Statement of Principles concerning erectile dysfunction (Balance of Probabilities) (No. 73 of 2022)

The instrument rests on a small set of legal and medical concepts articulated in statute and in Schedule 1. Core concepts are: the clinical definition of erectile dysfunction used for adjudication, the balance of probabilities standard, relevant service, clinical onset and clinical worsening, enumerated predisposing and precipitating factors, and defined thresholds for exposures and clinical measurements.

Erectile dysfunction is defined for these purposes as persistent or recurrent inability to develop or maintain an erection adequate for sexual intercourse (s7(2)(a)). The definition explicitly includes both psychogenic and organic impotence and excludes transient failures from fatigue, situational anxiety, alcohol or drugs (s7(2)(b)-(c)). The instrument recognises the ICD‑10‑AM codes commonly assigned to the condition (s7(3)-(4)), but instructs that the statutory definitional paragraph governs meaning for claims (s7(2)).

The legal test is the balance of probabilities. The RMA states (as its evidential foundation) that "on the sound medical‑scientific evidence available" it is of the view that erectile dysfunction can be related to relevant service on that standard (s8). The instrument is therefore intended to be used by decision makers to determine causation on a preponderance standard, not beyond reasonable doubt.

Relevant service is defined in Schedule 1 and covers certain types of service under the VEA and MRCA (see Schedule 1 definition of relevant service). The interaction with the underlying entitlement statutes is set out in s5; the instrument applies to claims under the VEA s120B and MRCA s339.

Section 9 contains the substantive causal factors. It is organised as a list; at least one factor must exist to support a finding of connection. The factors include mental health disorders of a specified severity, a specified list of cardiovascular diseases, specified medical conditions (for example diabetes and cirrhosis), systemic sclerosis, specified endocrine and neurological disorders, a range of urological conditions that cause lower urinary tract symptoms if present for at least six months, specified infections, herpes zoster affecting a sacral dermatome, hypertension, chronic renal failure, Peyronie disease, ischaemic priapism of at least four hours, certain surgical operations within three months, traumatic and surgical injuries to neurological structures with permanent impairment within three months, blunt or penetrating trauma to genitals/perineum/pelvis within three months, burns or electrical injury within three months, a defined smoking exposure, therapeutic radiation where the penis/pelvis/perineal region was in the field within ten years, obesity as defined in Schedule 1, taking specified drugs at the time of onset, inability to undertake physical activity greater than 3 METs for at least five years, and inability to obtain appropriate clinical management (variously appearing for onset and/or worsening) (s9; Schedule 1).

Timing and causal role distinctions are central. Section 10 requires that any factor in section 9 be related to the person’s relevant service (s10(1)). Section 10(2) restricts the factors listed in subsections 9(23) to 9(45) so that they apply only to material contribution to, or aggravation of, erectile dysfunction where the condition was suffered or contracted before, or during, the person’s relevant service but did not arise out of that service. That provision creates two operational pathways: factors in 9(1)-9(22) can be used to establish connection where erectile dysfunction arises in relation to service; factors in 9(23)-9(45) are limited to post‑existing conditions that are materially contributed to or aggravated by service.

Schedule 1 supplies operational definitions and measurement thresholds. Examples: obesity is BMI of 30 or greater or waist circumference thresholds (Schedule 1); chronic renal failure comprises GFR under 15 mL/min/1.73 m2 for at least three months or need for renal replacement therapy or chronic dialysis (Schedule 1); one pack‑year is defined and converted into gram equivalents for other tobacco forms; MET is defined (Schedule 1).

Finally, the instrument contains a dynamic cross‑reference mechanism. If a factor in section 9 refers to a disease or injury that is the subject of another SoP, that other SoP applies as in force from time to time (s11). That makes the SoP interoperable but also introduces an administrative dependence on other SoPs for causal assessment.

The instrument affects several cohorts of actors within the veterans’ compensation and medical‑assessment ecosystem. Primary affected persons are claimants under the VEA and MRCA who have erectile dysfunction or whose death is said to have been contributed to by erectile dysfunction (s5, s7(5)). For those claimants the SoP defines what medical factors and exposures will be considered sufficient to establish a nexus between erectile dysfunction and relevant service on the balance of probabilities (s8-s10).

