Citation Nr: 0024967 Decision Date: 09/19/00 Archive Date: 09/27/00 DOCKET NO. 94-18 570 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Service connection for gender dysphoria (transsexualism), as being secondary to, or aggravated by, service-connected PTSD. 2. Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently rated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD William D. Teveri, Counsel INTRODUCTION The veteran served on active duty from June 1971 to June 1974. This appeal arises from a March 1994 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. FINDINGS OF FACT 1. The claim of entitlement to service connection for gender dysphoria (transsexualism), as being secondary to, or aggravated by, service-connected PTSD, is not supported by cognizable evidence demonstrating that the claim is plausible or capable of substantiation. 2. The veteran's PTSD symptomatology does not indicate that his ability to establish or maintain effective or favorable relationships with people was considerably impaired, or that, by reason of psychoneurotic symptoms his reliability, flexibility and efficiency levels were so reduced as to result in considerable industrial impairment, under the former criteria. 3. The veteran's PTSD symptomatology is not productive of flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, under the revised criteria, from November 7, 1996. CONCLUSIONS OF LAW 1. The veteran's claim for service connection for gender dysphoria (transsexualism), as being secondary to, or aggravated by, service-connected PTSD, is not well grounded. 38 U.S.C.A. §§ 1110, 5107(a) (West 1991). 2. The criteria for an increased rating for PTSD, currently rated as 30 percent disabling, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1-4.14, 4.125-4.130, 4.132, Diagnostic Code 9411 (1993); 38 C.F.R. §§ 4.125-4.126, 4.130, Diagnostic Code 9411 (1999); Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board notes the veteran's claims were remanded in April 1997 to obtain Social Security, private, and VA medical records, and to provide the veteran psychiatric examinations to determine the nature and etiology of his sexual psychiatric disorder, and the level of disability of his service-connected PTSD. That development having been successfully completed, his appeal has been returned to the Board. I. Service connection for gender dysphoria, as being secondary to, or aggravated by, service-connected PTSD Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(a) (1999). In addition, certain chronic diseases, including a psychosis, may be presumed to have been incurred during service if they become manifest to a compensable degree within an applicable period after separation from active duty. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). No conditions other than those listed in § 3.309(a) can be considered chronic for purposes of presumptive service connection. 38 C.F.R. § 3.307(a). The United States Court of Appeals for Veterans Claims (formerly the United States Court of Veterans Appeals) (Court) has established rules for the determination of a well grounded claim based upon the chronicity and continuity of symptomatology provisions of 38 C.F.R. § 3.303(b). The Court has ruled that the chronicity provision of § 3.303(b) is applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded or reopened on the basis of § 3.303(b) if the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology. See Savage v. Gober, 10 Vet. App. 488, 493 (1997). The rules concerning chronicity and continuity of symptomatology, however, still require "medical expertise" to relate the veteran's present disability to his or her post-service symptoms. Savage, 10 Vet. App. at 497-98. The initial question which must be answered in this case is whether the veteran has presented a well grounded claim for service connection. In this regard, the veteran has "the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded," that is, the claim must be plausible and capable of substantiation. See 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for a claim to be well grounded, there must be competent evidence of current disability (established by medical diagnosis); of incurrence or aggravation of a disease or injury in service (established by lay or medical evidence); and of a nexus between the inservice injury or disease and the current disability (established by medical evidence). See generally Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S.Ct. 2348 (1998); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table). Medical evidence is required to prove the existence of a current disability and to fulfill the nexus requirement. Lay or medical evidence, as appropriate, may be used to substantiate service incurrence. