Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2021 Apr 1.
Published in final edited form as: Psychiatry. 2019 Oct 2;83(1):70–83. doi: 10.1080/00332747.2019.1672439

Sexual Desire among Veterans Receiving Prolonged Exposure Therapy for PTSD: Does Successful PTSD Treatment Also Yield Improvements in Sexual Desire?

Christal L Badour 1, Keith S Cox 2, Jessica RM Goodnight 3, Jessica Flores 1, Peter W Tuerk 4, Sheila AM Rauch 3,5
PMCID: PMC7083685  NIHMSID: NIHMS1540675  PMID: 31577915

Abstract

Objective:

People with posttraumatic stress disorder (PTSD) commonly report difficulties with sexual desire and other aspects of sexual functioning, but it is currently unknown if people who respond to psychotherapy for PTSD also report improvements in sexual desire.

Method:

One hundred and eighty-seven veterans with PTSD received prolonged exposure (PE) therapy at two outpatient PTSD specialty clinics and completed measures of PTSD symptoms (the PTSD Checklist – Military Version) and sexual desire (item 21 of the Beck Depression Inventory – Second Edition) repeatedly throughout the course of treatment.

Results:

The results of a conditional generalized mixed ordinal regression model showed a significant interaction between weeks in treatment and PTSD treatment response in predicting change in sexual desire across the course of treatment. Specifically, PTSD treatment responders reported improvement in sexual desire over the course of treatment, whereas nonresponders did not show changes in sexual desire over time. However, the effect of PTSD treatment response was no longer significant when accounting for severity of depression at the start of treatment. Participants reporting more severe depression at the start of treatment reported less improvement in sexual desire, regardless of PTSD symptom response.

Conclusions:

People with PTSD who respond to PE also report improvements in sexual desire over time, indicating that response to PE is associated with improved sexual desire, but the effect is complicated by the presence of co-occurring depression symptomatology.

Keywords: posttraumatic stress disorder, PTSD, sexual desire, sexual health, veterans

1. Introduction

Difficulties with sexual functioning are a common complaint among survivors of traumatic experiences (Badour et al., 2015). Across gender and trauma type, trauma survivors frequently report sexual problems such as loss of interest in sex, low satisfaction with sex, and difficulty with sexual arousal and/or achieving orgasm (Kotler et al., 2000; Letourneau et al., 1996). In fact, these difficulties are common to the extent that the manual for Prolonged Exposure (PE), an evidence-based psychotherapy treatment for PTSD, references sexual problems as a common reaction to trauma (Foa, Hembree, & Rothbaum, 2007). Research to date suggests that the presence of posttraumatic stress disorder (PTSD), rather than trauma exposure itself, appears to account for the presence of sexual problems after trauma (Yehuda, Lehrner, & Rosenbaum, 2015).

Biological factors may provide a partial account of why PTSD appears to inhibit sexual functioning. Biologically, PTSD is associated with chronic activation of the sympathetic nervous system (SNS; Yehuda, 2009). SNS activation results in increased heart rate, alertness, and focused attention, with suppression of reproductive behavior and reduced blood flow to the genitals. In healthy individuals, the adrenal glands release sufficient cortisol to inhibit SNS responses after a threat and restore homeostasis (Chrousos & Gold, 1992), but this system is impaired in PTSD. PTSD is associated with reduced levels of cortisol and increased release of catecholamines associated with threat responding, such as norepinephrine and adrenaline (Yehuda, 2009). Sexual arousal is associated with similar physiology, such as lowered cortisol (Hamilton, Rellini, & Meston, 2008) and increased release of catecholamines (Meston & Frohlich, 2000), but this relationship is curvilinear in nature (Lorenz et al., 2012). That is, a moderate level of SNS activation is associated with heightened sexual arousal, but a high level of activation, such as is found in PTSD, is associated with fear and anxiety responses that are sexually inhibitory.

