Wargasm: Sexuality, Intimacy, and Post-War Reintegration

When it comes to sexuality and intimacy, it is not enough to simply tackle outdated policies that shy away from love and sex. Sex must not be reduced to a violent, emotionless wargasm in a post-war homecoming.

Sex and intimacy issues can have a dramatic impact on any couple’s relationship. Add the military component, along with combat exposure, and chances for sexual dysfunction, emotional numbing, and divorce increase exponentially (Hirsch, 2009). Relationships shattered, families torn apart, and reintegration failures can possibly be prevented if VA Health Care would incorporate sexuality and intimacy-related therapy into ongoing veteran treatment.

Sex and intimacy certainly appear to be a vital pieces of the post-war reintegration discussion, but according to VA mental health clinicians, it is just not happening. Dr. Jessica Punzo, a psychology fellow at the San Diego VA and Dr. Linda Mona at the Long Beach VA, insist that veterans, with or without children, are struggling with sexual and intimacy issues, which undeniably impact intimate relationships and family dynamics (Cramer, 2015). A healthy sex life with intimacy is conducive to a healthy, satisfying life.

VA avoidance of the discussion of sex and intimacy beyond a mere question on an intake form, is reflected in VA benefits policies that exclude care for “sex therapy, sexual advice, sexual behavior modification or other similar services” (Veterans Health Administration, 2013). In order to achieve a successful post-war reintegration, sexuality and intimacy must be part of the conversation at VA and for any and all clinicians working with combat veteran relationship issues.

In Love and War

Sexual expression in previous wars is quite different from what it is today. During the American Revolution and Civil War, prostitutes were considered as “outlets” for sexual relief and in other cases, families could potentially accompany Soldiers to various posts (Rees, 1996).

In World Wars I and II, documentation of brothels for Service Members were not uncommon, in addition to German and Japanese propaganda taunting military personnel about their relationships back home as fragile and in danger during their absence (Fussell, 1989). However, in recent wars in Iraq and Afghanistan, predominantly Muslim countries, brothels were less apparent, but rape and human trafficking were still very much present (Hynes, 2004).

While we see these images of women being used as prostitutes, property, or place holders for absent men, what we have failed to discuss is the elephant in the room called intimacy. When enemy combatants, prostitutes, fellow Service Members, or women waiting on the home front for their spouse are not viewed as valued individuals – or human beings for that matter – intimacy has already gone AWOL.

When it comes to what women veterans deal with in dating, relationships, sex, and marriage, they are almost always excluded from this aspect of reintegration. According to Zinzow et. al., (2007), women veterans experience higher rates of exposure to traumatic incidents than the general public and are as likely to be exposed to combat as male veterans.

However, in the mainstream media and in various communities across the country, this is not being accurately depicted. The deficits in understanding the various problems women veterans face are directly reflected in the severe lack of client-centered resources for women. Are we asking too much from VA Health Care to look beyond symptoms of war and look at how love and intimacy - or the lack thereof - impacts morale, identity, psychological and physiological healing, and lasting reintegration success?

To negate the inner workings of the home front and the interpersonal, regardless of marital status, is a grave mistake being perpetuated by VA Health Care and veterans’ nonprofit organizations offering mental health services.

Sexual Adjustments in Returning Veterans

Lengthy separation from partners can certainly take its toll on not only the relationship during the deployment, but everything that happens in the homecoming process as well. When military personnel experience an extended lack of physical or verbal intimacy in meaningful relationships, a number of issues have the potential to arise.

If the veteran is in a committed relationship, role changes occur over the course of separation, as well as when facing military discharge and entry into the civilian sector full-time. When unemployment is an issue for either partner, this can also impact both renegotiations of roles and emotional intimacy. After war, feelings regarding sex can change. Have feelings changed regarding trust, feeling loved, important, valued? All of that is possible.

Changes in physical interaction, secondary to trauma or other psychiatric problems, can occur in addition to body image issues, feelings of guilt and low self-worth, or memories of traumatic events experienced during military service. Whether the issue is erectile dysfunction or a mood disorder, issues that affect intimate expression and sexual intercourse can create quite the complex case.

