Sexual dysfunction in male Iraq and Afghanistan war veterans: association with posttraumatic stress disorder and other combat-related mental health disorders: a population-based cohort study

Chronic psychological stress induces testicular oxidative stress affecting reproductive behavior in rats

The inhibitory effect of chronic psychological stress on reproductive behavior is widely recognized since long. However, the biological mechanisms underlying these effects, especially the cellular biology of the testicular cells, have not been fully investigated. This study aimed to investigate the effects of chronic psychological stress on rat reproductive behavior and its correlation with testicular cell damage and oxidative stress. The results showed that chronic psychological stress led to a decline in the preference scores of male rats for female rats and caused damage to the testicular tissue structure. Subcellular structures were particularly affected in the chronic psychological stress rats. Furthermore, the levels of MDA, NO, and NOS in testicular cells substantially increased under chronic psychological stress conditions. In conclusion, male reproductive behavioral disorders induced by chronic psychological stress are potentially linked to oxidative damage in testicular tissue.

Australian veteran sexual health: '…you are the first person I've spoken to about it.'

Background Sexual health and functioning outcomes have been shown to be poor among veterans due to factors associated with military service, as well as barriers to healthcare access. However, there is currently limited research attempting to assess the scope and extent of these issues in the Australian context. Methods Ten qualitative, semi-structured interviews were conducted with Australian professionals working within or adjacent to veteran sexual health and were analysed using inductive thematic analysis. Results Sexual health and functioning issues commonly develop among Australian veterans due to a variety of physical, psychological and social factors. Factors include mental ill-health, physical illness and injury, use of medication, and relationship strain. These contribute to physiological dysfunctions, poor sexual behaviours and difficulties in forming healthy, meaningful intimate relationships. Barriers, such as lack of awareness and understanding, stigma, and structural barriers, were suggested to interfere with healthcare access and worsen outcomes. Key informants recommended increasing provider training, research and military support, as well as de-stigmatising sexual health issues. Conclusions Veteran sexual health is not often on the radar of Australian health and research professionals. Our study is one of few studies in the Australian context, highlighting the need to conduct more research to better manage veteran sexual health and functioning needs.

Sexual Dysfunctions among Veterans with and without PTSD

BACKGROUND

Research on the relationship between posttraumatic stress disorder (PTSD) and sexual dysfunctions (SD) has clearly recognized the association among these conditions. The main objective of this research was to compare the levels of the overall and the level of certain domains of sexual functioning among veterans with and those without PTSD.

METHODS

Two hundred and fifty veterans with PTSD and 187 veterans without PTSD were included in the comparative study. The following assessments were conducted: LEC-5, PCL-5, ITQ, IIEF, PEDT, and MINI.

RESULTS

Veterans with PTSD had significantly higher levels of all types of SD in the PTSD group compared with the non-PTSD veterans. Veterans with PTSD more frequently experienced psychiatric and somatic comorbidities and use of medication that may contribute to the occurrence and severity of SD.

CONCLUSIONS

The present study emphasized that SDs are an important issue among patients with PTSD. The study comprehensively accounted for conditions that may contribute to the occurrence and severity of SD among veterans with PTSD. Future directions of the research that could further improve the healthcare of the patients were indicated.

Sexual compulsivity, erectile dysfunction, and suicidality among male survivors of military sexual violence

Although military sexual trauma (MST) is associated with an increased risk of suicide, suicide attempts, and suicidal ideation among service members and veterans, there is limited knowledge regarding the mechanisms of MST and suicidality among men. The current study examined whether MST was associated with sexual compulsivity and/or erectile dysfunction and if these, in turn, explained elevated suicidal thoughts and the likelihood of engaging in future suicidal behavior after accounting for mental health, military, and demographic characteristics. Service members and veterans who reported their gender as male (N = 508) were recruited via social media and completed online self-report measures assessing MST, erectile dysfunction, sexual compulsivity, suicidal ideation frequency, and the likelihood of engaging in future suicidal behavior. Path analysis was used to examine the study hypotheses. In total, 67 participants (13.2%) reported a history of MST; of these individuals, 27 (40.3%) reported suicidal ideation in the past 12 months, and 29 (43.9%) reported an increased likelihood of engaging in future suicidal behavior. MST was associated with increased sexual compulsivity, which, in turn, predicted more frequent suicidal ideation as well as a higher self-reported likelihood of engaging in future suicidal behavior. MST was associated with higher levels of erectile dysfunction, but erectile dysfunction was not associated with suicidal ideation in the adjusted model. Although the data were cross-sectional, precluding determinations of causality, the results support assessing and intervening with regard to sexual compulsivity to mitigate the risk for suicide-related outcomes among men who experience MST.

Male Sexual Health Related Complications Among Combat Veterans

INTRODUCTION

With improved armor and combat trauma care, more male service members in the 21st century are surviving devastating injuries to their genitourinary (GU) system. The impact of these injuries can have long lasting effect on their sexual function and fertility status.

OBJECTIVES

To review the current literature on sexual health-related complications and fertility implications among male service members sustaining combat related injuries.

METHODS

We performed a literature search that included male sexual health complications and combat injuries using PubMed and Google Scholar. We reviewed the impact of traumatic injuries to the pelvis and perineum on sexual function and fertility, and we also discuss sexual dysfunction from posttraumatic stress disorder (PTSD) and traumatic brain injuries (TBI).

RESULTS

Injuries sustained during combat are usually polytraumatic, especially in recent conflicts with improvised explosive devices. The majority of GU combat injuries involve the scrotum, testes, and penis resulting in lasting structural dysfunction. PTSD is associated with higher levels of erectile dysfunction, hypoactive sexual desire, and premature ejaculation. Overall, veterans diagnosed with PTSD had a higher risk of developing sexual dysfunction. Veterans with TBI experience sexual health complications, such as decreased libido, difficulties with arousal maintenance, and the ability to achieve orgasm. Combat related injuries can have significant fertility implications on service members as they typically serve in their peak fertility years.

