Female Sexual Dysfunction

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Female Sexual Dysfunction

Example 1 of 1 · fictitious patient (Veteran F)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Illustrative case. This fictitious veteran's history has been constructed so that every factor in both Statements of Principles is met, to show how each factor can be argued. A real claim needs only one factor to be met and connected to service.

Diagnostic Assessment

Gynaecological - Female Sexual Dysfunction

Reasonable Hypothesis SOP: Statement of Principles No. 43 of 2026 Balance of Probabilities SOP: Statement of Principles No. 44 of 2026

ADF History

The veteran, Date of Birth: [withheld], Administration Clerk (Australian Army), enlisted 17 Jan 2005 aged 17, medically discharged 8 Dec 2023. Operational service: Afghanistan (Operation SLIPPER) 2 Jul 2008 to 28 Jan 2009; Iraq (Operation OKRA) 12 Nov 2018 to 6 May 2019.

Occupational History

The veteran served in the Australian Regular Army as an administration clerk for almost 19 years. Her duties carried the physical demands common to all Army members: daily physical training, running on hard surfaces, fitness assessments, route marches carrying load, drill and parades, prolonged standing, field exercises, and lifting and carrying stores and equipment. These activities repeatedly load the spine, abdominal wall and pelvic floor. On operations she worked long hours in a deployed headquarters under the threat of rocket and mortar attack, wore body armour and carried a weapon and load daily, and lived with limited privacy, limited access to toilet and sanitary facilities, and limited access to gynaecological care. Military service requires members to attend training, courses and operations at fixed times regardless of pelvic or menstrual pain. The occupation also carries the psychological demands of a disciplined hierarchical workplace, of recruit training entered as a minor, and of repeated postings and deployments. Her gynaecological, pelvic, spinal and mental health conditions were assessed and treated through the Army health system throughout her service.

History

The veteran, an Army administration clerk, developed pain with intercourse on 14 Feb 2009, two weeks after returning from a seven-month deployment to Afghanistan during which she was concussed and injured in a rocket attack and was treated for painful periods, pelvic pain and urinary infections. The condition was diagnosed as deep dyspareunia on 25 Mar 2009 and worsened on three recorded occasions during her later service: in August 2009 after pelvic surgery and the onset of posttraumatic stress disorder, in June 2020 after a cauda equina injury sustained in Iraq, and in August 2023 after pelvic radiotherapy for cervical cancer.

Timeline

Jan to Apr 2005 - During recruit training, aged 17, the veteran was repeatedly struck, threatened and humiliated by senior recruits and an instructor, and was denied sleep and meals as punishment. She did not report it at the time. She disclosed it to an Army psychologist in 2009 and it is recorded in her mental health notes. "assaulted during recruit training"
Sep 2008 to Jan 2009 - While deployed in Afghanistan she was subjected to ongoing bullying and belittling by her immediate superior in the deployed orderly room, which she reported to her chain of command in November 2008. She was isolated from her family and partner throughout the deployment. "ongoing conflict with supervisor"
14 Oct 2008 - A rocket struck beside the accommodation lines at her base in Afghanistan. She was thrown against a blast wall, briefly lost consciousness, and was assessed at the base medical facility with concussion and lower back and pelvic bruising. She believed she would be killed. Low back and pelvic pain persisted from this date and limited her sitting, lifting and sleep. "brief LOC, concussion"
Aug 2008 to Jan 2009 - The deployed medical officer treated her for very painful periods and cramping pelvic pain with Microgynon 30, and for two urinary tract infections, with review at each sick parade. "V. painful periods"
19 Feb 2009 - Three weeks after returning to Australia she reported to the barracks health centre that intercourse with her partner the previous weekend had been painful. The medical officer thought she was probably tense after the deployment, noted her pelvic cramps with query endometriosis, and planned gynaecological review only if the pain continued. "intercourse painful since return"
25 Mar 2009 - She re-attended with bleeding after intercourse and deep dyspareunia. Vaginal examination showed deep tenderness and cervical tenderness with no masses. She was referred to a gynaecologist, who the same day recorded deep dyspareunia that was positional, with marked dysmenorrhoea. "Deep Dyspareunia (+) positional"
11 Jun 2009 - Laparoscopy, division of fine right-sided pelvic peritoneal adhesions and cautery of a cervical erosion at a private day hospital, arranged through her Army medical officer. No endometriosis was seen. "some fine peritoneal adhesions"
27 Jul 2009 - An Army psychiatrist diagnosed posttraumatic stress disorder arising from the rocket attack and commenced sertraline 50 mg daily. "PTSD - commence sertraline"
19 Aug 2009 - At gynaecological review, ten weeks after surgery and three weeks after starting sertraline, she reported that sex was painful again and that she now had little interest in sex and difficulty becoming aroused. No treatment directed at the sexual dysfunction was offered. "Sex is painful again"
3 May 2019 - While deployed in Iraq she developed sudden severe back pain, saddle numbness and urinary retention after lifting stores. MRI showed a large L5/S1 disc prolapse compressing the cauda equina. She was aeromedically evacuated and underwent emergency decompression on 5 May 2019. "cauda equina syndrome"
12 Mar 2020 - She reported to her medical officer and the unit welfare officer that her partner, also a serving member, had assaulted and threatened her repeatedly since November 2019. "assaulted by partner"
17 Jun 2020 - Rehabilitation review recorded persisting saddle numbness, loss of genital sensation, inability to reach orgasm and loss of sexual interest. She had mobilised only with a frame for short distances since May 2019 and her BMI was 31.4. "no genital sensation, anorgasmia"
9 Mar 2021 - Cervical screening, overdue since December 2018 because of the deployment, evacuation and rehabilitation, led to a diagnosis of stage IB3 squamous cell carcinoma of the cervix. "SCC cervix, stage IB3"
12 Apr to 21 May 2021 - Chemoradiation with external beam radiotherapy to the pelvis, followed by brachytherapy. Her periods ceased in April 2021. "pelvic EBRT 45 Gy"
14 Sep 2021 - Blood tests confirmed ovarian failure (hypogonadism) after radiotherapy. "FSH raised, oestradiol low"
16 Jan 2023 - Bilateral ureteric strictures from radiation fibrosis were diagnosed, with an estimated glomerular filtration rate of 12. It was 11 on 20 Apr 2023 and haemodialysis began on 8 May 2023. "eGFR 12, bilateral hydronephrosis"
23 Aug 2023 - Gynaecological oncology review recorded vaginal stenosis and dryness, severe pain on any attempted penetration and that intercourse was no longer possible. "vaginal stenosis, intercourse not possible"