Psychological factors also contribute to sexual problems in PTSD. Mood-related symptoms in PTSD, such as loss of interest in previous activities, feeling disconnected or cut off from others, and difficulty experiencing positive emotions, are likely to inhibit sexual desire (Avellanet et al., 2008). Physiological arousal associated with sexual activity may also trigger intrusive memories, flashbacks, or negative feelings associated with traumatic events, which may lead individuals to avoid engaging in sexual activity (Tran, Dunckel, & Teng, 2015). Feelings of guilt, shame, and disgust, which are common in PTSD (Badour & Feldner, 2018; Lee, Scragg, & Turner, 2001), may lead to sexually inhibiting cognitions, such as “I don’t deserve to feel good.” Finally, sexual problems may also be impacted by impairments in intimate relationship functioning associated with PTSD (Kotler et al., 2000; Tran et al., 2015). In particular, veterans with PTSD report high rates of relational discord and problems within intimate relationships (Monson, Taft, & Fredman, 2009).

Pharmacological treatment for PTSD may cause further problems with sexual desire. Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line pharmacological intervention for PTSD (Kelmendi et al., 2016), given their established efficacy for reducing PTSD symptom severity in numerous high-quality clinical trials (Stein, Ipser, & Seedat, 2006). However, these medications are associated with sexual side effects, with between 40% and 72% of patients reporting sexual dysfunction related to SSRI medications (Higgins, Nash, & Lynch, 2010). SSRIs are hypothesized to cause sexual dysfunction by elevating levels of serotonin in the periphery; when serotonin is elevated in these areas, reduced sensation in anatomical structures of the reproductive system results (Frohlich & Meston, 2000). Thus, although SSRIs improve the symptoms of PTSD, they may be unlikely to subsequently result in improvements in sexual problems, given their physiological mechanisms.

Of note, PTSD is also responsive to psychotherapy, with one empirically-supported approach being Prolonged Exposure (PE) therapy. PE is a psychological treatment which has no known sexual side effects. PE is a relatively brief (delivered in 8-13 sessions in this manuscript) psychotherapy that assists people with PTSD in emotionally processing traumatic experiences. PE involves repeated imaginal exposure to trauma memories, as well as in vivo exposure to avoided trauma-related stimuli (Foa et al., 2007). Across multiple randomized controlled trials, PE has demonstrated a large effect compared to control in reducing PTSD symptoms during treatment (Hedges’ g = 1.08), and a medium effect compared to control at follow-up (Hedges’ g = 0.68; Powers et al., 2010). People who respond to treatment with PE show reductions in excessive SNS activity (Hinton et al., 2009; Nishith et al., 2003; Schubert et al., 2019), reduced negative emotional reactivity to reminders of trauma (Sripada & Rauch, 2015), reduced depressive symptoms (Foa et al., 2005), and increased social connection (Rauch et al., 2009). Little to no research to date, however, has examined whether response to PE is associated with changes in aspects of sexual functioning. The present study examines whether veterans with PTSD who respond to Prolonged Exposure (PE) therapy also show specific improvement in one aspect of sexual functioning—sexual desire. Given that PE has resulted in improvement in the biological and psychological factors that may underlie problems with desire and other forms of sexual dysfunction in PTSD, we hypothesize that people who respond to PE will also report improvements in sexual desire.

2. Methods

2.1. Participants

Participants included 187 veterans engaged in PE for PTSD, between January 1, 2006 and August 22, 2013, in two outpatient PTSD specialty clinics located within two VA medical centers. 109 veterans were drawn from a Southeastern VA medical center, while 78 were drawn from a center in the Midwest. The sample was predominantly male (90.4%) and the mean age was 51.19 years (SD = 15.10, range: 22 – 91). Racial/ethnic background was 63.6% White, 11.8% Black or African American, 1.6% Hispanic, and 0.5% Native Hawaiian or other Pacific Islander. Racial/ethnic background was not reported by 22.5% of the sample. Service era included Vietnam (40.1%), Operation Enduring Freedom (OEF)/ Operation Iraqi Freedom (OIF) (27.8%), Desert Storm/Desert Shield (18.2%), Korea (0.5%), World War II (0.5%), and other (12.8%).

