Serving the Women Veteran Community

Serving the Women Veteran Community

Serving the Women Veteran Community We are dealing with veterans, not procedures; with their problems, not ours. Omar Bradley REFERENCES: - VA Women Veterans Report, The Past, Present and Future of Women Veterans, NCVAS, February 2017 - VA Study of Barriers for Women Veterans to

VA Health Care, Final Report, April 2015 - US Army, SHARP, restricted and unrestricted reporting - Title 38, U.S. Code, Part II, Chapter 11, Compensation for Service-ConnectedDisability or Death - 38 Code of Federal Regulations Part 3 and Part 4 - Adjudication Manual M21-1MR (Manual Rewrite), Part II and Part IV - Veterans Benefits Manual, Chapter 3, Compensation for Veterans with ServiceConnected Disabilities - NCIRE-The Veteran Health Research Institute - MST Fact Sheet, VBA, March 2016

- VBA: Women Veterans Health Care, Military Sexual Trauma - VA: National Center for PTSD - Military Psychology 21:387-395, 2009, Military Sexual Trauma in Treatment-Seeking Women Veterans - Veterans Statistics: PTSD, Depression, TBI, Suicide. Veterans and PTSD, September 20, 2015 - GAO analysis of VBA data - GAO analysis of Department of Veterans Affairs regulations, policies and procedures - National Center of Excellence in Womens Health, September 14, 2014

OBJECTIVE: To understand the demographics of Women Veterans and to learn the rules of VA serviceconnected disability compensation for PTSD and MST Women Veterans file claims for many of the same service-connected conditions as their male counterparts and are eligible for the same benefits. However, there are also some unique circumstances for women Veterans that require additional knowledge and cultural competency from claims representatives

DEMOGRAPHIC INFORMATION ABOUT WOMEN VETERANS Nationwide, women comprise approximately: 10% of all Veterans 15.5% of all active duty military 19% of all National Guard and Reserve There are 2 million women veterans currently living in the U.S. and Puerto Rico. - Women are one of the fastest growing cohorts of recruits joining and separating from the military. - The amount of women veterans is expected to increase at a rate of 18,000 per year over the next 10 years.

- The amount of male veterans is decreasing each year by 1.5%. - As of January 1, 2016 women were authorized to serve in all military occupations. 2015 TOP 5 HEALTH CONDITIONS FOR WOMEN VETERANS: 1. PTSD 48,000 women Veterans receive SCD compensation 12% of all SCD for women 2. Major Depressive Disorder 26,500 women Veterans receive SCD compensation 3. Migraines 24,000 women Veterans receive SCD compensation 4. Lumbosacral or cervical strain (lower back) 22,200

women Veterans receive SCD compensation 5. Uterus & ovaries removal 12,700 have had complete removal and 10,500 have had uterus removed TOP 4 SERVICE-CONNECTED DISABILITIES FOR WOMEN VETERANS: 1. 2. 3. 4. PTSD MAJOR DEPRESSIVE DISORDER MIGRAINES


ALMOST 20 OF EVERY 100 (20%) HAVE BEEN DIAGNOSED WITH PTSD AMONG WOMEN VETERANS OF VIETNAM 27 OF EVERY 100 (27%) SUFFERED FROM PTSD SOMETIME DURING THEIR POSTWAR LIVES WHAT STRESSORS DO WOMEN FACE IN THE MILITARY? COMBAT OPERATIONS: Women are not necessarily trained for combat operations. More women are receiving hostile fire, returning fire, and seeing casualties. MILITARY SEXUAL TRAUMA: 23% of women veterans using VA healthcare reported experiencing at least one

sexual assault while in the military. FEELING ALONE: Not feeling supported can be very hard. WORRYING ABOUT FAMILY: Often given little notice and having to be away from home for a year or longer. After returning home, some women find it is difficult to return to the mommy role and may find that they have more conflicts with their children. MILITARY SEXUAL TRAUMA (MST) Not a gender specific issue happens to both men and women Women are more likely to experience it 1 in 5 women Veterans and 1 in 100 men Veterans MST is an experience and not a diagnosis

Symptoms include: PTSD, depression, anxiety, and other(s) MST is more traumatic and debilitating than sexual assault in the civilian context. 2 out of 3 VA disability compensation claims involving PTSD related to MST were denied by the VA from FY2008 2012. 32% of PTSD claims related to MST were approved compared to 61.8% of non-MST related PTSD claims. FY 2014, over 6,100 service members reported being sexually assaulted while on active duty They estimate that only 25% of service members report their assaults

After reporting the assault, 59% perceived social retaliation and 40% perceived professional retaliation 62% who reported say they experienced some type of retaliation Particular aspects of military culture make it more difficult and complicated to report military sexual trauma: Loyalty to unit Strict code of chain of command Emphasis on self-reliance Minimization of weakness Effect on career (cant just quit and find another job) Need to rely on perpetrators for safety/security Report may not be believed, or victim may be punished DSM-V symptoms of PTSD:

