How PTSD Can Lead to Sexual Dysfunction
There's a strong study that proves there's a link between PTSD and sexual dysfunction . Here are just a few ways that PTSD affects your performance.

December 7, 2015

Laura Tedesco 

July 22, 2003, 2:13 P.M., Iraq Standard Time. The convoy was heading to Karib from Mosul, where Saddam Hussein’s sons had been killed just hours before. U.S. Army Specialist John Radell, then 35, was in the turret of a Humvee when a rocket- propelled grenade hit the vehicle in front of him.

The blast ejected Radell from his Humvee as the ambush erupted. He scrambled for cover, his senses heightened, and a familiar rush of adrenaline coursed through his body.

Urologists Say This May Be the Cure for Erectile Dysfunction

He took a round in his right leg but scarcely felt it. His eyes were trained on a figure who had popped up from behind a sand berm maybe 75 yards away and was working his way toward Radell.

It was a boy in traditional Iraqi garb-caftan, vest, woven cap—carrying an AK-47. The boy was a soldier.

“I don’t think I’ve ever seen a level of hate in somebody’s eyes like this child, about 12 years of age, had when he was looking at me,” says Radell. What happened next haunts Radell to this day.

When he pulled the trigger, killing the boy soldier, Radell ejaculated.

“That was probably the moment I broke,” Radell says now. “I was disgusted with myself. I started to believe I’m no different than the sick bastards, the Jeffrey Dahmers, of the world. To this day, when somebody walks up to me and says, ‘Thank you for your service,’ I cry because I feel ashamed.”

For starters, it’s not uncommon for soldiers to become erect on the battlefield, says Michael Sapiro, Psy.D.(c), who has trained as a neurocognitive rehabilitation specialist at the U.S. Department of Veterans Affairs.

“They’re not monsters. They’re not getting pleasure from killing. But it’s invigorating. There’s such an intensity to being on the field, shooting a weapon, the power of taking another life.”

At that moment, though, Radell believed he was inhuman—that he’d somehow become an animal.

“It became very easy to look at another human holding an AK-47 and see a piece of meat. If I can turn him into anything but another human being, then it becomes very simple for me to pull the trigger,” Radell says. “If you have any morals or scruples, that’s going to cause conflict at some point. In my case, that conflict resulted in a mental breakdown.”

Radell’s story is an extreme case of post-traumatic stress disorder (PTSD) and some acutely personal consequences. But his experience also illuminates a corner of the male psyche where aggression and sex combine—a volatile dynamic that is seldom discussed even among the many soldiers whose sex lives have suffered after war.

Radell’s PTSD symptoms showed up quickly upon his return home to California. Clinging to his military identity, he bought several guns and 2,500 rounds of ammo for each, rigged his property with dummy explosive devices and trip flares, and slept with a loaded .45 under his pillow and a sword under the mattress.

Psychologically, Radell was still on duty at Fort Liberty, Kuwait. Sex was either physically impossible or emotionally unbearable.

Sometimes Radell couldn’t become erect at all, or if he could, sex might spark a flashback to that child soldier. “I’d see myself pulling a trigger on my wife’s head as I was getting ready to climax,” he says. “That destroyed the sexual relationship altogether for me.”

On the battlefield, Sapiro says, a soldier has “a sense of total power over other people’s lives.” Back in civilian life, that disappears.

“Then when they lose their ability to use their sexual organ, which to them represents who they are as a man, all [remaining] power is stripped from their identity,” Sapiro says. “You’re seen as a hero if you lose a leg, but you’re seen as half a man if you’re limp.”

Even with a wife waiting on him at home, Radell recalls thinking, I’m way too young to be experiencing this. My life is over—I’m no longer even a man. Who the hell is going to want me for my personality?

For some, the mere sensations of intimacy can trigger the terror of war. The smell of lovers’ bodies becomes “connected to death and despair,” says Sapiro. “It’s just overwhelming.”

The VA’s solution for Radell: four Viagra tablets a month.

“They’ll give you only so many pills,” says Mitchell Tepper, Ph.D., M.P.H., founder of the Making Love After Making War initiative. “So if you want to have sex more often, you cut them up.” Radell says VA docs told him they weren’t there to be his sexual therapists.

