DOD Joint Executive Committee Sexual Trauma Working Group Department of the Army • Army Discharge Review Board • Family Advocacy Program • Installation Management Command • Medical Command • Sexual Harassment/Assault Response and Prevention • Training and Doctrine Command • Transition Assistance Program Department of the Navy • Bureau of Medicine and Surgery • Equal Opportunity Office • Family Advocacy Program • Sexual Assault Prevention and Response • Transition Assistance Program United States Marine Corps • Family Advocacy Program • Military Personnel Law Branch, Judge Advocate Division • Opportunity, Diversity, and Inclusion Branch • Sexual Assault Prevention and Response • Transition Readiness Program Department of the Air Force • Air Force Discharge Review Board • Air Force Equal Opportunity • Air Force Medical Service • Family Advocacy Program • Integrated Resilience Office • Air Force Personnel Center • Transition Assistance Program Page 122 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology Organization Office contacted Department of Veterans Affairs (VA) • Compensation Service • Office of Mental Health and Suicide Prevention • Outreach, Transition and Economic Development • Readjustment Counseling Service • VA Office of Inspector General • Veterans Benefits Administration • Veterans Experience Office • Veterans Health Administration Nongovernmental organization • Disabled American Veterans • Military Officers Association of America • Paralyzed Veterans of America • Reserve Organization of America • Veterans of Foreign Wars Source: GAO. I GAO-23-105381 Methods Used to Assess To assess the extent to which DOD and VA screen for and provide DOD and VA Behavioral access to behavioral health care to active-duty service members and veterans for experiences with unwanted sexual behavior during military Health Screening and service, we reviewed relevant DOD and VA policies and guidance. 4 We Care obtained and analyzed statutes, and departmental (DOD and VA) and military service guidance and documents to determine if, when, and how screening for experiences with unwanted sexual behavior and related behavioral health challenges should be conducted, what behavioral health care is available, and at what touchpoints such care is offered. We analyzed this guidance, conducted a literature search, and interviewed DOD and VA officials to determine the types of behavioral health care they provide, to understand the extent to which service members and veterans received behavioral health care for experiences with unwanted sexual behaviors at DOD and VA, and to understand how and under what 4See VA Veterans Health Administration Directive 1115(1), Military Sexual Trauma (MST) Program (May 8, 2018) (amended Dec. 1, 2021); VA Veterans Health Administration Handbook 1160.01(1), Uniform Mental Health Services in VA Medical Centers and Clinics (Sept. 11, 2008) (amended Nov. 16, 2015); VA Veterans Health Administration Directive 1011, Department of Veterans Affairs Liaison for Healthcare Serving Military Treatment Facilities and Public-Private Partnerships (May 9, 2022); DOD Directive 6495.01, Sexual Assault Prevention and Response (SAPR) Program (Jan. 23, 2012) (incorporating Change 5, Nov. 10, 2021); DOD Instruction 6495.02, Vol. 1, Sexual Assault Prevention and Response: Program Procedures (Mar. 28, 2013) (incorporating change 7, Sept. 6, 2022); Defense Health Agency Procedures Manual 6025.01, Primary Care Behavioral Health (PCBH) Standards (Dec. 20, 2019); DOD Instruction 1020.03, Harassment Prevention and Response in the Armed Forces (Feb. 8, 2018) (incorporating change 2, Dec. 20, 2022). Page 123 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology circumstances they screen service members and veterans for experiences with unwanted sexual behavior. In our virtual site visits, we discussed with officials any guidance, procedures, or information used to guide providers' decisions about screening clients for experiences with unwanted sexual behavior and related behavioral health challenges. We interviewed agency officials and conducted semi-structured interviews with primary care and behavioral health providers to obtain illustrative examples of how DOD and VA guidance on providing behavioral health care for conditions related to experiences with unwanted sexual behavior is operationalized, and any associated barriers or challenges to providing care or screening for unwanted sexual behavior. To determine the extent that DOD and VA provided behavioral health care to service members and veterans who experienced unwanted sexual behavior, we requested and received behavioral health care data from the Defense Health Agency (DHA), Veterans Health Administration, and VA Readjustment Counseling Service. Specifically, for DOD, we analyzed data from DOD's Military Health System Data Repository database for all active-duty service members who received medical behavioral health care from fiscal years 2015 through 2021 that was documented in the database on the same record as a diagnosis for unwanted sexual behavior. 5 For each service member, we analyzed information such as military service, gender, date care provided, diagnosis code, treatment location, type of treatment (inpatient or outpatient), and care location (direct care or private sector). 6 We analyzed the population of service members who received this care to determine the proportions of these characteristics among this population. This approach only captures behavioral health diagnoses that were on the same record as the diagnosis for unwanted sexual behavior. It does not include any 5For purposes of this review, we focused on DOD medical behavioral health care, although DOD offers both medical and non-medical behavioral health care services. Medical behavioral health care services include specialty mental health care such as clinical therapy for mental health conditions, intensive outpatient programs, and residential treatment. Non-medical behavioral health care services include short-term therapeutic counseling that is supportive in nature and addresses general conditions of living, life skills, improving relationships, stress management, martial problems, parenting, and grief and loss. 6We did not analyze data from the Space Force separately because it did not exist as a military service for most of the years of our data analysis, given its establishment in December 2019. For purposes of this report, any data for Space Force personnel was included in the Air Force data analyses. Page 124 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology behavioral health care records for these service members where there was not a diagnosis for unwanted sexual behaviors, which may underestimate these results. For the Veterans Health Administration, we analyzed data from Veterans Health Administration's Corporate Data Warehouse database for all service members and veterans who received care from fiscal years 2015 through 2021 that was documented in the database with a flag indicating that the care was for military sexual trauma. For each service member and veteran, we analyzed information such as veteran status, gender, race, military sexual trauma screening information, and date care provided. We analyzed the population of service members and veterans who received this care to determine the proportions of these characteristics among this population. For VA Readjustment Counseling Service, we analyzed data from the Readjustment Counseling Service RCS Net database for all service members and veterans who received psychosocial counseling from fiscal years 2015 through 2021 that was documented in the database as counseling for military sexual trauma. For each service member and veteran, we analyzed information such as veteran status, gender, race, military sexual trauma screening information, and date counseling provided. We analyzed the population of service members and veterans who received this care to determine the proportions of these characteristics among this population. To identify active-duty service members who reported experiences of unwanted sexual behavior to DOD during this period, we analyzed data for all unrestricted reports of sexual assault, formal reports of sexual harassment, informal reports of sexual harassment where identifying information was collected, and unrestricted reports of domestic sexual abuse involving victims who were active-duty service members from fiscal years 2015 through 2021. 