The Other Invisible Wounds: Sex & The Military Conference 2015
Table of Contents
In February Social Work License Map had the opportunity to attend The Other Invisible Wounds: Sex & the Military2015 Conference, a one-day conference that aims to raise awareness of the sexual intimacy problems experienced by military populations and to provide basic tools to help providers address these issues.
Sex Is a 13-Letter Word
Post-traumatic stress disorder (PTSD) is an inherently disruptive condition. It disrupts relationships by disconnecting patients from their sense of self and their loved ones. Patients who have been physically injured may require a caregiver, who is often a spouse or family member. For a spouse, the emotional strain, time commitment and other challenges of caregiving are exacerbated by intimacy difficulties.
For injured veterans, there are often physical challenges to maintaining a healthy sex life (due to the injury or the side effects of medication) as well as mental obstacles, including self-consciousness and body image issues. That is why communication between veterans and caregivers is critical — it bridges the disconnect and allows couples to reinvigorate their intimacy.
Dr. Jo Sornborger spoke about the importance of communication during sexual rehabilitation at “The Other Invisible Wounds: Sex & the Military”. Dr. Sornborger is the director of the Operation Mend-FOCUS Psychological Health Program and family care manager for UCLA Operation Mend; she gave a speech at the conference titled “Sex is a 13-Letter Word.”
Post-Trauma Challenges to a Sex Life
Many veterans face intimacy challenges when they return home with an injury — they are young and interested in being sexually active with current or potential partners. However, their physical and/or mental wounds permanently alter the dynamic of their sex life. For an intimate caregiver (i.e., a partner, rather than a family member caregiver), this becomes a challenge as well. Sex is an important part of any romantic relationship, and after an injury, multiple factors can interfere with a couple’s sex life.
First of all, an injury such as a burn or mutilation on the lower half of the body can make it physically difficult to have sex. An injury anywhere on the body may make a veteran self-conscious, interfering with his or her ability to perform. For example, Dr. Sornborger treated a veteran with extensive burns on his face and body who asked her, “How can my wife be intimate with a monster?” Whether his condition actually interferes with his wife’s physical attraction to him, or he is simply self-conscious, his injury affects their sex life. Injuries such as burns also make it difficult to actually feel intimate contact. As one veteran said to Dr. Sornborger, “How can I get aroused when I can’t feel what I’m doing not only to myself but to my partner?”
Many injured veterans also suffer from PTSD, which can result in symptoms such as depression, uncontrollable anger and substance abuse, among many others. These issues often interfere with the veteran’s capacity to participate in an intimate relationship. Antidepressants and other medications for PTSD can cause impotence or dull one’s sex drive, and unfortunately, often both members of the relationship are taking such medications.
Barriers to Treatment
According to Dr. Sornborger, one of the biggest barriers to successful treatment is incomplete communication between those involved in the recovery process. First, it is difficult to find effective sex therapy. Many couples enter therapy and the mental health professional simply doesn’t ask them the right questions about their intimacy challenges. Many therapists may neglect to address the mental health issues of the partner, who also may be suffering from depression. It is important for social workers supporting wounded veterans to ask questions that will holistically address the challenges to a healthy sex life and also facilitate communication between intimate partners.
Side effects of both physical trauma and PTSD medication can be sexually debilitating. Chronic pain is one of the primary side effects of an injury and can make sexual stimulation extremely difficult. Medication can have side effects that affect a patient’s sex life, ranging from impotence to weight gain. These issues can be physically limiting and also affect body image and self-confidence, further inhibiting a healthy sex life.
The most important 13 letters for regaining and maintaining an intimate and sexually healthy relationship are “communication.” Physical and psychological injuries from combat can undermine a patient’s self-confidence and create a rift between intimate partners. Communication can help bridge the intimacy gap and allow couples to figure out the best way to create a fulfilling sex life under challenging new circumstances. Social workers must communicate with veterans and their intimate partners about how to find effective sex therapy and how their relationship not only can continue but also thrive. Sometimes the trauma of war follows veterans home, and their partners and social workers can play a critical role in helping them take back the bedroom.