Symptoms

At the onset of the condition in February 2009 the veteran had pain with intercourse on her return from Afghanistan, against a background of painful periods, cramping pelvic pain and persistent low back and pelvic pain since the rocket attack of October 2008. By 25 Mar 2009 the pain had become deep, positional dyspareunia with bleeding after intercourse. After laparoscopy in June 2009 the pain returned, and from August 2009 she also had reduced sexual interest and arousal.

After the cauda equina injury of May 2019 she lost genital sensation and the ability to reach orgasm. Since pelvic radiotherapy in 2021 she has had vaginal stenosis and dryness, and penetration is not possible. Her current symptoms are absent sexual interest, absent arousal and orgasm, and severe pain on any attempted penetration, with marked distress.

Imaging

4 Mar 2009 - Pelvic ultrasound: "Normal uterus and ovaries. No free fluid."
4 May 2019 - MRI lumbar spine: "Large central L5/S1 disc extrusion with severe compression of the cauda equina."
2 Mar 2021 - MRI pelvis: "4.5 cm cervical mass confined to the cervix. No parametrial extension."
16 Jan 2023 - Renal ultrasound: "Bilateral hydronephrosis with distal ureteric narrowing."

Onset Date

The most likely date of onset of this condition is 14 Feb 2009. At that time the veteran was a Private posted to a brigade headquarters, two weeks after returning from Afghanistan on 28 Jan 2009. She still had low back and pelvic pain from the rocket attack of 14 Oct 2008 and was taking Microgynon 30 for painful periods. Intercourse with her partner that weekend was painful, which she reported to the medical officer on 19 Feb 2009, and the pain developed into the deep positional dyspareunia diagnosed on 25 Mar 2009.

This date is appropriate because it falls after her pre-deployment medical of June 2008, which recorded no sexual or pelvic complaint, and before her first presentation for the condition on 19 Feb 2009, during uninterrupted full-time service. The 6 months before onset run from 14 Aug 2008 to 14 Feb 2009 and contain the concussion of 14 Oct 2008. The 3 months of persistent pain before onset run from 14 Nov 2008 to 14 Feb 2009, throughout which her back and pelvic pain continued. The 5 years before onset run from 14 Feb 2004 to 14 Feb 2009 and contain the rocket attack. The 1 year before onset runs from 14 Feb 2008 to 14 Feb 2009 and contains the workplace bullying and isolation of the deployment. For the worsening factors, the 3 months before the worsening of 19 Aug 2009 run from 19 May 2009 and contain the laparoscopy of 11 Jun 2009, and the 30 days before it run from 20 Jul 2009 and contain the start of sertraline on 27 Jul 2009. The 1 year before the worsening of 17 Jun 2020 runs from 17 Jun 2019 and contains both her inability to exercise and the partner violence. The cancer, radiotherapy, menopause, hypogonadism and renal failure all precede the worsening of 23 Aug 2023.

1. What is the formal diagnosis of the condition claimed above?

The diagnosis is female sexual dysfunction, comprising genito-pelvic pain/penetration dysfunction (deep dyspareunia, later with vaginal stenosis), female sexual interest/arousal dysfunction and female orgasmic dysfunction. The DVA Statements of Principles that apply are the Statements of Principles concerning female sexual dysfunction, Reasonable Hypothesis No. 43 of 2026 and Balance of Probabilities No. 44 of 2026. The ICD-10 codes are N94.1 (Dyspareunia), F52.22 (Female sexual arousal disorder) and F52.31 (Female orgasmic disorder).

