1108.50-1402.30-2206 Filed August 25, 1988 DAVID E. LINQUIST BEFORE THE IOWA INDUSTRIAL COMMISSIONER NANCY L. McCONNELL, Claimant, vs. File No. 773872 CITY OF CLIVE, A P P E A L Employer, D E C I S I O N and ARGONAUT INSURANCE COMPANIES, Insurance Carrier, Defendants. 1108.50 - 1402.30 Claimant was well advised on appeal to abandon her claim that her condition (Raynaud's phenomenon) was caused by the stress of her employment. The medical evidence indicated that the condition is idiopathic. 1108.50 - 1402.30 - 2206 Claimant alleged that employment stress of alleged sex discrimination and sexual harassment exacerbated her condition. medical opinions were that cold and cigarette smoking would also exacerbate her condition. Furthermore, temporary flareups of claimant's conditions occurred after she left her employment. Claimant did not prove that her employment aggravated her condition. BEFORE THE IOWA INDUSTRIAL COMMISSIONER _________________________________________________________________ NANCY L. McCONNELL, Claimant, File No. 773872 VS. CITY OF CLIVE, A R B I T R A T I 0 N Employer, D E C I S I 0 N and ARGONAUT INSURANCE COMPANIES, Insurance Carrier, Defendants. _________________________________________________________________ INTRODUCTION This is a proceeding in arbitration brought by Nancy McConnell against the City of Clive, Iowa, her former employer, and Argonaut Insurance Companies, the employer's insurance carrier. Claimant alleges that she sustained a compensable injury in the nature of a weakening of her immune system which has been manifested by Raynaud's phenomenon, leukoplakia, neurasthenia, dyspnea, chest pain, weakness, and painful limbs. McConnell alleges that her ailments are a result of stress in her employment with the City of Clive which arose from being victimized by sex discrimination and sexual harassment perpetrated by the chief and other members of the Clive, Iowa police department. The issues presented for determination are whether claimant sustained an injury which arose out of and in the course of her employment; whether the alleged injury is a cause of disability, temporary or permanent; and determination of her entitlement to compensation for temporary or permanent disability. The parties stipulated that in the event of an award, McConnell's rate of compensation is $177.01 per week. The parties further stipulated in the prehearing report that medical expenses in the amount of $12,285.96 have been incurred, and that the providers of the care would testify that the fees charged were reasonable. it was stipulated that in the event of an award defendants are entitled to credit in the amount of $10,536.03 under section 85.38(2) for benefits provided under a nonoccupational group plan. The case was heard in Des Moines, Iowa, on December 9, 1986 and was fully submitted upon conclusion of the hearing. The record in this proceeding consists of testimony from Nancy McConnell, Honorable Allen Danielson, Dennis Diddy, Janice Rodriguez, Janet Hicks, Gary Walker, Jerry Miller, and Gilbert Dean Dymond. The record also contains joint exhibits 1 through 9, claimant's exhibits 10 and 11, and defendants, exhibits A, B, C, Dr E. and I. STATEMENT OF THE CASE The following is only a summary of pertinent evidence necessary for deciding the issues in this case. All evidence received at hearing was considered when making this decision even though it may not be specifically referred to herein. McConnell claims that her physical ailments developed or were aggravated by stress in her employment. She alleges that the stress arose from being victimized by sex discrimination and sexual harassment perpetrated by the chief and other members of the Clive, Iowa, Police Department. The events and practices of which she testified are adequately summarized in claimant's proposed findings of fact filed January 12, 1987. They include the following: 1. In 1977, Claimant Nancy McConnell began working for the Police Department, City of Clive, Iowa, as a night-time Dispatcher. (Tr. p. 28). 2. At the time of employment by the Clive Police Department (Clive), Ms. McConnell enjoyed good health. (Tr. p. 76). 3. After she began to work for Clive, Ms. McConnell was subjected to various job related situations which caused her to feel stress. 4. In 1978 Ms. McConnell applied for a patrol person position with Clive, but was forced to withdraw her name from consideration by her Supervisor, Dean Dymond, Clive's Chief of Police. (Tr. pp. 30 ,349). 5. Mr. Dymond admitted that he had felt that women should not be police officers, and Ms. McConnell recalled that he had said that women should be at home having babies - "spreading her legs for some nice guy instead of out there working." (Tr. pp. 32-3, 347-8 ) . 6. As a result of the withdrawal of her name from consideration as a patrol person, Ms. McConnell was promoted to a daytime dispatch position, which included the responsibility of serving as secretary to the Chief of Police. This was the preferred dispatch position. (Tr. pp. 33-4, 368). 