CONCLUSIONS

Traumatic GU injuries, PTSD, TBI, and associated endocrine dysfunction can all contribute to sexual dysfunction among combat veterans. Given the complex nature of sexual dysfunction in this population, these patients are best managed by a multidisciplinary team. Castillo O, Chen IK, Amini E, et al. Male Sexual Health Related Complications Among Combat Veterans. Sex Med Rev 2022;XX:XXX-XXX.

The effect of combat exposure on sexually transmitted diseases

Traumatic exposures can affect beliefs and behaviors related to the spread of sexually transmitted diseases (STDs), a persistent public health problem. I leverage a natural experiment created by variation in US military deployment location assignments to estimate how combat exposure changes a surviving deployed male veteran's probability of acquiring a sexually transmitted disease. I analyze longitudinal data from 1994 to 2008 on 485 deployed veterans with information theoretic methods to reduce the sensitivity of estimates to small samples, an infrequently observed outcome, and highly correlated covariates. For veterans assigned to a combat zone, I estimate combat exposure results in a 5.4 percentage point increase in the probability of acquiring an STD. Additional estimations provide evidence suggesting risky behaviors involving substance use or multiple sexual partners may serve as pathways from combat exposure to STDs. My results are relevant to discussions regarding STD screening and care needs for trauma exposed individuals.

Sexual Health Assessment Is Vital to Whole Health Models of Care

Sexual health is the state of well-being regarding sexuality. Sexual health is highly valued and associated with overall health. Overall health and well-being are more than the absence of disease or dysfunction. Health care systems adopting whole health models of care need to incorporate a holistic assessment of sexual health. This includes assessing patients' sexual orientation and gender identity (SOGI). If health systems, including but not limited to the Veterans Health Administration (VHA), incorporate sexual health into whole health they could enhance preventive care, promote healthy sexual functioning, and optimize overall health and well-being. Assessing sexual health can give providers important information about a patient's health, well-being, and health goals. Sexual concerns or dysfunction may also signal undiagnosed health conditions. Additionally, collecting SOGI information as part of a sexual health assessment would allow providers to address problems that drive disparities for lesbian, gay, bisexual, transgender, queer, and similar minority (LGBTQ+) populations. Health care providers do not routinely assess sexual health in clinical practice. One barrier is a gap in communication between patients and providers. Providers cite beliefs that patients will bring up sexual concerns themselves or might be offended by discussing sexual health. Patients often report an expectation that providers will bring up sexual health and being comfortable discussing sexual health with their providers. Within the VHA, the lack of a sexual health template within the electronic health record (EHR) adds an additional barrier. The VHA's transition toward whole health and updates to its EHR provide unique opportunities to integrate sexual health assessment into routine care. We highlight system modifications to address this within the VHA. These examples may be helpful for other health care systems interested in moving toward whole health. It will be vital for health care systems integrating a whole health approach to develop both practical and educational interventions to address the communication gap. These interventions will need to target both providers and patients in health care systems that transition to a whole health model of care, not just the VHA. Both the communication gap between providers and patients, and the lack of support within some EHR systems for sexual health assessment are barriers to assessing sexual health in primary care clinics. Routine sexual health assessment would benefit patient well-being and present an opportunity to address health disparities for LGBTQ+ populations. Health care systems (ie, both the VHA and other systems) can overcome these barriers by implementing educational interventions and updating their EHRs and back-end data structures. VHA's expertise in developing and implementing health education interventions and EHR-based quality improvements may help inform interventions beyond VHA.

Sexual Health Problems among Service Men: The Influence of Posttraumatic Stress Disorder

Military operational stressors, such as combat exposure, may increase the risk of sexual health problems. This study examined factors associated with sexual health problems, and tested the mediating effect of probable posttraumatic stress disorder (PTSD) on the association between stressors (i.e., combat deployment and sexual assault) and sexual health problems among U.S. service men. Using multivariable logistic regression (n = 16,603) and Cox proportional hazards models (n = 15,330), we estimated the risk of self-reported sexual health difficulties and sexual dysfunction medical encounters, respectively. Mediation analyses examined the effect of probable PTSD as an intermediate factor between high combat deployment and sexual assault on sexual health problems. Approximately 9% endorsed sexual health difficulties and 8% had a sexual dysfunction. Risk factors for these sexual health problems included older age, lower education level, enlisted rank, disabling injury, certain medical conditions, and higher body mass index. Probable PTSD significantly mediated the associations between high combat with sexual health problems and sexual assault with sexual dysfunction. Additionally, high combat was directly associated with sexual health difficulties. These findings indicate a relationship between these stressors and sexual health problems which suggests that treatment options should be expanded, especially to include psychogenic sexual dysfunctions.

Interpersonal Trauma and Sexual Function and Satisfaction: The Mediating Role of Negative Affect Among Survivors of Military Sexual Trauma

Healthy sexual function among women service members/veterans (SM/Vs) is associated with higher quality of life, lower incidence and severity of mental health diagnoses, higher relationship satisfaction, and less frequent suicidal ideation. Although trauma exposure has been established as a predictor of poor sexual function and satisfaction in women SM/Vs, no study to date has examined whether specific trauma types, such as military sexual trauma (MST), increase risk for sexual issues. Moreover, the possible mechanisms of this association have not been explored. The current study examined whether posttraumatic stress disorder (PTSD) and depression symptom clusters mediated the association of trauma type and sexual function and satisfaction in 426 trauma-exposed women SM/Vs. Two hundred seventy participants (63.4%) identified MST as their index trauma. Path analyses demonstrated that MST was related to poorer sexual function and lower satisfaction relative to the other traumas (χ²[28, N = 426] = 43.3, p = 0.03, CFI = 1.00, TLI = 0.99, and RMSEA = 0.04), and this association was mediated by higher non-somatic depressive symptoms and PTSD symptom clusters of anhedonia and negative alterations in cognition and mood (NACM). Causality cannot be inferred due to the cross-sectional nature of the data. However, our findings suggest that interventions aimed at decreasing sexual issues among female SM/Vs with MST should target depressogenic symptoms, whether the origin is depression or PTSD. Longitudinal research exploring the etiological processes that contribute to sexual dysfunction among those with MST is needed.