Female sexual dysfunction is a clinically significant problem in the female sexual response cycle that prevents a woman from experiencing satisfaction from sexual activity. It includes disorders of sexual interest and arousal, disorders of orgasm, and genito-pelvic pain/penetration disorder, which is persistent or recurrent pain in the vulva, vagina or pelvis during intercourse, difficulty with penetration, fear of pain, or tensing of the pelvic floor muscles. Deep dyspareunia is felt within the pelvis on deep penetration and usually has an organic pelvic cause such as endometriosis, adhesions, pelvic infection or chronic pelvic pain. Sexual interest, arousal and orgasm depend on intact pelvic nerves and blood supply, on ovarian hormones, and on psychological wellbeing, so they are impaired by spinal and pelvic nerve injury, by loss of oestrogen, by pelvic radiotherapy, by chronic pain and illness, by depression, anxiety and posttraumatic stress disorder, by trauma and abuse, and by medications such as antidepressants. Diagnosis is clinical, based on the history and pelvic examination. Management is directed at the underlying causes, together with pelvic floor physiotherapy, vaginal oestrogen and dilators, review of medication, and sexual and psychological counselling.

The Statement of Principles requires the problem to have persisted for at least 6 months. Pain with intercourse was recorded from 19 Feb 2009 to 19 Aug 2009 and at every later review of the condition, which meets the 6-month duration.

There is one diagnosis in this report with three components. The pain component began on 14 Feb 2009. The interest and arousal component was added from August 2009, the orgasmic component from May 2019, and the pain component became complete inability to tolerate penetration from 2021 to 2023. Each step followed a service-related injury, illness or treatment, as set out under question 4.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

Female sexual dysfunction: 14 Feb 2009. On 19 Feb 2009 she reported that intercourse the previous weekend had been painful [Service Medical Records.pdf, page 7], and on 25 Mar 2009 deep positional dyspareunia was recorded [Service Medical Records.pdf, page 8] [Specialist Reports.pdf, page 1].

When did the veteran first present to a health / medical provider for this condition?

19 Feb 2009

When was the condition confirmed / formally diagnosed?

25 Mar 2009

When did the veteran first present to you (or your practice) for this condition?

21 Sep 2026

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.

The diagnosis was made clinically by Army medical officers and specialists on the basis of the history and the findings on pelvic and neurological examination. On 19 Feb 2009 the medical officer recorded painful intercourse since her return from deployment [Service Medical Records.pdf, page 7]. On 25 Mar 2009 the medical officer recorded bleeding after intercourse and deep dyspareunia, with deep tenderness and cervical tenderness on vaginal examination, and the gynaecologist confirmed deep positional dyspareunia the same day [Service Medical Records.pdf, page 8] [Specialist Reports.pdf, page 1]. Pelvic ultrasound on 4 Mar 2009 was normal [Imaging.pdf, page 1], and laparoscopy on 11 Jun 2009 showed pelvic peritoneal adhesions and a cervical erosion, with no endometriosis [Specialist Reports.pdf, page 4].

On 19 Aug 2009 the gynaecologist recorded that intercourse was painful again with reduced interest and arousal [Specialist Reports.pdf, page 6]. On 17 Jun 2020 the rehabilitation physician recorded saddle numbness, loss of genital sensation and inability to reach orgasm after cauda equina syndrome, confirmed on MRI of 4 May 2019 [Specialist Reports.pdf, page 14] [Imaging.pdf, page 3]. On 23 Aug 2023 the gynaecological oncologist recorded vaginal stenosis on examination and that intercourse was no longer possible [Specialist Reports.pdf, page 22]. The persistence of the problem for more than 6 months, its effect on sexual satisfaction and the recorded distress confirm female sexual dysfunction as defined in the Statement of Principles.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

The veteran's female sexual dysfunction arose on 14 Feb 2009, two weeks after her return from operational service in Afghanistan, and was caused by the pelvic and genitourinary conditions, concussion, persistent pain and stressors of that deployment, on a background of serious harm suffered as a 17-year-old recruit. It was then worsened on three recorded occasions by further consequences of her service. Each factor in the 2026 Statements of Principles applies to clinical onset or to clinical worsening, so each factor is set out once below, under the event at which it is met. Every factor in both Statements of Principles is met.

Reasonable Hypothesis SOP No. 43 of 2026 - Causative Factors (met at the clinical onset, 14 Feb 2009)

9(1) having one of the following genitourinary conditions at the time of clinical onset or clinical worsening; (a) endometriosis; (b) interstitial cystitis/bladder pain syndrome; (c) Sjogren's syndrome involving the vagina; (d) urinary incontinence; (e) uterine adenomyosis; (f) uterine fibroids; (g) uterine prolapse; (h) other genitourinary condition of sufficient severity to warrant ongoing management by a medical practitioner. - MET

- Sub-paragraph (h) is met. At onset she had dysmenorrhoea, recurrent cramping pelvic pain and recurrent urinary tract infection, all of which arose and were treated during her deployment to Afghanistan from 2 Jul 2008 to 28 Jan 2009, with Microgynon 30, antibiotics and review at each sick parade. Limited hydration, limited toilet and sanitary facilities and body armour worn over the pelvis on operations contributed to them. They were under ongoing management by a medical practitioner at onset, and the pelvic adhesions found at laparoscopy four months later confirm an organic pelvic condition. Sub-paragraph (d), urinary incontinence, is also met for the worsening of 17 Jun 2020, when she had bladder dysfunction from cauda equina syndrome.

