Systematic Review of Sexual Dysfunction Among Veterans with Post‐Traumatic Stress Disorder

War-Time Stress and Sexual Well-Being in Israel

Objective

This study explored the relationship between war-related stressors and sexual well-being among a civilian population during the 2023 Israel-Hamas War, emphasizing a comprehensive assessment of sexual satisfaction, function, and distress. We aimed to investigate how direct exposure, media exposure, and acute stress symptoms during the war contribute to various dimensions of sexual well-being using a quasi-longitudinal online survey method.

Methods

An online survey with a convenience sample of 1033 Israeli adults, utilizing measures of direct and media exposure to war stress, acute stress symptoms, and various aspects of sexual well-being, both pre-war and present was distributed. Data analysis involved Pearson correlations and hierarchical regression.

Results

There were significant associations between stress-related variables and sexual well-being, highlighting the differential contribution of direct exposure, media exposure, and acute stress symptoms. Direct exposure to stress was uniquely associated with sexual dysfunction, while media exposure and acute stress symptoms contributed significantly to predicting various aspects of sexual well-being.

Conclusions

Recognizing the multifaceted impact of stress during wartime on sexual well-being is crucial for developing comprehensive mental health interventions that address individual and societal factors. This study contributes valuable insights into the relationships between stress-related variables and sexual well-being during wartime, emphasizing the need for holistic approaches in addressing the intimate challenges individuals face during times of conflict.

The impact of intensive trauma-focused treatment on sexual functioning in individuals with PTSD

Background

Individuals with posttraumatic stress disorder (PTSD) often experience sexual disturbances.

Objective

To determine whether intensive trauma-focused treatment is associated with an improvement in sexual functioning (i.e., sexual satisfaction and sexual desire) in individuals with PTSD.

Method

In total, 227 patients with PTSD (68.7% women, mean age = 40.97) participated in an intensive eight-day trauma-focused treatment program consisting of prolonged exposure, eye movement and desensitization and reprocessing (EMDR) therapy, physical activity, and psychoeducation. Patients were assessed (i.e., Clinician Administered PTSD Scale and Sexual Functioning Questionnaire) pre- and post-treatment and at 6-months follow-up.

Results

Sexual satisfaction and sexual desire increased significantly associated with trauma-focused treatment from pre-treatment to 6-months follow-up, albeit the effect sizes were small (Cohen's d = 0.39 and 0.17, respectively). Although men reported greater overall sexual desire than women, sexual functioning improved after treatment in both men and women. Furthermore, those with remission of PTSD reported greater sexual functioning post-treatment and at 6-months follow-up, than those without remission. However, changes in PTSD symptoms associated with treatment were not predictive of the level of sexual satisfaction or sexual desire 6 months after treatment.

Conclusion

The results of this uncontrolled study suggest that intensive treatment for PTSD can have beneficial effects on sexual satisfaction and desire in both men and women; however, this may not necessarily be due to a decrease in PTSD symptoms.

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.

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.

Posttraumatic stress disorder and the risk of erectile dysfunction: a nationwide cohort study in Taiwan : PTSD and erectile dysfunction

BACKGROUND

This study aimed to investigate the association between posttraumatic stress disorder and the risk of developing erectile dysfunction.

METHODS

In this population-based retrospective cohort study, we used Taiwan's National Health Insurance Research Database to analyze patients who were newly diagnosed with posttraumatic stress disorder (PTSD) between 2000 and 2013, with a 1:3 ratio by age and index year matched with patients in a non-PTSD comparison group, for the risk of erectile dysfunction.

RESULTS

In total, 5 out of 1079 patients in the PTSD group developed erectile dysfunction, and 3 out of 3237 patients in the non-PTSD group (47.58 vs. 9.03 per 100,000 per person-year) developed erectile dysfunction. The Kaplan-Meier analysis showed that the PTSD cohort had a significantly higher risk of erectile dysfunction (log-rank, p < 0.001). The Cox regression analysis revealed that the study subjects were more likely to develop an injury (hazard ratio: 12.898, 95% confidence intervals = 2.453-67.811, p = 0.003) after adjusting for age, monthly income, urbanization level, geographic region, and comorbidities. Psychotropic medications used by the patients with PTSD were not associated with the risk of erectile dysfunction.

