Citation Nr: 21026901 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 16-40 895 DATE: May 4, 2021 ORDER The claim of entitlement to service connection for erectile dysfunction, to include as secondary to posttraumatic stress disorder (PTSD) and diabetes mellitus, is denied. The claim of entitlement to service connection for hypertension, to include as secondary to PTSD and diabetes mellitus, is denied. FINDINGS OF FACT 1. The Veteran's erectile dysfunction is not secondary to service-connected PTSD or diabetes mellitus, and is not otherwise related to an in-service injury or disease. 2. The Veteran's hypertension is not secondary to service-connected PTSD or diabetes mellitus, and is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for erectile dysfunction are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Army from May 1966 to May 1968, to include service in the Republic of Vietnam. The instant matter is on appeal from an August 2013 rating decision. The Board remanded these issues in January 2019 for additional evidentiary development. Subsequent to that remand, the Regional Office (RO) granted entitlement to service connection for PTSD in a July 2020 rating decision. As award constitutes a full grant of benefits sought on appeal, the issue is no longer before the Board. Service Connection Generally, service connection will be granted for a disability resulting from an injury or disease caused or aggravated by service. 38 U.S.C. §§ 1110. A grant of service connection for a disability requires: (1) a present disability or persistent or recurrent symptoms of a disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the in-service event, injury, or disease. 38 C.F.R. § 3.303; see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, the regulations provide that service connection is warranted for a disorder that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected disability, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected disability, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). A worsening is not required to be permanent in order to establish secondary service connection on the basis of aggravation. See Ward v. Wilkie, 31 Vet. App. 233 (2019). Any incremental increase in disability or any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions regardless of permanence constitutes aggravation. When service connection is thus established for a secondary disorder, the secondary disorder shall be considered a part of the original disability. Absent affirmative evidence to the contrary, veterans who served in the Republic of Vietnam, including the territorial waters of Vietnam, during the Vietnam Era are presumed to have been exposed to certain herbicide agents. 38 U.S.C. §§ 1116, 1116A; 38 C.F.R. § 3.307; see also Procopio v. Wilkie, 913 F.3d 1371, 1376 (Fed. Cir. 2019). If a veteran was exposed to an herbicide agent (to include Agent Orange) during active service, certain diseases will be presumptively service connected, even though there is no record of such disease during service. See 38 C.F.R. § 3.307, 3.309. The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. VA has issued several notices in which it was determined that a presumption of service connection based upon exposure to herbicides used in Vietnam should not be extended beyond specific disorders, based upon extensive scientific research. See, e.g., 68 Fed. Reg. 27630 -27641 (May 20, 2003); 67 Fed. Reg. 42600 (June 24, 2002); 66 Fed. Reg. 2376 (Jan. 11, 2001); 64 Fed. Reg. 59232 (Nov. 2, 1999). Notwithstanding the presumption, service connection for a disability claimed as due to exposure to herbicide agents may be established by showing that a disorder resulting in disability or death was in fact causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C. § 1113 (b) and 1116 and 38 C.F.R. § 3.303. 1. The claim of entitlement to service connection for hypertension, to include as secondary to PTSD and diabetes mellitus The Veteran's contends that his hypertension is etiologically related to active duty service or his service-connected PTSD or diabetes mellitus. The Veteran's service treatment records do not reflect a diagnosis of hypertension or significantly elevated blood pressure readings during active duty. His separation examination, similarly, did not note a diagnosis of, or complaints related to, hypertension. Post-service treatment records reflect a diagnosis of hypertension around 2002. An April 2002 VA examination diagnosed him with essential hypertension. A May 2013 VA examination confirmed the diagnosis of hypertension with use of medication to control his blood pressure. As the Veteran's hypertension predated his diagnosis of diabetes mellitus, and his microalbumin was normal, his condition was diagnosed as essential hypertension and not secondary to diabetes. The Veteran's blood pressure additionally remained controlled; thus, the onset of diabetes did not aggravate his hypertension. A September 2019 medical opinion provided a more detailed discussion of the etiology of the Veteran's hypertension. A review of the record reflected a diagnosis of, and treatment for, hypertension around December 2001, which was decades after his discharge from service. Although the exact cause of essential hypertension remains unknown, factors and conditions are known to increase the risk of developing the condition, which include age, obesity, sedentary lifestyle, smoking, gender, and family history. Risk factors identified in the Veteran included age, body mass index, and gender. While the Veterans and Agent Orange Update of 2018 indicated some increasing association between herbicide agent exposure and essential hypertension, the examiner noted that there was still insufficient medical and scientific evidence to determine a causative association between them. While herbicide agent exposure was conceded, there remained no scientific validation of an etiological or causative association between hypertension and herbicide agent exposure sufficient to establish a nexus. Furthermore, while studies suggested a link between PTSD and cardiovascular health, there was no evidence that this association was