Psychiatric symptoms, physiological injuries such as amputation or Traumatic Brain Injury (TBI), or changes in attitudes or beliefs regarding sex and intimacy can have dire consequences that undoubtedly negatively impact a military or veteran client’s life in the post-war reintegration process (VHA Office of Public Health and Environmental Hazards, 2010). In order to proceed into talking about sex, intimacy, and communication, we must be willing to accept combat exposure as a direct cause of sexual dysfunction and psychological stress.

After we take this into account when considering current divorce rates, suicide attempts and completed suicides, and other reintegration failures, we can start looking into what works and what does not work for those who have survived combat and have trouble relating to others on an intimate, interpersonal level once they return home from war.

PTSD, TBI, and Sex

The impact of Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) on relationships can be manifested through marital issues, separation, divorce, parenting difficulties, maladaptive behaviors, family dysfunction, domestic violence, and reintegration failures (Matsakis, 2007). All of these negative responses and outcomes can be tied directly back to the couple and interpersonal instability.

When sexual dysfunction and intimacy deficits appear, underlying issues of anger and psychiatric symptoms are often associated with the root causes (Begic, 2001). The prevalence of PTSD and sexual dysfunction stand between 63-80 percent among combat veterans (Cosgrove, et al., 2002). All aspects of interpersonal interaction, physical and emotional, are affected by this comorbidity and manifests in sexual disinterest, Erectile Dysfunction (ED), premature ejaculation, decreases or failure in orgasm, lower sex drive, dissatisfaction, and other negative responses or behaviors (Cosgrove, et al., 2002).

Difficulties in sexual intercourse and intimacy are common with many forms of injuries. Reportedly, 60 percent of individuals with TBI will have some form of sexual dysfunction. The greater the injury, the higher the possibility of experiencing sexual dysfunction – whether physiological or psychological (Katz & Aloni, 1999). TBI and sexual dysfunction may also lead to difficulties in initiating and following through with sexual intercourse, as well as interpersonal communication in general. In order to achieve a truly satisfying sex life, a healthy understanding of intimacy is imperative. Some of the most common issues for individuals with TBI may include, but not limited to, decreases in sexual function and drive, difficulties in reaching orgasm, discomfort or decreased sensation during intercourse, and emotional disconnection.

While various studies have concluded that 40-60 percent of male veterans have problems with ED after TBI, and 33 percent experience difficulty in achieving an orgasm, there still seems to be a lack of data regarding women. Women who have served in combat and related sexual and intimacy data appear to be missing from many of these studies that include only extensive data on male sexual function.

So, what are the issues with women? In effort to understand what is happening with the entire PTSD/TBI veteran population regarding sexual health and social functioning, women must be included in any related studies. The ongoing objectification of women, in or out of the context of war, is a core part of rape, domestic violence, and other forms of direct and institutional violence (Carr, Green, & Ponce, 2015). If a male is experiencing difficulties in sex and intimacy because he no longer views his partner with respect, this can certainly be tied to violence against women before, during, and after war.

When sex is more about domination and subjugation, intimacy is completely lost and sex becomes dysfunctional and dangerous.

When Intimacy is Damaged

Sex and intimacy are relevant for understanding risk regarding social and psychological difficulties such as intimate partner violence. When resources vary for married or single Service Members and veterans, identifying risks and treating underlying issues becomes far more elusive. Mental health programs need to target different subgroups of military and veteran personnel based on their specific needs. Both marital status and gender must be examined with respect to mental health problems and intimate partner violence in order to determine the appropriate interventions, in addition to preventing intimacy issues before they explode post-combat.

The impact of PTSD and TBI on relationships in general appears to have negative effects on interpersonal issues (marriage or relationship), relationship breakdowns (divorce, break-ups, separation, custody battles over children), difficulties in maintaining healthy parenting with children, family discord, and interpersonal violence – whether physical, verbal, or psychological (Cosgrove et al., 2002).

When families are not functioning well, especially due to combat-related PTSD and TBI, we then become acutely aware of issues in readjusting to post-war everyday life. From reunion stress to sexual dysfunction or emotional withdrawal, the burden of war trauma becomes far too cumbersome for any individual to manage alone (Manguno-Mire et al., 2007). Comorbid disorders also factor in to the complexity of sexual health and intimate communications, to include depression, chronic pain, anxiety, sleep disorders, neurological injuries, and other pre-existing disorders.