7. Thereafter, and up to the date that she became ill on the job, Ms. McConnell was subjected to a variety of crude and sexist jokes and comments by Mr. Dymond and other employees of Clive, inclusive of the following: a). Mr. Dymond suggested that Ms. McConnell engage in sexual intercourse with him as had his previous secretary, whom he married, by asking Ms. McConnell if she "wouldn't like to have little Dymonds". (Tr. p. 37-8). b). Mr. Dymond told Ms. McConnell that the way to determine whether a woman is pregnant is to see if her nipples are pink, and asked Ms. McConnell to check her nipples. (Tr. p. 41). McCONNELL V. CITY OF CLIVE Page 3 c). On occasion when Ms. McConnell would wear a dress that was not banded at the waist, Mr. Dymond would ask if she was pregnant, and how she had gotten that way. d). During the years 1981, '82, and '83, Mr. Dymond told Ms. McConnell that he would play with the penis of his young son. (Tr. pp. 40-1, 378-9). e). Mr. Dymond told Ms. McConnell that when he was intimate with his wife he would pinch her tit and call her a whore. (Tr. p. 49). f). In 1982, '83, and '84, Mr. Dymond would tell Ms. McConnell about the sex life of his young daughters. (Tr. pp. 52-3, 377). g). Mr. Dymond would regularly ask Ms. McConnell if she had engaged in sexual intercourse the previous night when she would arrive at work looking tired. (Tr. pp. 39-40, 54, 311, 1. 8). h). When Ms. McConnell's dog became pregnant, Mr. Dymond suggested that her boyfriend had impregnated her dog. (Tr. pp. 54-5, 270, 373). i). Mr. Dymond would follow Ms. McConnell to the bathroom and talk to her through the door while she used the facility. Ms. McConnell found this to be degrading. (Tr. p. 51). j). When Ms. McConnell wore a dress that was not banded at the waist, Mr. Dymond asked if she was pregnant. (Tr. pp. 56-7). k). Mr. Dymond would occasionally suggest that Ms. McConnell was a prostitute by asking her how much money she had made the previous night working the streets. (Tr. p. 200). 8. Ms. McConnell objected to being subjected to these sexist comments and expressed that opposition to Mr. Dymond, but he took no action to correct the situation. In fact, Mr. Dymond encouraged his employees to tell jokes, including racists and sexist jokes. (Tr. pp. 43, 341-4). Mr. Dymond was the highest ranking employee in the department, and Ms. McConnell had no one else to complain to. (Tr . pp. 43, 221) . 9. During a performance evaluation in 1982 or '83, Mr. Dymond told Ms. McConnell that she would be a more fun person if she would just participate in the joking like other employees. (Tr. pp. 58-9, 31 2, 3 66 ) . 10. Ms. McConnell occasionally told jokes, but objected to jokes and comments that contained sexual McCONNELL V. CITY OF CLIVE Page 4 content as they made her feel uncomfortable, and found some of them to be plain humiliating and degrading. (Tr. p. 79, 1. 15; p. 202). 11. Because of her objection to the sexist treatment that she received, Ms. McConnell was denied a salary increase comparable to other employees of Clive, and was denied the opportunity to participate in training opportunities and the opportunity to represent the police department in collective bargaining activities. (Tr. pp. 59-60, 242, 367-8). 12. Ms. McConnell was subjected to other sexist acts, including physical contact. 13. On one occasion, in 1984, Mr. Dymond hit Ms. McConnell on her buttocks with a ticket book. (Tr. pp. 43, 356). 14. On one occasion, in 1983, Officer Dennis Diddy accosted Ms. McConnell in the hallway near Mr. Dymond's office, tore her clothing and simulated a sex act. (Tr. pp. 46, 218, 230). 15. Ms. McConnell did not consent to these acts, and protested to Mr. Dymond, but he took no corrective action. 16. On June 20, 1984, Ms. McConnell arrived late for work. She was observed by the City Manager, Gary Lago, who reported her tardiness to Mr. Dymond. Mr. Dymond required Ms. McConnell to complete a time slip for this incident. (Tr. pp. 65-6, 323). 17. Ms. McConnell had been both absent and late for work on other occasions, but these were excused absences. (Tr. p. 64). 18. On the same date, Ms. McConnell telephoned the office of the City Manager to inquire about job benefits, and upon learning that the City Manager had taken the afternoon off, jokingly asked his secretary if he had completed a time slip. (Tr. p. 66). 19. Several days later, on June 26, 1986, Mr. Dymond suspended Ms. McConnell for one day for demeaning the City Manager. (Tr. p. 67). 20. A male employee, Gary Walker, had told a crude joke to the City Manager, but he was not suspended for the action. (Tr. pp. 67-8; 266). 21. On one occasion Ms. McConnell advised Mr. Dymond that state investigators had advised her that her name had come up during the investigation of a prostitution ring, but that confidential personnel information was revealed to other employees by Mr. Dymond. It was subsequently established that Ms. McCONNELL V. CITY OF CLIVE Page 5 McConnell's telephone number had been obtained by accident. (Tr. pp. 198-9). 22. Ms. McConnell felt that she was being discriminated against on the basis of her sex and that she was being sexually harassed, and Ms. McConnell, a [sic] emotionally guarded and defensive individual (Dep. of Dr. Hines, p. 41, 1. 