causative in the development of hypertension. In the Veteran's case, the onset of PTSD and depression occurred well after the onset of hypertension. Given their overall severity, it was also unlikely that the Veteran's PTSD or depressive condition caused or aggravated his hypertension, and the examiner referenced continued control of the Veteran's blood pressure through this period after the psychiatric diagnoses. Thus, the examiner concluded that the Veteran's hypertension was less likely as not related to active duty service, to include conceded exposure to herbicide agents, and hypertension was not caused or aggravated by his service-connected PTSD or diabetes mellitus. After a thorough review of the medical and lay evidence of record, the Board finds that service connection for hypertension is not warranted. The Veteran did not report symptoms of hypertension around his discharge from service or within one year from separation. Instead, hypertension was diagnosed decades after discharge, and related to risk factors that included the Veteran's age, body mass index, and gender. The condition was not shown to have been aggravated by the Veteran's service-connected PTSD or diabetes mellitus and blood pressure remained controlled following these diagnoses. The Veteran believes his hypertension is related to either active duty service or his service-connected PTSD or diabetes mellitus, but he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires specialized medical knowledge and training. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). As the Veteran is not competent to render a nexus opinion on this issue, such lay statements cannot be afforded probative weight. Instead, the Board gives more probative weight to the competent, thorough medical evidence of record denying an etiological relationship. As the preponderance of the probative evidence of record weighs against a finding of an etiological relationship between hypertension and active duty service or service-connected disabilities, the rule regarding reasonable doubt is not for application. The claim of entitlement to service connection for erectile dysfunction must be denied. 2. The claim of entitlement to service connection for erectile dysfunction, to include as secondary to PTSD and diabetes mellitus The Veteran contends that he is entitled to service connection for erectile dysfunction as he believes it is caused by his service-connected PTSD and/or diabetes mellitus. The Veteran's service treatment records do not reflect a diagnosis of erectile dysfunction during service or upon separation. Post-service treatment records indicate that he experienced this condition beginning around 2003. VA treatment records reflect a diagnosis of erectile dysfunction with low normal testosterone level. A May 2013 VA examination confirmed the diagnosis of erectile dysfunction and noted that such predated the diagnosis of diabetes mellitus. The etiology of the condition was determined to be a combination of hypertension and his low testosterone. The Veteran's erectile dysfunction was less likely as not secondary to his diabetes mellitus as the condition predated the diagnosis of diabetes, and the erectile dysfunction persisted over time, but was not aggravated by the onset of diabetes. A September 2019 VA medical opinion discussed the etiology of the Veteran's erectile dysfunction in more detail. Review of the records indicated an approximate onset after starting medication for hypertension around April 2002. He was assessed with low testosterone around May 2013. The examiner concluded that the condition was less likely as not directly related to service as its onset was decades after his discharge. Erectile dysfunction was also noted to not be a presumptive condition of herbicide agent exposure, nor did the Veterans and Agent Orange Update of 2018 indicate even an association between the condition and herbicide agent exposure. Erectile dysfunction was diagnosed prior to the Veteran's psychiatric disorders, making it unlikely that the condition was caused by these mental health conditions. Further, erectile dysfunction was diagnosed before diabetes mellitus. Records did not reflect a worsening of his erectile dysfunction following the diagnoses of these disabilities. Instead, multiple factors could contribute to erectile dysfunction, to include hypertension, and altered hormone levels. In this case, the examiner determined that the Veteran's hypertension, antihypertensive medication, hyperlipidemia, and increased age equally contributed to the development of his erectile dysfunction. After a thorough review of the medical and lay evidence of record, the Board finds that service connection for erectile dysfunction is not warranted. The Veteran did not report symptoms of erectile dysfunction around his discharge from service or within one year from separation. Instead, erectile dysfunction was diagnosed many years later and attributed to hypertension, antihypertensive medications, hyperlipidemia, and advancing age. The condition was not shown to have been aggravated by the Veteran's service-connected PTSD or diabetes mellitus. (Continued on the next page) The Veteran believes his erectile dysfunction is related to his service-connected PTSD or diabetes mellitus, but he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires specialized medical knowledge and training. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377. As the Veteran is not competent to provide nexus opinions on this issue, such lay statements cannot be afforded probative weight. Instead, the Board gives more probative weight to the competent, thorough medical evidence of record denying an etiological relationship. As the preponderance of the probative evidence of record weighs against a finding of an etiological relationship between erectile dysfunction and active duty service or service-connected disabilities, the rule regarding reasonable doubt is not for application. The claim of entitlement to service connection for erectile dysfunction must be denied. S. Sorathia Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Fisher, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.