Erectile dysfunction in patients with anxiety disorders: a systematic review

Men with anxiety disorders have been identified as high risk of developing erectile dysfunction (ED). The aim of this review is to define the prevalence and severity of ED in the male anxiety disorder population. A literature search of three electronic databases (PubMed, Embase and PsychINFO) and a grey literature registry was conducted. Inclusion criteria were studies that investigated adult males, documented diagnosis of anxiety disorders made by a qualified psychiatrist and use of a validated tool to diagnose ED such as International Index of Erectile Function or ICD-10/DSM-IV. The search yielded 1220 articles and 12 studies were selected. The anxiety disorders investigated were post-traumatic stress disorder, obsessive-compulsive disorder, social phobia/social anxiety disorder and panic disorder. We found that the median [IQR] prevalence of ED was 20.0 [5.1-41.2]% and the median [IQR] International Index of Erectile Function-5 scores were 17.62 [13.88-20.88], indicating a mild to moderate severity. Our review suggests a high prevalence of ED in the anxiety disorder population and ED may be more severe in this cohort, therefore advocating this is an important clinical topic. However, the evidence is limited due to the high heterogeneity between the studies and more research is required in this field.

The Association of Exposure to Military Sexual Trauma and Romantic Relationship Satisfaction Among Partnered Men Service Members/Veterans: The Influence of Compulsive Sexual Behavior

Civilian literature shows a strong, consistent association between exposure to sexual violence and poor romantic relationship satisfaction. The impact of sexual violence that occurred during military service, or military sexual trauma (MST), on romantic relationship satisfaction among partnered men service members/veterans (SM/Vs) is understudied. However, a recent study conducted in women observed that MST that involved an assault was associated with poorer relationship satisfaction through higher sexual dysfunction and lower sexual satisfaction. The current study extended the literature by examining sexual function as a mediator of the association of exposure to MST and romantic relationship satisfaction among partnered men SM/Vs (N = 499). Participants completed self-report measures of MST exposure, romantic relationship satisfaction, erectile dysfunction, and compulsive sexual behavior, as well as a demographic inventory. The average score on relationship satisfaction was in the distressed range. Sixty-four participants (12.83%) reported MST exposure. MST exposure was related to lower relationship satisfaction through higher compulsive sexual behavior. The model explained 16% of the variance in relationship satisfaction. The indirect effect of erectile dysfunction was nonsignificant. Current findings are consistent with research in women SM/Vs: the association of MST and romantic relationship satisfaction appears to be indirect, through the effects of sexual function. Couples' therapy may be most effective if it addresses sexual health concerns among men MST survivors, particularly engagement in compulsive sexual behaviors. Due to low endorsement of MST that involved assault, the impact of MST severity could not be examined.

Relationship Between Posttraumatic Stress Disorder and Sexual Difficulties: A Systematic Review of Veterans and Military Personnel

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with sexual difficulties but the nuances of this relationship remain elusive. Research has increased in recent years, most notably following publication of several reviews in 2015.

AIM

This systematic review examines the relationship between PTSD and sexual difficulties in veterans/military personnel.

METHODS

A systematic review was conducted using PRISMA guidelines in PsycINFO and PubMed databases for studies examining a diagnosis of PTSD or PTSD severity in relation to a range of sexual difficulties. Forty-three studies were identified that met inclusion and exclusion criteria for this review.

RESULTS

PTSD was associated with increased risk of experiencing at least one sexual difficulty. PTSD was most clearly associated with overall sexual function, sexual desire, sexual satisfaction, and sexual distress. Results were mixed for sexual arousal, orgasm function, erectile dysfunction, premature ejaculation, sexual pain, and frequency of sexual activity. PTSD symptom clusters of avoidance and negative alterations in cognition/mood were most commonly associated sexual difficulties. Few studies compared results by gender and trauma type.

CLINICAL IMPLICATIONS

Clinicians should inquire about sexual health in relation to PTSD symptoms and target avoidance and negative mood symptoms by incorporating sexual exposure assignments and sexual activation exercises when appropriate.

STRENGTHS & LIMITATIONS

This systematic review synthesizes an extensive literature that has grown substantially in the past 5 years and includes studies with low to moderate risk of bias. Limitations of the existing literature include challenges differentiating between PTSD and depression, inconsistent measurement of PTSD and trauma histories, inconsistent operationalization and measurement of sexual outcomes, and largely cross-sectional study designs.

CONCLUSION

PTSD is linked to a range of sexual outcomes. The current literature suggests that PTSD is associated with sexual difficulties related to both the sexual response cycle (ie, sexual desire) and one's emotional relationship to sexual activity (eg, sexual distress). More research is needed to increase confidence in findings. Bird ER, Piccirillo M, Garcia N, et al. Relationship Between Posttraumatic Stress Disorder and Sexual Difficulties: A Systematic Review of Veterans and Military Personnel. J Sex Med 2021;18:1398-1426.

Transitional Care of Service Members With Genitourinary Injury

OBJECTIVE

To improve urotrauma care by describing veterans' current demographics and needs assessment during transitional care to the Veteran Health Administration (VHA) system.

METHODS

We utilized our previously identified cohorts obtained from the DoD Trauma Registry data for male service members injured in theater linked with VHA electronic health records. We included veterans who received care at VHA at least once from October 2001 through September 2011 for chart review. We investigate demographics, opportunities for care, combat-related trauma, disability, and associated mental health or urologic conditions specifically at the initial encounter with a VHA healthcare provider.

RESULTS

We queried 580 veterans' records in VHA from the linked databases. We idenfied that 141 (24.4%) veterans received addional care outside VHA and 17.1% (n = 99) of charts had insufficient data for injury validation. Reference to the urotrauma was mentioned in 72% of VHA initial visits (n = 416/580). The most common urotrauma occurred to the lower/external genitourinary injury (298, 51%). Of all the veterans identified with genitourinary trauma, approximately 28% (n = 160) were referred for urologic consultation, but only 14% were related to the original urotrauma. Ninety percent (522/580) of service members with urotrauma also had a mental health diagnosis, largely post-traumatic stress disorder (PTSD, 70.8%).