Decision makers and medical assessors are directly affected. The Repatriation Medical Authority sets the SoP (s3); the Department of Veterans’ Affairs (DVA) and MRCA decision makers will apply the SoP when assessing claims under the statutory sections indicated (s5). The instrument influences evidential standards and thresholds used in claim adjudication because it specifies timing, exposure quantities and clinical criteria. Where a factor refers to a condition that is the subject of another SoP, decision makers must apply that SoP as in force (s11), which affects how cross‑referenced conditions are treated.

Health practitioners and medical record custodians are affected in practice because claimants will need evidence to establish the factors listed. The Schedule sets objective measures that typically require documented clinical data. Examples are GFR or dialysis records for chronic renal failure (Schedule 1), weight and height for BMI (Schedule 1), documented waist circumference, documentation of surgical operations within specified windows, records of prescribed medicines and dates, and documentation of smoking history sufficient to calculate pack‑years (s9; Schedule 1). The MET requirement for inability to undertake activity greater than 3 METs for five years requires objective or longitudinal assessment of functional capacity.

Administrative entities that calculate entitlements, manage claims costings, or audit decisions will be affected indirectly because the SoP alters which claims are likely to be successful. The instrument expresses the RMA’s view that erectile dysfunction can be related to relevant service on the balance of probabilities (s8). Where claimants meet the enumerated factors, this will support findings of service connection; consequently agencies responsible for benefits under the VEA and MRCA will need to process such claims and potentially budget for outcomes. The instrument does not itself specify funding, but it interacts with the statutory entitlement regimes because it is the mechanism by which causation is assessed for those claims (s5).

Particular claimant subgroups are especially affected by the enumerated thresholds. For example, veterans with a documented 15 pack‑year smoking history who ceased within 20 years of clinical onset are captured by the smoking factor (s9(18), s9(40); Schedule 1). Veterans who underwent therapeutic radiation with the penis, pelvis or perineal region in the field within 10 years are captured by factors 9(19) and 9(41). People with pre‑existing erectile dysfunction who experienced clinical worsening may rely on the factors in subsections 9(23)-9(45), but only if the worsening was materially contributed to or aggravated by relevant service and the original condition was suffered or contracted before or during service but not arising out of it (s10(2)).

Finally, the instrument affects interactions between SoPs. Section 11 requires that where a factor in section 9 refers to an injury or disease covered by another SoP, that other SoP applies as in force from time to time. That affects claimants whose factors map to other SoPs, because those cross‑referenced SoPs may be updated independently; decisions will need to track current versions and apply them as operative.

This instrument does not directly create statutory duties in the criminal law sense, nor does it by itself confer monetary entitlements. Instead, it defines the framework that decision makers must follow when assessing causation for claims under specified provisions of the VEA and MRCA (s3, s5). The key operational duties and rights flow from that adjudicative role.

Duty to apply the SoP when relevant: Decision makers considering claims under VEA s120B or MRCA s339 are required to apply the relevant SoP as the authoritative statement of medical causation. The instrument itself is issued under statutory authority and the RMA’s stated role is to determine such SoPs for application in claims. While the instrument does not itself say "decision makers must do X", its purpose under subsection 196B(3) and its application provision (s5) create the practical duty on adjudicators to use it when determining claims under the specified statutory sections.

Right to a balance of probabilities assessment: The RMA frames the SoP on the balance of probabilities standard; it states that on sound medical‑scientific evidence it is of the view that erectile dysfunction can be related to relevant service on that standard (s8). Claimants therefore have the right, under the governing statutes, to have causation determined on that standard, and the SoP operationalises what factors will be accepted as meeting that standard.

Duty to show relation to service: Section 10(1) requires that any factor in section 9 must be related to the person’s relevant service. The SoP thereby places a procedural duty on claimants to connect the enumerated factor to their service. The instrument does not itself prescribe the form of evidence required to prove that relation, but the duty exists as a matter of the causal test.

Limits on aggravation presumption: Section 10(2) imposes a limit. Subsections 9(23) to 9(45) apply only where erectile dysfunction was suffered or contracted before or during relevant service and did not arise out of relevant service, and then only for material contribution to or aggravation. That constrains how the listed factors for "worsening" can be used. For practitioners this means a duty to establish timing and whether the condition arose out of service or pre‑existed service.

