Citation Nr: 21040040 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 17-02 805 DATE: July 2, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) and depressive disorder is granted. FINDING OF FACT The Veteran's PTSD and depressive disorder are etiologically related to a verified in-service stressor. CONCLUSION OF LAW The criteria for service connection for PTSD and depressive disorder have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had verified active duty service in the Army from December 1984 to May 1985. The matter comes on appeal from an October 2015 rating decision. Entitlement to service connection for PTSD and depressive disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). In adjudicating a claim for service connection for PTSD, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the veteran's military records and all pertinent medical and lay evidence. Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. § 1154 (a); 38 C.F.R. § 3.304 (f). The evidence necessary to establish the occurrence of an in-service stressor for PTSD will vary depending on whether or not the veteran "engaged in combat with the enemy." Id. Here, the Veteran has described a stressor related to in-service sexual assault. If the alleged stressor is not related to combat, the veteran's lay testimony by itself is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other evidence to corroborate the veteran's testimony or statements. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). The Veteran has a current diagnosis of PTSD due to military sexual assault as shown by VA treatment records, Vet Center records, and a January 2020 private psychological evaluation. The January psychological evaluation and VA treatment records also identified depressive disorder. The Board finds that the preponderance of the evidence shows that the Veteran's PTSD and depression are related to the identified sexual assault in service. The Veteran has provided multiple lay statements consistently describing the same in-service incident, the most recent statement was submitted in January 2020. She reported that after basic training, on the day of her graduation of advanced individual training, she went to a hotel with a "Spec 4" whom she had met. She reported that he offered her a drink and she woke up the next morning to find herself naked, and he was gone. She went to the hospital at Fort Gordon and they took a rape kit. A October 2013 Memorandum shows that service treatment records are unavailable for review, all efforts to obtain the needed military information had been exhausted, and further attempts would be futile. The Board finds, however, that findings from the Veteran's mental health treatment records are sufficient to verify the in-service sexual assault. Bronx Vet Center records include a March 2015 letter and an August 2016 Psychological Mental Capacity Assessment from the Veteran's counselor, a licensed master social worker. The records show that the Veteran had been receiving weekly therapy for PTSD due to military sexual trauma. VA mental health treatment records also identify diagnoses of PTSD in 2016 due to military sexual assault, noted to be treated at the Vet Center. A January 2018 VA initial psychiatric evaluation included a discussion of her psychiatric history and reported military sexual assault. It was noted that she had been receiving therapy for the past four years at the Vet Center. The VA psychologist found that the Veteran endorsed anxiety and stressor-related trauma due to her military sexual assault. She had a February 2018 diagnosis of adjustment disorder, to rule out PTSD. VA mental health treatment notes dated in 2019 identify PTSD due to military sexual trauma. A January 2020 private medical opinion was provided by Dr. J.P., a clinical psychologist at South Florida Psychological Associates. She reviewed the claims file and discussed relevant findings shown by the record, to include consistent descriptions of the Veteran's in-service stressor and findings from Vet Center records. Dr. J.P. opined that it was evident that the Veteran met the criteria for PTSD based on her stressor and symptoms associated with the traumatic event. She also met the criteria for unspecified depressive disorder. She opined, given records and statements showing the onset of mental health symptoms as a result of military sexual trauma, the chronicity of her symptoms, and lack of mental health disorder prior to service, that it is at least as likely as not that PTSD and depression were the direct result of the military sexual trauma she endured in service. The Board finds that the January 2020 opinion is probative as it was based on an accurate factual background as shown by the evidence of record, examination and interview of the Veteran, and the psychologist provided an adequate rational for the opinion provided. The Board finds that a preponderance of the evidence shows that PTSD and depressive disorder are etiologically related to her in-service stressor. The Veteran's VA treatment providers, her Vet Center counselor, and private psychologist have all related PTSD to the reported in-service sexual assault. The Board finds that the VA diagnoses, the Vet Center records, and the January 2020 medical opinion are probative evidence which corroborates the occurrence of the Veteran's in-service stressor. Resolving reasonable doubt in the Veteran's favor, the Board finds that PTSD and depressive disorder have been related to the verified in-service sexual assault. Resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for PTSD and depressive disorder is warranted. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christine C. Kung 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.