2.2. Procedures

The study was conducted as part of a PTSD archival data initiative approved by a VA institutional review board. Study data were collected during routine care. There were no research related exclusion criteria, and no incentives were given as part of study participation.

Participants were assigned to a clinical therapist for PE following a standardized PTSD assessment (Clinician Administered PTSD Scale [Blake et al., 1995] or PTSD Symptom Scale Interview [Foa et al., 1993]). Therapists included clinical psychologists, social workers, psychology postdoctoral residents, or predoctoral psychology interns. Standard clinic practices included weekly PE peer-group supervision. Inclusion criteria were: 1) use of PE throughout treatment, and 2) a baseline and at least one other assessment of PTSD symptoms and sexual interest within a single 180-day period. Prolonged Exposure therapy (PE; Foa et al., 2007) is a manualized cognitive-behavioral therapy protocol typically administered over 8 to 13 weekly 90-minute individual sessions. Primary elements of PE include: a) psychoeducation about trauma and PTSD, b) in-vivo exposures to safe situations avoided due to PTSD-related distress, d) repeated and prolonged imaginal exposure to traumatic memories, and e) processing of in-session imaginal exposures. Between sessions, patients complete in vivo exposures and listen to audio recordings of sessions (including imaginal exposures).

2.3. Measures

2.3.1. Demographic characteristics.

Participant gender, age, race/ethnicity, and service era were obtained from an intake demographic questionnaire. A substantial proportion of participants (22.5%) declined to provide information regarding race/ethnicity.

2.3.2. PTSD symptoms.

PTSD symptom improvement during treatment was assessed via the PTSD Checklist-military version (PCL-M; Weathers, Huska, & Keane, 1991). The PCL-M is a 17-item self-report measure based on Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) criteria for PTSD (American Psychiatric Association, 2000). Scores on the PCL-M range from 17 to 85 with higher scores indicating greater symptom severity. This measure has good convergent and discriminant validity and demonstrates adequate test–retest reliability and internal consistency among veteran samples (Wilkins, Lang, & Norman, 2011). Patients were classified as PTSD symptom responders if their scores on the PCL-M demonstrated reliable and clinically meaningful improvement as defined by a decrease in PCL-M total score ≥ 10 from the first through the last available assessment (Monson et al., 2008).

2.3.3. Sexual desire and depression.

In line with prior research (Sand et al., 2006; Yang et al., 2011), sexual desire was assessed via item 21 of the Beck Depression Inventory (item 21; BDI-II; Beck, Steer, & Brown, 1996). Although this method involves a single-item assessment of sexual desire, BDI-II item 21 has demonstrated convergent validity with other established measures of sexual desire (Yang et al., 2011). Each of the response options on BDI-II item 21 provide specific descriptions of sexual desire status and are presented on an ordinal scale from 0 to 3: “I have not noticed any recent change in my interest in sex” (0), “I am less interested in sex than I used to be”(1), “I am much less interested in sex now”(2), and “I have lost interest in sex completely”(3). Depression symptom severity, aside from sexual desire, was calculated by computing a sum of the 20 remaining items of the BDI-II.

2.3.4. Weeks in treatment.

Each measurement of PTSD symptoms and sexual desire had an associated date. As PE is typically offered on a weekly basis, single-point dates were transformed into a Weeks in Treatment value.

2.4. Data Analysis

Descriptive statistics and primary analyses were conducted using SPSS 24.0 software. The weeks in treatment variable was coded as 0 for the initial assessment, thus allowing intercepts in linear mixed and generalized mixed models to be interpreted as unconditional or conditional effects at the start of treatment. Symptom improvement in PTSD was examined via an unconditional linear mixed model with random intercepts and slopes including all available data. A second conditional model was examined to determine whether improvement in PTSD varied as a function of age, gender, or treatment site. A series of chi-squared tests of independence were then used to examine whether the proportion of participants classified as PTSD treatment responders differed from those classified as non-responders in terms of gender or treatment site. Independent-samples t-tests were then used to examine whether PTSD responders differed from non-responders in terms of baseline PTSD symptom severity, age, or number of weeks in treatment.