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Regulations also provide that a preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. §§ 1137, 1153; 38 C.F.R. § 3.306(a); see also Paulson v. Brown, 7 Vet. App. 466, 468 (1995); Crowe v. Brown, 7 Vet. App. 238, 247 (1994). For veteran's of wartime service and for peacetime service after December 31, 1946, clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. Due regard will be given the places, types, and circumstances of service and particular consideration will be accorded combat duty and other hardships of service. See 38 C.F.R. § 3.306. The presumption of aggravation is not applicable unless the preservice disability underwent an increase in severity during service. See Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991). The determination of whether a preexisting disability was aggravated by service is a question of fact. See Doran v. Brown, 6 Vet. App. 283, 286 (1994). In deciding a claim based on aggravation, after having determined the presence of a preexisting condition, the Board must first determine whether there has been any measured worsening of the disability during service and then whether such worsening constitutes an increase in disability. See Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). Temporary or intermittent flare-ups of the preexisting condition during service are not sufficient to be considered aggravation unless the underlying condition (as contrasted to the symptoms) has worsened. See Hunt, 1 Vet. App. at 296-97. The U. S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that section 3.306(b)(2) provides only a rebuttable presumption of aggravation, and does not irrebuttably establish service connection, or even aggravation. See Jenson v. Brown, 19 F.3d 1413, 1416-1417 (Fed. Cir. 1994). Unless there is clear and unmistakable evidence to the contrary, VA must presume that the veteran was in sound condition except as to those defects, infirmities, or disorders noted at the time of his entrance into service. 38 U.S.C.A. § 1132 (West 1991). The presumption of sound condition provides that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to those defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. This presumption exists only when there has been an induction examination in which the later-complained-of disability was not detected. The term "noted" denotes only such conditions as are recorded in examination reports. A reported history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.304; Crowe v. Brown, 7 Vet. App. 238, 245 (1994). Additionally, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.310(a). Secondary service connection may also be granted for the degree of aggravation to a non-service connected disorder which is proximately due to or the result of a service- connected disorder. Allen v. Brown, 7 Vet. App. 439, 448-50 (1995). The initial question which must be answered in this case, however, is whether the appellant has presented a well grounded claim for direct or secondary service connection. A claim for secondary service connection must, as must all claims, be well grounded under 38 U.S.C.A. § 5107(a). See Dinsay v. Brown, 9 Vet. App. 79, 86 (1996); see also Locher v. Brown, 9 Vet. App. 535, 539 (1996); Libertine v. Brown, 9 Vet. App. 521, 522 (1996) (requiring medical evidence showing a relationship between a service-connected disability and the condition claimed to be secondarily service connected). In this regard, the appellant has "the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded;" that is, the claim must be plausible and capable of substantiation. See 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). There must be evidence that the disability claimed is proximately due to or the result of the veteran's service-connected disability. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.310(a); Wallin v. West, 11 Vet. App. 509, 512 (1998). While the veteran has reported that his desire to wear women's clothing began at about age five or six (see February 1994 VA examination report), whether or not gender dysphoria preexisted his entrance onto active duty is immaterial to the present decision. The veteran's service medical records contain no report of treatment for, or diagnosis of, any psychiatric disorder, including gender dysphoria. His February 1974 separation physical examination report indicates that, upon clinical evaluation, he was found to be normal psychiatrically. The only evidence of record, other than the veteran's statements, which might be construed as relating his gender or sexual disorders to service is the report of the March 1990 VA examination. That report, however, indicates PTSD and gender identity disorder of adulthood, not otherwise specified, with reported onset in 1972, coinciding with post- combat stress. The statement, "with reported onset in 1972" dates the disorder to military service. However, it is based upon a history reported by the veteran. The Board is not bound to accept the opinion of a health professional that is based on the veteran's recitation of his medical history. See Wood v. Derwinski, 1 Vet. App. 190, 192 (1991); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute "competent medical evidence" satisfying the Grottveit v. Brown, 5 Vet. App. 91, 93 (1993), requirement. Such evidence cannot enjoy the presumption of truthfulness accorded by Robinette v. Brown, 8 Vet. App. 69, 75-76 (1995), (as to determination of well groundedness) and Justus v. Principi, 3 Vet. App. 510, 513 (1992), because a medical professional is not competent to opine as to matters outside the scope of his or her expertise, and a bare transcription of a lay history is not transformed into "competent medical evidence" merely because the transcriber happens to be a medical professional. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (in order for any testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration). The Board has also reviewed private and other VA medical evidence from 1981 to October 1998, including numerous VA and private psychiatric examination reports. There is no medical evidence of record which relates the veteran's gender dysphoria to his active duty service. Thus, the Board finds there to be no competent medical evidence that the veteran's gender dysphoria was manifest in service or was otherwise related to his period of active military service. Accordingly, the Board finds the veteran's claim for service connection for gender dysphoria, on a direct basis, to be not well grounded. The Board will now turn its attention to the veteran's claims that his gender dysphoria was caused or aggravated by his service-connected PTSD. The evidence reveals an August 1984 VA psychiatric examination report containing an Axis I diagnosis of sexual disorder, transvestism, and an Axis II diagnosis of atypical personality disorder. The veteran reported he cross-dressed 2-3 times a week since returning from Vietnam. PTSD was not diagnosed. There is no opinion contained in this report which indicates transvestism was related to PTSD. A January 1986 VA psychiatric examination report, which contained a diagnosis of PTSD, did not contain a diagnosis of any sexual disorder, including transvestism or gender dysphoria. The March 1990 VA examination report contained a diagnosis of Axis I PTSD and gender identity disorder of adulthood, not otherwise specified, with reported onset in 1972, coinciding with post-combat stress. The Board commented on this report earlier in this decision insofar associating gender dysfunction with service in 172. As far as suggesting gender dysfunction was caused by PTSD, the report does nothing of the sort. Rather, the report only says that both disorders began at the same time, not that one caused the other. A September 1993 private psychiatric examination report, in which it was noted that the purpose was for evaluation for a transsexual program, contains an Axis I diagnosis of PTSD and residual symptoms of a dysthymic disorder, and an Axis II diagnosis of possible schizoid personality disorder. The examiner indicated he did not feel the veteran was appropriate for participation in the transsexual program due to several problems, including continuing substantial symptoms of depression and PTSD. Nothing in this report implicates PTSD as the cause of gender dysfunction or suggests that the former made worse the latter. A November 1993 private psychiatric examination report contains Axis I diagnoses of transexualism, dysthymia, secondary type, undifferentiated somatoform disorder, and PTSD, and an Axis II diagnosis of rule out passive-aggressive personality disorder. While the examiner indicated a number of problems, going from the veteran's childhood to the present, and including PTSD, were "important factors contributing to his stress," he did not opine that PTSD caused or aggravated the transexualism. A February 1994 VA psychiatric examination report, in which it was indicated the examiner was a Ph.D., contains a history reported by the veteran of beginning cross dressing at the age of five or six. This report contained Axis I diagnoses of PTSD, dysthymia, and transsexualism, and an Axis II diagnosis of rule out passive aggressive and schizoid personality disorders. There was no opinion contained in this report, however, which indicated transsexualism was either caused or aggravated by PTSD. Another February 1994 VA psychiatric examination report, in which it was indicated the examiner was a medical doctor, contains Axis I diagnoses of PTSD, dysthymic disorder, and transsexualism, and an Axis II diagnosis of rule out passive aggressive and schizoid personality disorders. There was no opinion contained in this report, however, which indicated transsexualism was either caused or aggravated by PTSD. A June 1995 private psychiatric examination report also contains a history reported by the veteran of wanting to be a female since the age of five or six, and beginning cross dressing at age eight or nine. He reported he started cross dressing regularly in 1974, and stopped wearing male clothes completely in 1983. He also reported a "probable history of PTSD but he indicated that he believes the PTSD has resolved." The diagnostic impressions were gender identity disorder and probable PTSD. The examiner's summary and conclusions were that gender dysphoria and gender identity disturbance went back to childhood. The examiner stated his belief that the veteran's overall mental health appeared improved by comparison with that of 1993. A July 1995 Davidson County Tennessee Probate Court Order indicates the veteran changed his name from John A. Johnson to Jonnie A. Johnson. A July 1995 statement from a private