Eleven years later, this remains the VA’s primary treatment of erectile dysfunction among combat veterans returning from Iraq and Afghanistan. In 2014 alone, the agency spent $77.9 million on ED drugs like Viagra and Levi-tra, a nearly threefold increase since 2006.

By some estimates, nearly one in five U.S. soldiers returning home from Iraq and Afghanistan suffer from PTSD. And the majority of these veterans-those age 40 or below, who are in the prime of their sexual lives—face an 81 percent higher risk of sexual problems than those without a PTSD diagnosis, according to a 2013 study published in the Journal of Sexual Medicine.

Further research released last year in the same journal suggests a stronger link: Servicemen with probable PTSD were 29 times as likely as those without PTSD to report ED. Among men with genital injuries, for comparison, the risk of ED went up only nine fold.

When a serviceman physically can’t get it up, sending him home with a Viagra scrip makes sense. But psychological injuries have an effect on more than just the blood flow mechanics of a man’s erection.

“It’s not just a plumbing problem,” says Drew Helmer, M.D., director of the VA’s War Related Illness and Injury Study Centre in New Jersey. “What’s not working well are some of the circuits in the brain that tell the body what to do in terms of sexual arousal.”

That may explain why, in a recent BJU International study, Viagra was no more effective than a placebo at alleviating ED among combat vets with PTSD.

“It takes arousal, which begins in your brain, to start that erection,” says Tepper. “And Viagra isn’t going to affect your brain.”

Radell, a member of the Gabrielno-Tongva and Apache tribes, met his second wife, Aiyana, at a drum circle in 1996. They married seven years later, just weeks before his deployment.

In the years before Iraq, the sex was good—although sometimes sporadic—and Radell describes himself at that time as a touchy-feely guy in tune with his emotions.

But when he came home, almost two years after the ambush (his Alive Day, he calls it), he realized that the man Aiyana married had died alongside that 12-year-old boy in Iraq.

“I wasn’t capable of any emotional bonding, on any level. I wouldn’t allow anybody to even touch me. I don’t even think I hugged Aiyana or touched her for probably the first six months,” he says.

Radell tried to join in the welcome-home festivities, but his family’s response to the new John—laughing when they saw him dive under the kitchen table during Fourth of July fireworks—pushed him further inward.

“There was most definitely a fear of intimacy,” he says. Emotional numbing, like the effect Radell experienced, is a recognized symptom of PTSD—and according to a recent study in Military Health, it is the PTSD symptom most closely linked to sexual problems.

“If a person is cut off from his emotions, it makes sex less appealing-it becomes just a purely physical act,” explains Christopher Erbes, Ph.D., a psychologist at the Minneapolis VA and an associate professor of psychiatry at the University of Minnesota.

This may be especially true for soldiers who go to war in their sexually formative years.

“If you deploy when you’re 18 or 19, you’re still developing your sexual identity,” says Benjamin Breyer, M.D., a urologic surgeon at UC San Francisco who studies sexual dysfunction. Wartime trauma can affect that process, he says. Years normally spent exploring sexuality or building intimacy are spent in war zones, where survival requires emotional detachment.

In the aftermath of war, some veterans may engage in violent behaviour, including domestic violence and risky sexual practices, says Sherrie Wilcox, Ph.D., of the Centre for Innovation and Research on Veterans and Military Families at USC.

As Dr. Helmer puts it, “Coming back from deployment, all of life is kind of vanilla-like, I need more of a thrill, I need more of that adrenaline rush that made me feel alive.”

In Radell’s case, he avoided intimacy and re-created the thrill of war by cheating on his wife with women he met at his Alcoholics Anonymous meetings. “That’s ultimately what destroyed my marriage,” he says.

The VA doesn’t routinely screen returning veterans for sexual dysfunction. In fact, the Dole-Shalala Report, released in 2007 by the President’s Commission on Care for America’s Returning Wounded Warriors, failed to address sexual health care for veterans altogether.