7 We analyzed this data from reports maintained in the Defense Sexual Assault Incident Database, the Family Advocacy Program Central Registry, and each military service's sexual 7For Navy sexual harassment data, we were able to analyze formal sexual harassment cases from fiscal years 2019 through 2021 only, due to limitations in available data in earlier fiscal years. Page 125 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology harassment database. 8 For each reported incident, we analyzed information such as report date, incident type, military service, gender, and race. We then analyzed the behavioral health care provided to service members who reported experiences with unwanted sexual behavior. We matched service members who received care for unwanted sexual behavior from DOD or VA with records of reported incidents. We then determined the proportions of characteristics such as service, gender, diagnosis or type of care, provider type, and care location among service members who reported experiences with unwanted sexual behavior. Service members may have reported more than one incident or type of unwanted sexual behavior. If that occurred, we only included one count of unwanted sexual behavior per service member (labeled as multiple types), regardless of the total number of times they may have reported incidents. We used the same timeframe for all of our data analysis, so the follow up period in our analysis for behavioral health care will be shorter for those who reported an incident to DOD in fiscal year 2021 than for those who reported an experience with unwanted sexual behavior to DOD in fiscal year 2015. Conclusions regarding trends over time should be interpreted with this caveat in mind. We conducted data reliability assessments on the datasets we received from the databases in our review. We examined the documentation that officials provided to us on each database and conducted electronic tests on the data we received to check for completeness and accuracy. We also checked to see that values for variables were internally consistent and that results were not affected unduly by values that might suggest miscoded values. We also sent a list of written questions to database managers about how the data are collected and their appropriate uses. We also had discussions with database managers to discuss the accuracy and completeness of the data in their databases. We found the data were sufficiently reliable to report on the extent to which service members who received behavioral health care that was documented as being related to unwanted sexual behavior had or had not reported an experience with unwanted sexual behavior, and various characteristics 8The military service sexual harassment databases from which we analyzed incident data were the Army Sexual Harassment/Assault Response and Prevention (SHARP) Integrated Case Reporting System, Navy Sexual Harassment Database, Marine Corps's Discrimination and Sexual Harassment Database, and the Air Force Sexual Harassment AFEONet (Entellitrak) Database. Page 126 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology associated with those who received such behavioral health care, such as military service, veteran status, care location, diagnosis or type of care, and gender. 9 Methods Used to Assess To assess the extent to which DOD and VA document and monitor the DOD and VA behavioral health care provided to active-duty service members and veterans who experience unwanted sexual behavior, we reviewed Documentation and relevant DOD and VA policies and guidance. 10 We interviewed officials Monitoring of Behavioral from DHA (including DOD health care providers) and the Department of Health Care Veterans Affairs (including military sexual trauma coordinators and Vet Center counselors) to determine their processes for documenting and monitoring the behavioral health care provided to service members and veterans who experienced unwanted sexual behavior. In our virtual site visits, we discussed with officials any guidance, procedures, or information used to guide providers' decisions about documenting and monitoring care provided for conditions related to experiences with unwanted sexual behavior and related behavioral health challenges. We interviewed agency officials and conducted semi- structured interviews with primary care and behavioral health providers to obtain illustrative examples of how DOD and VA guidance on documenting and monitoring services is operationalized, and any associated barriers or challenges to providing care for unwanted sexual behavior. In addition, we determined that the information and communication component of internal control was relevant to this objective. 11 Specifically, we identified the underlying principles that management should use quality information-that is current, complete, accurate, accessible, and timely-and internally communicate that information to achieve objectives as relevant to this objective. We assessed DOD's processes for 9Figures and tables with results of our data analysis include a figure or table note that describes any caveats or limitations associated with a particular analysis. 10See VA Veterans Health Administration Directive 1115(1), Military Sexual Trauma (MST) Program (May 8, 2018) (amended Dec. 1, 2021); VA Veterans Health Administration Directive 1500(2), Readjustment Counseling Service (Jan. 26, 2021) (amended Dec. 30, 2021); DHA Procedural Instruction 6490.02, Behavioral Health (BH) Treatment and Outcomes Monitoring (July 12, 2018); DHA Administrative Instruction 3000.01, Analytics and Evaluation (A&E) (Aug. 3, 2020); DHA Procedures Manual 6025.01, Primary Care Behavioral Health (PCBH) Standards (Dec. 20, 2019). 11GAO, Standards for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C.: Sept. 10, 2014). Page 127 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology documenting behavioral health care received to determine whether DOD met these principles. Methods Used to Assess To assess the extent to which DOD and VA provide training to service DOD and VA Training members on the availability of VA resources for experiences with unwanted sexual behavior, we analyzed the military services' annual or periodic training provided to all service members on sexual harassment, sexual assault, and domestic sexual abuse. Specifically, we analyzed the trainings to determine whether they provide information about available VA resources for active-duty service members who experience unwanted sexual behavior during military service. We also conducted interviews with relevant military service officials about the training provided. We compared the information contained in the training to DOD guidance on sexual assault prevention and response and domestic sexual abuse regarding required training content. 