Unlearning Battlemind: Helping Veterans Deal with Emotional Restriction
On the battlefield, it is often necessary to control or suppress emotions in order to make critical decisions that can ensure survival and help service members achieve their objectives. Upon returning home from deployment, many veterans find it difficult to revert to an emotionally open state, and maintaining a pattern of emotional restriction can wreak havoc on their intimate relationships. Dr. Sarah Nunnink is a member of the clinical faculty at the University of California, San Diego, School of Medicine’s Department of Psychiatry. She spoke about the “Impact of Emotional Restriction on Sexual and General Relational Intimacy: Relevancy to Military Problems” at The Other Invisible Wounds: Sex & the Military.
Emotional Restriction and Relationships
Military service members are trained to endure pain and hardship without complaining and without displaying feelings. This is for a good reason; uncontrolled emotions can jeopardize the safety of a unit and the effectiveness of a mission. This type of “battlemind” is essential during combat but can be detrimental to intimate relationships when service members return home. Emotional readjustment is always a challenge, but it is particularly difficult when the transition is coupled with post-traumatic stress disorder (PTSD), which can exacerbate feelings of disconnectedness.
In the context of a romantic or intimate relationship, the inability to disengage from battlemind causes veterans to suppress or disconnect from the very emotions that are critical to communication within a healthy relationship — fear, pain and vulnerability. It is also often more difficult for veterans to clearly express empathy or love for their partners, even if they do feel these emotions. This combination can cause the people in the relationship to feel distant and disconnected from one another. The lack of emotional responsiveness and communication can threaten the long-term viability of relationships.
When partners can’t communicate, it can be especially difficult for them to establish or re-establish a healthy sexual relationship. Partners of veterans who suffer from emotional restriction often report that their partners are emotionally distant or inaccessible during sex, leading them to feel like they are just a body that could be replaced by any other. This makes them feel cut off and lonely, despite being in a supposedly intimate setting with a romantic partner.
Situational Video Vignette: Manny and Angela
The following video depicts a married couple suffering from emotional restriction caused in part by an injured veteran who also shows symptoms of PTSD.
Manny and Angela are clearly disconnected and having trouble communicating in general, but particularly in intimate settings. Angela thinks Manny watches porn because he doesn’t find her attractive anymore. During a therapy session, Manny reveals that, because of his injury, sex is physically more painful for him than he has been admitting. He feels obligated to have sex with his wife, so he goes through the motions and then uses porn to satisfy his sexual needs more completely (i.e., on his own terms, without pain).
Veterans may feel that their inability to control their sex lives makes them vulnerable, out of control or weak — qualities that clash with their self-images as warriors. They may shut down their emotions as a defense mechanism to protect their self-esteem. When couples face this type of emotional restriction, communication is paramount.
Communication Strategies for Sexual Issues
There are some strategies for veterans to create or regain healthy communication in an intimate relationship. Following are a few psychosocial behavioral interventions that couples can try:
- Date nights
- Focusing on non-sexual parts of the relationship
- Sensual touching that does not turn into sex
- Guided touch, focusing on the needs of the veteran — this will help him communicate what is pleasurable and which areas should be avoided (this is particularly applicable for veterans with genitourinary injuries).
Social workers should remind patients that adapting sexual repertoire should be part of any healthy long-term relationship, not just for those affected by PTSD or other military service-related traumas.
Introducing the Topic of Sex
Many patients will be uncomfortable discussing their sex lives, so social workers should be prepared to ask permission to discuss the intimate aspects of a couple’s relationship. This shows respect, can help to build trust and prepares the client for the ensuing conversation. Following are a few ways to introduce the topic of sex:
- I’d like to spend some time talking with you about your physical relationship as a couple. Would that be OK with you?
- I would like to begin a conversation about sex, which I know can be uncomfortable for people sometimes, but this is one of those conversations that tends to get easier once you begin. Would you like to give it a try?
- It sounds like there may be some concerns about the physical and sexual part of your relationship. Sex is an important part of any relationship, so it could be helpful to talk about some of these things and see if I can help. Would that be OK with you?