Recurrent, involuntary, and intrusive memories

Flashbacks and nightmares Psychological distress when exposed to triggers Avoidance of stimuli associated with the trauma Inability to recall key aspects of the trauma Hyper-vigilance Difficulty concentrating or sleeping Exaggerated startled response Irritable behavior and angry outburst Reckless/self-destructive behavior Sense of foreshortened future/suicide Symptoms must last more than one month and can begin any time following the stressor event, even years later. What is MST? Title 38 USC section 1720D:

Psychological trauma, which in the judgment of a VA mental health professional resulted from a physical assault of a sexual nature, battery of a sexual nature, sexual harassment which occurred while the veteran was serving on active duty, active duty for training, or inactive duty training. Sexual harassment consists of repeated unsolicited verbal or physical contact of a sexual nature which is threatening in character. WHY ARE WOMEN VETERANS HESITANT TO REPORT? COMMON ISSUES FACING VETERANS WITH PTSD/MST: Social isolation, career harmed, are charged with misconduct, experience shame, stigmatization, social taboos and guilt

Substance abuse secondary to disabling condition Misdiagnosis in service personality disorder is common Diagnosis of similar conditions anxiety disorder, panic attacks, phobia, OCD each of these requires continuity of symptoms and treatment; PTSD does not. WHATS REQUIRED TO FILE A SCD CLAIM FOR PTSD/MST? 1. The veteran has a current diagnosis for PTSD VA doctor preferable meets the DSM-V definition 2. In-service stressor -Evidence: Mental health treatment

records, advise client to obtain treatment, clients personal statement, lay statements. The evidentiary standards for proving this second element that an incident of MST occurred are set forth in 38 CFR 3.304(f)(5) If a PTSD claim is based on in-service personal assault, evidence from sources other than the veterans service records may corroborate the veterans account of the stressor incident. Proving in-service stressor 3.304(f) Evidence of behavior change, request for transfer, deterioration of work performance, substance abuse, unexplained econ/social behavior Lay statements should include: Unit, dates of service, MOS.

Describe as many details as possible surrounding assault What happened before Who was service member with What was service member doing Where did the assault occur How did assault end What did perpetrator say afterwards 3. Medical evidence of link- Nexus Connect the dots - Streamline the Raters review-dont dump and expect rater to figure out! DUE TO THE HIGH EVIDENTIARY STANDARDS REQUIRED


AZ v. Shinseki 731 F.3d 1303 (Federal Circuit, 2013) Consolidated 2 cases appealed from CAVC Issues: Does absence of contemporaneous mention in military service records of MST serve as perineum evidence against the existence of sexual assault. Does the absence of report to military authorities serve as evidence against the existence of sexual assault HOLDING: the BVA may not use the absence of records or reports to military authorities as affirmative proof that assault did not occur. Examples of evidence include, but are not limited to: Records from law enforcement authorities, rape crisis centers,

mental health counseling centers, hospitals, or physicians. Veterans personal statement use VAF 21-0781a. Lay statements corroborating the veterans account and/or describing a change in their behavior can be family, roommates, fellow service members, or clergy. M21-1MR states VA will accept: Diaries/journals, lay statements indicating use of leave or describing periods of depression, panic attacks, or anxiety, use of pregnancy tests, sudden request for a change of MOS, increase use of prescription medications, evidence of substance abuse, over/under eating, use of HIV/STD tests, unexplained economic or social behavior changes, treatment for physical injuries around the time of claimed trauma, the breakup of a primary relationship.

A SUCCESSFUL INTERVIEW CAN MAKE ALL THE DIFFERENCE 1. Use careful and purposeful words 2. Demonstrate compassionate listening 3. Obtain accurate and sufficient evidence 4. Do not take a veterans PTSD symptoms as signs of a lack of credibility 5. Be careful that you dont judge the degree of trauma No type of sexual trauma is worse or more traumatic than another type of sexual trauma A SUCCESSFUL INTERVIEW CAN MAKE ALL THE DIFFERENCE (cont.)

6. Mirror the survivors language 7. Be cautious when using language that may make a survivor feel like you doubt their truthfulness 8. Give the veteran time 9. Do not take the veterans PTSD symptoms personally It is a good idea to have mental health professionals contact information available if the veteran requests it or states that they are seeking services. If a veteran is in crisis, remain calm and supportive and make sure you always have relevant contact information on hand for veteran crisis centers if necessary.