Intimacy, when damaged or absent, can lead to a variety of problems in addition to symptoms related to combat-sustained injuries. However, if intimacy, communication, and the nature of a healthy sex life can be addressed in conjunction with other post-war reintegration issues, we may be closer to closing the gaps in care and decreasing intimate and personal violence.

Sexual Healing

While couples struggling with sex and intimacy issues may attempt to seek care through a local VA Vet Center, for example, chances are very slim that a certified sex therapist will be on staff to assist them in specific issues pertaining to sexuality and intimacy.

According to the American Association of Sexuality Educators, Counselors and Therapists (AASECT), certified sex therapists “are mental health professionals, trained to provide in-depth psychotherapy, who have specialized training in treating clients with sexual issues and concerns.” They handle both “simple sexual concerns” and “are prepared to provide comprehensive and extensive psychotherapy over an extended period of time in more complex cases.” A quick search through the AASECT website confirmed a lack of certified therapists working directly with veterans at VA-affiliated facilities.

Most recently, Iraq and Afghanistan veterans have endured polytrauma and complex injuries resulting from combat. Medical advances ensured higher survival rates from blast injuries, gunshot wounds, burns, and other physiological and psychological injuries. This complexity increases when issues of sexuality and intimacy come into play, and may deteriorate efforts at interpersonal intimacy when left unaddressed (Taft, Watkins, Stafford, Street, & Monson, 2011). Injuries ranging from PTSD to TBI can impact one’s daily life both interpersonally and professionally (Ponsford, 2003).

However, the issues of emotional numbing, extremes in sex drive, sexual dysfunction, fertility, interpersonal trust, sexual identity, intimacy, and objectification are often omitted from discussions and research pertaining to military/veteran mental health. The omission of sexuality and intimacy along with institutional biases against sex therapy present a sizable barrier to those seeking adequate mental health services (Weeks, 2005) Hertlein, Weeks, & Gambescia, 2015).

Change can, in fact, occur if VA policy changes and certified sex therapists are included in the qualified mental health professional recruitment in VA Health Care. Couples therapy and/or individual therapy may assist this population in adjusting, but the gender-bias must also be discussed and managed appropriately by professionals who are genuinely concerned with client-informed and culturally-competent care.

In December 2014, The Bob Woodruff Foundation hosted an event in Washington, DC entitled, “Intimacy After Injury.” While male veteran issues regarding genitourinary (GU) injury and infertility were closely examined and discussed with care, women veterans were largely excluded.

In the foundation’s 2015 annual report from the conference, women veterans are only mentioned four times in a very general, broad context throughout the entire 25-page report. Male genitorurinary injuries, on the other hand, were mentioned at least 23 times.

In order to help couples move from dysfunctional states toward functionality regarding sexuality and intimacy, institutional biases must be addressed. Through adequate research, open discussion, and connecting with certified professionals who specifically deal with sexuality and intimacy issues, we can begin a dramatic shift toward incorporating it into the reintegration process and ongoing treatment services.

Additionally, any program, VA-affiliated or not, that treats veterans should incorporate sex and intimacy questions into the initial intake and assessment process to engage military and veteran couples and provide a healthy discussion for overall care (Snyder, Gasbarrini, Doss, & Scheider, 2011).

Working It Out

According to the Maltz Hierarchy of Sexual Interaction, sexuality and intimacy are channeled in “destructive or life-affirming ways” (Maltz, 1995). In determining positive (i.e. fulfillment, genuine intimacy) or negative (objectification, abuse, etc.) sexual interaction, a sex therapist can help military and veteran couples explore issues pertaining to the origins of trust, safety, intimacy, communication, and peak sexual experience (Maltz, 1995).

Couples may explore, with the guidance of the therapist, obstacles tied to current distress, sexual dysfunction, emotional numbing, and other symptoms that are connected to both TBI and PTSD (Nunnink, Goldwaser, Niloofar, Nievergelt, & Baker, 2010). Topics such as masturbation, for example, may be difficult to discuss at times, but opening the discussion of self-pleasure versus intercourse could provide additional insight into defining what sexual satisfaction means for the individual (Hurlbert & Whittaker, 1991).

While the Maltz Hierarchy of Sexual Interaction is often used in sexual education for couples, it can also assist the therapist in identifying other interpersonal issues in a parent-parent relationship. According to Schnarch (1997), passionate interpersonal intimacy, both physically and sexually, requires each person in the couple to face the anxiety of defining oneself, while developing the relationship with their partner. Schnarch refers to this process as differentiation, and highlights the need for a deeper understanding of the self and defining the self before true intimacy can be experienced with one’s partner.

Ultimately, military and veteran couples, where one or both individuals experienced combat exposure, are challenged with relating to one another when two recurring factors persist: when identity is not clearly defined and trust is not established. As a result, physical and emotional connection and sexual expression suffer when intimacy and self-actualization are neglected within an intimate relationship. Both of these issues certainly pertain to the post-war reintegration process, which ties sexuality and intimacy to the Maltz Hierarchy of Sexual Interaction as a theoretical framework for understanding levels of sexual dysfunction.

Intimacy, Sex, and Psychoeducation

Sexual adjustments in veterans who have experienced combat tend to face a variety of issues that impact intimacy and communication. Extended periods of separation, roles changes, definitions of sex evolving at different paces for each partner, communication difficulties due to trauma, and body image contribute to the initial phase of reintegration and adjustment.

When OIF/OEF veterans experience physiological and psychological trauma, the meaning of sex and intimacy can certainly change and the definition of self may lose meaning upon exit from a combat theater into civilian society.

Psychoeducation for military and veteran couples is essential to developing a sound understanding of the impact of combat exposure on interpersonal dynamics. When there is distance between two people – geographic or emotional – maintaining feelings of trust can be a challenge. That distance can either become a long-term issue or lead to relationship breakdown.

While symptoms of PTSD, for example, can contribute to feelings of distrust in others or immediate environment, this can also be applied to platonic and intimate relationships. In an age of exceedingly high divorce rates nationwide, fidelity is another aspect of trust that needs to be addressed and defined between the individuals in the relationship.

Defining fears and desires relating to intimacy may give the opportunity for introspection and open the path of communication with one another. This can, in turn, provide more psychoeducational moments where the couple not only learns about what love, sex, and intimacy mean to them as individuals, but also understand what the other person needs and then proceed accordingly. While combat exposure and related injuries suffered during OIF/OEF may readily contribute to issues with sexuality and intimacy, prior trauma pre-dating war can also impact interpersonal dynamics.

The co-occurrence of sexual assault, in childhood and/or adulthood or other forms of interpersonal violence, can negatively affect the military/veteran couple transition and progress when paired with PTSD, TBI, or other combat-acquired injuries (Campbell, Greeson, Bybee, & Raja, 2008). In addition to cognitive behavioral and psychoeducational strategies, couples and individuals could also benefit from exploring various definitions of sexual expression, experimenting in what works for them personally, and opening communication when it comes to sexuality and intimacy.

Physical pain may also play a role in readjustment, and developing an understanding of both pain management and medication management would be imperative in treatment. Side effects of pain and medication on sexual function and adjusting accordingly can also be facilitated through psychoeducation and understanding what each person in a relationship needs and how to express it.

Evidence-Based Intervention

Military and veteran couples facing difficulties with sexual dysfunction and intimacy after war should be afforded the opportunity to seek assistance through an AASECT-certified sex therapist for thorough psychotherapy. Evidence-based approaches that may be considered include: Creating Lasting Family Connections Marriage Enhancement Program (CLFCMEP), Emotionally Focused Couple Therapy, and Cognitive-Behavioral Conjoint Therapy (CBCT) for PTSD (Johnson, 2002) (Monson & Fredman, 2012) (SAMHSA, 2016).

Intervention options should have relationship skill building along with means to address combat-related trauma through the interpersonal development with one’s spouse. While CLFCMEP can be used to address conflict resolution, mindfulness, and trust, it may not fully explore issues pertaining to sexuality and identity as in sex therapy. However, Emotionally-Focused Couple Therapy and CBCT have similar features and may suggest the non-sex therapist acquire additional, specific training.

While some interventions may assist in the process of confronting couples’ intimacy and sexuality, there are also online forums such as “Making Love after Making War”, which provides military veterans and their families a place to discuss sexual and intimacy-related healing. Providing Supportive Couples Therapy may also help in decreasing overall interpersonal distress and increase focus on partner support.

A relationship cannot survive in the long-term if only one individual – or no one at all – is working toward accomplishing a fulfilling life; in other words, creating a sense of balance and a new mission based on understanding. In effort to educate and apply the appropriate intervention, a therapist may seek help the couple understand trauma that exists in the relationship – military or not. After trauma is addressed and validated, the therapist can then provide the psychoeducation and positive coping strategies to deal with symptoms related to post-war life.

From de-escalating arguments to developing a safety plan in the event of violent behaviors, interventions can allow the couple and therapist to discuss emotional and physical concerns of everyday living. Role-playing exercises and encouraging couples to participate in activities with one another would also contribute to the development and strengthening of intimate bonds and effective communication.

Tackling Outdated Puritanical Policy

Possible interventions for early life trauma through adulthood needs to be addressed and considered when addressing not only veteran reintegration, but veteran health care policy. Advocacy for sexuality, intimacy, health, and post-war reintegration must continue to connect issues with emotional distress from combat, polytrauma and how they relate to the reintegration process and long-term positive coping strategies.

Benefits policies as they stand with VA impact adequate and needed care for veterans and military couples experiencing sexual and intimate dysfunction.

According to VA (2013) benefits coverage in Chapter 2, Section 23.1, Part V states sex therapy is an exclusion to coverage and is cited as “services and supplies are viewed as preventive care and are not covered.” This means counseling services for sex therapy, sexual advice, sexual behavior modification or other similar services are not specifically covered under VA care.

When sexual dysfunction and intimacy deficits exist due to trauma acquired in combat service, one would be inclined to not minimize the reintegration obstacle as a mere preventative care measure that is unnecessary in overall wellness and direct services. If the relationship and intimacy difficulties exist as a result of combat trauma or other military related injuries, then we are far past the phase of preventative care and fully engaged in damage control.

As a result of institutional neglect or bias, veteran health care through VA remains inadequate. Whether one wants to debate American puritanical hypocrisy and sexual suppression (Fessenden, Radel, & Zaborowska, 2014) or much needed structural changes within the VA health care system, policy must change and properly trained mental health professionals must be allowed to engage with couples who need them most in the post-war reintegration process.

A Professional Approach

Mental health professionals looking to assist military and veteran couples in achieving peak intimacy and sexuality in the wake of post-war injuries and trauma may do well to not only review and research related materials, but to consider AASECT certification.

Clinicians can make an impact by advocating for military families, parent-parent or couples without children, by gaining the training necessary in understanding underlying, complex issues and being able to be a direct resource in therapy.

While VA Health Systems have a way to go in revising policy and catching up to veterans needing sex therapy-related services, mental health professionals working with combat veterans can be frontline therapists or effective advocates in pushing for sound policy changes that will positively impact military and veteran marriages and families.

Questions regarding psychosexual and relationship history may help clinicians gain further insight as to what clients need. A comprehensive account of sexual history, attitudes, and beliefs and how combat has altered perception and sensation disability can possibly aid clients in clarifying sexual concerns throughout treatment.

Normalizing and validating concerns, in addition to providing support for couple and individuals dealing with post-war trauma, may also lead to further exploration into sexuality and intimacy. Inviting speakers to veteran-specific events to discuss success stories in overcoming sexual and intimacy dysfunction may also help normalize feelings of anxiety relating to dysfunction. ​

When it comes to sexuality and intimacy, it is not enough to simply tackle outdated policies that shy away from love and sex. Sex must not be reduced to a violent, emotionless wargasm in a post-war homecoming.

Therefore, we must take the steps as professionals to help single and married combat veterans realize what genuine intimacy truly entails. As mental health professionals working with combat veterans, let us proceed with an open mind and remember that everyone not only needs love and the opportunity to live a fulfilled life, but they need to know what that looks like as well.

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