Medical Doctor stated that the veteran suffered from gender identity disorder and PTSD, which was in remission. A January 1997 private Social Security Administration psychiatric examination report contains Axis I diagnoses of delusional disorder, persecutory type, gender identity disorder, and PTSD, in remission. A September 1998 VA psychiatric examination report, in which it is noted that the examination was conducted by a Medical Doctor who had reviewed the entire claims file and the Board's remand, contains Axis I diagnoses of gender dysphoria disorder and PTSD, mild, and an Axis II diagnosis of personality disorder not otherwise specified. The examiner noted that there was "no indication that the veteran's [PTSD] aggravated the pre-existing Gender Dysphoria." The examiner also indicated the "existence of Gender Dysphoria does not in any way preclude the presence of [PTSD]. The Gender Dysphoria is not an acquired Mental Disorder, a Developmental Disorder or a Personality Disorder." While the physician indicated the veteran "clearly" had "some motivation to present himself in a favorable light and not to have any psychiatric illness of any severity documented as this might tend to, perhaps, diminish his chances of getting sex change surgery," he indicated he had, "at the beginning of the examination, emphasize[d] that the present examination was specifically generated as a result of his Compensation claim, and [the physician] also emphasized the necessity for full disclosure of the nature and severity of any symptoms so that they may be documented and taken into account in making a diagnosis and determining any level of disability." An October 1998 VA psychiatric examination report in which it is noted that the examination was conducted by a Ph.D., indicated the examiner had reviewed the VA Medical Center medical records and the summary portion of the September 1998 VA psychiatric examination report, which summarized the claims file medical evidence. The examiner indicated that "[o]verall, [the veteran] denies significant current reexperiencing, avoidance or arousal symptoms associated with Vietnam-related trauma experiences." In summary, the physician indicated that the current symptomatology reported by the veteran would not "suggest a clinical diagnosis of PTSD." Thus, the physician indicated he could find "no significant evidence that [PTSD] symptoms exacerbate or effect a preexisting gender identity disturbance." Further, the physician indicated he did not find "obvious evidence of gender dysphoria, and in fact, found no evidence of significant psychological distress at the current time. However, it is important to note that [the veteran] approached our exam defensively, obviously wishing to present himself in a psychologically positive manner." Thus, the most current evidence is in equipoise as to whether the veteran currently suffers from PTSD. The Board notes, as did the October 1998 examiner, that his PTSD symptomatology has been found to be no more than mild, and sometimes not even diagnosed, for a number of years. Also, the most current psychiatric examiners have clearly concluded that his gender or sexual disorders were not caused or aggravated by his service-connected PTSD. The veteran's opinion that his gender dysphoria was caused or aggravated by his service-connected PTSD is also not competent medical evidence sufficient to well ground his claim. As noted above, a well grounded claim for secondary service connection requires medical evidence showing a relationship between a service-connected disability and the condition claimed to be secondarily service connected. See Dinsay, supra; Loche, supra; Libertine, supra. In this regard, the appellant has "the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded;" that is, the claim must be plausible and capable of substantiation. See 38 U.S.C.A. § 5107(a); Tirpak, supra. There must be evidence that the disability claimed is proximately due to or the result of the veteran's service-connected disability. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.310(a); Wallin, supra. The relationship of the veteran's service-connected disability and a non-service connected disability is not susceptible to informed lay observation, and thus, for there to be credible evidence of such a relationship, medical evidence is required. See, e.g., Libertine, supra; Reiber, supra; Schroeder, supra; Proscelle, 2 Vet. App. at 633. Therefore, the veteran has not met the first step for a well grounded secondary service connection claim, because he has not provided credible ("satisfactory") evidence that his service-connected PTSD caused his gender dysphoria. Consequently, as a well grounded claim for secondary service connection requires medical evidence that a service-connected disability either caused or aggravated another disability in order to be plausible, see Caluza and Lathan, both supra., and the veteran has submitted no such evidence, the veteran's claim for service connection for gender dysphoria, as being secondary to his service-connected PTSD, must be denied as not well grounded. II. An increased rating for PTSD When he originally filed his