Social workers should also have at least one session with each partner individually — this allows each person to speak freely about sensitive issues.
Questions to Help Clients Discuss Their Sex Lives
Once the couple agrees to talk about their sex life, here are some questions to facilitate a conversation.
- People have sex for many reasons — for fun, for pleasure, for expressing love. What are some of your reasons?
- How do you feel about the sex you’re having with ____?
- How satisfied are you with your sex life?
- What do you like about it?
If Not Satisfied
- What would you like to be different?
- Is something missing?
- Have you enjoyed sex with your partner in the past?
- Have you enjoyed sex with other partners in the past?
Intimacy is a critical part of any relationship, and it can often be challenged when veterans return from service. Veterans may struggle to leave behind the battlemind that served them well in combat, and many face PTSD or other service-related traumas that contribute to an emotionally restricted relationship. Social workers play a key role in helping veterans regain healthy emotional states and repair or create intimacy in their relationships. This can involve counseling the couple about communication, conducting sexual therapy or providing a combination of the two. Whatever the solution turns out to be, social workers are the professionals who can help veterans regain one of the most important parts of their lives — a healthy intimate relationship.
PTSD Medication and Sexual Dysfunction: Strategies for Conquering the Catch-22
Service members and combat veterans who have experienced trauma on duty have access to many resources to help them recover from the psychological impact of their service. However, what they may not expect is that even with treatment, trauma can follow them into the bedroom during intimate moments. Around 80 percent of veterans suffering from post-traumatic stress disorder (PTSD) also suffer from sexual functioning problems.
Sexual dysfunction can stem directly from PTSD, but is also often a side effect of medication. In those cases, veterans face a distressing Catch-22: They can confront PTSD symptoms without the aid of medication and maintain their ability to perform sexually, or they can control the nightmares through medication and sacrifice sexual functionality. Social workers treating military populations may have patients with medication-related sexual dysfunction challenges, and it is important to understand their patients’ medications and their options for alleviating the negative side effects through communication and intervention.
- About 80 percent of veterans with PTSD also have sexual functioning challenges.
- PTSD can make sexual functioning issues up to 30 times more likely.
- Between 20 to 70 percent of people taking PTSD medications experience sexual dysfunction. Often, the higher the dose, the higher the risk.
- The majority of men with erectile dysfunction report that it prevents them from forming new relationships.
- 50 to 70 percent of individuals taking PTSD medication get some relief.
- 20 to 70 percent of individuals taking PTSD medication experience sexual dysfunction.
Kimberly Finney, PsyD, ABPP, is a retired U.S. Air Force officer, a current certified clinical psychologist and a clinical associate professor at the USC School of Social Work. Dr. Finney presented at the conference and used an imaginary patient named Jake, a 22-year-old veteran suffering from PTSD, to introduce participants to the potential Catch-22 of PTSD medications.
In the scenario Dr. Finney presented, Jake is taking psychotropic medication to deal with nightmares related to trauma from his military service. When he started taking the medicine, he understood abstractly that it might affect his sex life, but he was not prepared for the ensuing impotency. As a young man, he prides himself on being sexually active and exciting to potential partners, and he includes his sexual ability in his perception of his own masculinity. His new erectile dysfunction challenges this perception of masculinity, and he wonders if it is better to quit the medicine and deal with the mood swings, nightmares and other negative effects of his PTSD, rather than continue to struggle with sexual dysfunction.
This is a tricky, but unfortunately common decision faced by veterans suffering from PTSD medication-related sexual dysfunction. The trouble is, quitting the medicine outright has its own undesirable side effects. It also puts the patient right back to where they started — suffering from PTSD, with no relief. So how should physicians and social workers guide veterans through these difficult decisions?
Education and communication are two of the most important parts of the treatment process for veterans receiving PTSD medications. Patients should clearly understand the potential risks, side effects, limitations and benefits of the medications — understanding is a crucial part of compliance and overall success. That means that all health professionals involved in the treatment must communicate clearly with the patient, but also with one another. Non-prescribing clinicians and prescribing physicians should make sure they are on the same page, in case the medication is contributing to the patient’s issues and must be adjusted, changed or discontinued.