CONCLUSIONS

The majority of men with urotrauma did have contact with VHA, yet there is no systematic approach to baseline assessment or long-term care strategy. However, only a small proportion of DoD-documented urotrauma requires ongoing care. We identified that coordinating care with mental health pathways (PTSD/traumatic brain injury) may be an opportunity to evaluate the long-term effects of urotrauma.

Sexuality and Intimacy Rehabilitation for the Military Population: Case Series

Sexuality and intimacy are important aspects of life that are frequently compromised after severe injury or illness, yet these aspects are often overlooked by medical and rehabilitation professionals. This case series describes the Occupational Therapy Sexuality and Intimacy program at a Military Treatment Facility (MTF). Three diverse clients with a range of physical, cognitive and emotional impairments were chosen to illustrate complexities of the Occupational Therapy Sexuality and Intimacy Program at this MTF, and unique skills employed by Occupational Therapists. Consistent themes discovered include: perceived value of the program; appreciation of safe spaces to discuss personal topics; and enhanced awareness of role identity, body image, and emotional regulation. These cases illustrate that sexuality and intimacy interventions may have profound effects on injured service members, improving social reintegration, and quality of life.

Saikosaponin D Rescues Deficits in Sexual Behavior and Ameliorates Neurological Dysfunction in Mice Exposed to Chronic Mild Stress

Often associated with sexual dysfunction (SD), chronic stress is the main contributing risk factor for the pathogenesis of depression. Radix bupleuri had been widely used in traditional Chinese medicine formulation for the regulation of emotion and sexual activity. As the main active component of Radix bupleuri, saikosaponin D (SSD) has a demonstrated antidepressant effect in preclinical studies. Herein, we sought to investigate the effect of SSD to restore sexual functions in chronically stressed mice and elucidate the potential brain mechanisms that might underly these effects. SSD was gavage administered for three weeks during the induction of chronic mild stress (CMS), and its effects on emotional and sexual behaviors in CMS mice were observed. The medial posterodorsal amygdala (MePD) was speculated to be involved in the manifestation of sexual dysfunctions in CMS mice. Our results revealed that SSD not only alleviated CMS-induced depressive-like behaviors but also rescued CMS-induced low sexual motivation and poor sexual performance. CMS destroyed astrocytes and activated microglia in the MePD. SSD treatment reversed the changes in glial pathology and inhibited neuroinflammatory and oxidative stress in the MePD of CMS mice. The neuronal morphological and functional deficits in the MePD were also alleviated by SSD administration. Our results provide insights into the central mechanisms involving the brain associated with sexual dysfunction. These findings deepen our understanding of SSD in light of the psychopharmacology of stress and sexual disorders, providing a theoretical basis for its potential clinical application.

"Operator syndrome": A unique constellation of medical and behavioral health-care needs of military special operation forces

OBJECTIVE

U.S. military special operation forces represent the most elite units of the U.S. Armed Forces. Their selection is highly competitive, and over the course of their service careers, they experience intensive operational training and combat deployment cycles. Yet, little is known about the health-care needs of this unique population.

METHOD

Professional consultations with over 50 special operation forces operators (and many spouses or girlfriends) over the past 6 years created a naturalistic, observational base of knowledge that allowed our team to identify a unique pattern of interrelated medical and behavioral health-care needs.

RESULTS

We identified a consistent pattern of health-care difficulties within the special operation forces community that we and other special operation forces health-care providers have termed "Operator Syndrome." This includes interrelated health and functional impairments including traumatic brain injury effects; endocrine dysfunction; sleep disturbance; obstructive sleep apnea; chronic joint/back pain, orthopedic problems, and headaches; substance abuse; depression and suicide; anger; worry, rumination, and stress reactivity; marital, family, and community dysfunction; problems with sexual health and intimacy; being "on guard" or hypervigilant; memory, concentration, and cognitive impairments; vestibular and vision impairments; challenges of the transition from military to civilian life; and common existential issues.

CONCLUSIONS

"Operator Syndrome" may be understood as the natural consequences of an extraordinarily high allostatic load; the accumulation of physiological, neural, and neuroendocrine responses resulting from the prolonged chronic stress; and physical demands of a career with the military special forces. Clinical research and comprehensive, intensive immersion programs are needed to meet the unique needs of this community.

Women's Sexual Desire, Trauma Exposure, and Posttraumatic Stress Disorder

Research suggests that posttraumatic stress disorder (PTSD) is associated with sexual dysfunction; however, there is a paucity of research examining the relations among trauma exposure, PTSD, and low sexual desire, specifically. Thus, the goal of the present study was to investigate whether women with hypoactive sexual desire disorder (HSDD; n = 132) were more likely to meet criteria for a diagnosis of current or lifetime PTSD relative to women with no sexual desire concerns (n = 137). We also sought to compare the type, frequency, and intensity of PTSD symptoms between the two groups. Finally, we examined whether women in the two groups were exposed to more, or different types of, potentially traumatic events. Compared to women with no sexual health concerns, women with HSDD were more likely to meet criteria for current PTSD, odds ratio (OR) = 5.50, 95% CI [1.18, 25.61]; and lifetime PTSD, OR = 2.78, 95% CI [1.56, 4.94]. Women in the HSDD group also had higher odds of meeting criteria for avoidance (5.10 times) and hyperarousal symptoms (4.48 times) and scored higher on measures of past-month PTSD symptom frequency, d = 0.62, and intensity, d = 0.57. No group differences were observed regarding reexperiencing symptoms, the associated features of PTSD, or type or frequency of exposure to potentially traumatic events. The findings indicate PTSD symptomatology may be a predisposing or perpetuating contributor to low sexual desire, and low sexual desire and PTSD may be related through an alteration in stress adaptability.