16), suffered stress from these acts. 23. "Stress" is caused by the perceptions of an individual that their expectations are being violated- that what they expect to happen in a particular situation, any situation irrespective of content, is not happening and that those expectations are violated with such intensity and such chronicity as to exceed the person's capability of coping with to that unusual or unexpected set of circumstances., It's basically a process of a person's coping skills being overwhelmed. (Dep. of Dr. Hines,p.45,1.1;Dep. of Dr. Rooney,pp.30-1). 25. The sexual harassment and sexual discrimination that Ms. McConnell was subjected to at the Clive Police Department violated her expectations and caused her to suffer stress. (Dep. of Dr. Hines, pp 45-47; Testimony of Nancy McConnell). 26. Stress may precipitate or exacerbate Raynaud's disease and heart disease, such as Prolapse Mitral Valve problems. (Dep. of Dr. Hines, p.48, 1. 8; Dep. of Dr. Rooney, p. 10). 27. During the winter of 1983, Ms. McConnell began to suffer physical pains, and her hands and feet would turn blue and purple. 28. Ms. McConnell also began to experience intermittent headaches on a regular basis. (Dep. of Dr. Ghrist,p.51,1.11). 29. Ms. McConnell began to suffer from such pain that she began to see a physician in May or 1984, and her illness was diagnosed as Raynaud's disease. (Dep. of Dr. Ghrist, p. 10, 1. 7). 30. Raynaud's disease is caused by an over activity of the autonomic, especially the sympathetic, nervous system. (Dep. of Dr. From, p. 63, 1.8; Dep. of Dr. Rooney, p. 17). 31. Raynaud's disease can be induced or aggravated by certain stressful events, either emotional or physical (Dep. of Dr. Swieskowski, p. 15, 11. 9-19; p. 26, 11. 16-20; pp. 37-38); Dep. of Dr. Rooney, p. 10; Deposition of Dr. Ghrist, p. 41; Dep. of Dr. From, p. 64, 1. 16; Exhibit 1, T3. 126, par. 2). 32. Sexual harassment and sexual discrimination McCONNELL V. CITY OF CLIVE Page 6 are the kinds of stimuli that may cause the autonomic nervous system to react (Dep. of Dr. From, p. 75, 1. 5; p. 77, 11. 14-25), and precipitate or exacerbate Raynaud's disease. (Dep. of Dr. Swieskowski, p. 17, 11. 11-21). 33. Ms. McConnell suffered from a severe case of Raynaud's disease. (Dep. of Dr. Swieskowski, p. 9, 11. 9-25). 34. The effects of a severe case of Raynaud's disease is to eliminate the ability of a person to use their hands for practically any purpose. (Dep. of Dr. Swieskowski, P. 10, 11. 5-12). It may also cause constant fatigue, ulceration of the extremities, and a variety of other debilitating conditions. (Dep. of Dr. Swieskowski, p. 15, 11. 3-8; Dep. of Dr. Rooney, pp. 13-4). 35. After receiving the notice of suspension from her job in June of 1984, Ms. McConnell obtained the services of legal counsel and served notice upon the City of Clive that she intended to pursue her legal rights by filing a civil rights complaint. (Tr. pp. 196, 197; 389-90). 36. After serving notice of intent to sue, Ms. McConnell was socially isolated in the workplace, and this caused her stress level to increase. (Tr. pp. 335, 390, 406, 410). 37. Ms. McConnell began to fear and dread going to work and she had nightmares about it. (Tr. p. 406). 38. Ms. McConnell found the work atmosphere to be so strained that she began to suffer from cyanosis, a condition associated with Raynaud's disease where the hands and feet becomes discolored. (Tr. p. 407-8; Dep. of Dr. Rooney, p. 9). 39. On September 3, 1984, Ms. McConnell appeared at work where she experienced a sudden onset of chest pain, vertigo, nausea, and weakness. (Tr.p.72;Exhibit 1, P.75). 40. She was taken to a hospital for emergency treatment where she was told by Dr. Ghrist that she had had an anxiety attack, and that she should go home and relax. (Tr. p. 73). 41. On September 4, 1984, Ms. McConnell still felt sick, and she began treatment with Dr. Brian Taylor, who felt that she had Raynaud's disease, and that she was suffering from "severe mental anguish she has been suffering with regard to the present employment situation." McCONNELL V. CITY OF CLIVE Page 7 42. Dr. Taylor and his assistant provided Ms. McConnell counseling for a stress problem growing out of her employment situation. (Tr. p. 194; Exhibit 1, pp. 66-7). 43. Dr. Taylor recommended that Ms. McConnell not return to her "aggravating job site" at that time. (Exhibit 1, p. 105). 44. Thereafter, Ms. McConnell saw and received treatment from a number of physicians, including her personal physician, Dr. David Swieskowski. (Tr. p.78-9). 45. Dr. Swieskowski confirmed the Raynaud's disease diagnosis, and found Ms. McConnell to be, disabled. He advised her that she shouldn't work at all because of the risk of sudden death associated with cardiac arrythmia.(Dep.of Dr.Swieskowski, p.33,11.10-14). 46. Dr. Swieskowski also found that Ms. McConnell was and continues to be disabled because of fatigue. (Dep. of Dr. Swieskowski, p. 34). 47. Ms. McConnell's illness was the result of her autonomics nervous system's response to job-related stress. (Dep. of Dr. Swieskowski, p. 38, 11. 