Given ordinal scaling of the BDI-21 item measuring sexual interest, non-parametric statistics (i.e., Kruskal-Wallace H test, Mann-Whitney U test) and nominal chi-square tests of independence were used to examine whether age, gender, treatment site, weeks in treatment, initial session PTSD symptoms, or PTSD treatment responder status varied as a function of level of interest in sex at the initial assessment. Change in interest in sex across treatment was also examined via a combination of the Wilcoxin signed rank test and a series of generalized mixed ordinal regression models. Unconditional change in interest in sex was examined via a random intercepts and slopes generalized mixed ordinal regression model including all available data. A second conditional random intercepts and slopes model was examined to determine whether initial interest in sex scores or change in interest in sex across treatment varied as a function of age, gender, treatment site, baseline PTSD symptom severity, or PTSD treatment response. Non-significant covariates were removed, resulting in a final reduced model with improved model fit per Akaikie Corrected and Bayesian Information Criteria indices. All generalized mixed ordinal regression models were coded with BDI-II item-21 = 0 as the reference group so that cumulative odds ratios (CORs) could be interpreted as the odds of reporting no change in interest in sex (score = 0) versus any loss of interest in sex (score = 1-3).

3. Results

3.1. Treatment Adherence and Change in PTSD Symptoms Across Treatment

Patients attended treatment for an average of 11.57 weeks (SD = 4.87; range: 3.00 – 25.57) and completed an average of 4.69 symptom assessments (SD = 2.22; range 2 – 13). The means for first and final session PCL-M total scores were 62.07 (SD = 11.14) and 48.36 (SD = 16.42), respectively. On average, PTSD symptoms on the PCL-M improved significantly across the course of treatment (B = −1.24, SE = 0.09, t = −13.25, p < .001, d = 1.23), resulting in a large effect. The majority of patients in the sample (61.0%) were classified as PTSD treatment responders at the final session, as evidenced by reliable and clinically meaningful change in PTSD symptoms. Neither the slope of change in PTSD symptoms, nor the proportion of participants classified as treatment responders varied as a function of age, gender, or treatment site. There were also no differences between PTSD treatment responders and non-responders in terms of initial session PTSD symptom severity (responders: M = 62.27, SD = 10.93; non-responders: M = 61.75, SD = 11.52; t = −0.31, p = .76) or number of weeks in treatment (responders: M = 11.03, SD = 5.31; non-responders M = 11.92, SD = 4.55; t = −1.22, p = .23).

3.2. Sexual Desire at the Initial Treatment Session

At the first session, 81.8% of patients reported some loss of interest in sex on the BDI-II. Seventy (37.4%) reported less interest in sex (score = 1), 47 (25.1%) reported much less interest in sex (score = 2), and 36 (19.3%) reported complete loss of interest in sex (score = 3). Both age (Χ2 = 12.24, p = .01) and initial session PTSD symptom severity (Χ2 = 15.30, p = .002) were positively related to loss of interest in sex at the initial session. Patients reporting any degree of loss of interest in sex on the BDI-II item (score = 1-3) were significantly older than patients reporting no change in interest in sex (score = 0), (ps < .05). Patients reporting much less (score = 2) or complete loss of interest (score = 3) also reported significantly higher symptoms of PTSD compared to those reporting no change in interest in sex (score = 0, ps < .05). Among patients reporting any loss of interest in sex, PTSD symptom severity was higher among those with a score of 3 compared to those with a score of 2 or 1 and among those with a score of 2 versus 1 (ps < .05). There were no gender (Χ2 = 1.38, p = .71), treatment site (Χ2 = 0.87, p = .83), or PTSD treatment response (Χ2 = 1.26, p = .74) differences in reported interest in sex at the initial session.