12 We also reviewed VA courses provided to service members who are separating from the military as part of DOD's Transition Assistance Program. We analyzed the VA courses to determine what information is included regarding VA's resources for service members and veterans who experienced unwanted sexual behavior during military service. We also conducted interviews with relevant VA and DOD officials about the Transition Assistance Program and the courses provided. We compared the information contained in the courses to relevant law. 13 To assess the extent to which DOD provides training to DOD medical providers on trauma related to such experiences, we analyzed the Defense Health Agency's first responder training for all health care personnel. We also conducted interviews with relevant DOD and military service officials and reviewed information about medical training provided to DOD medical providers. We compared the information from our analysis of training and interviews with relevant officials to DOD guidance on sexual assault health care management. 14 We also compared information contained in the military services' annual or periodic trainings and the Transition Assistance Program trainings with 12DOD Instruction 6495.02, Vol. 2, Sexual Assault Prevention and Response: Education and Training (Apr. 9, 2021) and DOD Instruction 6400.06. 1310 U.S.C. §1142(b)(7) and (11). 14DOD Instruction 6310.09, Health Care Management for Patients Associated with a Sexual Assault (May 7, 2019). Page 128 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology internal control standards for communicating the necessary quality information to achieve an agency's objectives. 15 We determined that the information and communication component of internal control was relevant to this objective. Specifically, we identified the underlying principles that management should use quality information-that is current, complete, accurate, accessible, and timely-and internally communicate that information to achieve objectives as relevant to this objective. We assessed this training content to determine whether DOD met these principles. Methods Used to Assess To assess the extent to which experiences with unwanted sexual Role of Unwanted Sexual behavior play a role in voluntary and involuntary separations of service members from the military, we obtained and analyzed statutes and DOD Behavior in Separations and military service guidance, documents, and information. 16 Specifically, we identified provisions in the statutes and guidance that specified separation processes applicable to service members who had experienced unwanted sexual behavior. In addition, we interviewed officials from DOD and each military service to obtain perspectives on how these provisions were implemented. We compared DOD processes to DOD strategic guidance and relevant internal controls to determine if these processes were consistent with this guidance and internal controls. 17 We determined that the policies and evaluations components 15GAO-14-704G. 1610 U.S.C. §1177; Pub. L. No. 112-239, §578 (10 U.S.C. §1561 note); DOD Instruction 1332.14, Enlisted Administrative Separations (Jan. 27, 2014) (Incorporating Change 7, June 23, 2022); DOD Instruction 1332.30, Commissioned Officer Administrative Separations (May 11, 2018) (Incorporating Change 3, Sept. 9, 2021); DOD Instruction 6490.04, Mental Health Evaluations of Members of the Military Services (Mar. 4, 2013, incorporating change 1, effective Apr. 22, 2020); Dept. of the Army, OTSG/MEDCOM Policy Memo 22-002, Behavioral Health Evaluations for Administrative Separations of Active Duty Enlisted Service Members under AR 635-200, 5-14 (Jan. 28, 2022); Army Regulation 635-200, Active Duty Enlisted Administrative Separations (June 28, 2021); Army Regulation 600-8-24, Officer Transfers and Discharges (Feb. 8, 2020); Army Regulation 635-40, Disability Evaluation for Retention, Retirement, or Separation (Jan. 19, 2017); SECNAV Instruction 1920.6D, Administrative Separation of Officers (July 24, 2019); Dept. of the Navy, Naval Military Personnel Manual (MILPERSMAN) Article 1910 (series) Enlisted Administrative Separations; SECNAV M-1850.1, Department of Navy Disability Evaluation System Manual (September 2019); Marine Corps Order 1900.16, Separation and Retirement Manual (Change 2, Feb. 15, 2019); Department of the Air Force Instruction 36-3211, Military Separations (June 24, 2022); Dept. of the Air Force, Separations Program: Personnel Services Delivery (PSD) Guide (version 10) (Apr. 29, 2022); Air Force Instruction 36-3212, Physical Evaluation for Retention, Retirement, and Separation (July 15, 2019, incorporating Change 1, Dec. 4, 2020). 17DOD, Strategic Management Plan Fiscal Years 2022-2026. Page 129 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology of internal control were relevant to this analysis. 18 Specifically, we identified the underlying principles that management should implement control activities through policies that include responsibilities for objectives and related risks, and that management periodically use separate evaluations to monitor the design and operating effectiveness of a specific function and obtain feedback on the effectiveness of ongoing monitoring. We assessed DOD's processes for considering service member experiences with unwanted sexual behavior when making separation decisions to determine whether DOD met these principles. In addition, we reviewed documentation and reported results for DOD and military service surveys of service members related to or asking about separations, to identify any questions related to the connection between unwanted sexual behavior and separation decisions. We also interviewed officials from DOD and each military department to obtain perspectives on how these survey questions were developed and analyzed. We analyzed departmental guidance and documents, and interviewed DOD and military service officials to identify any DOD and military service processes to correlate separation decisions with service member experiences with unwanted sexual behavior during military service. In our virtual site visits, we discussed with officials any guidance, procedures, or information used to guide decisions about separating service members who had experienced unwanted sexual behavior and related behavioral health challenges. We interviewed agency officials and conducted semi-structured interviews with personnel who provide input on, support, or decide separations cases to obtain illustrative examples of how DOD provisions for considering experiences with unwanted sexual behavior during the separation process is operationalized, and any associated barriers or challenges associated with separations of service members who have experienced unwanted sexual behavior. To determine the extent that service members who experienced unwanted sexual behavior separated from the military, we requested and received from the Defense Manpower Data Center data for all active-duty service members who separated from service from fiscal years 2015 through 2021. For each service member, we analyzed information such as separation date, separation program designator codes (these codes describe the reason for separation), characterization of discharge, reenlistment eligibility status, military service, and gender. We analyzed 18GAO-14-704G. Page 130 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology the population of separated service members to determine the proportions of characteristics, such as reason for separation, characterization of discharge, reenlistment eligibility status, gender, and military service, among others. We also calculated the time period between the incident report date and the separation date. To analyze the reason for separation, two analysts independently reviewed all of the separation program designator codes and their associated descriptions provided by the Defense Manpower Data Center. For each code, we categorized the reason for separation as falling into one of five groups that we created: disability, misconduct, retirement, service-initiated, and voluntary. 