15-22; Dep. of Dr. Rooney, pp. 21-2, 25-30, 32-34, 68). McCONNELL V. CITY OF CLIVE Page 8 48. Ms. McConnell continues to suffer dizziness, light-headedness, exhaustion and fatigue, swollen hands and feet, cramps, headaches, and chest pains. (Tr.p.81). 49. Ms. McConnell suffers from such exhausting fatigue that she has to have help with her house work.(Tr. p. 82). 50. Ms. McConnell suffers from a severe case of Raynuad's [sic] disease. (Dep. of Dr. Rooney, pp. 10-16; Dep. of Dr. Swieskowski, p. 9, 11. 9-25). 51. Ms. McConnell has not been released to return to work, her prognosis is poor, and she is not likely to get better. (Dep. of Dr. Swieskowski, p.39, 11. 6-19; Dep. of Dr. Rooney, pp. 70-1). 52. Dr. Swieskowski finds her to be completely disabled and unable to work (Dep. of Dr. Swieskowski, p. 40, 11. 8-24; Tr. p. 83, 11. 22-24), and Dr. Rooney did not find that she was able to return to her present job. (Dep. of Dr. Rooney, pp. 40, 60-1). 53. Ms. McConnell has not worked since September 3, 1984. The principal condition for which evidence was introduced was an ailment known as Raynaud's phenomenon (also referred to as Raynaud's syndrome or Raynaud's disease). Claimant also complained of extreme fatigue, headache and various other pains, discomfort, and general ill-being. The primary emphasis of the medical testimony in the record deals with Raynaud's phenomenon. Little emphasis is placed upon claimant's other complaints other than noting that she has the complaints. The consensus from the medical practitioners who have dealt with claimant is that she is afflicted by Raynaud's phenomenon. The medical treatise, the Merck Manual, 14th Edition, which was admitted into evidence as deposition exhibit 3 to exhibit 6 describes the ailment as follows: RAYNAUD'S PHENOMENON AND DISEASE Spasm of arterioles, especially in the digits (and occasionally other acra parts such as the nose and tongue), with intermittent pallor orcyanosis of the skin. Etiology Raynaud's phenomenon may be idiopathic (Raynaud's disease) or secondary to conditions such as connective tissue disorders (e.g., scleroderma, RA, SLE), neurogenic lesions (including the thoracic outlet syndromes), drug intoxications (ergot and methysergide), dysproteinemias, myxedema, primary pulmonary, hypertension, and trauma. Idiopathic McCONNELL V. CITY OF CLIVE Page 9 Raynaud's disease is most common in young women. Pathology and Pathophysiology Attacks of vasospasm of the digital arteries may last for minutes to hours, but are rarely severe enough to cause gross tissue loss.... Symptoms, Signs, and Diagnosis Intermittent attacks of blanching or cyanosis of the digits is precipitated by exposure to cold or by emotional upsets. The color changes may be triphasic, pallor, cyanosis, redness (reactive hyperemia); or biphasic: cyanosis, then reactive hyperemia. Normal color and sensation are restored by rewarming the hands. Color changes are not present proximal to the metacarpophalangeal joints and rarely involve the thumb. Pain is uncommon, but paresthesias consisting of numbness, tingling, or burning are frequent during the attack. Idiopathic Raynaud's disease is differentiated from secondary Raynaud's phenomenon by bilateral involvement and a history of symptoms for at least 2 yrs with no progression of the symptoms and no evidence of an underlying cause. In idiopathic Raynaud's disease, trophic skin changes and gangrene are either absent or present only in minimal cutaneous areas. The symptoms and signs of the underlying disease usually become manifest within 2 yr, occasionally longer.... Therapy of the secondary forms depends on recognition and treatment of the underlying disturbance. Mild cases of idiopathic Raynaud's disease may be controlled by protecting the body and extremities from cold and by using mild sedatives (e.g., phenobarbital 15 to 30 mg orally t.i.d. or q.i.d.). The patient must stop smoking since nicotine is a vasoconstrictor. Theodore W. Rooney, D.O., a rheumatologist, a field of medicine into which treatment of Raynaud's phenomenon falls, was in general agreement with the description contained in the Merck Manual and further stated: Well, Raynaud's Phenomena is the color changes that would occur in fingers or toes characterized by three phases of pallor, cyanosis, and ruber. In order to have a definite Raynaud's phenomena, you need to have two of those three phases. It's usually precipitated by exposure to cold but may come on spontaneously or may be precipitated by a variety of other factors. It is felt that the color changes seen in the fingers are used to make that diagnosis due to spasm of small little arteries within the digits, fingers, or toes. Q. Doctor, you have suggested that in terms of McCONNELL V. CITY OF CLIVE Page 10 causation exposure to cold may be one of the things that cause Raynaud's Phenomena, and then you suggested that a variety of other things might cause it. What are some of the other things that might cause it? A. Well, besides cold which is the most common precipitating factor, some people have a stress-related component whether it be emotional or physical