Risk of Psychiatric Morbidity in Psychosexual Disorders in Male Patients: A Nationwide, Cohort Study in Taiwan

This study aimed to investigate the association between males with psychosexual disorders (PSDs) and the risk of developing psychiatric disorders. A total of 34,972 enrolled patients, with 8,743 subjects who had suffered from PSD and 26,229 controls (1:3) matched for age and index year, from Taiwan’s Longitudinal Health Insurance Database (LHID) from 2000 to 2015, selected from the National Health Insurance Research Database (NHIRD). After adjusting all the confounding factors, the multivariate Cox regression model was used to compare the risk of developing psychiatric disorders, between the PSD and non-PSD groups, during the 15 years of follow-up. Of the all enrollees, 1,113 in the PSD cohort and 2,611 in the non-PSD cohort (1,180.96 vs. 954.68 per 100,000 person-year) developed psychiatric disorders. Multivariate Cox regression model survival analysis revealed that, after adjusting for gender, age, monthly income, urbanization level, geographic region, and comorbidities, the adjusted hazard ratio (HR) was 2.448 (95% CI [2.227, 2.633], p < .001). PSD has been associated with the increased risk in anxiety disorders, depressive disorders, bipolar disorders, sleep disorders, and psychotic disorders, respectively. Sexual dysfunctions, paraphilia, and gender identity disorders were associated with the overall psychiatric disorders with adjusted HRs as 1.990 (p < .001), 11.622 (p < .001), and 5.472 (p < .001), respectively. Male patients who suffered from PSD have a higher risk of developing psychiatric disorders, and this finding should be considered as a timely reminder for the clinicians to provide much more attention for these patients because of their mental health issues.

Sexual Dysfunction in Male Canadian Armed Forces Members and Veterans Seeking Mental Health Treatment

INTRODUCTION

There is mixed evidence regarding how posttraumatic stress disorder (PTSD) symptom clusters are associated with sexual dysfunction (SD), and most studies to date have failed to account for potentially confounding variables. Our study sought to explore the unique contribution of PTSD symptom clusters on (a) lack of sexual desire or pleasure, and (b) pain or problems during sexual intercourse, after adjusting for comorbidities and medication usage.

MATERIALS AND METHODS

Participants included 543 male treatment-seeking veterans and Canadian Armed Forces (CAF) personnel (aged <65 years), referred for treatment between September 2006 and September 2014. Each participant completed self-report measures of demographic variables, depressive symptom severity, chronic pain, alcohol misuse, and psychotropic medication usage as part of a standard clinical intake protocol. Hierarchical ordinal logistic regression analyses were used to determine the incremental contribution of PTSD symptom clusters on sexual dysfunction.

RESULTS

Nearly three-quarters (71.5%) of participants reported a lack of sexual desire or pleasure and 40.0% reported pain or problems during intercourse. Regression analyses suggested that avoidant/numbing symptoms were the only symptoms to be independently associated with lacking sexual desire or pleasure (AOR = 1.10; 95% CI 1.05-1.15). None of the PTSD symptom clusters were independently associated with pain or problems during intercourse.

CONCLUSIONS

Sexual dysfunction is prevalent among male treatment-seeking CAF personnel and veterans. Results suggest that PTSD symptoms are differentially associated with sexual desire or pleasure concerns. Assessing sexual function among CAF personnel and veterans seeking treatment for PTSD is critical in order to treat both conditions and improve overall functioning.

Nursing interventions for sexual dysfunction: An integrative review for the psychiatric nurse

Sexual dysfunctions are prevalent disorders in psychiatric patients that too often are not addressed by psychiatric-mental health nurses. An integrative review was conducted using PubMed, Joanna Briggs Institute, SCOPUS, PsycINFO and CINAHL databases to evaluate the evidence for independent, nursing interventions for sexual dysfunction across all nursing literature that could be implemented by psychiatric-mental health nurses. Out of 2448 articles, nine papers met inclusion criteria and were synthesized. Best available evidence was found for sexual teaching interventions for female sexual dysfunction. The implications for psychiatric-mental health nursing practice and recommendations for future research are discussed.

Predictors of Sexual Dysfunction in Veterans with Post-Traumatic Stress Disorder

Background: The problems in sexual functioning among patients with post-traumatic stress disorder (PTSD) are often overlooked, although scientific research confirms high rates of sexual dysfunctions (SD) particularly among veterans with PTSD. The main objective of this study was to systematically identify predictors of SD among veterans with PTSD. Methods: Three hundred veterans with PTSD were included in the cross-sectional study. The subjects were assessed by the Mini-International Neuropsychiatric Interview (MINI) and self-report questionnaires: PCL-5, i.e., PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) with Criterion A, International Index of Erectile Function (IIEF), Premature Ejaculation Diagnostic Tool (PEDT), and Relationship Assessment Scale (RAS). Several hierarchical multiple regressions were performed to test for the best prediction models for outcome variables of different types of SD. Results: 65% of participants received a provisional diagnosis of SD. All tested prediction models showed a good model fit. The significant individual predictors were cluster D (Trauma-Related Negative Alterations in Cognition and Mood) symptoms (for all types of SD) and in a relationship status/relationship satisfaction (all, except for premature ejaculation (PE)). Conclusions: The most salient implication of this study is the importance of sexual health assessment in veterans with PTSD. Therapeutic interventions should be focused on D symptoms and intended to improve relationship functioning with the aim to lessen the rates of SD. Psychotropic treatment with fewer adverse sexual effects is of utmost importance if pharmacotherapy is applied. Appropriate prevention, screening, and treatment of medical conditions could improve sexual functioning in veterans with PTSD.

Development and psychometric evaluation of the Treatment Adherence Questionnaire for Patients with Combat Post-traumatic Stress Disorder

PURPOSE

Treatment adherence is one of the major strategies in treating post-traumatic stress disorder (PTSD) in combat veterans. This study developed and psychometrically assessed the Treatment Adherence Questionnaire for Patients with Combat Post-Traumatic Stress Disorder.