19 Differences between the two analysts were reconciled to produce a final grouping of separation program designator codes into our five groups of reasons for separation. In addition, to analyze reenlistment eligibility status, two analysts independently reviewed all of the reenlistment eligibility codes and their associated descriptions in military service guidance. We determined whether each code indicated a reason for separation that fell into one of three groups that we created: eligible to reenlist, eligible to reenlist with a waiver/subject to a condition, or ineligible to reenlist. Differences between the two analysts were reconciled to produce a final grouping of reenlistment eligibility codes into our three reenlistment eligibility groups. We then analyzed data for separations among service members who reported experiences with unwanted sexual behavior, using the unwanted sexual behavior incident data discussed above. We matched separated service members with records of reported incidents. We then determined the proportions of characteristics such as reason for separation, characterization of discharge, reenlistment eligibility status, gender, military service, and time period between incident report date and separation date among separated service members who reported experiences with unwanted sexual behavior. Service members may have reported more than one incident or type of unwanted sexual behavior. If that occurred, we only included one count of unwanted sexual behavior per service member (labeled as multiple types) regardless of the total number of times they may have reported incidents. We used the same timeframe for all of our data analysis, so the follow up period in our analysis for behavioral health care and separations will be much shorter 19The service-initiated group includes separations that correspond to separation program designator codes with meanings such as failure to meet weight control standards, retention inconsistent with national security standards, erroneous entry or reenlistment, and failure to meet minimum retention standards, among others. Page 131 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology for those who reported an incident to DOD in fiscal year 2021 than for those who reported an experience with unwanted sexual behavior to DOD in fiscal year 2015. Conclusions regarding trends over time should be interpreted with this caveat in mind. In addition, we analyzed behavioral health diagnoses that were documented on the same record as a diagnosis for unwanted sexual behavior among service members who reported experiences with unwanted sexual behavior from the DOD medical data we received as discussed above. We consulted with DHA officials, GAO's nurse consultant, and other knowledgeable officials to group International Classification of Diseases (ICD) 9 and ICD 10 diagnosis codes into the following diagnosis categories: Attention-Deficit/Hyperactivity Disorder, conduct disorders, and hyperkinetic syndrome; alcohol use disorder; anxiety disorders (other than post-traumatic stress disorder); bipolar disorder; depressive disorders; drug use disorders; other behavioral health disorders; post-traumatic stress disorder (PTSD); personality disorders; schizophrenia and other psychotic disorders; and tobacco use disorders. We then determined the proportions of characteristics such as military service and gender for these diagnoses among service members who reported experiences with unwanted sexual behavior and who had diagnoses related to unwanted sexual behavior during our time period. Service members may have received more than one diagnosis. If that occurred, we included one count for each diagnosis received by an individual service member in a different diagnosis category. As a result, an individual service member could be counted multiple times in different diagnosis categories. According to DHA officials, this approach only captures behavioral health diagnoses that were on the same record as the diagnosis for unwanted sexual behavior. It does not include any behavioral health care records for these service members where there was not a diagnosis for unwanted sexual behaviors, which may underestimate these results. We conducted data reliability assessments on the datasets we received from the databases in our review. We examined the documentation that officials provided to us on each database and conducted electronic tests on the data we received to check for completeness and accuracy. We also checked to see that values for variables were internally consistent and that results were not affected by values that might suggest miscoded values. We also sent a list of written questions to database managers about how the data are collected and their appropriate uses or had discussions with database managers to discuss the accuracy and completeness of the data in their databases. We found the data was Page 132 GAO-23-105381 Unwanted Sexual Behavior Appendix I: Objectives, Scope, and Methodology sufficiently reliable to report on the extent that the service members who had separated had or had not reported an experience with unwanted sexual behavior to DOD, and various characteristics associated with their separation, such as the reason for separation, characterization of discharge, and reenlistment eligibility status. 20 We conducted this performance audit from August 2021 to August 2023 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. 20Figures and tables with results of our data analysis include a figure or table note that describes any caveats or limitations associated with a particular analysis. Page 133 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Appendix II: Additional DOD and VA Behavioral Health Data Analysis Behavioral Health Data Analysis This appendix contains additional tables and figures related to Department of Defense (DOD) care provision for experiences with unwanted sexual behavior, Department of Veterans Affairs (VA) care provision for experiences with unwanted sexual behavior, and VA screening data on those who screened positive for experiences with unwanted sexual behavior. DOD Care Provision for As discussed above, DOD provided medical behavioral health care Experiences with related to unwanted sexual behavior to 5,343 active-duty service members during fiscal years 2015 through 2021. These service members Unwanted Sexual received care across 42 U.S. states and territories. Figure 15 shows Behavior where service members received care and table 6 shows the associated state-by-state breakdown of where service members received care. 1 1We used DOD's Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Our analysis does not include information on behavioral health care that DOD does not track in its Military Health System Data Repository, such as the Family Advocacy Program's non-clinical counseling services. The Defense Health Agency (DHA) uses International Classification of Diseases (ICD)-10 codes related to sexual abuse to identify medical behavioral health care encounters related to unwanted sexual behavior. These codes' descriptions use the terms "sexual abuse" or "sexual harassment." Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. The number of service members who received behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed earlier in this report. Page 134 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis Figure 15: Number of Service Members Who Received Medical Behavioral Health Care Documented as Being for Experiences with Unwanted Sexual Behavior, by State and Territory, Fiscal Years 2015–2021 Note: We used the Department of Defense's (DOD) Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. An individual service member was counted only once in each state or territory, regardless of the number of times they received care, but the same service member could have been counted in multiple states or territories. The number of service members who received medical behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed earlier in this report. Page 135 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis Table 6: Number of Service Members Who Received Medical Behavioral Health Care Documented as Being for Experiences with Unwanted Sexual Behavior, by State and Territory, Fiscal Years 2015–2021 State or territory Number of service members treated Alabama (AL) 54 Alaska (AK) 101 Arizona (AZ) 80 Arkansas (AR) 13 California (CA) 321 Colorado (CO) 396 Connecticut (CT) <10 Delaware (DE) 20 District of Columbia (DC) <10 Florida (FL) 150 Georgia (GA) 314 Guam (GU) <10 Hawaii (HI) 168 Idaho (ID) 17 Illinois (IL) 29 Indiana (IN) 0 Iowa (IA) 0 Kansas (KS) 138 Kentucky (KY) 178 Louisiana (LA) 75 Maine (ME) 0 Maryland (MD) 74 Massachusetts (MA) <10 Michigan (MI) 0 Minnesota (MN) 0 Mississippi (MS) 16 Missouri (MO) 90 Montana (MT) 12 Nebraska (NE) 28 Nevada (NV) 24 New Hampshire (NH) <10 New Jersey (NJ) 39 New Mexico (NM) 41 New York (NY) 171 Page 136 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis State or territory Number of service members treated North Carolina (NC) 232 North Dakota (ND) 37 Ohio (OH) 27 Oklahoma (OK) 81 Oregon (OR) 0 Pennsylvania (PA) 0 Puerto Rico (PR) 0 Rhode Island (RI) <10 South Carolina (SC) 90 South Dakota (SD) 19 Tennessee (TN) <10 Texas (TX) 909 Utah (UT) 14 Vermont (VT) 0 Virginia (VA) 211 Washington (WA) 548 West Virginia (WV) 0 Wisconsin (WI) 0 Wyoming (WY) 17 Legend: <10 refers to states that have fewer than 10 service members who received medical behavioral health care documented as being for experiences with unwanted sexual behavior to protect privacy. Source: GAO analysis of Department of Defense information. | GAO-23-105381 Note: We used the Department of Defense's (DOD) Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Service members may have received behavioral health treatment related to unwanted sexual behaviors, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. An individual service member was counted only once in each state or territory, regardless of the number of times they received care, but the same service member could have been counted in multiple states or territories. The number of service members who received medical behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed earlier in this report. As discussed earlier in this report, DOD provides both inpatient and outpatient behavioral health care to service members. From fiscal years 2015 through 2021, 287 service members received inpatient behavioral health care related to unwanted sexual behavior. Of these, 77 female and 31 male service members did not make an unrestricted or formal report of their experiences with unwanted sexual behavior to DOD, while 142 Page 137 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis female and 37 male service members did report their experiences to DOD. During the same timeframe, 5,137 service members received outpatient behavioral health care related to unwanted sexual behavior. 2 Of these, 1,670 female and 1,046 male service members did not report their experiences with unwanted sexual behavior to DOD, while 2,086 female and 335 male service members did make an unrestricted or formal report of their experiences (see fig. 16). 3 2The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. 3We used DOD's Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non- medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. An individual service member was counted only once, regardless of the number of times they received care, but the same service member could have been counted in both outpatient and inpatient care counts. The number of service members who received medical behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed earlier in this report. Page 138 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis Figure 16: Number of Active-Duty Service Members Who Received Inpatient and Outpatient Medical Behavioral Health Care, by Reporting Status, Fiscal Years 2015– 2021 Note: We used the Department of Defense's (DOD) Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. An individual service member was counted only once in each fiscal year regardless of the number of times they received care in that fiscal year, but the same service member could have been counted in multiple fiscal years and in both inpatient Page 139 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis and outpatient care counts. The number of service members who received medical behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed earlier in this report. The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Our analysis of DOD data found that 5,371 service members received behavioral health care through the military health system related to experiences with unwanted sexual behavior between fiscal years 2015 through 2021. Of these, 5,178 service members received direct care while 193 received private sector care. Percentages among racial groups were similar. For example, 61 percent of direct care recipients and 60 percent of private sector care recipients were White, while 25 percent of direct care recipients and 23 percent of private sector care recipients were Black or African American (see fig. 17). Figure 17: Percentage of Service Members Who Received Behavioral Health Treatment through the Military Health System Related to Unwanted Sexual Behavior, by Care Source and Race, Fiscal Years 2015–2021 Note: We used the Department of Defense's (DOD) Military Health System Data Repository to identify behavioral health care records with diagnostic codes for unwanted sexual behaviors in direct care and in the private sector for active-duty service members. Private sector care includes care that was billed to TRICARE and paid in part or in full by TRICARE. Service members may have received behavioral health treatment related to unwanted sexual behavior, such as non-medical counseling, without such treatment being identified in DOD medical records with a diagnostic code related to unwanted sexual behavior, such as if unwanted sexual behavior was not the documented reason for the care. Additionally, DOD officials said that not all service members who experienced unwanted sexual behavior may want or need behavioral health care. An individual service member was counted