3.3. Change in Sexual Desire Across Treatment

Average interest in sex scores were 1.45 (SD = 1.00) at the first and 1.18 (SD = 1.05) at the last session. The non-parametric Wilcoxon Signed Rank test indicated a significant improvement in sexual interest during treatment on average (z = −4.19, p < .001). An improvement in sexual interest was reported by 35.8% of participants (n = 67; response improvement 1 to 0, 13.4%; 2 to 1, 11.8%; 2 to 0, 3.2%; 3 to 2, 4.3%; 3 to 1, 1.6%; 3 to 0, 1.6%). Approximately half the sample (49.2%, n = 92) reported no change in sexual interest from the first to last session (response unchanged: unchanged response = 0, 13.4%; unchanged response = 1, 17.1%; unchanged response = 2, 7.0%; unchanged response = 3, 11.8%). A greater loss of interest in sex was reported by 15.0% of the sample (n = 28; response deterioration 0 to 1, 4.8%; 1 to 2, 5.9%; 1 to 3, 1.1%; 2 to 3, 3.2%). Among the subsample of patients reporting any loss of interest in sex at the first session (n = 153), 22.2% (n = 34) reported a score of 0 on the loss of interest in sex question at the final session.

Consistent with results from the Wilcoxon Signed Rank test, findings from the unconditional mixed-effects ordinal logistic regression model found that the odds of reporting a score of 0 relative to any loss of interest in sex (score: 1-3) increased as a function of weeks in treatment (B = 0.08, SE = 0.02, t = 3.86, p < .001, cumulative odds ratio [COR] = 1.08, 95% confidence interval [CI] = [1.04 , 1.12]). Specifically, the odds of reporting a 0 on the BDI-II item-21 increased by an average of 8.0% per week that patients engaged in treatment. Thus, given an average length of treatment of 11.57 weeks in this sample, the odds of patients reporting a 0 on the loss of interest in sex item versus any loss of interest in sex (score: 1-3) increased by an average of 92.6% across the course of treatment.

As displayed in Table 1, results from the final conditional generalized mixed ordinal regression model found that older age, higher initial session PTSD symptom severity, and PTSD nonresponse during treatment were all associated with an increased likelihood of reporting some degree of loss of interest in sex at the initial assessment. When accounting for interest in sex at the initial assessment, and additional covariates of age and initial session PTSD symptom severity, there was a significant interaction between weeks in treatment and PTSD treatment response in predicting change in interest in sex across the course of treatment. Post hoc tests related to this interaction revealed that interest in sex improved significantly across the course of treatment among PTSD treatment responders (B = 0.11, SE = 0.03, t = 4.31, p < .001, COR = 1.12, 95% CI [1.06 , 1.18]), such that the odds of reporting a 0 on the sexual interest item compared to any loss of sexual interest increased by an average of 12.0% per week engaged in treatment. In contrast, interest in sex did not significantly improve across the course of treatment for PTSD treatment non-responders (B = 0.02, SE = 0.03, t = 0.51, p = .61, COR = 1.02, 95% CI [0.96, 1.08]). Figures 1–3 display the average predicted cumulative probabilities of reporting any loss of interest in sex (scores = 1-3; Figure 1), at least much loss of interest in sex (scores = 2-3; Figure 2), or complete loss of interest in sex (scores = 3; Figure 3) as a function of weeks in treatment and treatment PTSD responder status.

Table 1.

Generalized Mixed Ordinal Regression Model Predicting Change in Interest in Sex Across the Course of PTSD Treatment

