Citation Nr: 21040858 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 18-20 041 DATE: July 7, 2021 ORDER Entitlement to service connection for post-traumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for hypertension, to include as secondary to PTSD, is remanded. FINDING OF FACT Resolving all reasonable doubt in her favor, the Veteran's PTSD is etiologically related to in-service military sexual trauma (MST). CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from August 1981 to December 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2016 and March 2018 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2021, the Veteran testified before the undersigned at a hearing via videoconference. A transcript of her testimony has been associated with the claims file. Service Connection The Veteran asserts that she is entitled to service connection for PTSD due to military sexual trauma, or MST. More specifically, she reported that she was sexually assaulted by a drill sergeant at Fort McClellan, Alabama, in 1981. While on guard duty late at night, the drill sergeant approached her and asked to see her in his office. After reporting to his office, he began kissing her despite her protestations, took off her clothes, and raped her. Afterwards, he told her that if she told anyone what happened to her, he would make sure that she was thrown out of the military. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In this case, establishing service connection for PTSD requires specific findings. These are: (1) a current medical diagnosis of PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and, (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See 38 C.F.R. § 3.304(f). The diagnosis of PTSD must comply with the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, of the American Psychiatric Association (DSM-V). Id.; see 38 C.F.R. §§ 4.125(a), 4.130. 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 disease; 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 PTSD 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)(5). At the outset, the Board notes that the Veteran has a current diagnosis of PTSD pursuant to DSM-V criteria as shown by her VA treatment records, as well as a January 2017 disability benefits questionnaire submitted by the Veteran and a January 2020 private evaluation with Dr. J.A. As such, the first element of the test for service connection for PTSD is not in question. With respect to the second element, credible supporting evidence that her MST occurred during service, the Veteran's contentions with respect to MST are discussed in more detail above. As set forth in her testimony, the Veteran did not report the incident to her superiors in the military due to a fear of retaliation. She also stated that she received medical care at a hospital shortly after she was assaulted, but that the hospital did not take any action afterwards. As an initial matter, although the service treatment records that are currently in the record do not contain any reports of or treatment for MST, the RO does not appear to have obtained her complete service treatment records. Indeed, service treatment records from 1981 are generally missing from the claims file. The Board notes that the Veteran was married in 1984 and subsequently changed her maiden name to her current last name. However, the RO obtained medical records associated with the Veteran's married last name without obtaining medical records associated with her maiden name. To that end, the incomplete service treatment records are not dispositive with respect to corroborating the in-service MST. Nonetheless, she has consistently reported that she was sexually assaulted by a drill sergeant during basic training at Fort McClellan, Alabama, in 1981 while she was on guard duty. Service personnel records confirm that she began basic training at Fort McClellan in 1981. Moreover, the Veteran's post-service medical treatment records reflect extensive mental health counseling related to her assault, as well as problems such as weight gain and drug and alcohol abuse. For instance, in March and April 2015 VA treatment records, she described being sexually assaulted by a drill sergeant during basic training. She was later assessed with PTSD. These statements are considered especially trustworthy, as they were made for the purpose of receiving medical care and prior to filing a claim. See White v. Illinois, 502 U.S. 346 (1992). Additionally, the Veteran has submitted various buddy statements from her sister, former husband, and old roommate with respect to behavioral changes that occurred following her assault. Her sister E.C. indicated that her sister had not been the same since she served in the military. For instance, she was often depressed, had mood swings, and would cry for no apparent reason. Similarly, her ex-husband M.W. reported that she was angry and unfriendly and that she drank heavily and used drugs. Additionally, she would wake up in the middle of the night yelling at someone to get away. Likewise, her old roommate S.J. reported that she would have nightmares and scream in her sleep. S.J., who met the Veteran in 1981 or 1982, indicated that the Veteran told her that she had been raped during basic training and that she had witnessed changes in behavior, such as mood swings and crying spells. Furthermore, the record reflects that the Veteran was examined by Dr. J.A., a private psychologist, in January 2020. The private examiner confirmed the Veteran's diagnosis of PTSD and, after finding her lay statements regarding MST to be highly credible, rendered a positive nexus opinion. The examiner's findings are based on diagnostic testing, a review of the claims file, examination of the Veteran, and current psychiatric symptoms. As such, the Board finds the opinion of the examiner to be adequate for the purposes of adjudication. See Stefl v. Nicholson, 21 Vet. App. 120, 129 (2007). The Board notes that a medical opinion formed on the basis of a veteran's reported medical history cannot be rejected without the Board first finding that the veteran's allegations are not credible. Coburn v. Nicholson, 19 Vet. App. 427, 432 (2005); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Here, although the Veteran's MST stressor is not documented in the service records currently available in the file, the Board finds that her account is facially plausible. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). It is also consistent with the buddy statements she has submitted. Having considered the medical evidence finding that her symptoms are demonstrative of an in-service personal assault with resulting PTSD, the Board finds that her in-service MST is sufficiently corroborated. In making this finding, the Board acknowledges that the RO previously found that the Veteran did not supply enough information to substantiate her reported stressor. However, her lay statements regarding her in-service assault have remained consistent. The Board has no reason to doubt her credibility. To that end, she has not displayed any unwillingness to recount the details of her attack or psychiatric history that would signify deception. Indeed, she has been and continues to be transparent. Accordingly, resolving all reasonable doubt in her favor, the Board finds that service connection for PTSD based on MST is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). REASONS FOR REMAND The Veteran has also claimed entitlement to service connection for hypertension, which she alleges is secondary to her PTSD. VA has statutory duties to notify and assist claimants in substantiating a claim for VA benefits. See, e.g., 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. VA's duties to assist a claimant in the development of a claim may include scheduling a medical examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, there is evidence showing the Veteran has a current diagnosis of hypertension. Additionally, the Board has granted service connection for PTSD in this decision. The Veteran alleges that her hypertension is caused or aggravated by her PTSD. To date, however, no VA examination has been obtained with respect to the etiology of her hypertension. As such, the Board finds that remand is necessary to obtain a VA examination and medical opinion regarding the nature and etiology of her hypertension, to include whether it is secondary to service-connected PTSD. See McLendon, 20 Vet. App. at 83-86. Furthermore, as set forth above, the RO requested the Veteran's service treatment records but did not submit a request using her maiden name. As such, it appears that there are outstanding service treatment records. On remand, the RO should attempt to obtain any outstanding medical records from service by requesting records associated with her maiden name. Accordingly, the matters are REMANDED for the following action: 1. Attempt to obtain any outstanding service treatment records from the Veteran's active service. A search should be completed for records using the Veteran's maiden name. 2. After obtaining appropriate authorization, obtain and associate with the claims file all outstanding VA treatment records and all outstanding, relevant private treatment records. 3. Thereafter, obtain a VA examination with an appropriate examiner with respect to the nature and etiology of the Veteran's hypertension. The Veteran's claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. The examiner is asked to compile a detailed history before doing the following: (a.) Opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that her hypertension had its onset during or is otherwise related to active service. (b.) Opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that her hypertension was (1) caused, or (2) aggravated by her service-connected PTSD, including its treatment. The examiner is reminded that causation and aggravation are distinct legal concepts that must be addressed separately. "Aggravation" is defined as worsening beyond the natural progression of the disability. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner must consider all relevant lay and medical evidence of record, including the Veteran's hearing testimony and post-service treatment records. The examiner is reminded that the absence of contemporaneous service treatment records, alone, is an insufficient basis for a negative medical nexus opinion. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Rademacher, Associate 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.