only once for each care source, regardless of the number of times they received care, but the same Page 140 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis service member could have been counted in both direct and private sector care counts. The number of service members who received medical behavioral health care identified as related to unwanted sexual behavior is likely undercounted because of DOD's inconsistent care documentation practices, discussed earlier in this report. VA Care Provision for As discussed earlier in this report, our analysis of Veterans Health Experiences with Administration data found that VA medical centers and clinics provided behavioral health care to 316,666 separate veterans and service Unwanted Sexual members for experiences with unwanted sexual behavior during fiscal Behavior years 2015 to 2021. Additionally, as discussed above, VA provided behavioral health care related to unwanted sexual behavior to 38,882 veterans and service members at Vet Centers, where a referral is not needed for active-duty service members to obtain care, during fiscal years 2015 through 2021 (see fig. 18). 4 4We identified these data using VA codes related to military sexual trauma. An individual was counted only once for each service category, regardless of the number of times they received care, but the same service member could have been counted as both a veteran and a currently serving service member if they received VA care in both capacities over our time period. Individuals also could have received care from DOD. The term veteran includes any former service member who received VA care for unwanted sexual behavior. The number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. Page 141 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis Figure 18: Percentage of Service Members and Veterans Who Received VA Behavioral Health Care for Experiences with Unwanted Sexual Behavior, by Gender, Military Service, and Care Type, Fiscal Years 2015–2021 Note: We identified these data using Department of Veterans Affairs (VA) codes related to military sexual trauma. An individual was counted only once in each service for each care type, regardless of the number of times they received care, but the same veteran or service member could have been counted in multiple services, in both care types, and as both a veteran and a currently serving service member. Individuals also could have received care from the Department of Defense. The term veteran includes any former service member who received VA care for unwanted sexual behavior. According to VA officials, the number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. Of those veterans and service members who received behavioral VA health care related to experiences with unwanted sexual behavior, Whites made up the largest racial group (59 percent of both veterans and service members), while Blacks and African Americans were the second largest racial group (28 percent of veterans and 29 percent of service members) (see fig. 19). Page 142 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis Figure 19: Percentage of Veterans and Service Members Who Received Behavioral Health Treatment Related to Unwanted Sexual Behavior at VA Medical Centers or Clinics, by Race, Fiscal Years 2015–2021 Note: We identified these data using Department of Veterans Affairs (VA) codes related to military sexual trauma. An individual was counted only once in each fiscal year for each racial group or service status, regardless of the number of times they received care, but the same veteran or service member could have been counted in multiple racial groups and as both a veteran and a service member if they received VA care in both service capacities or identified with different races over our time period. Individuals also could have received care from the Department of Defense. The term veteran includes any former service member who received VA care for unwanted sexual behavior. According to VA officials, the number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. Of the more than 300,000 veterans and service members who received behavioral VA health care treatment related to experiences with unwanted sexual behavior, only 5,650 reported their experiences. Of these, 2,974 White veterans (57 percent) and 231 White service members (55 percent) made an unrestricted or formal report of an experience with unwanted sexual behavior to DOD, and 1,229 Black or African American veterans (24 percent) and 104 Black or African Page 143 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis American service members (25 percent) made an unrestricted or formal report of their experiences to DOD (see fig. 20). 5 Figure 20: Percentage of Veterans and Currently Serving Service Members Who Reported an Experience with Unwanted Sexual Behavior and Received Related Behavioral Health Treatment at Department of Veterans Affairs Medical Centers or Clinics, by Race, Fiscal Years 2015–2021 Note: We identified these data using Department of Veterans Affairs (VA) codes related to military sexual trauma. An individual was counted only once in each fiscal year for each racial group or service status, regardless of the number of times they received care, but the same veteran or service member could have been counted in multiple racial groups and in both service statuses if they received VA care in both capacities or identified as different races over our time period. Individuals also could have received care from the Department of Defense (DOD). The term veteran includes any former service member who received VA care for unwanted sexual behavior. According to VA officials, the number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. 5The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Page 144 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis According to our analysis of VA Readjustment Counseling Service data, 19,441 clients received Vet Center counseling during fiscal years 2015 through 2021. Of these, 9,856 (51 percent) were White and 5,965 (31 percent) were Black or African American (see fig. 21). Figure 21: Percentage of VA Clients Who Received Vet Center Counseling Related to Unwanted Sexual Behavior, by Race, Fiscal Years 2015–2021 Note: We identified these data using Department of Veterans Affairs (VA) codes related to military sexual trauma. An individual was counted only once regardless of the number of times they received care, but the same veteran or service member could have been counted in multiple races if they received VA care and identified as different races over our time period. Individuals also could have received care from the Department of Defense. Veterans and Service As discussed earlier in this report, VA requires all former service Members Who Screened members seen in VA medical facilities to be screened at least once for military sexual trauma, and it encourages screening at the time of intake Positive for Unwanted for behavioral health care services. Our analysis of VA data found that Sexual Behavior by Race 362,507 veterans and service members screened positive for military and Gender sexual trauma between fiscal years 2015 and 2021. Of these who screened positive, 340,687 (94 percent) screened positive at a VA medical center or clinic while 21,820 (6 percent) screened positive at a VA Vet Center. With respect to race and ethnicity, 207,433 (61 percent) of those who screened positive at a VA medical center or community-based outpatient clinic and 10,676 (49 percent) of those who