First published in Times of Israel

Post-traumatic stress disorder, or PTSD, is a serious condition that can affect individuals after being directly or indirectly exposed to a traumatic, life-threatening event. The symptoms of PTSD are intrusive. They include flashbacks and nightmares and difficulties with concentration and sleep. People with PTSD tend to easily get anxious and irritated. Because they become easily triggered, they may avoid crowds or overly stimulating events. PTSD symptoms impact not only individual quality of life and sense of self, but also the individual’s social, recreational and occupational lives.

Although only a small percentage of people who experience a trauma will go on to develop the symptoms of PTSD, there appears to be increasing awareness about this condition amongst mental health professionals as well as the lay population, especially here in Israel, where traumatic events occur frequently and the military is a normative part of life. Particularly around Yom Kippur, and Israel Remembrance Day, radio and television ads encourage those who are experiencing symptoms of posttraumatic stress, to seek help.

As a couples therapist who deals with the most intimate aspects of people’s lives, some of whom have been diagnosed with PTSD, I observed that PTSD symptoms can have a devastating effect on a couple, both in and out of the bedroom, and believe that people with PTSD, their loved ones, and the therapists who treat them, need to acknowledge and better understand how PTSD affects their intimate relationships, and in particular, their sexual lives.

To understand more, I contacted Rachel Yehuda, Professor of Psychiatry and Neuroscience, and the Director of the Traumatic Stress Studies Division at the Mount Sinai School of Medicine. Dr. Yehuda is a recognized leader in the field of traumatic stress studies and has authored more than 250 published papers, chapters, and books in the field of traumatic stress and the neurobiology of PTSD. Fortunately, I was able to reach her easily, as she also happens to be my sister. Along with Dr. Amy Lehrer, we collaborated on a literature review of PTSD and sexual functioning, and formulated a theory that explains how the symptoms of posttraumatic stress, and the normative sexual response interact incompatibly.

Our literature review provided us with some important data and led us to publish our findings that in fact, individuals with PTSD, including combat veterans, have higher rates of sexual functioning problems. We cited several reasons that were noted in the papers we reviewed. For one thing, individuals with PTSD are wired to be alert and hypervigilant. They often cannot easily regulate their emotions and they can become agitated and even aggressive. They have an exaggerated startle response so a partner’s reaching out with an intimate gesture can result in a hyper-reactive and rejecting response. Sexual intimacy requires feelings of safety, emotional and physical vulnerability, connectedness and the ability to let go, states which are difficult for individuals with PTSD to attain. Furthermore, PTSD affects mood and is associated with depression and anxiety. These mood states affect sexual desire but to make matters worse, anti-depressants, a common intervention, negatively affect sexual functioning as well.

Other factors that we found contributed to sexual dysfunction are also what is known as ‘co-morbid’, or, associated. Many combat veterans with PTSD abuse drugs and alcohol that are likely to affect sexual functioning. Finally, many traumatic events result in physical injury, including genital injuries, chronic pain and traumatic brain injury and these factors can also play a salient role through their affect on body image, self-image, and sexual functioning.

An important insight gleaned from our review, and that we as authors corroborated from our clinical practices, is that people with PTSD may avoid partnered sex, but not because their body parts aren’t working as they should. In fact, some trauma survivors report that although they lack desire or are unable to function sexually with their partners, they are able to self-stimulate to orgasm. Some have reported that this allows them physical release without investing the emotional energy required in partnered intimacy. For others, they are simply “numbing” themselves.

We also came to understand that the trauma survivor’s narrative of the traumatic events might be meaningful. Some combat veterans reported, to their shame and horror, experiencing sexual arousal in the midst of battle. Neurophysiologists can understand that. The release of brain chemicals such as testosterone, dopamine and norepinephrine that would occur in combat are the same ones associated with sexual desire and arousal. Once that occurs, however, sexual arousal becomes connected with fear, horror and guilt, and once that connection is made, it is difficult to separate those experiences in normative sexual situations.

After gathering this information, we observed that the explanations provided for sexual problems had to do with factors associated with PTSD, but we also wanted to understand if PTSD is an independent risk factor for sexual dysfunction.

So, we compared the neurophysiology of sexual desire, arousal and orgasm to the neurophysiology of PTSD and began to understand the incompatibility. Sexual functioning is a lot like a car. You need the gas pedal to get going, but need to step on the brakes in order not to crash. Sexual desire involves parts of the brain and release of brain chemicals that are similar to those involved in the stress response. Our excitatory mechanisms cause the heart rate to increase and the blood to flow but our inhibitory centers, the brakes, let us know that even though our body is in a state similar to the flight or fight response, we have nothing to fear.

People with PTSD lack that regulation. Once they experience sensations and a physiological reality that mirrors stress, they may experience a heightened fear response.

In sexual arousal, the limbic system, the brain’s emotional center, is active. The amygdala is part of the limbic system and is associated with fear. Recent brain scan studies of orgasm indicate that while the amygdala is active in sexual arousal, in order to reach orgasm, it needs to be turned off. In individuals with PTSD, the amygdala doesn’t easily turn off.

Understanding all this can be incredibly relieving for individuals with PTSD and their partners. With the appropriate therapy, couples can learn to re-create the intimacy that has been lost and enjoy making love, and not war.