stress that can precipitate their attacks. Some people get attacks without any underlying precipitating factors. Certain medications may precipitate attacks, including beta-blocker used to treat blood pressure or headaches, Ergotamine used to treat migraine headaches so certain medications can actually bring about an attack, and then obviously people that smoke or have anything else that is a stress to blood oxygen or whatever can be another so there is many factors that can potentially bring on episodes of this sort. (Ex. 2, pp. 10-11). The medical practitioners who have addressed the nature of Raynaud's phenomenon and its causes are in substantial agreement with Dr. Rooney and the Merck Manual. (David E. Swieskowski, M.D., exhibit 3A, pages 20, 21, 43, 44, and 48; Paul From, M.D., exhibit 5, pages 30 through 36, 62 through 64; John H. Ghrist, M.D., exhibit 6, pages 20, 21, 25, 26, 38-48.) Recognized sources of aggravation of Raynaud's phenomenon known to produce the attacks which characterize it are cold, nicotine, stress, or emotional disturbance and certain medications. Attacks are also known to occur without any identifiable precipitating factor. (Exhibit 2, pages 11, 25, 26, 41, 42, 68; exhibit 3A, pages 15-21; exhibit 34, pages 15-21, 37, 48; exhibit 6, pages 20, 21, and 26.) Dr. Rooney and Dr. Swieskowski have indicated that stress is an aggravating factor in McConnell's case. (Exhibit 2, pages 34 and 68; exhibit 3A, pages 15-19.) Their opinions are accepted as correct. As indicated by Dr. From, some medical authorities have suggested that stress may possibly cause the onset of Raynaud's phenomenon, but the existence of any such cause and effect relationship is only a theory and is not generally recognized in the medical community. (Exhibit 5, pages 63-64 and 101.) The greater weight of the evidence is that Raynaud's phenomenon is either etiopathic (no known cause) or is caused by some other underlying disease process. When the condition results from an underlying disease process, it is often progressive. McConnell's condition does not appear to have progressed during the past two years. It is possible that some as yet unidentified underlying disease process exists, but any such disease has not been clearly manifested. (Exhibit 2, pages 25, 42, 49, 67; exhibit 3A, pages 7, 11-13, 24, 31, 32, 43-45, 47 and 52; exhibit 5, page 89.) Raynaud's phenomenon is manifested by attacks of vasospasm where the skin discolors. The attacks are transient or temporary and in most cases, including the McConnell's, do not result in death or damage to the affected tissues. The evidence has not provided any indication that the source of the attack has any bearing on the effect or the severity of the attack. (Exhibit 2, McCONNELL V. CITY OF CLIVE Page 11 pages 44, 51, 71, and 72; exhibit 3A, pages 8, 42, and 49; exhibit 5, pages 81, 82, and 86; exhibit 6, pages 20, 21, 25, 26, and deposition exhibit 3.) Claimant's testimony relates an ongoing course of working in a setting filled with unwanted and offensive discussions and comments of a sexual nature. She also testified concerning denial of an opportunity to apply for a regular police officer position in 1978, being accosted and subjected to a simulated sex act at the police department in 1983, being hit on the buttocks with a ticket book in 1984, being denied salary increases comparable to that received by other employees, being denied the opportunity to participate in training opportunities, and being denied the opportunity to represent the dispatchers in collective bargaining activities. Claimant fixed the onset of her Raynaud's phenomenon symptoms as occurring in 1983. Her suspension and civil rights complaint were in June 1984. She thereafter apparently continued to work even though she was symptomatic until September 3, 1984 when she had an attack or spell while at work and was taken by ambulance to the hospital. Dr. Ghrist, who treated her for the Raynaud's phenomenon prior to the attack and who also treated her for the attack, opined that the attack was most likely pleuritic chest pain associated with an upper respiratory infection. He recognized the possibility that the attack may have been a stress-induced attack of some type. (Exhibit 6, pages 18, 56, and 57.) No definite diagnosis for the cause or type of the attack has been made by any other medical practitioner. Dr. From acknowledged the possibility that the September 3, 1984 attack could have resulted from something connected with claimant's work as did Dr. Rooney. (Exhibit 2, page 26; exhibit 5, pages 51 and 52.) Dr. Ghrist testified that things that happened in 1984 would neither cause nor exacerbate symptoms of the phenomenon at the present time. (Exhibit 6, pages 20-21.) Dr. From's statements are in substantial agreement with those from Dr. Ghrist. (Exhibit 5, page 52.) Dr. Swieskowski agreed that events from 1984 or earlier would not aggravate claimant's condition at the present time. (Exhibit 3A, page 42.) Dr. Rooney agreed that in claimant's case the exacerbation of claimant's condition due to stress would be transient unless the stimuli continued. (Exhibit 