Cross‑SoP interaction duty: Section 11 requires that where a factor in section 9 refers to an injury or disease covered by another SoP, that other SoP applies in accordance with its terms as in force from time to time. This creates a duty on decision makers to identify cross‑references and to consult and apply those SoPs. Practically, this means decision makers must be aware of the current versions of other SoPs and how they frame causation for the referenced conditions.

Evidence thresholds and definitional obligations: Schedule 1 contains precise definitions and thresholds for many concepts used in the SoP. For example, obesity is defined by BMI or waist circumference; chronic renal failure is defined by GFR thresholds or dialysis; one pack‑year is defined with a gram equivalence (Schedule 1). The presence of these definitions imposes an evidential duty on claimants to provide records that meet these objective thresholds where those factors are relied upon.

No criminal or pecuniary penalty provision in the instrument: The SoP does not itself impose fines, imprisonment, or administrative penalties. It is an adjudicative medical standard instrument. The enforcement of entitlements or ramifications for incorrect claims will be governed by the VEA and MRCA and by administrative processes external to this SoP. Therefore the instrument’s rights and duties are procedural and evidentiary in the context of claims processing, not punitive in their own terms.

The Statement of Principles is an adjudicative tool; it does not prescribe direct penalties, fines or criminal sanctions. The instrument is made under the Repatriation Medical Authority’s statutory function, and its purpose is to provide a basis for medical causation decisions for claims under sections of the VEA and the MRCA (s3, s5, s8). Enforcement in the sense of penal sanctions is not a feature of the instrument text. Instead, the instrument will be used by administrative decision makers whose decisions may have legal consequences under the VEA and MRCA frameworks.

Practical enforcement mechanisms are therefore indirect and administrative. Decision makers will apply the SoP when determining whether erectile dysfunction or death from erectile dysfunction is connected with relevant service. If a claim is accepted on the basis of the SoP, the claimant will receive whatever entitlements are available under the governing statute , those entitlements and the enforcement mechanisms for benefit provision or withdrawal are set by the VEA and the MRCA, not by this instrument. Conversely, if a claim is rejected because none of the factors in section 9 is shown, or because the factor is not related to relevant service, the claimant may have access to internal review, merits review or judicial review processes available under the VEA and MRCA regimes; those procedural rights exist outside the text of this SoP.

Administrative compliance and evidentiary scrutiny are the primary enforcement risks for claimants. The SoP sets distinct objective thresholds for many factors (for example GFR thresholds for chronic renal failure, pack‑years for smoking, BMI and waist circumference criteria for obesity, timing windows for surgery, trauma and radiation) (Schedule 1; s9). Failure to meet or to document these thresholds will lead to a refusal of causation in practical terms. The instrument thereby creates a compliance burden: claimants must obtain and produce medical records, diagnostic test results, surgical and radiation records, medication histories, and functional capacity evidence to satisfy the listed criteria.

There is an enforcement implication for decision makers and for the RMA itself. Section 11 makes the application of other SoPs dynamic; decision makers must keep up to date with those instruments as they may change "from time to time" (s11). Administrative enforcement therefore requires processes to ensure the correct version of cross‑referenced SoPs is applied.

The SoP also creates potential for dispute about interpretation. Definitions in Schedule 1 contain precise thresholds but may still give rise to disagreements about whether the available evidence meets those thresholds in an individual case. The instrument does not supply dispute resolution mechanics; such mechanisms are provided in the VEA and MRCA frameworks. Therefore enforcement and penalties for false statements or fraudulent claims are matters routed through the separate statutory machinery rather than the SoP itself.

The instrument is expressly connected to the Veterans' Entitlements Act 1986 through the authority under which it is made (s3). It applies to claims under VEA s120B and MRCA s339 (s5). The SoP is not free‑standing law but an administrative medical standard that is used to determine causal connection for statutory claims. Its interaction with other laws is therefore mediated by the application provisions of those statutes; the instrument itself references the MRCA and the VEA as the statutory contexts in which it operates (Schedule 1 definitions and s5).

Section 11 provides a direct interaction mechanism with other Statements of Principles. If a factor in section 9 refers to an injury or disease covered by another SoP determined under subsection 196B(3) of the VEA, the other SoP applies in accordance with its terms as in force from time to time (s11). That cross‑reference means the ED SoP does not operate in isolation where conditions overlap. For instance, if a factor refers to diabetes mellitus and there is a separate SoP covering diabetes, the diabetes SoP will govern the assessment of that factor as currently promulgated. This creates a statutory chain between SoPs and requires decision makers to consult and apply the current versions of related SoPs.