increased rating claim in June 1993, the veteran essentially contended his disability had worsened, warranting a rating in excess of 30 percent disabling. During his September 1998 VA psychiatric examination the veteran indicated his current PTSD symptoms were being "cautious about people and not really trusting." He also reported he felt he had his "stress under control." He also reported he wanted to be employed, and specifically, that he wanted to go into hotel/motel management. He also reported he did not feel there was any reason he could not do so or perform any such duties. He reported he had some friends. He also reported he was "better than I was 10 years ago." He reported no ongoing feelings of nervousness, tremulousness, palpitations, shortness of breath, chest pain, anger, irritability, worry, fear, tension, changes in memory or concentration, and no recent flashback or avoidance behavior. He reported no history of hypomanic or manic episodes, paranoid symptoms, delusions, or bizarre thoughts, and that he had a good appetite, slept six to seven hours per night, felt rested when he awoke, and had nightmares but once per month. He also reported that he enjoyed reading the DSM- IV. The examiner indicated the veteran was friendly and cooperative during the sessions, made good eye contact, was well groomed (in a dress, high heels, with makeup), showed no evidence of anxiety or depression, had a calm affect, was relaxed throughout the examination, showed a full range of appropriate affect, had a good and appropriate sense of affect, and described his mood as being "okay." The veteran was noted to be alert and oriented to person, place, time, and situation, showed no unusual psychomotor activity, gestures, or behavior, nor deficits of cognition, memory, learning, or attention. His thought was noted to be coherent and logical without flight of ideas or loose association, and with no suicidal or homicidal ideations. No evidence of auditory or visual hallucinations, delusions, paranoia or psychotic thought was noted, nor was a deficit of calculation, abstraction, similarities, or general information, or organicity. His judgment was noted to be good, and he had some psychological insight and some likelihood of developing further insight. The diagnoses were: (Axis I) gender dysphoria disorder, PTSD, mild; (Axis II) personality disorder, not otherwise specified; (Axis III) hormone therapy; (Axis IV) residential move, PTSD symptoms; (Axis V) highest Global Assessment of Functioning (GAF) for the past year, 61-70, mild symptoms - current GAF 61-70. The examiner indicated that PTSD symptoms were minimal and apparently significantly less than as reported previously. The examiner indicated that the veteran did tend to avoid social contact, and that it was not clear what his actual level of disability was, as he had no been employed for approximately 17 years. While the examiner indicated the veteran clearly had some motivation to present himself in a favorable light, i.e., that a psychiatric illness of any severity diminished his chances of being approved for sex change surgery, the examiner indicated he fully explained to the veteran the purpose of the examination was to evaluate him for compensation purposes. An October 1998 VA psychiatric examination report, in which it was noted the examination was conducted by a Ph.D., who had reviewed the VA Medical Center records and the September 1998 VA examination report. The Board notes that the September 1998 report was rendered subsequent to a thorough review of the claims file, and the Ph.D. indicated in his report details of that review. Several different psychological tests were conducted, as was the PTSD stress disorder scale for American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The examiner indicated the specific PTSD symptoms test revealed inconsistencies in the veteran's responses. On the Mississippi Scale for Combat Related PTSD, the veteran produced a score of 91, which the examiner indicated fell below the cut-off of 107 for individuals with Vietnam-related combat PTSD. The examiner summarized that, on a structured diagnostic interview for PTSD, no current evidence of significant reexperiencing, arousal, or avoidance symptoms which would suggest a clinical diagnosis of PTSD were found. The examiner also indicated that, while the veteran has been diagnosed with PTSD for a number of years, he currently denied any significant PTSD symptoms, and had minimal symptoms upon examination in January 1997, when PTSD was found to be in remission. The Board notes, initially, that during the pendency of the appeal, the schedular criteria for rating PTSD were changed, effective from November 7, 1997. Where the law or regulations change while a case is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). To give the veteran every consideration with respect to the current appeal, the claim will be rated under the former rating criteria from June 30, 1993, the date of receipt of his increased rating claim, to November 6, 1997, and under both the former and the revised rating criteria from November 7, 1997. Revised or liberalizing statutes or regulations