screened positive at a VA Vet Center were White, while 86,767 (25 percent) of those who screened positive at a VA medical center or clinic and 6,744 (31 percent) of those Page 145 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis who screened positive at a VA Vet Center were Black or African American (see fig. 22). Figure 22: Percentage of Veterans and Service Members Who Screened Positive for Military Sexual Trauma, by Race and Facility Type, Fiscal Years 2015–2021 Note: More than half of the individuals who screened positive at a Department of Veterans Affairs (VA) medical center or clinic were screened every year from fiscal years 2015 through 2021, and more than 30 percent were screened in multiple years, although not every year. The term veteran includes any former service member who was screened by VA for unwanted sexual behavior. An individual was counted only once for each racial group, regardless of the number of times they were screened, but the same veteran or service member could have been counted in multiple racial groups if they screened positive and identified as different races over our time period. According to VA officials, the number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. With respect to gender, female veterans were the largest category of those who screened positive, with 61 percent screening positive at a VA medical center or clinic and 74 percent screening positive at a VA Vet Center. Male veterans were the second largest category with 37 percent screening positive at a VA medical center or clinic and 22 percent screening positive at a VA Vet Center (see fig. 23). Page 146 GAO-23-105381 Unwanted Sexual Behavior Appendix II: Additional DOD and VA Behavioral Health Data Analysis Figure 23: Percentage of Veterans and Service Members Who Screened Positive for Military Sexual Trauma, by Gender and Facility Type, Fiscal Years 2015–2021 Note: More than half of the individuals who screened positive at a Department of Veterans Affairs (VA) medical center or clinic were screened every year from fiscal years 2015 through 2021, and more than 30 percent were screened in multiple years, although not every year. The term veteran includes any former service member who was screened by VA for unwanted sexual behavior. An individual was counted only once, regardless of the number of times they were screened, but the same individual could have been counted as both a veteran and a service member if they screened positive in both service capacities over our time period. According to VA officials, the number of service members who received VA care identified as related to unwanted sexual behavior is likely undercounted because VA does not systematically screen all active-duty service members for military sexual trauma for confidentiality reasons. Page 147 GAO-23-105381 Unwanted Sexual Behavior Appendix III: Character of Discharge and Appendix III: Character of Discharge and Reenlistment Eligibility Status of Separated Reenlistment Eligibility Status of Separated Service Members Service Members Our analysis of separations data and reports to the Department of Defense (DOD) of unwanted sexual behaviors found that a greater proportion of service members who made an unrestricted or formal report to DOD of an experience of unwanted sexual behavior had a general or other than honorable discharge than the overall active-duty population that separated from fiscal years 2015 through 2021, as shown in figure 24. 1 1The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Page 148 GAO-23-105381 Unwanted Sexual Behavior Appendix III: Character of Discharge and Reenlistment Eligibility Status of Separated Service Members Figure 24: Character of Discharge of All Separated Service Members Compared to Service Members Who Reported an Experience of Unwanted Sexual Behavior to the Department of Defense, Fiscal Years 2015–2021 Note: The analysis of those who reported unwanted sexual behavior to the Department of Defense (DOD) includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Service members who receive an honorable characterization of service are eligible for all Department of Veterans Affairs (VA) benefits and services. Service members who receive a general (under honorable conditions) characterization of service are eligible for most VA benefits and services, with the exception of some VA education assistance. Service members who receive an other than honorable characterization of service may not be eligible for any VA benefits and services, including Page 149 GAO-23-105381 Unwanted Sexual Behavior Appendix III: Character of Discharge and Reenlistment Eligibility Status of Separated Service Members health care. 2 However, regardless of the characterization of discharge, veterans may be eligible to receive care for unwanted sexual behavior that occurred during military service even if they are not eligible for VA health care under other treatment authorities. If eligible, veterans may receive these services: (1) at any time after experiencing unwanted sexual behavior, (2) even if they are not enrolled in the VA health care system to receive other VA care, and (3) even if they did not file a Veterans Benefits Administration claim for unwanted sexual behavior. Our analysis of separations data and reports to DOD of unwanted sexual behavior found that a greater proportion of service members who made an unrestricted or formal report of an experience of unwanted sexual behavior to DOD were either ineligible to reenlist or needed a waiver to reenlist compared to the overall active-duty population that separated from fiscal years 2015 through 2021, as shown in figure 25. 3 2DOD Instruction 1332.14, Enlisted Administrative Separations (Jan. 27, 2014) (Incorporating Change 7, June 23, 2022); DOD Instruction 1332.30, Commissioned Officer Administrative Separations (May 11, 2018) (incorporating Change 3, Sept. 9, 2021). 3The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Page 150 GAO-23-105381 Unwanted Sexual Behavior Appendix III: Character of Discharge and Reenlistment Eligibility Status of Separated Service Members Figure 25: Reenlistment Eligibility Status of All Separated Service Members Compared to Separated Service Members Who Reported an Experience of Unwanted Sexual Behavior to the Department of Defense, Fiscal Years 2015–2021 Note: For purposes of this analysis, we created these four groups and organized all of the reenlistment eligibility codes into these groups. The analysis of those who reported unwanted sexual behavior to the Department of Defense (DOD) includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Our analysis of DOD separation data and reports to DOD of unwanted sexual behaviors during fiscal years 2015 through 2021 found that the separation rates of service members who made unrestricted or formal reports of an experience with unwanted sexual behavior were substantially higher than service members overall, but that the rates were Page 151 GAO-23-105381 Unwanted Sexual Behavior Appendix III: Character of Discharge and Reenlistment Eligibility Status of Separated Service Members similar for males and females both overall and for those who reported experiences with unwanted sexual behavior, as shown in figure 26. 4 Figure 26: Separations of All Separated Service Members Compared to Separated Service Members Who Reported an Experience of Unwanted Sexual Behavior to the Department of Defense, by Gender, Fiscal Years 2015–2021 Note: The analysis of those who reported unwanted sexual behavior to the Department of Defense (DOD) includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015 or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. 