The instrument also embeds medical coding reference to ICD‑10‑AM (s7(3)-(4)). The SoP notes that while erectile dysfunction commonly attracts the ICD‑10‑AM codes F52.2 or N48.4, the statutory meaning given in subsection 7(2) governs application. Nevertheless, the explicit reference to the ICD classification (including the specific edition and copyright owner) links the instrument to standard medical classification schemes and to any interpretation of disease identity that relies on those codes. It does not, however, make ICD coding decisive where the statutory textual definition is explicit.

Definitions in Schedule 1 reference clinical measurements and concepts that are commonly used in other statutes and guidelines. Examples include BMI, GFR, dialysis, and METs. Where other legislation or regulation uses these concepts, there will be conceptual overlap but the SoP’s specific numeric thresholds and definitions govern their use within claims for erectile dysfunction under the VEA and MRCA.

The instrument repeals a prior SoP (No.44 of 2013) (s4). That repeal alters the body of administrative medical standards that apply to erectile dysfunction claims, and requires decision makers to apply the new instrument prospectively from commencement (s2). Because s11 requires other SoPs to be applied as in force, the repeal and replacement mechanism can have ripple effects where the newly issued SoP changes how cross‑referenced conditions are treated.

The SoP interacts indirectly with evidentiary and procedural law because the causal findings it supports are used in statutory determinations that can be reviewed judicially. The instrument itself contains no procedural remedy text, but decisions that rely on or depart from the SoP may give rise to merits review or judicial review challenges under the administrative law framework applicable to decisions under the VEA and MRCA. The SoP may therefore feature as primary evidence of the RMA’s view of causation in any administrative or judicial review.

Finally, the SoP specifies application to death from erectile dysfunction where the death is from a terminal event or condition that was contributed to by erectile dysfunction (s7(5); Schedule 1 defines terminal event). That creates an intersection with death and bereavement provisions under the veterans’ compensation regimes, bringing the SoP into play where cause of death and contribution by erectile dysfunction is contested within the statutory compensation frameworks.

The instrument identifies its date and commencement and notes a repeal action. It is dated 24 June 2022 and commences on 25 July 2022 (s2; preamble and date). The instrument explicitly repeals the Statement of Principles concerning erectile dysfunction No. 44 of 2013 (Federal Register of Legislation No. F2013L01137) which had been made under subsections 196B(3) and (8) of the VEA (s4). No other historical amendments are recorded within the text supplied.

Because section 11 requires that factors referring to an injury or disease covered by another SoP be assessed in accordance with that other SoP "as in force from time to time", there is an implicit potential for amendment linkage. When other SoPs are amended, the ED SoP will operate in concert with the new terms of those instruments for cross‑referenced conditions. This instrument therefore forms part of a larger administrative network of SoPs that can be changed independently, with interactive effects.

The instrument’s commencement date is explicit. Any claims with clinical onsets or worsenings after commencement will be considered under this SoP where claimants apply under the VEA or MRCA provisions referenced (s2, s5). The instrument does not state transitional arrangements or savings for claims assessed under the repealed SoP. The absence of explicit transitional provisions in the instrument text means that adjudicators must refer to the governing statutes and administrative practice for guidance on transitional handling, including whether and how previously lodged or decided claims are to be treated; those matters are not set out in the SoP itself.

The Schedule contains definitions that cross‑refer to external resources, for example the ICD‑10‑AM Tenth Edition effective date of 1 July 2017 (s7(4)). Any future updates to the ICD classifications would be relevant only to the extent other instruments or decision makers incorporate them. The SoP explicitly anchors its ICD reference to a specific edition; unless the SoP is amended, decision makers are instructed to treat that edition as the referenced one for the purposes of the SoP (s7(4)).

No amendment process is described in the instrument itself beyond the statutory authority under which the RMA makes SoPs. The authority to amend or create SoPs derives from the VEA; future amendments would therefore proceed by the statutory process that governs the RMA’s determinations. The instrument does not itself provide a record of prior drafts, consultations, or explanatory memoranda; it is a final instrument containing the operative definitions and factors.