Gary Area Vet Center 107 E. 93rd Ave Crown Point, IN 46307 Phone: 219-736-5633 Or 877-927-8387 Are you in crisis? * Call 911 * Go to the nearest Emergency Room * Call the Suicide Prevention Lifeline 1-800-273-8255 * Contact the Veterans Crisis Line: 1-800-273-8255 and press 1

or text 838255 Evansville Vet Center 1100 N. Burkhardt Rd Evansville, IN 47715 Phone: 812-473-5993 Or 877-927-8387 Fort Wayne Vet Center 5800 Fairfield Ave., Suite 265 Fort Wayne, IN 46807 Phone: 260-460-1456 Or 877-927-8387 Indianapolis Vet Center 8330 Naab Road, Suite 103 Indianapolis, IN 46260 Phone: 317-988-1600 Or 877-927-8387

South Bend Vet Center 4727 Miami Street South Bend, IN 46614 Phone: 574-231-8480 Or 877-927-8387 Questions NOT to ask Are you a combat veteran? Did you ever discharge your weapon? Did you ever kill someone? How do you feel about the war? How do you feel about your service? Why did you enlist? Do you have a mental health problem? Psychiatric problem? What was the worst thing you saw?

What was the worst thing you didhad to do? Examples of better questions to ask Do you believe that you have any mental health conditions, or emotional injuries, as a result of your time in service? What are some of the events or images from your deployment that stick with you most today? How do you feel differently today than you did before you deployed? (or before the events you just described?) What are some of the things you experience today that you attribute to your PTSD? Can you describe the events or experiences that led to your PTSD? HOW TO ASK QUESTIONS TO GET THE

MOST INFORMATION A veteran served in the Army as military police and often escorted high security detainees. Her life was in danger during these escorts. Her life was further threatened by the fact that she was never issued a proper flak jacket in addition to other protective gear required for the high-risk duties she was performing. Because she was located in a dangerous area of Iraq she was also exposed to mortar blasts regularly. Due to these stressors she developed PTSD. How would asking if she had any combat related stressors impact the information you hope to get? HOW TO ASK QUESTIONS TO GET THE

MOST INFORMATION (cont.) She is sensitive about not being considered a combat veteran. Even within the veteran community non-combat veterans are often not afforded as much respect as combat veterans, and are not considered to have had a legitimate or valorous wartime experiences as those who engaged in combat. And it is understood that if you were not a combat veteran by definition, you should not self-identify as one. What can you do differently? Because she had already identified that she wanted to file a claim for PTSD, your next line of questions could have looked something like this:

Were you ever deployed while you were in service? Do you believe that some of the events or experiences that you had while you were deployed led to your current PTSD? If you feel comfortable, could you share with me what some of those events and experiences were? How did those events and experiences make you feel at the time? Things you can do to develop a strong claim: Get copy of Official military personnel file (OMPF) Look for sexual trauma markers such as: Deterioration of job performance (excellent reports

before event and bad after) Asks for transfer out of unit AWOL Ask did vet go to outside counseling clinic, did vet tell someone else family or friend lay statements from someone who knew vet before and after service that can testify of social changes Completed application to the VA should include:

VAF 21-526EZ VAF 21-0781a (PTSD stressor statement) VAF 21-22 POA this would be done if you did Intent to File Lay statements Medical records* Military records* Advocacy brief * non-adversarial tone, cite to attached exhibits veterans statement, excerpts of medical records, excerpts of military records, lay statements, include section on current symptom severity.

*would make claim strongest DONT FORGET TO CONSIDER MENTAL HEALTH CONDITIONS SECONDARY TO PHYSICAL CONDITIONS AND PHYSICAL CONDITIONS SECONDARY TO MENTAL HEALTH CONDITIONS REVIEW 1. As of January 1, 2016 women were authorized to serve in all military occupations. T/F 2. The amount of male veterans entering the military is

decreasing each year. T/F 3. The Top 4 service-connected disabilities for women veterans are ____, _____, migraines, and _______. 4. 23% of women veterans using VA healthcare reported experiencing at least one _________ while in the military. 5. Recurrent, involuntary and intrusive memories, difficulty concentrating or sleeping, reckless, selfdestructive behavior are all signs of what? 6. A repeated unsolicited verbal or physical contact of a sexual nature which is threatening in character is called? REVIEW 7. What percentage of service members report their

assaults? 8. A mental disorder is defined by a diagnostic and statistical manual called what? 9. Whats required to file a service-connected disability compensation claim for PTSD? 10. What is a VA Form 21-0966? 11. What are MST survivors often misdiagnosed with? 12. In AZ v Shinseki 731 F3d 1303 (Federal Court, 2013) the CAVC determined that the BVA may not use the absence of records or reports to military authority as affirmative proof that an assault did not occur? T/F 13. MST is a __________ not a ___________. For all you do to serve our States

Veterans and your partnership We Thank you!

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