Flaws in the System

According to GAO, this underreporting of sexual assault incidents could have several causes, including a lack of consistent sexual assault definition for reporting purposes; limited and unclear expectations for incident reporting at VA Central Office; and deficiencies in VA’s central oversight of sexual assault incidents.

There is no VA-wide definition of sexual assault used for incident reporting, GAO investigators found. The levels of detail defining sexual assault vary from facility to facility and in the four VISNs that GAO investigated. There was no definition of sexual assault in VISN policies.  

In addition to this lack of definition, VA does not have a clearly-documented expectation of what types of sexual assault incidents need to be reported to leadership. While one VISN official said that leaders in their network expected to be informed of all sexual assaults, that expectation was not documented in their policy.

At the facility level, reporting expectations also were unclear. Investigators found several cases in which VA police had not been informed of incidents that were reported to medical facility staff. The GAO report lists one example in which an alleged perpetrator had been involved in previous sexual assault incidents that were not reported to VA police: Staff did not report the previous incidents because they believed the behaviors were a manifestation of the veteran’s clinical condition.

At that same facility, quality management staff identified five sexual assault incidents that had not been reported to VA police, despite these incidents being reported to their office.

At the Central Office, there is no regular exchange of information regarding sexual assault incidents between those who are in line to receive reports of those incidents and officials who are responsible for overseeing the locations in which they occurred. For example, VA officials responsible for residential programs and inpatient mental health units told GAO that they do not receive regular reports of sexual assault incidents that occur within those programs or units.

In the three VISNs that GAO reviewed, there were 18 sexual assault incidents in residential programs or inpatient mental health units between January 2007 and July 2010.

Congressional Response

The GAO report triggered immediate response from legislators. Rep. Ann Marie Buerkle (R-N.Y.), chair of the House VA Subcommittee on Oversight and Investigation submitted H.R. 2074, the Veterans Sexual Assault Prevention Act, which would require VA to establish a comprehensive policy on reporting and tracking sexual assault incidents and other safety incidents as they occur at VA facilities.

At a hastily-scheduled hearing on the subject, Buerkle called the lack of reporting a “contempt of justice and requires immediate action.” 

Rep. Jeff Miller (R-Fl.), chair of the full House VA Committee and co-sponsor of the bill, said that only one assault of this nature not being properly reported is unacceptable. “In the past week, some have dismissed these allegations, comparing the size of the VA system and the number of allegations to the private sector,” Miller said. “There is no comparison. Just one is too many.”

VA officials told the committee that VISN directors had been ordered to prepare a report on the safety infrastructures at their facilities, designed to protect patients, staff and visitors. William Schoenhard, VA’s deputy under secretary for health operations and management, said such a report is necessary if VA leadership is to have good understanding of what is going on in the field.

“We cannot solve a problem we cannot see,” Schoenhard said. “And a full investigation is essential for all incidents that have been reported.”

Miller said he was particularly interested in facilities’ physical security measures. The GAO report listed several instances in which VA police were understaffed or alarm systems were nonfunctioning or only partly functional. There is an ongoing investigation by the Oversight Subcommittee, Miller said, that alleges leadership at least at one VA facility siphoned money away from security to fund other departments.

As for the cases that the GAO report identifies as having gone wrongfully unreported, OIG officials said they would confer with VA police once they have a better grasp on those cases.

Buerkle and Miller’s bill was introduced June 1 and referred to committee, where it remained, as of mid-June.

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