B SE t p COR 95% CI
Thresholds (Intercepts) for BDI-II item-21 scores (0 weeks)
 Score = 3 −10.66 1.41 −7.54 <.001
 Score = 2 −8.11 1.38 −5.88 <.001
 Score = 1 −4.39 1.35 −3.24 .001
Predictors of BDI-II item-21 scores (0 weeks)
 Age −0.04 0.03 −2.66 .01 0.96 0.93 – 0.99
 Initial session PTSD symptom severity (PCL-M) −0.09 0.02 −4.11 <.001 0.92 0.88 – 0.96
 PTSD treatment response (non-responder) −0.50 0.49 −1.01 .31 0.61 0.23 – 1.59
Predictors of change in BDI-II item-21 scores
 Weeks in treatment 0.11 0.03 4.31 <.001 1.12 1.06 – 1.18
 PTSD treatment responder status (non-responder) −0.10 0.04 −2.40 .02 0.91 0.84 – 0.98
Open in a new tab

Note: BDI-II = Beck Depression Index-II; CI = confidence interval; COR = cumulative odds ratio; PCL-M = PTSD Checklist-Military; PTSD = posttraumatic stress disorder. Reference group for BDI-II item-21 is 0. Several additional predictors were examined prior to determining the best-fitting model. Age and initial session PTSD symptom severity were not associated with change in BDI-II item-21 scores. Treatment site and gender were not related to initial session or change in BDI-II item-21. These predictors were not retained in the final model.

Figure 1.

Figure 1.

Open in a new tab

Average Cumulative Probability of Reporting any Loss of Sexual Interest (score = 1-3) on BDI-II item 21 during the 12 weeks Following an Initial Assessment as a Function of Week in Treatment and PTSD Responder Status

Figure 3.

Figure 3.

Open in a new tab

Average Cumulative Probability of Reporting “Complete Loss”(3) of Sexual Interest on BDI-II item 21 during the 12 weeks following an initial assessment as a function of week in treatment and PTSD responder status

Figure 2.

Figure 2.

Open in a new tab

Average Cumulative Probability of Reporting “Much Less”(2) or “Complete Loss”(3) of Sexual Interest on BDI-II item 21 during the 12 weeks following an initial assessment as a function of week in treatment and PTSD responder status

3.3.1. Is change in depression driving improvement in sexual desire?

Given an established relationship between depression and decreased sexual desire (Kennedy & Rizvi, 2009), as well as findings that PE results in improvements in depression among veterans (Eftekhari et al., 2013), additional exploratory analyses were conducted to examine whether associations between PTSD symptom response and improved sexual desire remained significant after accounting for change in symptoms of depression. As displayed in Table 2, the interaction between PTSD symptom response and weeks in treatment was no longer significant when initial session depression severity and change in depression were included in the model. Of note, the interaction between change in depression and weeks in treatment was not significant, indicating that change in depression symptoms was not correlated with change in sexual desire. However, there was a significant interaction between initial session depression severity and weeks in treatment. Post hoc tests revealed that interest in sex improved more among individuals reporting less severe depression symptoms (−1 SD: B = 0.24, SE = 0.08, t = 3.03, p = .003, COR = 1.27, 95% CI [1.09 , 1.48]) compared to those reporting more severe depression symptoms (+1 SD: B = 0.10, SE = 0.05, t = 2.19, p = .03, COR = .95, 95% CI [1.01 , 1.21]) at the start of treatment.

Table 2.

Generalized Mixed Ordinal Regression Model Predicting Change in Interest in Sex Across the Course of PTSD Treatment

B SE t p COR 95% CI
Thresholds (Intercepts) for BDI-II item-21 scores (0 weeks)
 Score = 3 −9.45 1.43 −6.62 <.001
 Score = 2 −6.61 1.39 −4.77 <.001
 Score = 1 −2.39 1.36 −1.75 .08
Predictors of BDI-II item-21 scores (0 weeks)
 Age −0.05 0.01 −3.48 .001 0.95 0.93 – 0.98
 Initial session PTSD symptom severity (PCL-M) 0.33 0.02 1.35 .18 1.03 0.99 – 1.08
 PTSD treatment response (non-responder) 0.33 0.51 0.65 .52 1.39 0.52 – 3.74
 Initial session depression symptom severity (BDI-II) −0.21 0.03 −6.91 <.001 0.81 0.77 – 0.86
 Change in depression symptoms (BDI-II) −0.19 0.03 −6.46 <.001 0.82 0.78 – 0.87
Predictors of change in BDI-II item-21 scores
 Weeks in treatment 0.17 0.06 2.77 .01 1.18 1.05 – 1.33
 PTSD treatment responder status (non-responder) 0.04 0.05 0.74 .46 1.04 0.94 – 1.14
 Initial session depression symptom severity (BDI-II) −0.01 0.002 −3.41 <.001 0.99 0.99 – 1.00
 Change in depression symptoms (BDI-II) 0.002 0.003 0.62 .53 1.00 1.00 – 1.01
Open in a new tab

