Citation Nr: 0636000 Decision Date: 11/20/06 Archive Date: 11/28/06 DOCKET NO. 04-31 362 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Nevada Office of Veterans' Services WITNESSES AT HEARING ON APPEAL Appellant and her friend, T.S. ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The veteran had honorable active service from August 1985 to July 1990. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2004 rating decision by the Reno, Nevada, Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the benefits sought on appeal. The veteran testified during a hearing at the RO chaired by the undersigned in May 2005. A transcript of the hearing is associated with the veteran's claims folders. As set forth below, the Board has confined its consideration to the veteran's claim for service connection for PTSD. The February 2004 VA examination report includes a diagnosis of major depression. If the veteran wishes to raise a new claim for service connection for an acquired psychiatric disorder, other than PTSD, she or her service representative should contact the RO regarding that matter. FINDINGS OF FACT 1. The veteran has a current medical diagnosis of PTSD, and at least one VA medical clinician has related the diagnosis to her claimed in-service sexual assault/rape. 3. The veteran's claimed in-service stressor is not related to combat. 4. The occurrence of the veteran's claimed in-service sexual assault/rape is not supported by credible corroborating evidence. 5. The current diagnosis of PTSD is based upon unsubstantiated reports of a stressor, or stressors, as provided by the veteran. CONCLUSION OF LAW PTSD was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.1, 3.102, 3.159, 3.303, 3.304 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist Under 38 U.S.C.A. § 5102 VA first has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. Second, under 38 U.S.C.A. § 5103(a), VA has a duty to notify the claimant of the information and evidence needed to substantiate and complete a claim, i.e., evidence of veteran status; existence of a current disability; evidence of a nexus between service and the disability; the degree of disability, and the effective date of any disability benefits. The veteran must also be notified to submit all evidence in her possession, what specific evidence she is to provide, and what evidence VA will attempt to obtain. VA thirdly has a duty to assist claimants in obtaining evidence needed to substantiate a claim. This includes obtaining all relevant evidence adequately identified in the record, and in some cases, affording VA examinations. 38 U.S.C.A. § 5103A. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d. 1328 (Fed. Cir. 2006). In the Mayfield case, the United States Court of Appeals for Veterans Claims (hereinafter referred to as "the Court") addressed the meaning of prejudicial error (38 U.S.C.A. § 7261(b)), what burden each party bears with regard to the Court's taking due account of the rule of prejudicial error, and the application of prejudicial error in the context of the VCAA duty-to-notify (38 U.S.C.A. § 5103(a)). Considering the decisions of the Court in Pelegrini and Mayfield, the Board finds that the requirements of the VCAA have been satisfied in this matter, as discussed below. In this case, there is no issue as to providing an appropriate application form or completeness of the application. Written notice provided in April 2003, prior to the March 2004 rating decision, and in January 2005, fulfills the provisions of 38 U.S.C.A. § 5103(a) save for a failure to provide notice of the type of evidence necessary to establish a disability rating or effective date for the disability on appeal. The claim was readjudicated in a May 2005 supplemental statement of the case. The failure to provide notice of the type of evidence necessary to establish a disability rating and an effective date for the disability on appeal is harmless because the Board has determined that the preponderance of the evidence is against the claim for service connection. Hence, any questions regarding what rating or effective date would be assigned are moot. See e.g., Dingess v. Hartman, 19 Vet. App. 473 (2006). Finally, VA has secured all available pertinent evidence and conducted all appropriate development. The service medical records are available, as well as VA treatment records, and there is no pertinent evidence which is not currently part of the claims file. As well, the veteran testified during a hearing before the undersigned in May 2005. The Board concludes that the notifications received by the appellant adequately complied with the VCAA and subsequent interpretive authority, and that he has not been prejudiced in any way by the notice and assistance provided by the RO. See Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993); VAOPGCPREC 16-92 (57 Fed. Reg. 49,747 (1992)). Likewise, it appears that all obtainable evidence identified by the appellant relative to her claim has been obtained and associated with the claims file, and that neither she nor her representative has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. Thus, for these reasons, any failure in the timing or language of VCAA notice by the RO constituted harmless error. Thus, the