2, pages 51 and 69.) There is evidence in the record of a mitral valve prolapse, which evidence arises from Stuart Winston, M.D. He indicated that claimant's complaints of chest tightness could possibly be caused by anxiety. (Exhibit 1, page 7.) A further extensive cardiac workup performed under the direction of William S. Wheeler, M.D., a cardiologist, showed no evidence of mitral valve prolapse. (Exhibit 1, page 142.) Dr. Wheeler further indicated that claimant's Raynaud's phenomenon was not related to going to work, and that the supposed cardiac arrests which claimant had suffered were not caused by her work. He indicated that the records from the paramedics did not confirm claimant's statements regarding cardiac arrest. He felt that claimant's Raynaud's phenomenon would not prevent her from working. (Exhibit 1, page 142.) Brian T. Taylor, M.D., received a history from claimant which indicated that on two occasions she was pulseless and needed to be resuscitated. (Exhibit 1, page 26.) In September 1984, he indicated that claimant had a physiologic dysfunction which was apparently related to severe mental anguish resulting from her McCONNELL V. CITY OF CLIVE Page 12 employment. He indicated that the history involved an attempted rape by claimant's employer which was aborted by a fellow employee. (Exhibit 1, pages 105 and 115.) He felt that she was totally disabled. (Exhibit 1, page 104.) Dr. Rooney felt that claimant was not disabled from performing some types of gainful employment but that she should avoid exposure to cold temperatures. (Exhibit 2, pages 34-36.) Dr. Ghrist felt that claimant was not totally disabled. (Exhibit 1, page 128.) Dr. From found claimant to have no cardiac abnormalities and felt that she was capable of being employed. (Exhibit 1, page 36; exhibit 5, pages 48, 51, 52, and 85.) Dr. Swieskowski felt that claimant is currently completely disabled because she fatigues easily. (Exhibit 3A, page 40.) APPLICABLE LAW AND ANALYSIS It is assumed, without deciding, that the events of sexual harassment and sex discrimination of which claimant complained are true. In a workers' compensation case, the burden of proof that an injury which arose out of and in the course of employment occurred rests upon the claimant. McDowell v. Town of Clarksville, 241 N.W.2d 904 (Iowa 1976). The injury must both arise out of and be in the course of the employment. Crowe v. DeSoto Consol. Sch. Dist., 246 Iowa 402, 68 N.W.2d 63 (1955) and cases cited at pp. 405-406 of the McCONNELL V. CITY OF CLIVE Page 13 Iowa Report. See also Sister Mary Benedict v. St. Mary's Corp., 255 Iowa 847, 124 N.W.2d 548 (1963) and Hansen v. State of Iowa, 249 Iowa 1147, 91 N.W.2d 555 (1958). The words "out of" refer to the cause or source of the injury. Crowe, 246 Iowa 402, 68 N.W.2d 63. The claimant has the burden of proving by a preponderance of the evidence that the injury of September 3, 1984 is causally related to the disability on which she now bases her claim. Bodish v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965). Lindahl v. L. 0. Boggs, 236 Iowa 296, 18 N.W.2d 607 (1945). A possibility is i sufficient; a probability is necessary. Burt v. John Deere Waterloo Tractor Works, 247 Iowa 691, 73 N.W.2d 732 (1955). The question of causal connection is essentially within the domain of expert testimony. Bradshaw v. Iowa Methodist. Hospital, 251 Iowa 375, 101 N.W.2d 167 (1960). However, expert medical evidence must be considered with all other evidence introduced bearing on the causal connection. Burt, 247 Iowa 691, 73 N.W.2d 732. The opinion of experts need not be couched in definite, positive or unequivocal language. Sondag v.Ferris Hardware, 220 N.W.2d 903 (Iowa 1974). However, the expert opinion may be accepted or rejected, in whole or in part, by the trier of fact. Id. at 907. Further, the weight to be given to such an opinion is for the finder of fact, and that may be affected by the completeness of the premise given the expert and other surrounding circumstances. Bodish, 257 Iowa 516, 133 N.W.2d 867. See also Musselman v. Central Telephone Co., 261 Iowa 352, 154 N.W.2d 128 (1967). Our supreme court has stated many times that a claimant may recover for a work connected aggravation of a preexisting condition. Almquist v. Shenandoah Nurseries, 218 Iowa 724, 254 N.W. 35 (1934). See also Auxier v. Woodward State Hosp. Sch., 266 N.W.2d 139 (Iowa 1978); Gosek v. Garmer and Stiles Co., 158 N.W.2d 731 (Iowa 1968); Barz v. Oler, 257 Iowa 508, 133 N.W.2d 704 (1965 ); Olson v. Goodyear Service Stores, 255 Iowa 1112, 125 N.W.2d 251 (1963) Yeager v. Firestone Tire & Rubber Co., 253 Iowa 369, 112 N.W.2d 299 (1961); Ziegler v. United States Gypsum Co., 252 Iowa 613, 106 N.W.2d 591 (1960). When an aggravation occurs in the performance of an employer's work and a causal connection is established, claimant may recover to the extent of the impairment. Ziegler, 252 Iowa 613, 620, 106 N.W.2d 591, 595 (1960). The Iowa Supreme Court cites, apparently with approval, the C.J.S. statement that the aggravation should be material if it is to be compensable. Yeager, 253 Iowa 369, 112 