PARTICIPANTS AND METHODS

This methodological study was conducted in Tehran, Iran, during 2016-2017 in two phases. First, the concept of treatment adherence in combatants with PTSD was analyzed using a hybrid model. This model consisted of three phases: literature review phase, fieldwork phase, and final analysis phase. The consequences and attributes of the concept of treatment adherence in combatants with PTSD were identified, and based on the findings, the Treatment Adherence Questionnaire for PTSD veterans was developed. In the second stage, the face and content validities of the questionnaire were investigated both quantitatively and qualitatively. Exploratory factor analysis and confirmatory factor analysis were used to determine the questionnaire's validity. Internal consistency correlation coefficient of the questionnaire was estimated with Cronbach's alpha coefficient, while the reliability of the questionnaire was established using intra-class test-retest correlation coefficient. Study participants were selected from inpatients and outpatients referred to a hospital, clinic, and health center in Tehran and Kashan, Iran. All patients were diagnosed with combat PTSD by a psychiatrist, based on psychiatric interview and other clinical findings.

RESULTS

The Persian version of the Treatment Adherence Questionnaire for Patients with Combat Post-Traumatic Stress Disorder included 17 items. Exploratory factor analysis identified three factors which accounted for a total of 87.57% of the total variance of treatment adherence score. The identified factors were labeled as "maintenance of treatment", "follow-up and treatment contribution", and "purposefulness and responsibility". The Cronbach's alpha correlation coefficient was 0.92 and the intra-class correlation coefficient of the questionnaire's reliability was estimated at 0.92 (P<0.001).

CONCLUSION

The data obtained confirmed the hypothesis of the factor structure model with a latent second-order variable. The final version of the Treatment Adherence Questionnaire for Iranian combatants with PTSD can be applied as a valid and reliable questionnaire for measuring treatment adherence in these patients.

PTSD, psychological morbidity and marital dissatisfaction in colonial war veterans

Background: Forty years after Colonial War, veterans still show psychological disturbances affecting their marital and sexual satisfaction.Aims: This study analyzed the relationships between Post-Traumatic Stress Disorder (PTSD), number of PTSD symptoms and symptom clusters, psychological morbidity, marital dissatisfaction and sexual dissatisfaction; the variables that contributed to marital dissatisfaction and the mediator role of marital dissatisfaction and sexual dissatisfaction, in a sample of colonial War Veterans.Method: The sample included 138 Portuguese war veterans who answered Index of Marital Satisfaction; Index of Sexual Satisfaction; Beck Depression Inventory; State Trait Anxiety Inventory; Post-Traumatic Stress Disorder Scale.Results: PTSD, number of PTSD symptoms and symptom clusters were associated with psychological morbidity, marital and sexual dissatisfaction. Age, depression symptoms and sexual dissatisfaction contributed to marital dissatisfaction and the model explained 55% of the variance. Marital dissatisfaction mediated the relationship between depression symptoms and sexual dissatisfaction, as well as between number of PTSD symptoms and sexual dissatisfaction.Conclusions: Health professionals need to take into consideration the veteran's marital and sexual relationship in clinical routine consultations. As such, treating the veteran in the couple' context seems warranted.

The Unique Health Needs of Post-9/11 U.S. Veterans

This article applies a hazard-based approach to the identification of physical, mental, and psychosocial health needs of post-9/11 veterans. The weaponry, survival, and population of servicemen and women by the military have evolved over time, particularly during the post-9/11 era. It is evident that military hazards and potential exposures vary depending on not only the deployment era but also the specific location and role. Many individual factors may affect the development of health problems. Recent evidence-based literature about post-9/11 veterans' long-term complex health issues is summarized, so occupational health nurses can advocate for the provision of veteran-sensitive care.

Resveratrol ameliorated the behavioral deficits in a mouse model of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) has become a major psychiatric and neurological issue. Resveratrol is shown to be effective on depression and anxiety. However, the mechanism of anti-PTSD-like effects of resveratrol remains unknown. The present study aimed to explore the possible molecular and cellular mechanisms underlying the anti-PTSD-like effects of resveratrol. Following a 2-day exposure to inescapable electric foot shocks, animals were administered resveratrol (10, 20, and 40mg/kg, i.g.) during the behavioral tests, which included contextual freezing measurement, elevated plus maze test, staircase test, and open field test. Similar to the positive control drug sertraline (15mg/kg, i.g.), the behavioral deficits of stressed mice were blocked by resveratrol (20 and 40mg/kg, i.g.), which reversed the increased freezing time in contextual freezing measurement and the number of rears in the staircase test and blocked the decrease in time and number of entries in open arms in the elevated plus maze test without affecting the locomotor activity in the open field test. In addition, resveratrol (20 and 40mg/kg, i.g.) antagonized the decrease in the levels of progesterone and allopregnanolone in the prefrontal cortex and hippocampus. Furthermore, long-term resveratrol attenuated the dysfunctions of hypothalamic-pituitary-adrenal axis simultaneously. Collectively, the evidence indicated that the anti-PTSD-like effects of resveratrol were associated with the normalization of biosynthesis of neurosteroids in the brain and prevention of the hypothalamic-pituitary-adrenal axis dysfunction.

Disinhibited Exposing Behavior, Hypersexuality, and Erectile Dysfunction as a Consequence of Posttraumatic Stress in a 42-Year-Old Male Patient

Research into sexual dysfunction and its explanations within a cognitive behavioral framework in patients with posttraumatic stress is sparse. In this report, we present the case of a 42-year-old male with severe posttraumatic stress symptoms who displayed apparent exhibitionistic behavior, hypersexual behavior in the form of excessive masturbation, and erectile dysfunction. Differential diagnostics showed that the presented exhibitionistic behavior could be more accurately classified as non-paraphilic disinhibited exposing behavior. Functional behavioral analysis of his sexual behavior suggested that disinhibited exposing and hypersexual behavior served as dysfunctional coping strategies for trauma-associated negative emotions. Erectile dysfunction seemed to be the result of trauma-associated hyperarousal and excessive masturbation. Within the context of operant learning processes, we propose that his sexual behaviors became highly automated and were used as the main strategies to regulate trauma-associated negative emotions. Implications for the diagnoses and suggestions for the conceptualization and incorporation into a cognitive behavioral therapy treatment of posttraumatic stress disorder are made.

