Sexual Dysfunction in Male Operation Enduring Freedom/Operation Iraqi Freedom Patients With Severe Post-Traumatic Stress Disorder

MILITARY MEDICINE, 174, 5:520, 2009 Sexual Dysfunction in Male Operation Enduring Freedom/ Operation Iraqi Freedom Patients With Severe Post-Traumatic Stress Disorder Kenneth A. Hirsch, MD, PhD* ABSTRACT The medical records of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans who entered the post-traumatic stress disorder (PTSD) residential recovery program were retrospectively reviewed for presence of diminished libido, erectile dysfunction, and ejaculatory delay. Of 53 patients, 39 reported diminished libido, 26 reported erectile dysfunction, and 8 reported ejaculatory dysfunction. This rate of prevalence is comparable to that observed in prior studies of patients with chronic PTSD of many years duration, suggesting that the mechanism underlying such dysfunction is directly related to PTSD rather than age, other health concerns, chronicity of PTSD symptoms, or lifestyle. Severe PTSD is sufficient in and of itself to engender clinically significant sexual dysfunction of sufficient severity as to impair quality of life. INTRODUCTION It has long been recognized that many individuals suffering from post-traumatic stress disorder (PTSD) also experience a loss of sexual function.1–3 Literature predating the diagnosis of PTSD in diagnostic nomenclature refers to trauma-related sexual dysfunction.4,5 Letourneau et al.6 reported that over 80% of the study’s combat veteran patients “… were experiencing clinically relevant sexual difficulties.” Indeed, Green7 has argued that impaired libido should be one of the diagnostic criteria for PTSD, noting that 69% of his study sample suffered from significant loss of libido. Cosgrove et al.8 found that Viet Nam combat veterans with PTSD had significantly more sexual dysfunction than did their non-PTSD combat veteran controls. Thus, it does not seem to be exposure to trauma per se that engenders the sexual dysfunction. While anxiety of various types has been etiologically associated with sexual dysfunction, Kaplan9 reports that “Anxiety concerning sexual performance or relationship issues, such as intimacy and partner rejection, is also the critical element in sexual avoidance patterns.” Clearly such issues are not unique to PTSD, but difficulty with intimacy is such a pervasive problem for patients with PTSD as to arguably place such patients at especially high risk for sexual dysfunction. There have been no studies comparing the prevalence of sexual dysfunction in patients with PTSD resulting from different types of trauma, and most articles have focused upon victims of combat-related PTSD. The subjects of nearly all of these have been veterans of Viet Nam having chronic PTSD of at * Traumatic Stress Disorders Program, Mental Health Services VHA– Pacific Islands Health Care System, and VA National Center for PTSD, Pacific Islands Division, 459 Patterson Road, Honolulu, HI 96819. This material is the result of work supported with resources and the facilities at the Department of Veterans Affairs, Pacific Islands Health Care System, Honolulu, HI. This manuscript was received for review in September 2008. The revised manuscript was accepted for publication in February 2009. least 10 years duration and typically having had PTSD for well in excess of 20 years. Uniquely, Kotler et al.10 included patients of age 21 through 55, thus including at least some patients with much shorter duration of symptomology. Patients with PTSD from various types of traumatic events were included, but the study did not address symptom duration or type of precipitating trauma as potential influencing variables. The nearly complete reliance upon older, long-term, PTSD patients for the investigation of PTSD-related sexual dysfunction has engendered two different types of potential confounding: patient age and symptom duration/chronicity. Most research has included only patients of age 40 and older, with precipitating trauma occurring 20 to 35 years in the past. No current research in this area was found; there have as yet been no reports in the literature of sexual dysfunction in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. Given that these conflicts are ongoing and began relatively recently, the issues of patient age and chronicity of PTSD symptoms are different from prior research. METHODS Clinical data from all OIF/OEF veterans treated in a residential PTSD treatment center from October 1, 2006 through September 30, 2007 were reviewed for manifestations of sexual dysfunction; this review included a total of 53 patients after exclusions as described below. Data were collected not as part of a formal study, but as part of the routine clinical interviews administered to all patients. Patients with combat experience in any prior conflict were excluded from aggregated data, even if there were no apparent symptoms of PTSD until after involvement in OIF/OEF. The program itself is a residential PTSD treatment program, serving individuals whose symptoms are sufficiently severe as to be judged too great for outpatient intervention. This program provides residential care to only male patients, thus limiting this examination to male gender. Patients included active duty Army (5), 520 MILITARY MEDICINE, Vol. 174, May 2009 Sexual Dysfunction in Male OEF/OIF Patients with Severe PTSD Marine (6), and Air Force (1) personnel, Army Reservists (37) brought back on active duty to participate in PTSD treatment (“MRP2” status), and Army (3) and Marine (1) veterans who had already been discharged from active duty. Patient age ranged from 22 to 53 years, with a mean and a median age of 35 and 33, respectively. Patients had returned from combat deployment between 7 and 22 months before program entry, with a mean and a median of 14.2 and 14.5 months, respectively. Program entry requires referral from a mental health provider who had made a diagnosis of PTSD. Diagnostic confirmation was conducted as part of the assessment at the residential treatment program, both by interview before program entry and by more extensive interview and assessment during the first week of treatment. All patients scored at least 50 on the PTSD checklist–military version.11 As part of the routine clinical assessment upon program entry, patients were asked about three specific types of sexual dysfunction: loss of libido, erectile dysfunction, and ejaculatory delay and/or incompetence. RESULTS Aggregate data are summarized in Table I. At the time of assessment, only 11 patients were on or had been on psychotropic medication, and those patients were questioned as to any potential temporal relationship between medication and sexual dysfunction. Any sexual symptom that did not clearly predate initiation of medication was presumed to be a medication side effect and was therefore omitted from presented data. This resulted in the elimination of 4 patients from the data presented, all of whom had been prescribed selective serotonin reuptake inhibitors. To be included, decreased l (...truncated)