CONCLUSIONS

Patients who suffered from PTSD had a higher risk of developing erectile dysfunction.

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.

The Importance of a Multi-Disciplinary Approach to the Endometriotic Patients: The Relationship between Endometriosis and Psychic Vulnerability

Endometriosis is a chronic inflammatory condition, which is distinguished by the presence of the endometrial-like glands and stroma outside the uterine cavity. Pain and infertility are the most commonly expressed symptoms, occurring in 60% and 40% of cases, respectively. Women with endometriosis, especially those with pelvic pain, also have a greater vulnerability to several psychiatric disorders. There is, in particular, a tendency to contract affective or anxiety disorders as well as panic-agoraphobic and substance use disorders. Endometriosis with pelvic pain, infertility and psychic vulnerability usually leads to disability and a markedly lower quality of life for women of reproductive age. Thus, the burden of endometriosis is not limited to the symptoms and dysfunctions of the disease; it extends to the social, working and emotional spheres, leading to a severe impairment of global functioning. An analysis of scientific literature revealed a close relationship between specific temperamental traits, the expression of several psychiatric symptoms, chronicity of pain, risk of substance use and lower probability of a positive outcome. Endometriosis symptoms and the impact of related psychological consequences, increased vulnerability and the possible onset of psychiatric symptoms may influence coping strategies and weaken resilience, so triggering a vicious cycle leading to a marked deterioration in the quality of life. A multidisciplinary approach consisting of a medical team composed of gynecologists, psychologists, psychiatrists, experts in Dual Disorder, algologists and sexologists, would guarantee the setting of a target and taking the best decision on a personalized treatment plan. That approach would allow the prompt detection of any psychopathological symptoms and improve the endometriosis-related physical symptoms, bringing a healthier quality of life and a greater likelihood of a positive outcome.

Is Sexual Dysfunction in Young Adult Survivors to the L'Aquila Earthquake Related to Post-traumatic Stress Disorder? A Gender Perspective

BACKGROUND

Mental disorders are frequently related to sexual dysfunction (SD) but scant data are still available on trauma-related disorders, particularly post-traumatic stress disorder (PTSD).

AIM

To evaluate the relationships between SD and PTSD in 2009 L'Aquila (Italy) earthquake young adult survivors, with particular attention to gender differences.

METHODS

Five hundred twelve high-school senior students were assessed 21 months after exposure by the following: Trauma and Loss Spectrum-Self-Report (TALS-SR), for post-traumatic spectrum symptoms; Mood Spectrum-Self-Report (MOODS-SR) lifetime version, for mood spectrum symptoms (including SD-related symptoms). Descriptive and inferential statistics were adopted.

OUTCOMES

TALS-SR and MOODS-SR scores were analyzed to evaluate PTSD- and SD-related symptoms.

RESULTS

Around 6.5% of subjects reported SD-related symptoms with males showing higher rates than females in each symptom, with a statistically significant difference in item n = 154 (…less sexually active). Survivors with symptomatological PTSD reported rates up to 10%, with higher ratio of endorsing at least one SD-related symptom than with NO-PTSD. Significantly higher total MOODS-SR SD-related symptom scores emerged in survivors with symptomatological PTSD than in those with NO-PTSD, and a 2-way ANOVA showed a significant main effect of symptomatological PTSD and gender and gender × PTSD interaction.

CLINICAL IMPLICATIONS

SD-related symptoms are reported among young adult survivors to earthquake exposure and the number of symptoms is related to PTSD, particularly in males, suggesting the need for accurate evaluation.

STRENGTHS & LIMITATIONS

Strengths are the large sample of young adult survivors to a massive natural disaster; the long-time frame from exposure corroborating the role of PTSD; the assessment of symptoms specifically occurring after exposure. Limitations are as follows: the lack of a specific scale for SD; the self-report instruments other than clinical interviews, that may be less accurate; the lack of information on the presence of somatic illness and other mental disorders; the lack of a control group; the young age of the sample because of the lifetime sexual experiences of the subjects, in addition to the lack of a comparison measure of sexual functioning before the earthquake.