Board may proceed without prejudice to the appellant. II. Factual Background A review of the veteran's service medical records (SMRs) reveals they are unremarkable for any evidence in the way of relevant complaints, diagnoses, or treatment of a sexual assault or stress- related mental illness; nor do they contain any evidence of any psychiatric complaints or treatment. An emergency room record in August 1988 reveals that the veteran was seen for vaginal bleeding and pelvic pain. She reported having a D&C (dilation and curettage) at a Korean medical facility. According to the record, a hand written report noted the removal of a POC (product of conception). She had not yet taken any prescribed medication although it was noted that the Korean physician gave her prescriptions for medication. On examination, the veteran was alert and oriented and appeared upset and uncomfortable. She was advised to take the prescribed medication and scheduled for routine follow-up. Modified duty was recommended. There was no evidence indicating any complaint of an assault, rape, or complications from this procedure in service. An April 1990 medical record reflects a complete spontaneous abortion. Service records reveal that the veteran performed her duties in a satisfactory manner. The veteran requested a hardship discharge in July 1990 as she was a sole parent. Her separation from service was based on the grant of this hardship request. The veteran waived a separation examination. Post service, VA medical center (VAMC) mental health clinic treatment records beginning in July 2002 reveal reports of confusion and depression. The veteran was scheduled for a PTSD evaluation. At a September 2002 VAMC clinical mental health evaluation, the veteran reported a history of rape and abortion in service. The rape and abortion in service were very stressful and she suffered great physical and emotional pain from the abortion. She also reported other events indicating total chaos and confusion in her late teens to early 20s. This included childhood sexual assault by her father. The diagnosis was PTSD with depressive features. A February 2003 VAMC clinical treatment report diagnosed at Axis I- PTSD, major depression 'years'; and, at Axis IV- extremely severe, raped in the army, antecedent sexual molestation. According to an April 2003 VAMC clinical report, a history of sexual trauma as a child and in the military was noted. The veteran reported being sexually abused by her father beginning at age 11. After her 16 yr old sister ran away from home and returned, she told a therapist about the sexual abuse, and the siblings, including the veteran, were picked up by authorities. The veteran agreed to file charges against her father. Her mother was in denial about the events. The record further indicates that the veteran planned to escape her family problems by joining the army but became pregnant. She married the father; had a baby girl; enlisted one year later; subsequently was divorced; gained custody of her daughter; was assigned to Korea; allegedly was raped the first day she arrived in country; became pregnant; had an abortion; reenlisted; was granted a hardship separation from service as a single parent; remarried after again becoming pregnant; was divorced; granted custody of her son who had multiple medical and psychological problems; and lost custody of her daughter. The Board notes that in an 18 page written statement from the veteran, dated in August 2003, she described losing custody of her daughter to her first husband after being accused of allowing her father and second husband to sexually molest the child. She further indicated that she bled profusely after the D & C procedure at the Korean medical facility and was almost unconscious and incoherent when she went to the base hospital. The veteran was afforded a VA psychiatric examination in February 2004. According to the examination report, the examiner reviewed the veteran's medical records prior to examination. The examiner noted that the veteran began treatment at the VAMC mental health clinic in 2002. She reported memory problems, bad dreams, decreased concentration, obesity, feeling vulnerable, chaotic and confused some days, and a history of sexual abuse by her father. She was upset over an elective abortion. She could not recall any of her nightmares but awakened feeling scared and with a rapid heartbeat. Her symptoms reportedly began about 10 to 15 years ago; she had just gotten out of the service that was a year after she allegedly was raped in June 1988. The examiner noted that the veteran had an older brother and 3 younger sisters all who weighed over three hundred pounds and had heart problems. One sister was schizophrenic. While growing up, the veteran was beaten daily and forced to have sex with her father. She was married twice, both times for one year. The first marriage ended because she no longer wanted to be married. She had a daughter from the first marriage who lived with her until she was 7 or 8 years old and then went to live with an old baby sitter. The second marriage was in 1991 and she had one son of whom she currently had custody. She worked but had no hobbies. She did not go to church, movies, or restaurants, and