4The analysis of those who reported unwanted sexual behavior to DOD includes only unrestricted reports of sexual assault or domestic sexual abuse, and formal and some informal reports of sexual harassment made to DOD in fiscal years 2015 through 2021. For complaints reported to the Navy, we analyzed formal sexual harassment reports for fiscal years 2019 through 2021 only, due to limitations in available data. If a service member reported an experience to DOD prior to fiscal year 2015, or filed a restricted or a confidential informal report, the report of unwanted sexual behavior would not be included in the analysis of those who reported unwanted sexual behavior to DOD. Page 152 GAO-23-105381 Unwanted Sexual Behavior Appendix IV: Comments from the Appendix IV: Comments from the Department of Defense Department of Defense Page 153 GAO-23-105381 Unwanted Sexual Behavior Appendix IV: Comments from the Department of Defense Page 154 GAO-23-105381 Unwanted Sexual Behavior Appendix IV: Comments from the Department of Defense Page 155 GAO-23-105381 Unwanted Sexual Behavior Appendix IV: Comments from the Department of Defense Page 156 GAO-23-105381 Unwanted Sexual Behavior Appendix IV: Comments from the Department of Defense Page 157 GAO-23-105381 Unwanted Sexual Behavior Appendix IV: Comments from the Department of Defense Page 158 GAO-23-105381 Unwanted Sexual Behavior Appendix V: Comments from the Department Appendix V: Comments from the Department of Veterans Affairs of Veterans Affairs Page 159 GAO-23-105381 Unwanted Sexual Behavior Appendix V: Comments from the Department of Veterans Affairs Page 160 GAO-23-105381 Unwanted Sexual Behavior Appendix V: Comments from the Department of Veterans Affairs Page 161 GAO-23-105381 Unwanted Sexual Behavior Appendix V: Comments from the Department of Veterans Affairs Page 162 GAO-23-105381 Unwanted Sexual Behavior Appendix VI: GAO Contact and Staff Appendix VI: GAO Contact and Staff Acknowledgments Acknowledgments Brenda S. Farrell, (202) 512-3604 or farrellb@gao.gov GAO Contact In addition to the contact named above, Kimberly Mayo (Assistant Staff Director), Renee Brown (Analyst in Charge), Vincent M. Buquicchio, Molly Acknowledgments Callaghan, Peter Casey, Tyler Dennis, Megan Ferren, Ashley Gavin, Nicholas Graves, David Jones, Serena Lo, Grant Mallie, Omar Williams, and Emily Wilson made key contributions to this report. Page 163 GAO-23-105381 Unwanted Sexual Behavior Related GAO Products Related GAO Products Women in Special Operations: Improvements to Policy, Data, and Assessments Needed to Better Understand and Address Career Barriers. GAO-23-105168. Washington, D.C.: December 15, 2022. Sexual Harassment and Assault: The Army Should Take Steps to Enhance Program Oversight, Evaluate Effectiveness, and Identify Reporting Barriers. GAO-22-104673. Washington, D.C.: May 27, 2022. Defense Health Care: Prevalence of and Efforts to Screen and Treat Mental Health Conditions in Prenatal and Postpartum TRICARE Beneficiaries. GAO-22-105136. Washington, D.C.: May 23, 2022. VA Vet Centers: Opportunities Exist to Help Better Ensure Veterans' and Servicemembers' Readjustment Counseling Needs Are Met. GAO-22-105039. Washington, D.C.: May 17, 2022. Sexual Assault: DOD and Coast Guard Should Ensure Laws Are Implemented to Improve Oversight of Key Prevention and Response Efforts. GAO-22-103973. Washington, D.C.: March 28, 2022. Domestic Abuse: DOD Needs to Enhance Its Prevention, Response, and Oversight. GAO-21-604T. Washington, D.C.: May 25, 2021. Domestic Abuse: Actions Needed to Enhance DOD's Prevention, Response, and Oversight. GAO-21-289. Washington, D.C.: May 6, 2021. Sexual Assault in the Military: Continued Congressional Oversight and Additional DOD Focus on Prevention Could Aid DOD's Efforts. GAO-21-463T. Washington, D.C.: March 24, 2021. Sexual Harassment and Assault: Guidance Needed to Ensure Consistent Tracking, Response, and Training for DOD Civilians. GAO-21-113. Washington, D.C.: February 9, 2021. Sexual Violence: Actions Needed to Improve DOD's Efforts to Address the Continuum of Unwanted Sexual Behaviors. GAO-18-33. Washington, D.C.: December 18, 2017. DOD Health: Actions Needed to Ensure Post-Traumatic Stress Disorder and Traumatic Brain Injury Are Considered in Misconduct Separations. GAO-17-260. Washington, D.C.: May 16, 2017. Page 164 GAO-23-105381 Unwanted Sexual Behavior Related GAO Products Sexual Assault: Better Resource Management Needed to Improve Prevention and Response in the Army National Guard and Army Reserve. GAO-17-217. Washington, D.C.: February 27, 2017. Military Personnel: DOD Has Processes for Operating and Managing Its Sexual Assault Incident Database. GAO-17-99. Washington, D.C.: January 10, 2017. Human Capital: Additional Actions Needed to Enhance DOD's Efforts to Address Mental Health Care Stigma.GAO-16-404. Washington, D.C.: April 18, 2016. Sexual Assault: Actions Needed to Improve DOD's Prevention Strategy and to Help Ensure It Is Effectively Implemented. GAO-16-61. Washington, D.C.: November 4, 2015. Military Personnel: Actions Needed to Address Sexual Assaults of Male Servicemembers. GAO-15-284. Washington, D.C.: March 19, 2015. Defense Health Care: Better Tracking and Oversight Needed of Servicemember Separations for Non-Disability Mental Conditions. GAO-15-266. Washington, D.C.: February 13, 2015. Military Personnel: DOD Needs to Take Further Actions to Prevent Sexual Assault during Initial Military Training. GAO-14-806. Washington, D.C.: September 9, 2014. Military Sexual Trauma: Improvements Made, but VA Can Do More to Track and Improve the Consistency of Disability Claim Decisions. GAO-14-477. Washington, D.C.: June 9, 2014. Military Personnel: DOD Has Taken Steps to Meet the Health Needs of Deployed Servicewomen, but Actions Are Needed to Enhance Care for Sexual Assault Victims. GAO-13-182. Washington, D.C.: January 29, 2013. Military Personnel: Prior GAO Work on DOD's Actions to Prevent and Respond to Sexual Assault in the Military. GAO-12-571R. Washington, D.C.: March 30, 2012. Preventing Sexual Harassment: DOD Needs Greater Leadership Commitment and an Oversight Framework. GAO-11-809. Washington, D.C.: September 21, 2011. Page 165 GAO-23-105381 Unwanted Sexual Behavior Related GAO Products Military Justice: Oversight and Better Collaboration Needed for Sexual Assault Investigations and Adjudications. GAO-11-579. Washington, D.C.: June 22, 2011. Defense Health Care: Status of Efforts to Address Lack of Compliance with Personality Disorder Separation Requirements. GAO-10-1013T. Washington, D.C.: September 15, 2010. Military Personnel: DOD's and the Coast Guard's Sexual Assault Prevention and Response Programs Need to Be Further Strengthened. GAO-10-405T. Washington, D.C.: February 24, 2010. Military Personnel: Additional Actions Are Needed to Strengthen DOD's and the Coast Guard's Sexual Assault Prevention and Response Programs. GAO-10-215. Washington, D.C.: February 3, 2010. Military Personnel: DOD's and the Coast Guard's Sexual Assault Prevention and Response Programs Face Implementation and Oversight Challenges. GAO-08-924. Washington, D.C.: August 29, 2008. Military Personnel: The DOD and Coast Guard Academies Have Taken Steps to Address Incidents of Sexual Harassment and Assault, but Greater Federal Oversight Is Needed. GAO-08-296. Washington, D.C.: January 17, 2008. 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