Note: BDI-II = Beck Depression Index-II; CI = confidence interval; COR = cumulative odds ratio; PCL-M = PTSD Checklist-Military; PTSD = posttraumatic stress disorder. Reference group for BDI-II item-21 is 0. Several additional predictors were examined prior to determining the best-fitting model. BDI-II total scores (minus item-21) was disaggregated into two components prior to entry as a level 1 predictor: a between-person intercept (initial session depression symptom severity) and a within-person deviation (change in depression symptoms).

4. Discussion

Results from the present study indicate that among this primarily male sample of older veterans with PTSD, those whose PTSD symptoms responded to Prolonged Exposure (PE) therapy also showed improvement in self-reported sexual desire. For each week a PE responder continued in treatment, their odds of reporting a score of 0 on item-21 of the BDI-II assessing loss of interest in sex increased by 12%. Non-responders to PE did not significantly improve in their sexual interest over the course of treatment. PE does not specifically target sexual desire (Foa et al., 2007), but it is logical that responders to this treatment would experience improvements in their sexual desire. When people respond to PTSD treatment, they often experience improvements in systems associated with excessive physiological arousal, such as cortisol, blood pressure, and heart rate variability (Hinton et al., 2009; Nishith et al., 2003; Schubert et al., 2019). They also experience reductions in depressive symptoms, which are sexually inhibitory (Kennedy & Rizvi, 2009). In addition, as people in PE start to reconnect with their social networks (friends, family, spouse, etc.), they often report increased social function in general including better relationships (Rauch et al 2009).

As improvement in symptoms of depression is one pathway through which PTSD treatment response might lead to improvements in sexual desire, additional exploratory analyses were conducted to determine whether change in symptoms of depression or severity of depression at baseline were driving these findings. Surprisingly, change in depression during PE was unrelated to improvement in sexual desire. However, PTSD treatment response was no longer related to change in sexual desire once baseline symptoms of depression were accounted for. Participants with more severe symptoms of depression at baseline reported less improvement in sexual desire, regardless of PTSD treatment response.

Although these results are interesting, they present with limitations. First, sexual desire was measured by a single item on the BDI-II which queried interest in sex. This prevents conclusions regarding effects of PE on sexual functioning as a broader construct, only allowing for examination of the odds of reporting loss of sexual interest on the item. Some psychometric properties of this item, such as test-retest reliability, are also not available. The ordinal nature of the data necessitated use of non-parametric statistics, which can be less powerful than corresponding parametric tests, particularly if the data are actually drawn from an underlying normal distribution. Although the BDI-II is widely used to measure depression symptom improvement during treatment, the response wording may be confusing in the context of repeated assessment, as there is no response that explicitly identifies improvement in interest in sex or no loss of interest in sex (0 = I have not noticed any recent change in my interest in sex). However, this item has shown convergent validity with other measures of sexual desire and has been used to successfully measure change in this construct over a similar period of time (Sand et al., 2006; Yang et al., 2011). In addition, the BDI-II was used to measure both sexual desire and depression in this study, which introduces the possibility of artificially inflated correlations due to shared common method bias. Future studies would benefit from utilizing independent, reliable measures of sexual desire and depression to allow for a more precise examination of the role of depression in the impact of PTSD treatment on sexual desire. Clinician-administered interviews to assess PTSD and depression symptom change will also increase precision. Inclusion of measures of other domains of sexual functioning would further allow for exploration of other aspects of sexual functioning that may be influenced by successful PTSD treatment, such as dissatisfaction with sex, difficulty with sexual arousal or achieving orgasm. Additionally, some early research has indicated that combining PTSD treatment with specific sex therapy can be effective for resolving sexual dysfunction (Baggett et al., 2017; Chudakov et al., 2008). It will be important to determine whether sexual difficulties among individuals with PTSD may be resolved without the need for specific sex therapy and how the presence of co-occurring depression might impact treatment needs.