did not attend community events, or any school activities. A physical examination revealed no impairment of thought process, or communication. There were no delusions, or hallucinations. She was neatly and cleanly dressed with good hygiene and grooming. She appeared nervous through most of the interview. There was no inappropriate behavior, or suicidal or homicidal ideations. She claimed she could not remember what she did at work and forgets things on a daily basis. Her speech was goal oriented and logical with good tone and rhythm. Her comprehension, perception, and judgment were generally good. Perception was normal; insight fair to good, and coordination good. There was no sign or symptoms of psychosis, or organic brain syndrome. The examiner noted that the veteran stated that she was raped in Korea about 20-22 years ago while in the military. She had memories of the rape and dreamed about it happening all over again. She had just arrived in Korea and went to call her daughter when someone hit her on the head and she blacked out. She awoke with her clothes off, bruised and bleeding. It took her awhile to realize what happened. She gathered up her stuff and ran to the showers. She reported it to her sergeant sometime later, and subsequently discovered that she was pregnant. The sergeant convinced her to get an abortion. She felt guilty about it saying, "I killed somebody, I killed my chid." "That's why God punished me, because my son is messed up, it's all my fault." The VA examiner said that the veteran did not have persistent avoidance of stimuli (no restricted range of affect, no detachment, etc.); and, there was no increased arousal (no hypervigilance, no exaggerated startle response, no difficulty falling asleep.) All of the veteran's symptoms were explainable as major depression. The examiner opined that the veteran did not have PTSD. Instead she had major depression brought about by the guilt she felt from having the abortion. The depression also affected her interaction with others at home so that she ignored her son and boyfriend most of the time. The diagnosis was, Axis I- major depression; Axis II- personality disorder NOS; Axis V- GAF 38. A September 2004 signed statement from T.S. is to the effect that she befriended the veteran in 1983. In essence, the history of the veteran reported in this statement is the same as the veteran's prior statements to her VAMC clinicians and written statements. In an October 2004 VAMC mental health clinic progress report, the treating clinician summarized the veteran's history noting that her diagnosis included PTSD, and major depression 'years.' Her stressors were considered to be extremely severe: raped in the army, and antecedent sexual molestation. The clinician noted that her psychiatric diagnoses and symptoms were well documented in her army medical records. Her military medical records were consistent with panic disorder, depression with panic attacks and somatic anxiety. She was treated for these symptoms without menton of what caused them. These symptoms were also included in the definition of PTSD, but diagnoses of depression and anxiety make the severity of PTSD worse. During her May 2005 Board hearing, the veteran's service representative, in essence, noted that although the veteran alleged that she was raped in June 1888, a review of the veteran's 201 file indicates that it may have occurred as early as March 1988. She noted that the veteran required further treatment to "get some clarity of her memory." The representative further referred to an October 2004 evaluation of the veteran by a psychiatrist at VAMC who diagnosed the veteran with PTSD. The Board notes that this psychiatrist was her treating clinician, and the evaluation was the aforementioned October 2004 VAMC mental health clinic progress report. T.S. testified, in essence, repeating her September 2004 statement. The veteran testified that she believed that she was knocked unconscious and was raped resulting in a pregnancy. However the Board notes that she could not actually remember if she was in fact raped. The service representative asked her if she had been dating or sleeping with anyone prior to the rape. She testified that she had not been dating or sleeping with anyone. She further testified that she could not have been pregnant before leaving for Korea. The Board notes that in the typed statement dated August 2003, the veteran noted that prior to leaving for Korea she was engaged to another soldier. Upon returning from Korea they broke up after she told him of the rape and abortion. She apparently later discovered that he married someone during their engagement. III. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection for PTSD requires medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). In Patton v. West, 12 Vet. App. 272, 278 (1999), the Court pointed out that there are special evidentiary procedures for PTSD claims based on personal assault contained in VA ADJUDICATION MANUAL M21-1, Part III, para. 5.14c (February 20, 1996), and former M21-1, Part III, para. 7.46(c)(2) (October 11, 1995). In personal assault cases, more particularized requirements are established regarding the development of "alternative sources" of information as service records "may be devoid of evidence because many victims of personal assault, especially sexual assault and domestic violence, do not file official reports either with military or civilian authorities." VA ADJUDICATION PROCEDURAL MANUAL M21-1, Part III, para. 5.14c(5). With respect to personal assaults, 38 C.F.R. § 3.304(f) was amended in March 2002, to add the following: If a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a post-traumatic stress disorder claim that is based on in- service personal assault without first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(3). Moreover, the 2002 amendment to section 3.304(f) also does not require further development of this case, because there is no unresolved factual issue as to the occurrence of the scenario that constitutes the claimed personal assault "stressor" in service. In fact, as will be discussed below, the available record is not referable to any complaint of or treatment for a sexual assault in service, and the veteran has not alluded to any additional information that would counter that lack of supportive evidence. The Board would note, at the outset, that the record reflects that some medical professionals have questioned whether the veteran has PTSD related to service. In 2002 and 2003, and in 2004, VA clinicians diagnosed PTSD, noting her sexual assault in childhood and in the military, however, in February 2004, a VA psychiatrist concluded that the veteran did not have PTSD. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). The record reflects that the veteran has described alleged stressors that caused her PTSD; specifically that she was raped and knocked unconscious shortly after arriving in Korea. Subsequent post service VA medical records reflect her history of childhood sexual trauma. In this case, the veteran during her hearing, very clearly expressed that other than confiding in her sergeant, whose name she could not recall, and her friend T.S., about the sexual assault, there was no evidence that was not of record that would support her claim. In regard to her claim of being sexually assaulted, the veteran testified at her hearing that she did not report it and she did not go for any treatment. VA medical records dated from 2002 reflect diagnoses of PTSD based on the veteran's report of the inservice sexual assault. Accordingly, the Board finds that there is some evidence of a stressor incident or incidents in service, evidence of a current disability, and also seemingly competent evidence that the current disability is a "residual" of the stressor experienced in service. With that in mind, the Board must review the claim on its merits, account for the evidence that it finds to be persuasive and unpersuasive, and provide reasoned analysis for rejecting evidence submitted by or on behalf of the claimant. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For a claim to be denied on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9Vet. App. 518, 519 (1996). As noted above, the Board is not directly questioning the diagnosis of PTSD in this claim. However, by law, the evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the veteran engaged in "combat with the enemy." See Gaines v. West, 11 Vet. App. 353 (1998) (Board must make a specific finding as to whether the veteran engaged in combat). If the claimed stressor is not combat related, the veteran's lay testimony, by itself, is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain credible supporting evidence from any source that corroborates the veteran's testimony or statements. YR v. West, 11 Vet. App. 393, 397 (1998); Cohen v. Brown, 10 Vet. App. 128, 147 (1997). In the particular case of claimed personal assault, VA has established special procedures for evidentiary development. See VA Adjudication Procedure Manual M21-1 (hereinafter Manual M21-1), Part III, paragraph 5.14c (Feb. 20, 1996) (substantially enlarging on the former Manual M21-1, Part III, paragraph 7.47c(2) (Oct. 11, 1995)). These procedures take into account the difficulty establishing the occurrence of the stressor through standard evidence, and the need for development of alternate sources of evidence. The provisions of Manual M21-1 dealing with PTSD are substantive rules that are the equivalent of VA regulations; VA is therefore required to follow these provisions. Patton v. West, 12 Vet. App. at 277; YR, supra, 11 Vet. App. at 398-99; Cohen, 10 Vet. App. at 139. Moreover, the 2002 amendments to 38 C.F.R. § 3.304(f), quoted above, have augmented the substantive law pertaining to such claims. The final requirement of 38 C.F.R. § 3.304(f) for service connection of PTSD is medical evidence of a nexus between the claimed in-service stressor and the current disability. In cases of claimed personal assault, VA recognizes that some evidence may require interpretation by a clinician to establish a relationship to the diagnosis, per Manual M21-1, Part III, paragraph 5.14c(9). Accordingly, the general rule that post-service medical nexus evidence cannot be used to establish the occurrence of the stressor is not operative in such cases. Patton, 12 Vet. App. at 280. See Cohen, 10 Vet. App. at 145; Moreau v. Brown, 9 Vet. App. 389, 396 (1996), aff'd, 124 F.3d 228 (Fed. Cir 1997) (table). The starting point for any determination with regard to PTSD is whether there is a "stressor." Under all versions of the controlling regulation, there must be credible supporting evidence that the claimed in-service stressor(s) actually occurred. 