CONCLUSIONS

Our results highlight relevant rates of SD-related symptoms in young adults exposed to the L'Aquila earthquake, particularly males and subjects with PTSD, suggesting SD may represent a specific male gender-related somatic complaint. Our results highlight the need for accurate investigation of SD in such population to improve clinical management and appropriate treatment. Carmassi C, Dell'Oste V, Pedrinelli V, et al. Is Sexual Dysfunction in Young Adult Survivors to the L'Aquila Earthquake Related to Post-traumatic Stress Disorder? A Gender Perspective. J Sex Med 2020;17:1770-1778.

Disrupted Rhythmicity and Vegetative Functions Relate to PTSD and Gender in Earthquake Survivors

Background: Increasing evidence indicates that survivors to traumatic events may show disruption of sleep pattern, eating and sexual behaviors, and somatic symptoms suggestive of alterations of biorhythmicity and vegetative functions. Therefore, the aim of this study was to investigate these possible alterations in a sample of survivors in the aftermath of earthquake exposure, with particular attention to gender differences and impact of post-traumatic stress disorder (PTSD). Methods: High school senior students, who had been exposed to the 2009 L'Aquila earthquake, were enrolled 21 months after the traumatic event and evaluated by the Trauma and Loss Spectrum Self-Report to investigate PTSD rates and by a domain of the Mood Spectrum Self-Report-Lifetime Version (MOODS-SR), to explore alterations in circadian/seasonal rhythms and vegetative functions. Results: The rates of endorsement of MOODS-SR rhythmicity and vegetative functions domain and subdomain scores were significantly higher in survivors with PTSD with respect to those without it. Among all earthquake survivors, women reported higher scores than men on the rhythmicity and vegetative functions domain and subdomain scores, except for the rhythmicity and sexual functions ones. Female survivors without PTSD showed significantly higher scores than men in the rhythmicity and vegetative functions total scores and the sleep and weight and appetite subdomains. Potentially traumatic events burden predicted rhythmicity and vegetative functions impairment, with a moderation effect of re-experiencing symptoms. Conclusions: We report impairments in rhythmicity, sleep, eating, and sexual and somatic health in survivors to a massive earthquake, particularly among subjects with PTSD and higher re-experiencing symptoms, with specific gender-related differences. Evaluating symptoms of impaired rhythmicity and vegetative functions seems essential for a more accurate assessment and clinical management of survivors to a mass trauma.

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.

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.

Sexual problems and post-traumatic stress disorder following sexual trauma: A meta-analytic review

OBJECTIVE

Difficulties with sex often develop following sexual trauma, yet are rarely targeted within treatment of post-traumatic stress disorder (PTSD). Where outcomes of sexual function are included, they are secondary to other measures. This review aimed to assess whether psychological treatment for PTSD (from sexual trauma) has an effect on sexual functioning.

METHODS

Systematic searches of MEDLINE, PsycINFO, EMBASE, and trial registers were performed. Five studies met inclusion criteria. Pre-post treatment effect sizes were also calculated.

RESULTS

Data from four good-quality RCTs were included in the meta-analyses. These examined females (n = 799) who had experienced adult sexual trauma or child sexual abuse. Studies compared psychological treatment to control conditions, but no effect on outcomes of sexual concerns, standardized mean difference (SMD) = 0.03 and dysfunctional sexual behaviour, SMD = 0.02, was found. Pre-post treatment effect sizes were small to medium (SMD = 0.36 and 0.47, respectively).

CONCLUSIONS

While firm conclusions cannot be drawn, the available evidence suggests that psychological treatment for PTSD has no effect on sexual problems. Pre-post effects indicate some improvement over the course of treatment, which may be strengthened if treatment actively targeted sexual problems. The paucity of evidence in this area suggests that there is substantial need for further research in order to establish a set of evidence-based guidelines for practitioners implementing treatment in this area.

PRACTITIONER POINTS

The measurement of sexual problems is overlooked in psychological treatment RCTs for sexual trauma. Current treatments for post-traumatic stress disorder (PTSD) from sexual trauma do not appear to be addressing sexual problems. Integrated treatments for comorbid sexual problems and PTSD treatment may be warranted. It is imperative that in future, RCTs that examine people with PTSD from sexual trauma use outcomes of sexual problems.