The text of this Statement of Principles contains no reference to any judicial decisions, litigation record, or challenge history. It names no cases and does not summarise any prior decisions in which the SoP or its predecessor was considered. The instrument does not claim to bind courts; rather, it states the Repatriation Medical Authority’s view of causal connection on the available medical scientific evidence (s8).

Because the SoP is an administrative instrument used in adjudication of benefits under the VEA and MRCA, it is conceivable that decisions applying the SoP could be subject to merits review or judicial review processes under the governing statutes. The SoP itself does not include or refer to any litigation outcomes, and the instrument does not record whether the prior SoP No.44 of 2013 was the subject of litigation. Any litigation history relevant to interpretation or judicial treatment of SoPs in general is therefore not present in the supplied text and cannot be asserted here.

Practitioners should therefore treat the SoP as an authoritative administrative statement of the RMA’s view, likely admissible and highly relevant in administrative decision making; however courts retain their oversight functions and may in particular cases scrutinise whether decision makers properly applied the SoP or whether a decision is otherwise legally defective. The SoP is evidence of the RMA’s medical view rather than an absolute rule of law; the instrument does not attempt to alter judicial standards of review or statutory interpretation under the VEA and MRCA.

If claimants or agencies anticipate litigation risks or disputes over interpretation, they must rely on the statutory review and appeal pathways in the VEA and MRCA, and seek court guidance on any contested interpretive issues. The instrument itself provides no litigation guidance, case law, or precedent analysis.

The instrument contains several technical features and timing rules that commonly trip up claimants, clinicians and decision makers if they are overlooked. Below are notable practical pitfalls, with direct references to the operative provisions.

1. Onset versus worsening distinction and its limits (s9; s10). The SoP separates factors applicable at clinical onset and at clinical worsening. Critically, subsections 9(23) to 9(45) apply only to material contribution to, or aggravation of, erectile dysfunction where the person’s erectile dysfunction was suffered or contracted before or during relevant service and did not arise out of relevant service (s10(2)). This means that many of the later‑listed factors, including inability to obtain appropriate clinical management (s9(45)), only operate for pre‑existing conditions and cannot be used to establish primary causation for erectile dysfunction that arose out of service.

2. Objective thresholds must be met and documented (Schedule 1). Several factors rely on specific numeric thresholds. Examples are: smoking at least 15 pack‑years with cessation window of 20 years for post‑cessation capture (s9(18), s9(40); Schedule 1); obesity defined as BMI≥30 or waist circumference thresholds (Schedule 1); chronic renal failure defined by GFR<15 mL/min/1.73 m2 for at least three months or need for renal replacement therapy (Schedule 1); ischaemic priapism defined by persistent erection with little or no arterial inflow and a continuous period of at least four hours before onset/worsening (s9(13), s9(35); Schedule 1). Absent documentation meeting these precise criteria, causation may be denied.

3. Smoking pack‑year conversion oddities (Schedule 1). The Schedule converts other tobacco forms into cigarette equivalents on a mass basis, treating 1 gram of tobacco as equal to one cigarette (Schedule 1 Note 1). This conversion produces counterintuitive equivalences for pipe tobacco and cigars, and could affect older or non‑standard tobacco use histories. Practitioners should ensure the smoking history is framed using the SoP’s definition to avoid miscalculation.

4. ICD reference is not determinative of the SoP definition (s7(3)-(4)). The SoP recognises ICD‑10‑AM codes but makes clear that the statutory textual definition in s7(2) governs. Do not rely on an ICD code alone; show that the clinical picture meets the statutory definition of persistent or recurrent inability to develop or maintain an erection adequate for sexual intercourse.

5. Cross‑SoP dependencies (s11). Where a section 9 factor refers to another injury or disease covered by a separate SoP, the other SoP applies as in force from time to time. This creates two practical issues. First, decision makers must identify cross‑references and apply the current version of the other SoP. Second, amendments to other SoPs may change the causal assessment for a listed factor without amendment to the ED SoP itself.

6. “Related to relevant service” remains a separate requirement (s10(1)). Even if one of the factors in s9 is present, it must be related to the person’s relevant service. The SoP does not remove the need to show association between the enumerated factor and that service. The instrument does not prescribe what evidence constitutes sufficient linkage; claimants should therefore assemble service records and contemporaneous medical evidence to show that relationship.