N.W.2d 299; 100 C.J.S. Workmen's Compensation 555(17)a. The pivotal issue in this case is proximate cause. A cause is proximate if it is a substantial factor in bringing about the results; it need not be the only cause. Blacksmith v. All-American, Inc., 290 N.W.2d 348, 354 (Iowa 1980). Expert testimony that a condition could possibly be related to a claimant's employment, although insufficient alone to support a finding of causal connection, could be coupled with nonexpert McCONNELL V. CITY OF CLIVE Page 14 testimony to show causation and be sufficient to s sustain an award. Giere v. Aase Haugen Homes, Inc., 259 Iowa 1065, 146 N.W.2d 911, 915 (1966). Such evidence does not, however, compel an award as a matter of law. Anderson v. Oscar Mayer & Co., 217 N.w.2d 531, 536 (Iowa 1974). The Merck Manual indicates that Raynaud's phenomenon may be idiopathic or secondary to some other underlying disease. The idiopathic form is indicated to be most common in young women. No underlying disease has been identified in claimant. The greater weight of the evidence is that McConnell's affliction with Raynaud's phenomenon is idiopathic. Even if the condition were due to some underlying disease, there is no evidence in the record which shows claimant to have contracted any such disease as a result of her employment. The theory that stress may induce (rather than merely aggravate) the Raynaud's phenomenon is only a theory and, under the current state of the medical knowledge as reflected in the record, does not carry with it the probability (as opposed to mere possibility) necessary to support an award. Injuries arising out of risks or conditions personal to the claimant do not arise out of the employment unless the employment contributes to the risk or aggravates the injury. 1 Larson Workmen's Compensation Law, section 12.00. The crucial issue in this case is, therefore, what caused Nancy McConnell to be afflicted with Raynaud's phenomenon. That question is unanswerable. The condition is generally considered to be idiopathic and the greater weight of the evidence in this case is consistent with the generally accepted view. As a young woman, claimant is in the group most commonly afflicted by the condition, her history of smoking is a definite known aggravator of the condition. Claimant had stress from many sources. It is not necessary for the employer to prove that the condition is not work related, to the contrary, the burden rests on the claimant to prove that it is probable (more likely than not) that the condition is work related. The evidence in this case fails to establish that it is more likely than not that something in claimant's work at the Clive Police Department was a substantial factor in causing her to become afflicted with Raynaud's phenomenon. It is important to distinguish between a person being afflicted by Raynaud's phenomenon and the occurrence of the attacks which characterize the phenomenon. The greater weight of the evidence from the physicians in this case is that the attacks are transitory and generally cause no permanent harm to the individual. Factors which produce the onset of the attacks have been medically identified and are generally recognized. Claimant appears to fit the normal recognized pattern in this regard. A person afflicted with Raynaud's phenomenon, she reacts to stress, cold, and nicotine. She has been away from the employment setting since 1984, but her condition has not shown any substantial change since that time. Claimant has been a relatively heavy smoker throughout most of the time material to this case. That alone could be the most substantial aggravation of her condition. It would explain the lack of apparent improvement since claimant's employment ended. If claimant's complaints of sexual harassment and sex discrimination are true, it is certainly likely that those events, and any other events which emotionally disturbed her, would have also induced attacks. McCONNELL V. CITY OF CLIVE Page 15 The record fails to include evidence, however, that the onset of attacks Produced disability from performing the normal duties of her employment. The greater weight of the evidence fails to show that she was ever physically unable to perform the duties of her employment due to vasosoasm attacks. Claimant was evaluated by Todd Hines, Ph.D., who found her to have no abnormal psychological condition.