9(7) having a concussion in the 6 months immediately preceding the clinical onset or clinical worsening; - MET

- On 14 Oct 2008, in Afghanistan, she was thrown against a blast wall by a rocket strike, briefly lost consciousness and was diagnosed with concussion at the base medical facility. The 6 months before onset run from 14 Aug 2008 to 14 Feb 2009, so the concussion falls four months before onset. It occurred on operational service as a direct result of enemy action.

9(9) having persistent pain of at least 3 months, which is severe enough to interfere with daily living, at the time of clinical onset or clinical worsening; - MET

- Low back and pelvic pain began with the blast injury of 14 Oct 2008 and was still present at onset on 14 Feb 2009, four months later. It limited her sitting at her desk, lifting, wearing body armour and sleeping, and required regular analgesia, so it interfered with daily living. The pain was caused by an injury on operational service. Persistent pain was again present at the worsenings of 2020 and 2023, from her spinal injury and from radiation fibrosis.

9(14) experiencing a category 1A stressor in the 5 years immediately preceding clinical onset or clinical worsening; - MET

- The rocket attack of 14 Oct 2008 was a life-threatening event in which she was injured and believed she would be killed. That is a category 1A stressor. The 5 years before onset run from 14 Feb 2004 to 14 Feb 2009, and the attack falls four months before onset, on operational service.

9(15) having experienced as a child (under the age of 18) one of the following; (a) serious physical, emotional, or sexual harm; (b) neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing by adults with obligations to provide such necessities; before clinical onset or clinical worsening; - MET

- Sub-paragraph (a) is met. She enlisted on 17 Jan 2005 aged 17 and, during recruit training from January to April 2005, while still under 18, was repeatedly struck, threatened and humiliated by senior recruits and an instructor. Sub-paragraph (b) is also met, as she was deprived of sleep and meals as punishment by adults responsible for her welfare. The harm occurred in the course of her Army service, four years before onset, and was not documented at the time; the absence of a contemporaneous record does not mean it did not occur, and her later disclosure to an Army psychologist is consistent and credible.

9(19) experiencing a category 2 stressor in the 1 year immediately preceding clinical onset or clinical worsening; - MET

- From September 2008 to January 2009, while deployed, she was subjected to ongoing bullying and belittling by her immediate superior, reported to her chain of command in November 2008, and she was isolated from her family and partner for seven months. Ongoing disharmony and bullying in the workplace, and social isolation, are chronic negative life events of the kind described as a category 2 stressor. The 1 year before onset runs from 14 Feb 2008 to 14 Feb 2009 and contains the whole of this period, which occurred on operational service.

Reasonable Hypothesis SOP No. 43 of 2026 - Worsening Factors (met at the clinical worsenings of 19 Aug 2009, 17 Jun 2020 and 23 Aug 2023)

9(11) experiencing blunt or penetrating trauma to the vulva, vagina, perineum or pelvis, including surgical trauma and traumatic childbirth, in the 3 months immediately preceding clinical onset or clinical worsening; - MET

- On 11 Jun 2009 she underwent laparoscopy, division of pelvic adhesions and cervical cautery, which is surgical trauma to the pelvis. The 3 months before the worsening of 19 Aug 2009 run from 19 May 2009, so the surgery falls ten weeks before it. The surgery investigated pelvic pain that began on operational service and was arranged and paid for by the ADF. The blunt pelvic trauma of the blast on 14 Oct 2008 also preceded the onset.

9(13) having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: (a) alcohol use disorder; (b) anxiety disorder; (c) eating disorder; (d) depressive disorder; (e) obsessive-compulsive disorder; (f) panic disorder; (g) posttraumatic stress disorder; (h) schizophrenia; (i) substance use disorder; - MET

- Sub-paragraph (g) is met. Posttraumatic stress disorder arising from the rocket attack in Afghanistan was diagnosed by an Army psychiatrist on 27 Jul 2009 and was under active treatment at the worsening of 19 Aug 2009, when reduced sexual interest and arousal were first recorded. Avoidance, emotional numbing and hyperarousal directly impair sexual interest and arousal. The disorder was caused by operational service and remained present at the later worsenings.

9(17) taking a medication from the specified list, in the 30 days immediately preceding clinical onset or clinical worsening; (a) antiepileptics; (b) antipsychotics; (c) aromatase inhibitors; (d) irreversible monoamine oxidase inhibitors; (e) selective serotonin reuptake inhibitors; (f) serotonin and noradrenaline (norepinephrine) reuptake inhibitors; (g) tamoxifen; or (h) tricyclic antidepressants. - MET

- Sub-paragraph (e) is met. Sertraline, a selective serotonin reuptake inhibitor, was commenced on 27 Jul 2009 and taken daily. The 30 days before the worsening of 19 Aug 2009 run from 20 Jul 2009, so she was taking it throughout the three weeks before the worsening. It was prescribed by an Army psychiatrist for posttraumatic stress disorder caused by operational service, and reduced libido and arousal are recognised effects of this class. Sub-paragraph (a) is also met for the worsening of 17 Jun 2020, when she was taking pregabalin for neuropathic pain after cauda equina syndrome.

9(6) having one of the following neurological disorders at the time of clinical onset or clinical worsening; (a) cauda equina syndrome; (b) cerebrovascular accident; (c) moderate to severe traumatic brain injury; (d) multiple sclerosis; (e) Parkinson disease or secondary parkinsonism; (f) spinal cord injury. - MET

- Sub-paragraph (a) is met. Cauda equina syndrome from an L5/S1 disc prolapse occurred on 3 May 2019 while she was lifting stores on operational service in Iraq, and its residual saddle numbness and loss of genital sensation were present at the worsening of 17 Jun 2020. The sacral nerve roots carry genital sensation and the reflexes of arousal and orgasm, so their injury directly caused the loss of orgasm recorded that day.

9(16) inability to undertake any physical activity greater than 3 METs for at least the 1 year before clinical onset or clinical worsening; - MET

- From 3 May 2019 she could mobilise only short distances with a frame and could not walk at a normal pace, climb stairs or exercise, which is an inability to undertake activity greater than 3 METs. The 1 year before the worsening of 17 Jun 2020 runs from 17 Jun 2019, and the inability had by then lasted more than 13 months without a break. It resulted from the spinal injury sustained on operational service in Iraq.

9(10) having a Body Mass Index (BMI) of 30 or greater at the time of clinical onset or clinical worsening; - MET

- Her BMI was 23.5 at her pre-deployment medical in October 2018 and 31.4 when measured at the worsening of 17 Jun 2020. The weight gain followed 13 months of enforced inactivity after the spinal injury sustained in Iraq, together with pregabalin and sertraline, both prescribed for service-related conditions.

9(18) experiencing intimate partner violence in the 1 year immediately preceding clinical onset clinical onset or clinical worsening; - MET

- She was assaulted and threatened repeatedly by her partner from November 2019 to March 2020 and reported it to her medical officer and the unit welfare officer on 12 Mar 2020. The 1 year before the worsening of 17 Jun 2020 runs from 17 Jun 2019 and contains the whole of this period. The violence occurred in Defence housing, the partner was a serving member, and it began while she was dependent on him for care after the injury sustained on operational service, which is how it is related to her service.

9(3) having a haematological or solid organ cancer before clinical onset or clinical worsening; - MET

- Squamous cell carcinoma of the cervix, a solid organ cancer, was diagnosed on 9 Mar 2021, more than two years before the worsening of 23 Aug 2023. Her cervical screening fell due in December 2018, during her deployment to Iraq, where screening was not available, and was then not done during her evacuation, surgery and rehabilitation. The cancer was therefore found at stage IB3, when it required radiotherapy and not surgery alone. The delay in diagnosis is related to her operational service.

9(4) undergoing a course of radiotherapy for cancer, where the lower abdomen, pelvis or perineal region was in the field of radiation, before clinical onset or worsening; - MET

- From 12 Apr to 21 May 2021 she had external beam radiotherapy to the pelvis, followed by brachytherapy to the cervix and upper vagina, for cervical cancer. The pelvis and vagina were in the field. Radiotherapy caused the vaginal stenosis, dryness and loss of elasticity recorded at the worsening of 23 Aug 2023. It was needed because of the stage at which the cancer was found, as set out under factor 9(3).

9(12) having undergone menopause before clinical onset or clinical worsening; - MET

- Her final menstrual period was in April 2021, during pelvic radiotherapy, and she had been without periods for 12 months by April 2022, aged 34, which establishes menopause 16 months before the worsening of 23 Aug 2023. The menopause was caused by radiation to the ovaries during treatment provided and paid for by the ADF. Loss of oestrogen causes vaginal atrophy, dryness and reduced arousal.

9(5) having one of the following endocrine disorders at the time of clinical onset or clinical worsening; (a) adrenal insufficiency; (b) Cushing syndrome; (c) diabetes mellitus; (d) Hashimoto disease with hypothyroidism; (e) hyperprolactinaemia; (f) hyperthyroidism; (g) hypogonadism; (h) hypopituitarism; (i) hypothyroidism. - MET

- Sub-paragraph (g) is met. Hypogonadism from radiation-induced ovarian failure was confirmed on 14 Sep 2021 by a raised follicle stimulating hormone level and a low oestradiol level, and was present at the worsening of 23 Aug 2023. Ovarian hormones sustain sexual interest, arousal and lubrication. The hypogonadism is a consequence of the same service-related treatment.

9(2) having chronic renal failure at the time of clinical onset or clinical worsening as indicated by: (a) a glomerular filtration rate of less than 15 mL/min/1.73 m2 for a period of at least 3 months; or (b) undergoing chronic dialysis for renal failure. - MET

- Both sub-paragraphs are met. Her estimated glomerular filtration rate was 12 on 16 Jan 2023 and 11 on 20 Apr 2023, which is below 15 for more than 3 months, and she began chronic haemodialysis on 8 May 2023. Chronic renal failure was therefore present at the worsening of 23 Aug 2023. It resulted from bilateral ureteric strictures caused by pelvic radiotherapy, and so from the same service-related cancer and treatment. Uraemia, fatigue and the burden of dialysis reduce sexual interest and arousal.

9(8) having a severe, chronic medical condition at the time of clinical onset or clinical worsening; - MET

- At the worsening of 23 Aug 2023 she had dialysis-dependent renal failure, the late effects of treated cervical cancer and residual cauda equina syndrome. These substantially affected her social and occupational functioning and required management almost every day under the supervision of health practitioners, including haemodialysis three times a week. Each condition is related to her service for the reasons given above.

9(20) inability to obtain appropriate clinical management for female sexual dysfunction before clinical worsening. - MET

- When she first reported painful intercourse on 19 Feb 2009 it was attributed to tension and referral was deferred. After laparoscopy found no endometriosis, no pelvic floor physiotherapy, sexual counselling or review of her medication was offered, and when she reported at the worsening of 19 Aug 2009 that the pain had returned with loss of interest and arousal, again nothing was offered. No sexual rehabilitation was provided after cauda equina syndrome in 2019, and no vaginal dilator therapy or vaginal oestrogen was provided after radiotherapy in 2021. She was dependent on Defence health services throughout, twice while recovering from operational service, and the intimate nature of the symptom, which had to be raised with medical officers in her own unit, is a subjective barrier of the kind recognised in Brew v Repatriation Commission. Each worsening followed a period without appropriate clinical management.

Balance of Probabilities SOP No. 44 of 2026 - Causative Factors (met at the clinical onset, 14 Feb 2009)

The Balance of Probabilities factors are assessed on the same documented facts. Each is more probable than not on the records summarised in the timeline.

- Sub-paragraph (h) is met. The deployed medical officer's sick parade entries from August 2008 to January 2009 document dysmenorrhoea, recurrent pelvic pain and two urinary tract infections under continuing treatment, and Microgynon 30 was still being prescribed at onset on 14 Feb 2009. These are contemporaneous records of a genitourinary condition under ongoing medical management at onset, which arose during and was aggravated by her service.

9(8) having persistent pain of at least 3 months, which is severe enough to interfere with daily living, at the time of clinical onset or clinical worsening; - MET

- The records document low back and pelvic pain from the blast injury of 14 Oct 2008 at each review up to and beyond 14 Feb 2009, a period of four months, with regular analgesia and restrictions on lifting and sitting. The 3 months before onset, 14 Nov 2008 to 14 Feb 2009, are fully covered by documented pain from an injury sustained in service.

9(13) experiencing a category 1A stressor in the 5 years immediately preceding clinical onset or clinical worsening; - MET

- The rocket attack of 14 Oct 2008 is recorded in the base medical facility notes and in the unit incident report. She was injured in it and feared for her life, which is a category 1A stressor, and it occurred four months before onset, within the 5 years from 14 Feb 2004 to 14 Feb 2009.

9(14) having experienced as a child (under the age of 18) one of the following; (a) serious physical, emotional, or sexual harm; (b) neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing by adults with obligations to provide such necessities; before clinical onset or clinical worsening; - MET

- Her enlistment record confirms she was 17 throughout recruit training from January to April 2005. Her account of being struck, threatened, humiliated and deprived of sleep and meals was given to an Army psychologist in 2009 and repeated consistently to her psychiatrist. On that evidence it is more probable than not that she suffered serious physical and emotional harm as a child, in the course of her service and before onset.

Balance of Probabilities SOP No. 44 of 2026 - Worsening Factors (met at the clinical worsenings of 19 Aug 2009, 17 Jun 2020 and 23 Aug 2023)

9(10) experiencing blunt or penetrating trauma to the vulva, vagina, perineum or pelvis, including surgical trauma and traumatic childbirth, in the 3 months immediately preceding clinical onset or clinical worsening; - MET

- The operation record of 11 Jun 2009 documents laparoscopy, division of pelvic adhesions and cervical cautery. The worsening was recorded on 19 Aug 2009, ten weeks later and inside the 3 months that run from 19 May 2009. The surgery was arranged by her Army medical officer for a condition that arose in service.

9(12) having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: (a) alcohol use disorder; (b) eating disorder; (c) depressive disorder; (d) posttraumatic stress disorder; (e) schizophrenia; - MET

- Sub-paragraph (d) is met. Posttraumatic stress disorder was diagnosed by an Army psychiatrist on 27 Jul 2009 and required ongoing psychiatric review and medication, so it was clinically significant and present at the worsening of 19 Aug 2009. It is an accepted condition caused by her service.

9(16) taking a medication from the specified list, in the 30 days immediately preceding clinical onset or clinical worsening; (a) antiepileptics; (b) antipsychotics; (c) aromatase inhibitors; (d) irreversible monoamine oxidase inhibitors; (e) selective serotonin reuptake inhibitors; (f) serotonin and noradrenaline (norepinephrine) reuptake inhibitors; (g) tamoxifen; or (h) tricyclic antidepressants. - MET

- Sub-paragraph (e) is met. The prescribing record shows sertraline dispensed from 27 Jul 2009, within the 30 days from 20 Jul 2009 to the worsening of 19 Aug 2009. It was prescribed for a service-caused condition.

- Sub-paragraph (a) is met. Cauda equina syndrome is confirmed by the MRI of 4 May 2019 and the operation record of 5 May 2019, and its residual deficits are documented at the worsening of 17 Jun 2020. It was caused by lifting stores on duty.

9(15) inability to undertake any physical activity greater than 3 METs for at least the 1 year before clinical onset or clinical worsening; - MET

- Rehabilitation notes from May 2019 to June 2020 record mobility limited to short distances with a frame throughout, which covers the whole year from 17 Jun 2019 to the worsening of 17 Jun 2020. The inability resulted from the service injury.

9(9) having a Body Mass Index (BMI) of 30 or greater at the time of clinical onset or clinical worsening; - MET

- A BMI of 31.4 was measured and recorded on 17 Jun 2020, the date of the worsening. The weight gain followed enforced inactivity and medication for service-related conditions.

9(17) experiencing intimate partner violence in the 1 year immediately preceding clinical onset clinical onset or clinical worsening; - MET

- Her report of 12 Mar 2020 to her medical officer and the unit welfare officer documents repeated assaults and threats by her partner from November 2019, within the year from 17 Jun 2019 to the worsening of 17 Jun 2020. It occurred in Defence housing while she was dependent on a serving partner for care after her service injury.

9(3) having a haematological or solid organ cancer before clinical onset or clinical worsening; - MET

- Histology of 9 Mar 2021 confirms squamous cell carcinoma of the cervix, before the worsening of 23 Aug 2023. Screening that fell due in December 2018 was missed because of her deployment, evacuation and rehabilitation, which links the stage at diagnosis to her service.

9(4) undergoing a course of radiotherapy for cancer, where the lower abdomen, pelvis or perineal region was in the field of radiation, before clinical onset or worsening; - MET

- The radiation oncology summary documents pelvic external beam radiotherapy from 12 Apr to 21 May 2021 and brachytherapy, before the worsening of 23 Aug 2023.

9(11) having undergone menopause before clinical onset or clinical worsening; - MET

- Her final menstrual period was in April 2021, so menopause was established by April 2022, before the worsening of 23 Aug 2023. It was caused by pelvic radiotherapy.

- Sub-paragraph (g) is met. Hypogonadism was confirmed biochemically on 14 Sep 2021 and was present at the worsening of 23 Aug 2023.

- Pathology results of 16 Jan 2023 and 20 Apr 2023 show an estimated glomerular filtration rate of 12 and 11, and dialysis records show chronic haemodialysis from 8 May 2023. Both sub-paragraphs were met at the worsening of 23 Aug 2023.

9(7) having a severe, chronic medical condition at the time of clinical onset or clinical worsening; - MET

- At the worsening of 23 Aug 2023 she had dialysis-dependent renal failure and the late effects of cancer treatment and cauda equina syndrome, requiring almost daily supervised management and substantially limiting her social and occupational functioning.

9(18) inability to obtain appropriate clinical management for female sexual dysfunction before clinical worsening. - MET

- The records show deferred referral in February 2009 and no treatment directed at the sexual dysfunction before any of the three worsenings: no pelvic floor physiotherapy or counselling in 2009, no sexual rehabilitation after cauda equina syndrome in 2019, and no dilator therapy or vaginal oestrogen after radiotherapy in 2021. Recurrent presentations managed without investigation or treatment of the condition itself show an inability to obtain appropriate clinical management.

Service after the onset of the condition therefore aggravated, and contributed in a material degree to, the female sexual dysfunction. The worsening is measurable at each step: return of pain with new loss of interest and arousal in August 2009, loss of genital sensation and orgasm in June 2020, and vaginal stenosis with inability to have intercourse in August 2023.

The % contribution of the causes is 100% and significant

Sequelae

The female sexual dysfunction is a sequela of several conditions that arose from the veteran's service: the pelvic pain, dysmenorrhoea and pelvic adhesions treated from 2008 to 2009; posttraumatic stress disorder from the rocket attack of 14 Oct 2008; cauda equina syndrome from the lumbar disc prolapse of 3 May 2019; and cervical cancer with its treatment, which caused radiation-induced menopause, hypogonadism, vaginal stenosis and chronic renal failure. This report is to be read together with the reports on those conditions.

Unintended Consequence

The condition is in part an unintended consequence of medical treatment provided and paid for by the ADF, in three ways. The pain with intercourse returned within 3 months of the laparoscopy, division of adhesions and cervical cautery of 11 Jun 2009. Loss of sexual interest and arousal followed the sertraline commenced on 27 Jul 2009, and antidepressants of this class commonly reduce libido, arousal and orgasm. Pelvic radiotherapy from 12 Apr to 21 May 2021 caused ovarian failure, menopause and vaginal stenosis. Each treatment was appropriate, and each contributed to the condition as an unintended consequence.

Inability to Attain Appropriate Medical Management (for worsening)

MET. The veteran first reported painful intercourse on 19 Feb 2009, when it was attributed to tension and gynaecological review was deferred. After laparoscopy found no endometriosis, no treatment directed at the sexual dysfunction was offered, and her further presentation on 19 Aug 2009 was not investigated or treated. No sexual rehabilitation followed cauda equina syndrome in 2019, and no vaginal dilator therapy or vaginal oestrogen followed radiotherapy in 2021. More than fourteen years passed between the first presentation and the last recorded worsening without treatment of the condition itself. Recurrent presentations managed conservatively and not offered investigation are indicative of barriers to health care. The intimate nature of the symptom, which she had to raise with medical officers in her own workplace, and her history of abuse in training, are subjective barriers to seeking treatment of the kind the Full Federal Court recognised in Brew v Repatriation Commission. The inability to attain appropriate medical management contributed to each worsening.

5. Please provide a Health Summary and a medication / prescribing history.

-see attached report

References

14 Oct 2008, Deployed Medical Facility Record (blast injury, brief loss of consciousness, concussion, low back and pelvic bruising), Medical Officer, General Practice [Service Medical Records.pdf; page 3]
Aug 2008 to Jan 2009, Sick Parade Records (dysmenorrhoea, pelvic pain, urinary tract infections, Microgynon 30), Deployed Medical Officer, General Practice [Service Medical Records.pdf; pages 2-6]
19 Feb 2009, Outpatient Clinical Record (painful intercourse since return from deployment), Medical Officer, Barracks Health Centre, General Practice [Service Medical Records.pdf; page 7]
4 Mar 2009, Pelvic Ultrasound Report, Radiologist, Radiology [Imaging.pdf; page 1]
25 Mar 2009, Outpatient Clinical Record (bleeding after intercourse, deep dyspareunia, pelvic tenderness; referral), Medical Officer, Barracks Health Centre, General Practice [Service Medical Records.pdf; page 8]
25 Mar 2009, Specialist Report (deep positional dyspareunia, dysmenorrhoea), Gynaecologist, Obstetrics and Gynaecology [Specialist Reports.pdf; page 1]
11 Jun 2009, Operation Record (laparoscopy, division of adhesions, cervical cautery), Gynaecologist, Obstetrics and Gynaecology [Specialist Reports.pdf; page 4]
27 Jul 2009, Psychiatric Assessment (posttraumatic stress disorder; sertraline commenced; disclosure of abuse in recruit training), Psychiatrist, Psychiatry [Specialist Reports.pdf; page 5]
19 Aug 2009, Specialist Review (intercourse painful again; reduced interest and arousal), Gynaecologist, Obstetrics and Gynaecology [Specialist Reports.pdf; page 6]
4 May 2019, MRI Lumbar Spine Report, Radiologist, Radiology [Imaging.pdf; page 3]
5 May 2019, Operation Record (L5/S1 decompression for cauda equina syndrome), Neurosurgeon, Neurosurgery [Specialist Reports.pdf; page 11]
12 Mar 2020, Outpatient Clinical Record (report of intimate partner violence), Medical Officer, General Practice [Service Medical Records.pdf; page 41]
17 Jun 2020, Rehabilitation Review (saddle numbness, loss of genital sensation, anorgasmia, BMI 31.4, mobility with frame), Rehabilitation Physician, Rehabilitation Medicine [Specialist Reports.pdf; page 14]
9 Mar 2021, Histopathology Report (squamous cell carcinoma of the cervix), Pathologist, Pathology [Specialist Reports.pdf; page 17]
21 May 2021, Radiotherapy Treatment Summary (pelvic external beam radiotherapy and brachytherapy), Radiation Oncologist, Radiation Oncology [Specialist Reports.pdf; page 19]
14 Sep 2021, Pathology Report (raised FSH, low oestradiol), Pathologist, Pathology [Service Medical Records.pdf; page 52]
16 Jan 2023 and 20 Apr 2023, Pathology Reports and Renal Ultrasound (eGFR 12 and 11; bilateral hydronephrosis), Nephrologist, Nephrology [Specialist Reports.pdf; page 20] [Imaging.pdf; page 5]
23 Aug 2023, Specialist Review (vaginal stenosis, intercourse not possible), Gynaecological Oncologist, Gynaecological Oncology [Specialist Reports.pdf; page 22]

Need a Diagnostic Assessment like this written from your own medical record? A VHC Chart Review finds every claimable condition in your file, and each one is written up against its Statement of Principles. Fixed fee $600 + GST per stage — see all fees or book an appointment.

Female Sexual Dysfunction — DVA claim example