7. Inability to undertake activity >3 METs is a long‑term capacity measure (s9(22), s9(44); Schedule 1). The SoP requires incapacity for at least five years before onset or worsening. Proving a longitudinal functional limitation for that duration typically requires repeated clinical assessments or occupational health records; a single contemporary report is unlikely to suffice.

8. Timing windows for trauma, surgery, radiation and operations are strict (s9). Many physical precipitants require occurrence within three months before onset/worsening for trauma or surgery (s9(14)-(17), s9(36)-(39)), and radiation requires occurrence within ten years (s9(19), s9(41)). Claims relying on events outside these windows will not meet the factors as written.

9. The instrument does not specify evidentiary forms or procedural steps; decision makers may require additional proof. Because the SoP sets criteria but not evidentiary processes, there is potential for disputes about what records are sufficient. Where a factor requires specific tests, obtaining those tests promptly is critical.

10. The “inability to obtain appropriate clinical management” factor (s9(45)) is open to interpretive disagreement. The SoP lists this as a factor for clinical worsening; however it does not define the contours of what constitutes inability, what treatment would have been appropriate, or the reasons for the inability (for example, access, availability, refusal). Given this absence of specificity, claimants relying on s9(45) face potential contest about the standard of care and proof of attempts to obtain management.

In sum, the SoP’s apparent clarity can mask evidentiary and timing traps. Practitioners should map each element of a claim to the precise wording and definitions in s9, s10 and Schedule 1, and gather contemporaneous records that meet the numeric and temporal thresholds set out in the instrument.

For claimants, treating clinicians and advisers preparing or presenting claims under the VEA or MRCA, compliance means assembling and presenting evidence that demonstrates both the medical criteria in section 9 and the relationship of the relevant factor to the person’s relevant service (s9, s10). Below is a practical checklist organised by the common categories of factors in the SoP, with the evidentiary types that will most directly support the requisite findings.

1. Establish the clinical diagnosis of erectile dysfunction. Provide contemporaneous clinical notes documenting persistent or recurrent inability to develop or maintain an erection adequate for sexual intercourse, excluding transient causes such as situational anxiety, acute intoxication or fatigue (s7(2)). Where available, include urology assessments, sexual health clinic notes, specialist letters and any diagnostic testing used in practice. Do not rely solely on an ICD code; link the code to the statutory clinical definition (s7(2)-(4)).

2. Show timing: clinical onset or clinical worsening. Precisely determine the date of clinical onset and, where relevant, the date of clinical worsening. Many factors are explicitly tied to timing relative to onset or worsening (s9). Where the claim proceeds under subsections 9(23)-9(45), confirm that the erectile dysfunction was suffered or contracted before or during relevant service and did not arise out of relevant service, because those factors apply only to material contribution or aggravation in that context (s10(2)).

3. For mental health factors (s9(1), s9(23)): document diagnosis of a clinically significant disorder of mental health as specified in Schedule 1. Provide psychiatric or GP records showing ongoing management or a history consistent with conditions listed in Schedule 1 (bipolar disorder, cannabis use disorder, depressive disorder, schizophrenia and other persistent psychoses). Management need not have been actually provided, but the disorder must be of sufficient severity to warrant ongoing management (Schedule 1).

4. For cardiovascular diseases and medical conditions (s9(2), s9(24)-s9(25)): submit clinical records confirming the specific condition is in the specified lists, for example diagnoses of aortic aneurysm, peripheral artery disease, diabetes mellitus or cirrhosis of the liver. Link dates of diagnosis to the timing of onset/worsening.

5. For endocrine and neurological disorders (s9(5), s9(6), s9(27), s9(28)): provide specialist letters, test results (for example hormone assays for hypogonadism), neuroimaging, EMG, or neurological consult notes that document the specified disorders and the timing relative to onset/worsening.

6. For urological conditions causing lower urinary tract symptoms (s9(7), s9(29)): provide urology clinic notes demonstrating diagnosis and documenting that lower urinary tract symptoms were present for at least six months prior to clinical onset/worsening.

7. For infections specified (s9(8), s9(30)): provide serology or microbiology confirming chronic hepatitis B, HIV, HTLV‑1, or tuberculosis of the penis, with date references at or before onset/worsening.