38 C.F.R. § 3.304(f). The question of whether the veteran was exposed to a stressor in service is a factual determination, and VA adjudicators are not bound to accept such statements simply because treating medical providers have done so. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); Wilson v. Derwinski, 2 Vet. App. 614 (1992). The existence of an event alleged as a stressor that results in PTSD (though not the adequacy of the alleged event to cause PTSD) is an adjudicative, not a medical determination. See Zarycki v. Brown, 6 Vet. App. 91 (1993). As the veteran does not allege that she engaged in combat, and as her reported stressors are not related to combat, her assertions, standing alone, cannot, as a matter of law, provide evidence to establish that an in-service event claimed as a stressor occurred. See Dizoglio v. Brown, 9 Vet. App. 163 (1996); West v. Brown, 7 Vet. App. 70, 76 (1994). Furthermore, service department records must support, and not contradict, the claimant's testimony regarding non-combat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). This does not mean that she cannot establish that the alleged in-service events occurred; it only means that other "credible supporting evidence" from some source is necessary. See Cohen. Since there is a diagnosis of PTSD here, it must be determined whether there is credible supporting evidence of the veteran's alleged stressor, i.e., whether service records or other independent credible evidence corroborates the alleged stressor. See Dizolgio, supra. The Court has held repeatedly that, where there is a current diagnosis of PTSD, it must be presumed that the physician(s) making the diagnosis accepted the sufficiency of the in- service stressor(s). Nevertheless, since the diagnostician does not generally have firsthand knowledge of whether a stressor actually occurred, credible evidence is required to verify that element. Pentecost v. Principi, 16 Vet. App.124 (2002). Based upon a review of the entire record in this case, and in view of the factors discussed above, the Board finds that the evidence of record has not corroborated the veteran's allegation of a rape in service. The veteran maintained that she was raped in or near a phone booth near processing barracks by an unknown assailant shortly after her arrival in Korea, although she has provided no specifics of the alleged event. The record also contains 2002 through 2004 records from VA clinicians to the effect that the veteran reported being sexually assaulted in service. The Board notes references in the veteran's clinical treatment records wherein her clinicians attempted to help her remember the alleged incident and helped her develop her stressor statement and claim. The Board notes that the notations by the examiners are merely a report of the veteran's account of what took place during service. They do not constitute corroborating evidence that the attack factually occurred as those examiners were not present during any attack during service. See Jones v. West, 12 Vet. App. 383 (1999). Thus, in sum, the veteran contends that she was sexually assaulted during service. She contends that she was knocked unconscious and awoke bruised and with her clothes torn off. She later discovered she was pregnant and underwent an abortion on her sergeant's advice. She said she was incoherent when she went to the base hospital for treatment. She testified at the May 2005 hearing that she had not been seeing anyone or sleeping with anyone prior to the alleged rape. However in an 18 page document dated in August 2003, she detailed her engagement to be married prior to going to Korea; and the breaking of the engagement after returning home. The testimony and the reports contradict each other and the veteran. The statement was prepared by the veteran as part of her clinical treatment for her mental disorders in an attempt to have her remember the details of the alleged rape. A written statement from T.S., the veteran's friend, dated in September 2004, and oral testimony, was submitted to support the veteran's claim. The details were first provided many years after the alleged assault and the veteran's separation from service. In the introduction to her testimony, the veteran could not recall if the rape occurred in March or June 1988, but testified that she called T.S. about a week after the rape. Due to the inconsistencies, the fact that the statements are not contemporaneous to service and are remote from the time of the alleged attack and the veteran's separation from service, the statements are not credible and therefore, not probative evidence. Since the lay evidence is not credible and therefore not probative, there is no verification of the alleged stressor. A review of the evidentiary record thus reveals that the medical diagnoses of PTSD are attributed to the veteran's own account of an in-service stressor undocumented in the available service records and unsupported in the record. While the VAMC