FROM TRAUMA TREATMENT FROM THE TRENCHES
SILVER SPRING, MD. (FRONTLINE MEDICAL NEWS) – Tending to the psychiatric and physical needs of military servicemen, servicewomen, and veterans must include attention to their sexual functioning, according to Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH.
“Think of sexual activity as an activity of daily living,” Dr. Ritchie said at the Trauma Treatment from the Trenches meeting at the Forest Glen Annex in Silver Spring, Md., organized by Sawsan Ghurani, MD, a psychiatrist and Navy captain, and sponsored by the Walter Reed National Military Medical Center in Bethesda, Md.
“This is my new soapbox,” Dr. Ritchie said. “We don’t do a good enough job of talking about sexual health. You don’t always ask patients about sex when you first meet them. But think about when you want to do it.”
Despite the deployment of 2.7 million service members over more than 15 years of war in the United States, research on the sexual health of this population has been scant, Dr. Ritchie said. Research has been similarly limited in the civilian population, except for the work that has been done among civilians on the impact of spinal cord injuries on sexual dysfunction, she said ( J Spinal Cord Med. 2016 Aug 31:1-12 ).
Clinicians who work with service members and veterans find that wives complain about the impact of medical interventions on their partners, said Dr. Ritchie, a former Army psychiatry consultant and current chief of Community-Based Outpatient Clinics at the Washington (D.C.) Veterans Affairs Medical Center . “As part of the discussion on sexual health, I remind them that sexual activity is broader than penetration.”
Another issue to be aware of among service members is anger. “Often our patients are angry, and often that anger comes out to us as therapists,” she said. “We need to tell our colleagues about this and get them to expect it.”
Treating post-traumatic stress disorder can be a tricky proposition because of the sexual side effects caused by selective serotonin reuptake inhibitors, Dr. Ritchie said. She prefers bupropion because it is not linked to sexual side effects. Mood stabilizers cause weight gain, as do antipsychotics. Meanwhile, drug holidays lead to problems with adherence, she said. To mitigate side effects, Dr. Ritchie advised “trying one thing at a time and adding trazodone in low doses for sleep.” However, trazodone has been linked to priapism ( Gen Hosp Psychiatry. 2015 Jan-Feb;37:40-5 ), and so must be used with care.
Another treatment for PTSD that is showing promise is stellate ganglion block, which has proven effective for treating hot flashes in postmenopausal women and in addressing estrogen depletion tied to breast cancer treatment in small numbers of patients ( Med Hypotheses. 2009 Jun;72:657-61 ).
“Studies have found a reduction in PTSD symptoms as well as pain,” Dr. Ritchie said. “I’m pushing the VA to do more research in this area.”
In effort to treat sexual dysfunction, Dr. Ritchie said she and her colleagues prescribe a lot of Viagra and other phosphodiesterase inhibitors. She speculated that flibanserin, a selective agonist for 5-HT1A and an antagonist for 5-HT2A receptors approved in 2015 by the Food and Drug Administration for premenopausal women with hypoactive sexual desire disorder, “will start making its way into the general population,” said Dr. Ritchie, whose comments about using phosphodiesterase inhibitors and doing blocks pertain to VA patients – not necessarily to those served by Walter Reed.
Many service members who participated in Operation Iraqi Freedom and Operation Enduring Freedom were aged 18-25 years. Partly because the Department of Defense (DOD) and the VA work with very young families, clinicians are tasked with teaching them about their needs as couples, including the need to discuss intimacy and sexual health. For political reasons, Dr. Ritchie said, in vitro fertilization is not covered by the VA, although injuries from bomb blasts can make it impossible for couples to conceive naturally.
Toxic and infectious substances faced by troops that are not commonly found in the United States, such as chemicals, pesticides, and motor oils, also need to be acknowledged and addressed by clinicians. “We don’t do a good job about what a veteran thinks about what exposure does to their reproductive systems,” Dr. Ritchie said.
In an interview, Dr. Ghurani said that she came up with the title of the meeting to illustrate the extent to which providers treat PTSD in the military every day. Conference speakers examined the latest treatments on sexual trauma, and the state of the art therapy and research taking place at Walter Reed.
At the meeting, she discussed the distinction between military sexual trauma (MST) and sexual trauma within the civilian population. Research shows that veterans who screen positive for MST “are more likely to have a history of a suicide attempt documented in their VA medical record” ( Psychiatry Res. 2016;244:257-65 ).
A 2008 study found that women are far more likely to screen positive for MST than men. Specifically, the study found that 25% of women and 1.3% of men who are screened for MST within the Veterans Health Administration screen positive ( Trauma Violence Abuse. 2008 Oct;9250-69 ).
Walter Reed’s Interpersonal Recovery Program at the Psychiatry Continuity Service is the only intensive outpatient program within the DOD that provides ongoing treatment for active duty service members with PTSD from a sexual trauma, Dr. Ghurani said.
Earlier during the meeting, Capt. (Ret.) William P. Nash, MD, director of psychological health at the Marine Corps and a 30-year veteran of the Navy, discussed moral injury , and contrasted it with PTSD and other sequelae of psychological trauma. He also described his work on the Moral Injury Events Scale as a tool for recognizing potentially morally injurious events in clinical and research settings.
Dr. Ritchie is the editor of “Intimacy Post-Injury: Combat Trauma and Sexual Health,” (New York: Oxford University Press, 2016). Dr. Ghurani contributed to a chapter in “Intimacy Post Injury,” and Dr. Nash has written extensively about PTSD, particularly among deployed Marines.
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