A Place for Sexual Dysfunctions in an Empirical Taxonomy of Psychopathology

Sexual dysfunctions commonly co-occur with various depressive and anxiety disorders. An emerging framework for understanding the classification of mental disorders suggests that such comorbidity is a manifestation of underlying dimensions of psychopathology (or "spectra"). In this review, we synthesize the evidence that sexual dysfunctions should be included in the empirical taxonomy of psychopathology as part of the internalizing spectrum, which accounts for comorbidity among the depressive and anxiety disorders. The review has four parts. Part 1 summarizes the empirical basis and utility of the empirical taxonomy of psychopathology. Part 2 reviews the prima facie evidence for the hypothesis that sexual dysfunctions are part of the internalizing spectrum (i.e., high rates of comorbidity; shared cognitive, affective, and temperament characteristics; common neural substrates and biomarkers; shared course and treatment response; and the lack of causal relationships between them). Part 3 critically analyzes and integrates the results of the eight studies that have addressed this hypothesis. Finally, Part 4 examines the implications of reconceptualizing sexual dysfunctions as part of the internalizing spectrum, and explores avenues for future research.

Prevalence of use of erectile dysfunction medication by Dutch military personnel between 2003 and 2012

Use of ED medication can be seen as a marker for ED. ED is associated with increasing age, exposure to traumatic events and physical injuries in military veterans. The objective of this study was to assess the prevalence of use of ED medication in Dutch military personnel in the period 2003-2012 and to assess its association with age and psychotropic medication use. Data on dispensing of ED medication, age and co-medication with psychotropic medication of all Dutch military personnel between 2003 and 2012 were collected. The prevalence of ED medication use in each year was estimated, stratified for age and use of psychotropic medication. The number of ED medication users increased a hundredfold from 0.09 to 9.29 per 1000 per year between 2003 and 2012. ED medication was more often used by men over 40 than under 40 (prevalence in 2012: 2.4% vs 0.2%, OR (2003-2012, adjusted for calendar year) 15.6, 95% CI 13.5-17.9) and by men using psychotropic medication (prevalence in 2012: 3.8% vs 0.9%, OR (2003-2012, adjusted for calendar year) 3.13, 95% CI 2.66-3.67). This study shows a strong increase between 2003 and 2012 in a number of ED medication users in male Dutch military personnel. ED medication use increases with age and with psychotropic medication use.

Sexual Health in Male and Female Iraq and Afghanistan U. S. War Veterans With and Without PTSD: Findings From the VALOR Cohort

We sought to determine whether posttraumatic stress disorder (PTSD) was associated with sexual health in returned warzone-deployed veterans from the recent Iraq and Afghanistan conflicts. We studied 1,581 males and females from the Veterans After-Discharge Longitudinal Registry, a gender-balanced U.S. Department of Veterans Affairs registry of health care-seeking veterans with and without PTSD. Approximately one quarter (25.1%) of males (n = 198) and 12.7% of females (n = 101) had a sexual dysfunction diagnosis and/or prescription treatment for sexual dysfunction. Both genders were more likely to have a sexual dysfunction diagnosis and/or prescription treatment if they had PTSD compared with those without PTSD (male: 27.3% vs. 21.1%, p = .054; female: 14.9% vs. 9.4%, p = .022). Among the 1,557 subjects analyzed here, males with PTSD had similar levels of sexual activity compared to those without PTSD (71.2% vs. 75.4%, p = .22), whereas females with PTSD were less likely to be sexually active compared to females without PTSD (58.7% vs. 72.1%, p < .001). Participants with PTSD were also less likely to report sex-life satisfaction (male: 27.6% vs. 46.0%, p < .001; female: 23.0% vs. 45.7%, p < .001) compared with those without PTSD. Although PTSD was not associated with sexual dysfunction after adjusting for confounding factors, it was significantly negatively associated with sex-life satisfaction in female veterans with a prevalence ratio of .71, 95% confidence interval [.57, .90].

Sexual Problems Predict PTSD and Depression Symptom Change Among Male OEF/OIF Veterans Completing Exposure Therapy

OBJECTIVE

A growing literature documents frequent sexual problems among Operations Enduring/Iraqi Freedom (OEF/OIF) veterans with post-traumatic stress disorder (PTSD). However, there has been no examination of how (1) sexual problems may be affected by evidenced-based psychotherapy for PTSD or (2) how the presence of sexual problems might impact effectiveness of evidenced-based psychotherapy for PTSD. As such, the present study investigated associations among symptoms of PTSD, depression, and problems with sexual desire and arousal among 45 male OEF/OIF veterans receiving behavioral activation and therapeutic exposure (BA-TE), an evidence-based behavior therapy targeting co-occurring symptoms of PTSD and depression.

METHOD

Participants completed clinical interviews and several questionnaires including measures of sexual arousal, sexual desire, PTSD symptoms, and depression symptoms at baseline and after completion of 8 sessions of BA-TE treatment. A records review was also conducted to assess for relevant medication use.

RESULTS

Overall, sexual desire and sexual arousal problems did not improve during the course of treatment. Moreover, veterans with co-occurring sexual problems at baseline evidenced significantly less improvement in symptoms of PTSD and depression across treatment as compared to veterans without sexual problems.

CONCLUSIONS

These findings suggest that veterans with co-occurring symptoms of PTSD and sexual problems may require additional assessment and treatment considerations in order to improve their treatment outcomes for both primary psychiatric symptoms as well as sexual problems. Future research on combination treatments of medication for sexual problems and psychotherapy for PTSD is needed.