“Sexual health has been discounted as a ‘lifestyle’ issue. But this isn’t just about getting off-these things affect the person’s emotional, mental, and relationship health,” says Tepper, who is part of a small band of clinicians, many of whom are disabled, lobbying for the VA to change its approach.

“I became disabled at 20, and sex was important to me,” he says. “The able-bodied docs and psychologists, I believe, take sex for granted.”

In 2010, a new law permitted the VA for the first time to treat not only veterans but also their partners.

Five years later, the VA is still in the process of making couples therapy widely available.

The counselling Radell was offered “didn’t have anything to do with the sexual aspects of our marriage,” he says. “Basically it was how [Aiyana] could learn to live with a crazy person.”

Erbes emphasizes involving the veteran’s partner from the get-go. Some couples have had years of marital distress: “It’s unreasonable to think that just because the symptoms of PTSD are being addressed, boom, the couple is going to hug and just go about their business. What’s more likely is that the marital distress could interfere with the individually based treatment.”

According to a 2013 UNC Chapel Hill study, about 60 percent of the soldiers surveyed with probable PTSD sought mental health treatment by seeing a counsellor, psychologist, or psychiatrist. It’s simpler to try Viagra and Levitra-still the frontline treatment for veterans who have sexual problems.

This may be partly the fault of the VA, whose neglect of patients-and cover-up of those lapses-erupted in scandal last year. (The scandal wasn’t just an affront to those who serve, and suffer, for our security. Here’s why the Veterans Affairs Scandal Says Terrible Things About All of Us.)

But it also reveals veterans’ reluctance to seek mental health care. In the military, “there is a culture of strength,” says Dr. Breyer. “Veterans think this kind of thing is perceived as a weakness. There is a stigma associated with seeing a therapist.”

Some guys stop their psych medications-which they often suspect to be causing their erectile trouble-cold turkey, without a doctor’s supervision. “They’d rather be hard than sane,” says Sapiro. A common outcome: They remain limp, because cutting out meds isn’t necessarily an effective route to erection.

They can then become stuck in hyper-vigilant mode, “always tense and looking around the corner,” he says.

The key is uncovering the root psychological cause of ED, ideally with the partner present. Partners are a primary source of support for veterans, says Erbes. “Generally, the more support you have, the better you do in terms of PTSD.”

Couples therapy isn’t a quick fix, but over the long term it can help salvage a veteran’s sex life. In a 2008 Israeli study, two months of behavioural and sex therapy involving both partners significantly improved erectile function, sexual satisfaction, and orgasm scores in PTSD patients.

“Intimacy is valuable in helping a service member with PTSD heal,” says Seth Messinger, Ph.D., an associate professor of anthropology at the University of Maryland.

Some psychologists liken sex to prolonged exposure therapy, an effective PTSD treatment during which patients are gradually exposed to a trauma trigger in order to strip it of its power.

If the VA adopts this approach consistently, some of the stigma of erectile dysfunction and therapy may dissipate, says Tepper.

And that, adds Dr. Helmer, could percolate down to treatment of civilians: “You could have a young, healthy person who is otherwise able to get an erection, but when he’s put in an awkward, anxiety-provoking situation, the brain just kind of shuts down the process.”

Dr. Helmer’s patients understand.

“They’re saying, ‘Don’t just give me a pill. I’m 25 years old—I don’t just want a pill for PTSD and a pill for ED. I want to get better. How do I get better?’”

In Sapiro’s view, this shift is part of a reframing of what it means to be a man.

“Men go into war thinking, ‘I might die. I signed up for that. I might lose a limb. I signed up for that,’” he says. “Do they go into war thinking they might never be able to have penetrative sex again? We can help them see there is so much more than ‘I don’t use my penis in the same way I used to.’ You can be sane and totally intimate and loving, and you can still be a man.”

Radell now lives in Las Vegas and works as a spiritual leader for a Native American group. He remarried and his sex life rebounded.

He no longer drinks and is off his VA-prescribed medications, although he does smoke medicinal cannabis to treat his back pain and anxiety. He’s sleeping and eating normally.

“I’m back to a point where I feel like I’m in control of my faculties 100 percent,” he says. “I’m able to leave the house now. I’m able to be an active participant in my life.”