If a patient decides to use medications that impact his sexual functionality, there are interventions he can use to reduce some of the adverse side effects, including medications that treat the sexual dysfunction that can be given as an adjunct.
If the veteran or service member is in a committed relationship, taking steps to build and maintain intimacy and communication in that relationship is also important for addressing side effects that challenge the patient on a daily basis.
Following are some potential interventions to improve intimacy:
- Go on a date night.
- Take a bath or shower together.
- Focus on non-sexual parts of the relationship.
- Breath together while looking into each other’s eyes.
For building communication between intimate partners, sentence completion can be a great exercise. Following are a few examples couples can use:
- “What I like about your body is…”
- “I’ve often fantasized about…”
- “What I like about our sex life is…”
- “My injury makes it difficult for me to…”
- “A sexual activity I’d like to try is…”
- “Turn-ons for me are…”
Couples can make their own sentences, and/or ask their therapist to help them come up with new ones, based on what the therapist has seen during their sessions.
Ultimately, patients already suffering from PTSD may feel that they have only one of two difficult choices: deal with the trauma without any help, or treat it with medication, at the expense of a healthy sex life. Social workers and other mental health professionals involved in the treatment process can help patients navigate this challenge by educating patients on the benefits and risks of medications and other treatments, as well as by communicating clearly with other professionals to ensure consistent and effective treatment. Patients who decide to use medication with adverse side effects on their sexual functionality can engage in a variety of interventions and communication exercises with their intimate partners to reduce some of these effects. It can require a lot of work from all of the people involved in the process, but it is possible to treat PTSD without sacrificing your sex life.
Sexual Trauma in the Military: Treating Male Veterans
Sexual assault of men in the military is rarely discussed yet alarmingly common. More than 10,000 men are raped in the military each year — few report it, and fewer receive adequate treatment. The effects of military sexual trauma extend far beyond the physical act, often leading to myriad emotional and psychological issues after a man’s military service is over.
Capt. Tim Hoyt, Ph.D., is the director of the Intensive Outpatient Program atMadigan Army Medical Center. He outlined how military sexual assault affects men and how they can access effective treatment at The Other Invisible Wounds: Sex & the Military.
Military sexual trauma (MST) is psychological trauma that results from harassment, assault or battery of a sexual nature that occurred while a veteran was on active duty, active duty for training or inactive duty training. You can read the Department of Veterans Affairs (VA) official definition here. According to Hoyt, officially, 1 to 2 percent of male veterans experienced military sexual assault during their service, though an estimated 60 to 90 percent of cases are not reported, so the prevalence is probably much higher.
Reasons for Nondisclosure
Many survivors do not disclose being harassed or assaulted for a variety of reasons, including stigma, fear of retribution and hopelessness. There is a strong stigma attached to admitting weakness in the military, and survivors can often feel emasculated by the assault or are worried that they will be perceived as homosexual. They also may worry about exposing a fellow soldier. According to Brian Lewis, the first male survivor of sexual assault to ever testify before Congress, “outing a shipmate is tantamount to treason,” so a lot of servicemen remain silent.
Sometimes VA facilities can engage in practices that unintentionally discourage male sexual trauma victims from seeking help. Hoyt explained that many VA facilities survey veterans in the waiting room, instead of in front of a trained clinician, which can deter survivors from disclosing their assault. Who would be comfortable saying in a crowded waiting room, “Yes, I was sexually assaulted”? Additionally, many VA centers use the same sexual assault services for both men and women, further deterring male survivors from seeking treatment.
How Military Sexual Assault Affects Men
Sexual assault can ruin one’s sense of self, affecting the way survivors remember their military service and disrupting their relationships, careers, and physical and mental well-being. Survivors may experience one, or a combination, of the following challenges after an assault:
- Post-traumatic stress disorder
- Physical health problems (chronic pain, weight problems, gastrointestinal problems)
- Sexual difficulties
- Strong and uncontrollable emotions (mood swings, sudden anger)
- Substance abuse issues
- Insomnia and/or persistent nightmares
Aspects of Military Sexual Assault
- As many as 85 percent of investigated cases have involved multiple assailants.