Sexual dysfunction and neuroendocrine correlates of posttraumatic stress disorder in combat veterans: Preliminary findings

Sexual dysfunction is not a symptom of PTSD but is a common clinical complaint in trauma survivors with this disorder. In that there are biological parallels in the neuroendocrine processes underlying both PTSD and sexual behavior, we conducted an exploratory investigation of the relationship of PTSD and related neuroendocrine indicators with sexual dysfunction in armed service veterans. Major Depressive Disorder, highly comorbid with PTSD and sexual dysfunction, was also assessed. In veterans with PTSD, sexual problems were associated with plasma DHEA and cortisol, urinary catecholamines, and glucocorticoid sensitivity, even when controlling for the effects of comorbid depression. In a subsample analysis, testosterone levels did not distinguish PTSD or sexual dysfunction, suggesting that sexual problems reported by veterans in this sample were not the result of organic disorder. PTSD did predict higher dihydrotestosterone (DHT) levels, which were associated with sexual problems. More detailed assessment of sexual dysfunction in biologically informed studies of PTSD is warranted to clarify the relationships of PTSD symptomatology and related neurobiology with sexual dysfunction.

Perspectives on Sexual Health and Function of Recent Male Combat Veterans of Iraq and Afghanistan

Background

U.S. veterans of recent wars in Iraq and Afghanistan may be at greater risk for sexual dysfunction due to injuries, mental health conditions, medications used to treat those conditions, and psychosocial factors.

Objective

To explore the perceptions of recent Veterans about sexual health and dysfunction, contributing factors, its impact and solutions.

Design

Qualitative study.

Participants

Eight men who screened positive for sexual dysfunction at initial presentation to a postdeployment clinic at a Veterans Affairs medical center

Approach

Patients who screened positive for sexual dysfunction and indicated an interest in participating were contacted and scheduled for an in-person private interview with a researcher. Interviews were semistructured, utilizing open-ended and follow-up probe questions to elicit the individual's perspective about sexual dysfunction and its cause, impact and solutions. Interviews were recorded, transcribed and analyzed for themes.

Key Results

These heterosexual men discussed a range of sexual dysfunction in their activities including lack of desire, erectile dysfunction, delayed orgasm, premature ejaculation, and distraction. They also discussed the importance of setting or context and changes over time to their sexual health and function. The men shared their ideas about contributory factors, including normal aging, medication side effects, injury and a possible role for combat deployment more generally. Reported solutions for sexual dysfunction included medications, herbal remedies, and new positions and approaches to sexual activity. Participants reported discussing sexual dysfunction with their health-care providers and what was helpful. Finally, the men expressed in their own words the significant impact of sexual dysfunction on their self-perception, their partners, and their relationships.

Conclusions

Sexual dysfunction in recent combat veterans can have important negative effects on their health and relationships. Our findings elucidate perceived contributory factors and preferred solutions, which can be applied by health-care providers to improve the management of sexual dysfunction in these patients.

Sexual functioning in military personnel: preliminary estimates and predictors

INTRODUCTION

Although the military is a young and vigorous force, service members and veterans may experience sexual functioning problems (SFPs) as a result of military service. Sexual functioning can be impaired by physical, psychological, and social factors and can impact quality of life (QOL) and happiness.

AIMS

This study aims to estimate rates and correlates of SFPs in male military personnel across demographic and psychosocial characteristics, to examine the QOL concomitants, and to evaluate barriers for treatment seeking.

METHODS

This exploratory cross-sectional study was conducted using data from a larger nationwide study conducted between October 2013 and November 2013. This sample consists of 367 male active duty service members and recent veterans (military personnel) age 40 or younger.

MAIN OUTCOME MEASURES

Erectile dysfunction (ED) was determined using the five-item International Index of Erectile Function, sexual dysfunction (SD) was determined using the Arizona Sexual Experiences Scale, Male, and QOL was determined using the World Health Organization Quality of Life, Brief.

RESULTS

SFPs were associated with various demographic, physical, and psychosocial risk factors. The rates of SD and ED were 8.45% and 33.24%, respectively, for male military personnel aged 21-40. Those who were 36-40, nonmarried, nonwhite, and of lower educational attainment reported the highest rates of SFPs. Male military personnel with poor physical and psychosocial health presented the greatest risk for ED and SD. SFPs were associated with reduced QOL and lower happiness, and barriers for treatment were generally related to social barriers.

CONCLUSIONS

SFPs in young male military personnel are an important public health concern that can severely impact QOL and happiness.

Sexual Healthcare for Wounded Warriors with Serious Combat-Related Injuries and Disabilities

INTRODUCTION

Short of the rich literature on sexuality in men following spinal cord injury, started largely by physicians and mental health professionals within the United States Department of Veterans Affairs (VA) system following earlier wars, little attention has been paid to the sexual healthcare of wounded warriors with other serious combat-related injuries. The recent wars in Iraq and Afghanistan-Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND)-resulted in physical injuries including traumatic brain injuries (TBIs), amputations, and serious burns. There are wounded warriors who are left blind or deaf, and a significant percent of OEF/OIF/OND warriors acquire other "invisible" injuries. While the signature injury of the war in Iraq is said to be TBI, there are a substantial number of service members surviving with posttraumatic stress disorder (PTSD). Many with serious injury are struggling with co-occurring depression. Furthermore, many of our wounded warriors are surviving with polytrauma (multiple traumatic injuries, i.e., amputation plus burns). One specific constellation of injuries seen too frequently among our service members in Afghanistan is referred to as a Dismounted Complex Blast Injury (DCBI) sometimes resulting in orchiectomy and/or penile injury. As with other blast injuries, burns, shrapnel injuries, vision loss, hearing loss, TBI, and PTSD often accompany DCBIs. All of the above injuries have significant sexual, endocrine, psychological, and relationship issues that need to be addressed.

AIM

This article presents an overview of the effects of serious, combat-related injuries on sexual health and provides medical and other health professionals a framework within which to address comprehensive sexual healthcare using a medical rehabilitation model.

CONCLUSIONS

Sexual healthcare for persons with combat-related disabilities presents a complex array of biopsychosocial and relational issues that call for a coordinated interdisciplinary approach that connects physical health, psychological health, and sexual health. Tepper MS. Sexual healthcare for wounded warriors with serious combat-related injuries and disabilities. Sex Med Rev 2014;2:64-74.