8. For herpes zoster in sacral dermatomes (s9(9), s9(31)): include dermatology or GP notes that locate zoster to sacral dermatomes at the relevant time.

9. For hypertension and chronic renal failure (s9(10), s9(33)): provide blood pressure records and renal function tests. For chronic renal failure the Schedule requires GFR<15 for at least three months, or dialysis/transplant records; include those documents.

10. For Peyronie disease, priapism, burns and trauma (s9(12)-s9(13), s9(15)-s9(17), s9(35)-s9(39)): provide surgical notes, emergency department records, outpatient clinic letters, imaging and operative reports. Observe the look‑back windows: surgery or trauma must be within three months before onset/worsening for many of these factors (s9(14)-s9(17), s9(36)-s9(39)) and ischaemic priapism must be continuous for at least four hours before onset/worsening (s9(13), s9(35)).

11. For specified surgical operations (s9(14), s9(36)): provide operative reports for cystectomy, prostate surgery (excluding biopsy), resection of malignant neoplasm of the prostate or rectum, with dates within three months of onset/worsening as required.

12. For radiation exposure (s9(19), s9(41)): provide radiotherapy treatment records showing fields, dosimetry and dates. The instrument requires that the penis, pelvis or perineal region was in the field within ten years before onset/worsening.

13. For medications (s9(21), s9(43)): provide pharmacy dispensing records, prescription charts and specialist opinions showing the person was taking a drug on the specified list at the relevant time. The Schedule lists specific classes and medicines; ensure the exact medication is identified.

14. For smoking history (s9(18), s9(40)): calculate pack‑years according to the Schedule definition and document cessation dates if any. The Schedule sets out how to convert other tobacco types into cigarette equivalents; follow that method for consistency. If cessation occurred, ensure the clinical onset/worsening is within 20 years of cessation to meet the factor.

15. For obesity and waist circumference (s9(20), s9(42)): provide contemporaneous weight and height to calculate BMI or waist circumference measurements by a clinician. The Schedule describes BMI formula and waist thresholds.

16. For physical capacity measures (METs) (s9(22), s9(44); Schedule 1): obtain objective evidence of functional capacity, for example exercise testing, occupational health assessments, cardiopulmonary exercise tests or documented specialist evaluations. The SoP requires inability to undertake activity greater than 3 METs for at least five years before onset/worsening; longitudinal documentation is therefore necessary.

17. For inability to obtain appropriate clinical management (s9(45)): document attempts to obtain care, referrals, cancellations, service unavailability, waiting lists, or barriers that demonstrate inability and link those events temporally to the clinical worsening. Provide clinical opinions as to how appropriate management would have altered the course, if available.

18. Relate factors to relevant service (s10(1)). For each factor, assemble service records, deployment histories, accident reports, occupational health files and contemporaneous medical notes that connect the factor to the person’s relevant service. The SoP requires that factors be related to relevant service; the form of proof is not specified, so contemporaneous documents and nexus opinions from treating clinicians are advisable.

19. Cross‑referenced SoPs (s11). If a factor refers to another injury or disease covered by a different SoP, identify and comply with the requirements of that other SoP as in force. Collect the documents that would satisfy the cross‑referenced instrument.

20. Prepare medico‑legal and specialist opinions that explicitly address the SoP. Request that treating clinicians or independent specialists address the specific SoP factors, the timing, and the causal connection to service on the balance of probabilities. Opinions should refer to the SoP terminology and Schedule definitions where possible.

21. For decision makers: document the application of the SoP explicitly in the reasons for decision. State which subsection of section 9 is relied upon, the evidence that meets the Schedule thresholds, the relation to relevant service per s10(1), and, where applicable, the use of cross‑referenced SoPs under s11. Where a factor is not found, explain which part of the SoP’s criteria is missing.

22. Retain contemporaneous records when a diagnosis is first suspected. The instrument’s timing windows and duration thresholds reward contemporaneous evidence. Early documentation of symptoms, functional capacity, smoking habit, obesity measures, trauma details, surgical or radiation exposures will materially assist later claims.

Following the SoP’s definitions closely is critical. The instrument provides precise language and thresholds in s9 and Schedule 1; compliance is primarily documentary and medical. Practitioners should map each element required by the SoP onto the available clinical and service evidence, and where evidence is lacking, consider obtaining retrospective assessments, imaging, test results or specialist reviews that can support the required findings.