PTSD and sex: How past trauma influences sexual health

PTSD and sexual dysfunction often present as comorbidities. Researchers writing in Frontiers in Psychology note that 60%–85% of male veterans with PTSD also struggle with sexual dysfunction, and 81% of women with PTSD attributed to childhood sexual abuse also struggle with sexual dysfunction.^[]

Underlying causes

There are several reasons why individuals with PTSD exhibit high rates of sexual dysfunction. As the Frontiers in Psychology authors explain, these include comorbid mood disorders, the use of psychopharmaceuticals, and exposure to sexual assault. Nevertheless, the presence of PTSD symptoms alone—regardless of exposure to trauma—could underlie sexual dysfunction.

“This notion is supported by the frequent presence of sexual problems and decreased sexual satisfaction in combat veterans and ex-prisoners of war who generally did not experience sexual violence,” the authors wrote. As for female veterans, the type of trauma experienced was not associated with differences in sexual functioning, according to one study.

A study in female veterans found that the severity of PTSD symptoms was correlated with dysfunctional sexual behavior and sexual concerns.

Taiwanese researchers examining the association between PTSD and erectile dysfunction point to pathological changes and PTSD medications as possible etiologies for sexual dysfunction.^[]

They wrote, “Endothelial dysfunction, sexual hormones and inflammation in the neural circuitry, susceptible to PTSD, may play crucial roles on the pathogenic effects of [erectile dysfunction]. Furthermore, in clinical practice guidelines, the most common psychotropic medications used by patients with PTSD include selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), other antidepressants, sedative-hypnotics, and antipsychotics.”

Antipsychotics and lithium are often prescribed for PTSD and have known adverse effects on sexual function. Erectile dysfunction has been reported with antidepressants, antipsychotics, and benzodiazepines.

DSM-5 criteria and guidelines

Although many people with PTSD experience sexual dysfunction, it’s not one of the criteria for a DSM-5 classification of PTSD. Sexual dysfunction is also rarely targeted within trauma-focused treatment protocols. This lack of focus on sexual dysfunction could be because sexual problems are not a primary complaint in those struggling with PTSD. Regardless, sexuality is an important part of life and interpersonal relationships, with significant impacts on quality of life. 

The Frontiers in Psychology authors state that even those struggling with PTSD report that sex is important to quality of life.

Investigators in Germany evaluated a sample of 137 women with PTSD after childhood sexual abuse to assess the prevalence of female sexual dysfunction (FSD) according to the DSM-5 criteria.^[] They also wanted to determine the clinical correlates of FSD in this population. Among these women, 2.9%–12.4% met criteria for at least one of the three sexual dysfunction diagnoses per DSM-5.

Notably, these rates of FSD were lower than those previously reported in the literature. The investigators attributed this to the way in which they assessed and diagnosed FSD. “We conducted a detailed clinical interview,” they explained, “in which all DSM-5 criteria were taken into consideration, including the required duration of symptoms and related distress, as well as possible influential factors (eg, partnership factors, medication, psychiatric disorders).” 

In the authors’ opinion, “This way of assessing sexual functioning seems to capture sexual problems rather than a diagnosis of FSD (according to DSM-5) and could be the major reason for differences between our numbers and previously reported prevalence rates.”

Potential interventions

Clinicians can recommend various forms of psychotherapeutic interventions to help PTSD patients cope with sexual dysfunction.

The authors writing in Frontiers in Psychology presented the results of their investigation of the effects of a brief, intensive, trauma-focused treatment program on PTSD-related sexual dysfunction. This was an 8-day program consisting of prolonged exposure, eye movement and desensitization and reprocessing (EMDR) therapy, physical activity, and psychoeducation. 

University of Washington researchers provide the following advice to clinicians treating sexual dysfunction in PTSD patients.^[]

“Clinicians should inquire about sexual health, including sexual functioning, distress, satisfaction, and frequency, and specifically ask about PTSD symptoms experienced in relation to sexual activity, as part of comprehensive intake assessment,” they wrote.

Certain types of interventions are possible, including behavioral activation, to address the anhedonic symptoms of PTSD; prolonged exposure therapy, incorporating sex-related behavioral in-vivo exposure assignments; and cognitive behavioral conjoint therapy, which could involve patients creating an “approach activity” list that includes activities around physical intimacy.