treating clinician in October 2004 noted that the veteran's psychiatric diagnoses and symptoms were well- documented in her army medical records; and, that her military medical records were consistent with panic disorder, depression with panic attacks and somatic anxiety, this is simply not supported by the claims file. As detailed above, the veteran's service medical records are entirely silent as to any treatment for any psychiatric disorder. Contravening the above PTSD diagnoses, is the fact that the February 2004 VA psychiatric examiner, who reviewed the claims file, specifically noted the veteran's absence of persistent avoidance of stimuli, and absence of increased arousal, and concluded that the veteran's symptoms could be explained on the basis of major depression. Likewise, medical statements which attempt to accept a claimant's reports as credible and then relate a diagnosis of PTSD to events experienced in service do not constitute the requisite credible evidence of a stressor. Moreau v. Brown, 9 Vet. App. at 389. As noted above, several VA treatment reports reflect that the examiners have indicated that the veteran's current diagnosed psychiatric disorders, particularly PTSD, were due to sexual assault/rape. Clearly, those treating psychiatric physicians and psychologists did not undertake review of the veteran's service records, but based their premises of in-service sexual assault solely upon the veteran's statements to them. The filtering of the veteran's account of her military service through her physician does not transform her account into competent medical evidence, or an accurate account of those experiences, merely because the transcriber happens to be a medical professional. See Leshore v. Brown, 8 Vet. App. 409 (1995). Moreover, with regard to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that a post-service reference to injuries sustained in service, without a review of service medical records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). A medical opinion based upon speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the claimant's history, and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Further, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). A medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998); LeShore v. Brown, supra. In fact, in February 2004, the VA psychiatric examiner concluded that the veteran did not have PTSD, although in October 2004, a VA clinician found she had PTSD and major depression As a layperson, the veteran is not competent to render a medical opinion in this regard. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). Accordingly, the veteran is not entitled to service connection for PTSD under the theory that it resulted from unverified, vaguely reported stressors during service. In light of the foregoing, the Board finds that the record does not support the veteran's assertion that she was raped during active service. Thus, although the foundation for the diagnosis of PTSD in this case was the veteran's account of having been raped, we must conclude that the claimed stressor has not been satisfactorily established as having occurred. The veteran may very well consider events that occurred in conjunction with her alleged sexual events in service to be stressful, but she has failed to provide even one factual detail of the alleged events on which to base her claim, other than a specific description of an alleged sexual assault during service. Thus, while the veteran does have a diagnosis of PTSD based upon her purported in-service stressor, that stressor is not shown by satisfactory evidence to have occurred. The Board appreciates the testimony offered at her Travel Board hearing before the undersigned. With all due respect to the veteran, we find that her and her friend's oral and written statements in support of her claim are, thus, unsubstantiated and are of little evidentiary weight. Having so concluded, the Board finds that the preponderance of the credible evidence is against the claim, and that neither a VA psychiatric examination nor further interpretation by a clinician of the in-service symptoms/behavior is necessary. See M21-1, Part III, 5.14(c); Patton v. West, supra at 280. We have considered the doctrine of reasonable doubt. Under that doctrine, when there is an approximate balance between evidence for and against a claim, the evidence is in equipoise, there is said to be a reasonable doubt, and the benefit of such doubt is given to the claimant. 38 U.S.C.A. § 5107(b); see Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); 38 C.F.R. § 3.102. However, when the evidence for and against a claim is not in equipoise, then there is a preponderance of evidence either for or against the claim, there is no reasonable doubt, and the doctrine is inapplicable. Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993). Since the objective medical evidence preponderates against the veteran's claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, supra. Based upon the evidence of record, service connection PTSD must be denied. ORDER Service connection for PTSD is denied. ____________________________________________ D.J. DRUCKER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs