Statement of Principles concerning anal fissure (Reasonable Hypothesis) (No. 87 of 2019)

The SoP operates through a small set of tightly defined concepts, each of which channels how evidence and decision‑making must be approached. The primary concepts are: the meaning of "anal fissure" as used in the SoP (s 7(2)); the set of factors that will raise a reasonable hypothesis that an anal fissure is connected to relevant service (s 9); the temporal and causal relationship required between those factors and the claimant's relevant service (s 10); and inter‑SoP interaction where a listed factor refers to another injury or disease already covered by a separate SoP (s 11).

"Anal fissure" is defined by anatomy and aetiology, not by billing or diagnostic codes. The instrument states that while anal fissure is associated with certain ICD‑10‑AM codes, the operative meaning for the SoP is the textual definition in s 7(2). The SoP expressly excludes several anal conditions: anal inflammatory bowel disease, anal neoplasia and anal infections (s 7(2)). This means coding alone is insufficient; decision makers must apply the SoP definition when determining whether a claimant’s condition falls within the SoP.

The factors listed in s 9 are alternative springs for raising a reasonable hypothesis. Only one needs to be present. They are: (1) trauma to the anal area at the time of clinical onset, (2) prior infection with human immunodeficiency virus before clinical onset, (3) straining at stool due to constipation within two weeks before clinical onset, (4) treatment with isotretinoin at the time of clinical onset, and (5) inability to obtain appropriate clinical management for anal fissure. The SoP provides a definition of "trauma to the anal area" in the Schedule, and gives examples including childbirth, laceration by a foreign body, sexual assault and surgical procedure (Schedule 1).

"Relevant service" is defined in the Schedule as encompassing a number of statutory categories under the VEA and MRCA, including operational, peacekeeping, hazardous, British nuclear test defence service, warlike and non‑warlike service (Schedule 1). Section 10 requires that any factor relied on must be related to the relevant service rendered by the person. In addition, s 10(2) places a temporal and causal restriction on the application of factor 9(5): the inability to obtain appropriate clinical management applies only where the fissure was suffered or contracted before or during (but did not arise out of) the person's relevant service, and then only to material contribution to, or aggravation of, the anal fissure.

Section 11 addresses cross‑application of other SoPs. If a factor in s 9 refers to an injury or disease that is itself the subject of another SoP, the factors set out in that other SoP apply "in accordance with the terms of that Statement of Principles as in force from time to time" (s 11). That creates a modular linkage across SoPs where comorbidity or aetiology overlaps.

Finally, the instrument lists sample "terminal events" that count for death‑from‑anal‑fissure scenarios, such as pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function (Schedule 1). The SoP therefore contemplates both morbidity and mortality pathways, subject to the need to establish that the anal fissure contributed to the terminal event (s 7(5)).

This instrument affects three broad groups: claimants (veterans, members of Peacekeeping Forces, and members of the Forces covered by the VEA or MRCA), administrative decision makers who assess entitlement under the VEA and MRCA, and medical practitioners and experts who provide clinical records or expert opinions used in claims.

Claimants: The SoP applies to persons making claims to which s 120A of the VEA or s 338 of the MRCA applies (s 5). Those statutory references indicate that the SoP is relevant when a person seeks a service‑causation or service‑connection outcome for anal fissure or death from anal fissure. The instrument is therefore directly material to veterans and former or current members of the relevant forces who either present with an anal fissure or whose death is claimed to have been contributed to by an anal fissure. Relevant service is defined to include operational, peacekeeping, hazardous, British nuclear test defence service and MRCA warlike and non‑warlike service categories (Schedule 1). A claimant’s eligibility for an outcome under the VEA or MRCA will depend on whether a factor in s 9 exists and is related to the person's relevant service (s 10(1)).

Decision makers and the Repatriation Medical Authority: The instrument is made by the Repatriation Medical Authority under its statutory power (s 3) and supplies the medical‑scientific basis decision makers must use when considering whether a reasonable hypothesis exists linking the condition to service (s 8 and s 9). Administrative officers and tribunals that determine entitlement will rely on the SoP to frame evidentiary requirements and to assess whether the minimum legal threshold for a service link has been met. The SoP constrains how medical evidence is interpreted by specifying definitions and enumerating supporting factors.

Medical practitioners, hospitals and expert witnesses: The SoP creates demand for reliable medical records and expert opinion on the five listed factors and on whether a factor is "related to" the person’s relevant service (s 10(1)). Practitioners may be requested to document clinical onset dates, records of trauma (with the Schedule 1 examples such as childbirth or surgical procedure), HIV infection history, records of constipation or straining within two weeks prior to onset, isotretinoin treatment timing, and evidence concerning access to appropriate clinical management. For death claims, practitioners or pathologists may be asked to demonstrate that an anal fissure contributed to a terminal event (s 7(5), Schedule 1).

Indirectly affected parties: Private sector providers of expert reports and allied health professionals supply evidence to support claims and will face the evidentiary demands that follow from the SoP’s factors. The Departmental agencies processing claims will incur administrative costs in applying the SoP, including interpreting ambiguous concepts such as "inability to obtain appropriate clinical management" and establishing whether a factor is related to relevant service.

Who pays and who decides: Ultimately, the Commonwealth pays entitlements if claims are accepted under the VEA or MRCA. Decision makers in the statutory claims system apply the SoP when deciding whether to accept the causal link. The Repatriation Medical Authority decides the content of the SoP, within its statutory power (s 3). Claimants bear the immediate compliance costs of collecting evidence and obtaining medical reports. The Department and tribunal systems bear administrative costs of applying the SoP.

The SoP does not itself create duties in the punitive or criminal sense. Instead it prescribes the evidential and definitional scaffolding that rights‑bearing persons may rely upon when making claims under the VEA or MRCA, and that decision makers must obey when applying medical criteria in determinations.

Rights of claimants: A person who asserts that an anal fissure or death from an anal fissure is connected to relevant service has the right to have their claim assessed using the SoP as the medical‑scientific benchmark. The SoP sets the criterion that a "reasonable hypothesis" must be raised, and identifies the factors which, if established and shown to be related to relevant service, satisfy the minimum threshold for that hypothesis (s 9 and s 10(1)). Death claims also carry the right for the claimant to show that the anal fissure contributed to the terminal event or condition (s 7(5), Schedule 1). Where a factor in s 9 refers to another injury or disease covered by a separate SoP, the claimant benefits from the cross‑application established in s 11.

Obligations on decision makers: Decision makers processing claims under s 120A of the VEA or s 338 of the MRCA (s 5) must apply the SoP definitions, consider the enumerated factors in s 9, and ensure that any factor relied upon is related to the person's relevant service (s 10(1)). The Repatriation Medical Authority’s statement that it has sound medical‑scientific evidence (s 8) places an evidentiary starting point; decision makers must take the SoP’s content as the authoritative articulation of the medical links the Authority considers sound.

Evidential duties on medical witnesses and claimants: To satisfy the SoP, claimants must adduce evidence that at least one of the factors in s 9 existed and that it was related to the claimant’s relevant service (s 10(1)). For factor 9(5) (inability to obtain appropriate clinical management) an additional evidentiary and temporal limit exists: it applies only to material contribution or aggravation where the fissure was suffered or contracted before or during (but did not arise out of) the person’s relevant service (s 10(2)). Medical practitioners who provide reports or certifications will need to address these timing and causation constraints when giving evidence.

Interaction rights: Section 11 gives claimants and decision makers a right to rely on other SoPs where a factor in s 9 refers to an injury or disease that is already the subject of another SoP. That means a claimant whose theory of causation invokes, for example, an underlying disease addressed elsewhere will have that disease’s SoP criteria applied in accordance with its current terms (s 11).

Administrative limits and non‑creation of new legal remedies: The instrument does not create statutory entitlements by itself; it is applied within the entitlement frameworks of the VEA and MRCA. It does not create judicial review rights beyond those already available under administrative law or the underlying statutes. It also does not create obligations on private persons beyond the evidentiary duties they assume when participating in the claims process, for example providing records or expert evidence.

The SoP does not prescribe criminal penalties, civil sanctions, or administrative penalties. It is an evidentiary tool used by administrators to determine whether a claimant has raised a reasonable hypothesis connecting anal fissure or death from anal fissure with relevant service. Enforcement therefore operates through administrative decision‑making under the VEA and MRCA, not through enforcement mechanisms within the instrument itself.

Authority and administrative application: The SoP is made under the Repatriation Medical Authority’s statutory power (s 3). That power authorises the Authority to determine medical principles for the purposes of the VEA. Decision makers assessing claims under s 120A of the VEA or s 338 of the MRCA must apply the SoP when determining whether a claim meets the medical evidence threshold. The practical effect is that an application of the SoP that supports acceptance of causation may lead to administrative outcomes such as pension, compensation or rehabilitation entitlements under those statutes. Conversely, failure to satisfy the SoP will usually lead to rejection of the claim or a requirement for further evidence.

No express enforcement provisions or sanctions: Unlike a statute that prescribes fines or criminal offences for non‑compliance, this instrument sets criteria. There are no sections that authorise audits, penalties, or coercive measures against medical practitioners who supply evidence, nor are there enforcement mechanisms for claimants who fail to produce evidence. The "enforcement" is the adjudicative outcome of benefit decision‑making under the VEA and MRCA.

Administrative remedies and review paths remain in the parent statutes: Remedies against decisions that apply the SoP incorrectly will, if available, be those provided by the VEA, MRCA and general administrative law. The instrument itself does not modify those dispute resolution pathways. Practitioners must therefore consider the SoP as binding guidance for medical causation assessment within the statutory claims process, but any contest about a decision applying it will be carried out under the procedural framework of the underlying Acts.

Operational implication for departments and tribunals: The Department and tribunals will need to interpret and apply the SoP’s terms, including potentially contested concepts such as "inability to obtain appropriate clinical management" and "related to the relevant service" (s 10(1)). Those interpretive choices will determine whether a factor is accepted and therefore whether administrative entitlements flow. Such interpretive decisions, if disputed, will be amenable to internal review, merits review or judicial review in accordance with the statutory processes relevant to VEA and MRCA decisions.

This SoP functions within a legal ecosystem where the Veterans' Entitlements Act 1986 and the Military Rehabilitation and Compensation Act 2004 are the primary entitlement statutes. It is a statutory instrument made under subsection 196B(2) of the VEA and is explicitly designed to be applied to claims under s 120A of the VEA and s 338 of the MRCA (s 3 and s 5). The SoP therefore interacts with those Acts in three specific ways.

First, it provides the medical‑scientific standards decision makers must apply when determining whether a reasonable hypothesis of service connection exists for anal fissure or death from anal fissure. The Authority’s expression that "there is sound medical‑scientific evidence" is the Authority's basis for setting the SoP (s 8). Decision makers under the VEA and MRCA will take this as the authoritative medical framework, and apply it when operating the causation tests embedded in the underlying statutes.

Second, the SoP cross‑references other Statements of Principles. If a factor in s 9 refers to an injury or disease that is itself the subject of another SoP, the factors in that other SoP "apply in accordance with the terms of that Statement of Principles as in force from time to time" (s 11). That creates a statutory cross‑reference network. Where comorbidity or causation depends on conditions considered in another SoP, decision makers must harmonise the instruments by applying the relevant provisions of the other SoP as those rules currently stand.

Third, the SoP interacts with diagnostic coding systems by reference but retains statutory primacy for meaning. The instrument notes that while anal fissure attracts ICD‑10‑AM codes K60.0, K60.1 or K60.2, the operative meaning in the SoP is the textual definition in s 7(2) and not the code alone (s 7(3)-(4)). This means that codified hospital or administrative data may be informative, but the SoP requires application of its definition rather than reliance solely on ICD coding.

Limits on overlap and temporal boundaries: Section 10(2) imposes a specific interactional constraint between service timing and the factor concerning inability to obtain appropriate clinical management. It applies only to material contribution to, or aggravation of, anal fissure where the fissure was suffered or contracted before or during relevant service and "did not arise out of" that relevant service. This provision therefore allocates causal responsibility and sets temporal limits that must be reconciled with the causation rules in the VEA and MRCA.

No alteration of other statutory rights: The instrument does not alter other statutory rights or duties external to the VEA/MRCA claims framework. It does not change criminal law, immigration law, workers’ compensation or other legal regimes. Its effect is confined to informing administrative determinations under the specified sections of the VEA and MRCA. Any conflict between the SoP and the parent statutes would be resolved in favour of the statutes, since the SoP is an instrument made under the statutory power of the Repatriation Medical Authority.

This SoP contains a concise amendment record within the instrument itself. It was made and dated 23 August 2019 and is stated to commence on 23 September 2019 (s 2). Section 4 expressly repeals the previous Statement of Principles concerning anal fissure No. 73 of 2010 (Federal Register of Legislation No. F2010L02312). No other amendments, schedules of amendment, transitional provisions or saving clauses are included in the text. There are no subsequent amendment items in the instrument.

What is recorded therefore is a replacement event: the 2019 SoP superseded the 2010 instrument on commencement. The instrument does not record the substance of the changes between the repealed 2010 instrument and the 2019 instrument. It does not include amendment notes, consultation summaries, or an explanatory memorandum in the text provided here. The only legal history recorded is the repeal of the earlier numbered SoP and the new commencement date.

Because the instrument states that cross‑referenced SoPs apply "as in force from time to time" (s 11), it contemplates further change elsewhere. That means future amendments to other SoPs could alter how this instrument operates in practice where a factor in s 9 refers to another injury or disease. The instrument itself, however, contains no mechanism for modification except by replacement or amendment under the Authority’s statutory powers.

Users should therefore treat this instrument as current as of its commencement date and as the controlling SoP for anal fissure from 23 September 2019 until further amendment or repeal by the Repatriation Medical Authority. The instrument does not specify any transitional treatment of claims pending at commencement; practitioners must therefore identify whether a claim falls for assessment under the new SoP by reference to the application provisions in s 5 and the underlying statutory processing rules.

The instrument does not record any litigation history. It names no cases and cites none. There are no judicial decisions incorporated into, or referenced by, the text. As a Statement of Principles issued by the Repatriation Medical Authority under its statutory power, the SoP itself is an administrative instrument intended for use in decision making under the VEA and MRCA. Any litigation that challenges a decision which applies this SoP would be pursued under the review and appeals mechanisms available in those Acts and in administrative law more generally.

Because this instrument contains neither a recorded list of judicial interpretations nor cross‑references to case law, readers relying on it for decision making must seek external case law (if any) through other sources to determine how courts or tribunals have interpreted similar SoPs or applied the Repatriation Medical Authority’s instruments in contested cases. The instrument itself gives no guidance on how courts have treated its definitions, how strictly tribunals apply the listed factors, or how disputed concepts such as "inability to obtain appropriate clinical management" have been judicially construed.

In short, there is no litigation history contained in the instrument. Any statements about subsequent case law must be sourced from external legal research beyond the text of this SoP.

Several features of the SoP can produce unintended evidentiary or administrative consequences if not handled with care. Those features create practical risks around interpretation, proof thresholds and administrative discretion.

Definition controls over ICD coding: While the instrument acknowledges ICD‑10‑AM codes (K60.0, K60.1, K60.2), it makes clear that the operative meaning of "anal fissure" for the SoP is the textual definition in s 7(2) and not the code itself (s 7(3)-(4)). A "gotcha" here is treating hospital coding as conclusively determinative. An ICD code without evidence that the condition matches the s 7(2) definition will not, by itself, meet the SoP.

Exclusions in the definition: The textual definition explicitly excludes anal inflammatory bowel disease, anal neoplasia and anal infections (s 7(2)). Claims that rely on coded diagnoses which might include these conditions need careful differentiation. Practitioners should ensure that medical records separate an isolated anal fissure from conditions specifically excluded by the SoP.

The "at least one" threshold: Section 9 requires only one of the listed factors to exist to raise a reasonable hypothesis. This can lead to a surprisingly low evidentiary threshold in some cases. However, the factor relied upon must still be related to the person's relevant service (s 10(1)). A claimant may therefore secure acceptance by proving a single, well‑documented factor that is contemporaneous with service.

Factor 9(5) and its temporal/cause limitation: Factor 9(5) (inability to obtain appropriate clinical management) is limited by s 10(2) so that it applies only to material contribution to or aggravation of an anal fissure that was suffered or contracted before or during (but did not arise out of) relevant service. That is a technical constraint. A "gotcha" is attempting to use inability to obtain care to establish primary causation where the fissure arose out of service. The SoP bars that application by the terms of s 10(2).

Vague standard for "inability to obtain appropriate clinical management": The instrument provides no definition of "inability to obtain appropriate clinical management". That vagueness places interpretive weight on decision makers, medical experts and documentary evidence. The absence of a clear evidentiary standard creates discretion and therefore the risk of inconsistency in outcomes.

Requirement that the factor be "related to" relevant service: Section 10(1) requires the factor to be related to the relevant service. The SoP does not articulate the analytic test for "related to", for example whether it requires but‑for causation, material contribution, or merely temporal connection. Practitioners must therefore demonstrate service nexus through medical and service records; absence of explicit tests can produce contested interpretations.

Death claims hinge on contribution to terminal event: For death outcomes, the SoP treats anal fissure as including "death from a terminal event or condition that was contributed to by the person's anal fissure" (s 7(5)). The instrument supplies a non‑exhaustive list of terminal events (Schedule 1). The "gotcha" is that contributory involvement must be established; a mere temporal coincidence between fissure and death will not suffice unless medical evidence shows contribution.

Cross‑SoP complexity: Section 11 instructs decision makers to apply other SoPs where a factor in s 9 refers to another injury or disease. This can complicate proof if the other SoP has different criteria or thresholds. Practitioners must map the interaction carefully; failing to do so can result in incomplete or inconsistent reliance on linked medical principles.

Replacement of earlier SoP: The instrument repeals the 2010 SoP (s 4). Practitioners should not assume continuity in wording or thresholds. Claims in progress at the time of commencement may require attention to whether the new SoP applies, and to whether any evidentiary gaps arise from the change.

Narrow list of factors: The authoritative list in s 9 is finite. If a claimant's plausible service‑related pathway does not match one of the enumerated factors, the SoP does not provide an avenue to establish causation under this instrument. That may push such matters into contested factual inquiries or arguments about whether an unlisted factor falls within the ambit of an existing factor or a different SoP under s 11.

For claimants, advisers and medical experts, compliance means aligning evidence collection and presentation with the SoP’s textual definitions, factor list and the requirement that any factor be related to the person's relevant service (s 7, s 9, s 10).

1. Establish that the condition falls within the SoP definition. Use contemporaneous clinical notes to demonstrate an acquired linear longitudinal split in the anoderm of the distal anal canal. Explicitly rule out the excluded conditions listed in s 7(2): anal inflammatory bowel disease, anal neoplasia and anal infections. Do not rely purely on ICD coding; attach clinical descriptions that satisfy s 7(2) because s 7(3)-(4) makes the textual definition controlling.

2. Prove at least one of the s 9 factors, with dates and linkage to clinical onset. The SoP requires that the factor be present "before" or "at the time of clinical onset" depending on the factor. For trauma to the anal area (s 9(1)) assemble records such as emergency department notes, obstetric records (childbirth is an example in the Schedule), surgical records, or forensic reports where relevant. The Schedule defines "trauma to the anal area" and gives examples (Schedule 1). For HIV infection (s 9(2)) supply documented evidence of a positive HIV diagnosis predating clinical onset. For straining due to constipation (s 9(3)) provide GP or hospital notes, bowel habit records, or contemporaneous complaints indicating severe constipation within two weeks before the fissure onset. For isotretinoin exposure (s 9(4)) provide prescription records, specialist notes, or pharmacy dispensation data showing treatment at the time of clinical onset. For inability to obtain appropriate clinical management (s 9(5)) assemble evidence that attempts to obtain care were made but not provided, and crucially attend to the temporal limit in s 10(2): this factor only applies where the fissure was suffered or contracted before or during (but did not arise out of) relevant service.

3. Demonstrate the relationship to relevant service. Under s 10(1) any factor relied upon must be related to the relevant service as defined in the Schedule (operational, peacekeeping, hazardous, British nuclear test defence service, warlike and non‑warlike MRCA service). Evidence linking the factor to service may include service medical records, incident reports, unit medical entries, deployment schedules, incident timing aligned with service periods, and contemporaneous treatment logs. The SoP does not set out an analytic test for "related to", so claimants should present both medical opinion evidence and documentary service records to show the causal or material nexus between the factor and the relevant service.

4. For death claims, show contribution to the terminal event. If the claim relates to death, demonstrate that the anal fissure contributed to the terminal event listed in Schedule 1 or another proximate or ultimate cause. Obtain death certificates, coroner reports, hospital discharge summaries, pathology reports, and medical opinion evidence specifying how the fissure materially contributed to outcomes such as pneumonia or respiratory failure (s 7(5) and Schedule 1).

5. Where a s 9 factor references another SoP, comply with that SoP’s criteria. If the factor invokes a disease or injury that is itself covered by a separate SoP, follow the factors and evidentiary requirements in that other SoP as it is "in force from time to time" (s 11).

6. Anticipate interpretive gaps. The SoP leaves undefined concepts such as "inability to obtain appropriate clinical management" and "related to relevant service". Practical compliance therefore requires carefully drafted medical opinions that address how the facts meet these concepts. Expert reports should state the factual basis, explain the clinical reasoning, define what "appropriate clinical management" would have been in the circumstances, and articulate how the absence of that management materially contributed to or aggravated the condition if 9(5) is relied upon.

7. Document timing precisely. Many provisions hinge on temporal relationships: clinical onset, dates of treatment, timing of trauma, the two‑week window for constipation prior to onset, and whether the condition was contracted before, during or arising out of service (s 9(3), s 10(2)). Use dated contemporaneous records wherever possible; retrospective reconstructions are weaker.

8. Coordinate with expert witnesses and record custodians. Obtain supporting statements from treating clinicians, pharmacists, hospital medical records, obstetric records, or pathology services where applicable. Practitioners should request clear statements about whether a clinician believes a factor is related to service and the clinical basis for that belief.

9. Prepare for cross‑SoP evidence. If a claimed factor is linked to another SoP, gather the necessary documentary and expert material required by that instrument too, because s 11 mandates application of the other SoP’s factors.

10. Expect administrative scrutiny and potential need for review. Because the SoP leaves interpretive questions to decision makers and experts, be prepared to respond to requests for further information and to pursue internal merits review or tribunal review where a decision is contested. Maintain a clear chronological and factual narrative that maps service events, clinical onset, treatment efforts and any barriers to care.

Following these steps will align evidence and submissions with the SoP’s text, reduce interpretive friction, and present decision makers with the specific factual and medical materials the SoP requires.