(Exhibit1,pages 22 and 23.) FINDINGS OF FACT On September 3, 1984, Nancy McConnell was employee as a secretary and dispatcher for the Clive, Iowa, Police Department. Nancy McConnell is afflicted with a condition known as Raynaud's phenomenon. Raynaud's phenomenon is a condition which the greater weight of medical authority characterizes as being either idiopathic, with no definite known cause, or as secondary to some other underlying disease. The idioioathic form is most common in young women. Claimant has not been diagnosed as having any underlying disease which would produce her Raynaud's phenomenon. The evidence in this case indicates that claimant's Raynaud's phenomenon is idiopathic in nature, and the reason why she is afflicted with the ailment is unknown. The evidence in this case fails to show that it is more likely than not that anything connected with claimant's employment was a substantial factor in producing the Raynaud's phenomenon with which she is afflicted, or any of her other symptoms even if it is assumed that her complaints of stress resulting from sexual harassment and sex discrimination are true. During the time claimant was employed by the Clive, Iowa, Police Department she had attacks of the type which are characteristic of persons with Raynaud's phenomenon. The attacks were precipitated by her use of nicotine, stress and the other factors known to produce the attacks. The evidence fails to show that the attacks which occurred made claimant unable to perform the duties of her employment at any time. The evidence further fails to show that suffering the attacks in any way produced any change, acceleration or lighting up of the Raynaud's phenomenon beyond the time that the attack continued. The evidence fails to show that it is probable, as opposed to merely possible, that claimant's current physical condition is in any way a result of anything that occurred during her term of employment with the Clive, Iowa, Police Department. No findings are made with regard to whether or not the incidents of sexual harassment or sex discrimination of which claimant complains actually occurred. McCONNELL V. CITY OF CLIVE Page 16 The evidence fails to show that anything connected with claimant's employment was a substantial factor in producing the attack which claimant sustained while at work on September 3, 1984, or the similar attack which she suffered later during the month of September 1984. The evidence fails to establish that claimant's employment was a substantial factor in bringing about any cardiac condition with which she is afflicted. The evidence fails to establish, by a preponderance of the evidence, that claimant is afflicted by a mitral valve prolapse or any other abnormal cardiac condition. The evidence fails to establish that claimant is afflicted by any abnormal psychological condition or disability. The evidence fails to establish that anything connected with claimant's employment was a substantial factor in bringing about any psychological condition with which claimant may be afflicted. CONCLUSIONS OF LAW Claimant has failed to prove by a preponderance of the evidence that her affliction with Raynaud's phenomenon was proximately caused by sex discrimination, sexual harassment, or any other occurrences connected with her employment with the City of Clive, Iowa. Claimant has failed to prove by a preponderance of the evidence that the Raynaud's phenomenon with which she is afflicted is the result of an injury which arose out of and in the course of her employment with the Clive, Iowa,'Police Department. Claimant has failed to prove by a preponderance of the evidence that she suffered any disability that was proximately caused in any manner by her employment with the Clive, Iowa, Police Department. Claimant has failed to establish, by a preponderance of the evidence, that she is entitled to receive any benefits available under chapters 85 or 85A of the Code of Iowa. ORDER IT IS THEREFORE ORDERED that claimant take nothing from this proceeding and her petition is dismissed on the merits with prejudice. IT IS FURTHER ORDERED that costs are assessed against claimant. McCONNELL V. CITY OF CLIVE Page 17 Signed and filed this 1st day of June, 1987. MICHAEL G. TRIER DEPUTY INDUSTRIAL COMMISSIONER Copies To: Mr. Thomas Mann, Jr. Attorney at Law 4921 Douglas Ave., Suite 4 Des Moines, Iowa 50310 Mr. Harry Dahl Attorney at Law 974 73rd St., Suite 16 Des Moines, Iowa 50312 1108.50; 1402.10; 1402.20; 1402.30; 2206; 2209 Filed 6-1-87 Michael G. Trier BEFORE THE IOWA INDUSTRIAL COMMISSIONER _________________________________________________________________ NANCY L. McCONNELL, Claimant, File No. 773872 VS. CITY OF CLIVE, A R B I T R A T I 0 N Employer, D E C I S I 0 N and ARGONAUT INSURANCE COMPANIES, Insurance Carrier, Defendants. _________________________________________________________________ 1108.50; 1402.10; 1402.20; 1402.30; 2206; 2209 Claimant, who is afflicted with Raynaud's phenomenon, alleged that her condition was either induced or aggravated by practices of sex discrimination and sexual harassment that occurred in her employment with the Clive Police Department. The medical evidence indicated that Raynaud's phenomenon is an idiopathic condition and that stress is not a recognized cause of the condition. The medical evidence further indicated that stress is known to precipitate attacks of vasospasm in individuals who are afflicted with Raynaud's phenomenon, but that such attacks are transitory and produce no permanent or lasting effects. No specific findings were made with regards as to whether or not claimant's complaints of sex discrimination and sexual harassment were true. (It was assumed, arguendo, that they were true for purposes of deciding the case.) It was nevertheless found that there was a lack of causal connection between the alleged stress and claimant's condition.