- Assaults are often part of a ritual or initiation ceremony, and thus viewed as “bonding exercises,” rather than traumatizing attacks.
- In many cases, authority figures assault subordinates. This makes it much more difficult for the survivor to disclose the assault.
- Survivors will often try to escape the situation (by going AWOL, for example), which can get them into trouble and/or ostracize them from the unit.
Following is a list of online resources and treatment centers for male survivors:
Military sexual assault is a pervasive, under-recognized and under-supported issue for servicemen. Survivors often suffer long-lasting physical and mental health challenges as a result of their assaults, while facing many deterrents to disclosing and receiving adequate support. Social workers who intend to work with military populations should be aware of the difficult and complex challenges for male survivors of military sexual assault and prepare to address the problem and possibly stem its growth.
Urotrauma on the Battlefield: Managing the Long-Term Impact
Around 12 percent of injuries sustained during recent American military operations overseas involved damage to the genitourinary (GU) system — trauma to the genitals, bladder, urinary tract or kidneys. These injuries are typically the result of improvised explosive devices (IEDs), and the mental, emotional and psychological effects of the damage often extend far beyond the initial physical trauma.
In recent surveys of soldiers, GU injuries were rated more significant than lower limb injuries. This is understandable, since GU trauma can have a direct effect on a man’s sexual and reproductive capabilities, as well as his sense of body image and masculinity. Following GU trauma, there are clear increases in diagnoses of depression, post-traumatic stress disorder (PTSD), substance abuse, suicidal ideation and attempts, panic disorder and other mental health challenges. This is why, once patients are stabilized physically, social workers play such a critical role in helping them lead healthy and happy lives.
Maj. Steven Hudak. M.D., is a staff urologist at the San Antonio Military Medical Center and the San Antonio Uniformed Services Health Education Consortium. He spoke about “Urotrauma on the Modern Battlefield: Epidemiology, Management and Long-Term Impact” at “The Other Invisible Wounds: Sex & the Military,” and walked attending social workers through the initial, delayed and late phases of urological problems, steps for treatment and presented future initiatives by the Department of Veterans Affairs (VA).
The Three Phases of Urological Trauma
The initial phase of genitourinary trauma is focused on physically stabilizing the victim and putting them in a position that allows for adequate healing.
Once the patient is stabilized, they enter the delayed phase, which can last from several weeks to many years. The goals during this phase are to preserve tissue, allow wounds to heal and to restore function. Successfully restoring urinary and sexual function depends entirely on the severity of the physical injury.
The late phase is when social workers become involved, and it is the most important phase in terms of long-term mental health and wellness for the patients. Counseling can help patients get through the restoration process or adapt to a new life if function cannot be restored. In any case involving GU trauma, patients will require some degree of sexual rehabilitation, involving the spouse or partner and psychological support.
Future Initiatives and Direction
According to Dr. Hudak, two of the biggest challenges for advancing treatment of urological problems are access to affordable fertility options and lack of adequate research. Fertility treatment is expensive but can become necessary for service members who suffered GU trauma and hope to have children. The Department of Defense and TRICARE offer in vitro fertilization to service members while they are on active duty, but once they finish their service and enter the VA system, that support is lost. Going forward, it will be important to smooth that transition for service members. At the beginning of their military duty, service members are also encouraged to bank sperm at their own expense, but they rarely do. This service should be covered or service members should be better educated on the importance of banking sperm before deployment.
The long-term effects of GU trauma are insufficiently studied, despite growing evidence of negative long-term psychological, emotional and sexual repercussions for victims. The Trauma Outcomes and Urogenital Health (TOUGH) project aims to create the largest-ever database of battlefield GU injury. Once the project receives funding, the team can begin conducting in-person physical examinations to pair with the data in order to make recommendations to improve overall quality of life for patients.
Genitourinary injuries can be physically and psychologically debilitating for many veterans. Recovering GU patients often experience long-term emotional, sexual and psychological challenges. This is where social workers step in to guide and support patients and their partners through the psychological and sexual rehabilitation that can restore their mental wellness and quality of life.