may only be considered in rating a veteran's service-connected disability on and after the effective date of the law. See Rhodan v. West, 12 Vet. App. 55, 57 (1998). Under the former criteria, found at 38 C.F.R. § 4.132, Diagnostic Code 9411 (1993), a 50 percent rating required that the veteran's ability to establish or maintain effective or favorable relationships with people was considerably impaired. By reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels were so reduced as to result in considerable industrial impairment. A 70 percent rating required that the veteran's ability to establish and maintain effective or favorable relationships with people was severely impaired. The psychoneurotic symptoms were to be of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. A 100 percent rating required that the veteran's attitudes of all contacts except the most intimate were so adversely affected as to result in virtual isolation in the community. It required totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. The veteran had to be demonstrably unable to obtain or retain employment. As noted above, for a 50 percent rating under the former criteria, the evidence must show that the veteran's ability to establish or maintain effective or favorable relationships with people was considerably impaired, and that by reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels were so reduced as to result in considerable industrial impairment. Such is not shown in this case. As noted above, the two most current examinations of the veteran, see Francisco, supra, indicate no more than a mild disability, and very few, if any, PTSD symptoms, and the veteran himself reported few, if any, PTSD symptoms. As the veteran has indicated he reads the DSM-IV for enjoyment, the Board notes a 61-70 GAF score is related in that publication to "some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, [and] has some meaningful relationships." Thus, the most recent medical evidence does not indicate that, by reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels were so reduced as to result in considerable industrial impairment. Specifically with respect to the effect of the veteran's psychiatric impairment on his ability to work, the veteran reported, during his September 1998 examination, as noted above, that he wanted to go into hotel/motel management, and that he did not feel there was any reason he could not do so or perform any such duties. Based on the foregoing, the Board finds that the veteran's PTSD symptomatology does not rise to the considerable level required for a 50 percent rating under the former criteria. Moreover, by definition, it does not meet the criteria for a 70 percent or 100 percent rating, as these require that his symptomatology produce more occupational and social impairment than that required for a 50 percent rating. See Shoemaker v. Derwinski, 3 Vet. App. 248, 253 (1992). Mental disorders are currently rated in accordance with 38 C.F.R. § 4.130, Diagnostic Code 9201-9521. PTSD is rated in accordance with 38 C.F.R. § 4.130, Diagnostic Code 9411. Under that section, a 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The next higher rating, 70 percent, requires occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. The highest rating, 100 percent, requires total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. As noted above, the medical evidence indicates that the veteran has no more than a mild PTSD illness, with few, and mild, PTSD symptoms. Applying the same symptomatology, GAF scale scores, and rationale as with the former PTSD criteria, the Board finds that the veteran's symptomatology does not exhibit the necessary flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships as to warrant a 50 percent rating under the revised criteria, from November 7, 1996. Specifically with respect to the effect of the veteran's psychiatric impairment on his ability to work, the revised criteria for a 50 percent rating requires reduced reliability and productivity which is more than occasional. As noted in the analysis as to former criteria, above, the veteran does not contend that he has this requirement. As the veteran does not meet the criteria for a 50 percent rating under the revised criteria, he, by definition, does not meet the criteria for a 70 percent or 100 percent rating under that criteria, as these require that his symptomatology produce occupational and social impairment to an even greater degree than that required for a 50 percent rating. See Shoemaker, supra. Accordingly, the Board finds that the preponderance of the evidence is against an increased rating for the veteran's PTSD, under either the former, or the revised criteria, from November 7, 1996, and his request for an increased rating must be denied. In reaching this decision the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for gender dysphoria (transsexualism), as being secondary to, or aggravated by, service-connected PTSD, is denied. An increased rating for post-traumatic stress disorder (PTSD), currently rated as 30 percent disabling, is denied. BRUCE KANNEE Member, Board of Veterans' Appeals