Another limitation is the lack of experimental control when collecting data in routine clinical care. For example, the fidelity of providers to the PE manual and the degree to which they engaged in accurate assessment of PTSD is unknown. In addition, data regarding SSRI and other psychotropic medication use was unavailable for this sample, which is an important limitation given the impact of certain medications on sexual desire and other dimensions of sexual functioning. However, there is a paucity of research on improvements in sexual desire with PTSD treatment, and the current study is a first step that addresses these questions in an treatment effectiveness context.

In addition, PE is only one of several available psychological treatments for PTSD, thus it is impossible to know whether results of this study are specific to veterans whose PTSD symptoms responded to PE therapy or if similar improvements in sexual desire would be seen in response to other forms of treatment. Moreover, PE, and other empirically-supported treatments for PTSD, tend to have higher dropout in real-world clinical settings compared to in randomized controlled trials (Najavits, 2015), and certain groups including African Americans are less likely to complete PE and other empirically supported treatments for PTSD compared to Caucasians. Although patients in this study attended treatment for 12 weeks on average, some patients attended treatment for as few as three weeks. Though we did not see any differences in improvement in sexual desire as a function of race/ethnicity or gender, many participants chose not to report their racial and/or ethnic identity, and the small numbers of women in the study may have prevented meaningful gender differences in the models from emerging. Studies including larger samples of female veterans should also consider the impact of sexual victimization on change in sexual desire, as history of sexual trauma both within and outside the military is more common among female veterans. It will also be important for future studies to examine whether results generalize to younger veterans and to those identifying as sexual and/or gender minorities. Researchers should further consider the impact of current intimate relationship status and quality, and reflect upon how concerns regarding sharing details about sexuality might be impacted by receiving care within the VA system. Finally, although the majority of participants were classified as treatment responders, many still reported substantial residual symptoms of PTSD at the end of treatment. It will be important for future studies to determine whether continued reduction of PTSD or depression symptoms results in additional improvements in sexual desire whether from PE or another form of treatment. In addition, this study did not include a follow-up assessment which is critical for determining whether improvements in sexual desire persist beyond the conclusion of treatment.

Despite these limitations, the findings of this study have practical clinical significance. Trauma survivors frequently complain of sexual problems (Badour et al., 2015; Yehuda et al., 2015). Providers of PE for PTSD discuss sexual problems as part of the education surrounding common reactions to trauma as part of the manual (Foa et al., 2007), and relational distress and low sexual desire may be important motivators for treatment seeking, especially among male combat veterans. However, little to no previous research has offered information on whether PE would result in improvements to sexual desire. The present study offers clinicians insight regarding questions that may arise during this discussion; when PE reduces symptoms of PTSD, sexual desire also appears to improve. However, this effect may not generalize to other patients and it appears to be largely driven by baseline depression, with sexual desire improving more among veterans with less severe co-occurring symptoms of depression.

Acknowledgements

Dr. Badour receives support from Grant Number K12 DA035150 from the Office of Research on Women’s Health (ORWH) and the National Institute on Drug Abuse (NIDA). The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health or the Department of Veterans Affairs. Preparation of this manuscript was supported by the Mental Health Service at VA Ann Arbor Healthcare System, Ralph H. Johnson VAMC, and the VA Atlanta Healthcare System.

Footnotes

Conflicts of Interest

The authors have no conflicts of interest to disclose.

References

  1. American Psychiatric Association; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: Author; 2000. [Google Scholar]
  2. Avellanet Y, Ortiz A, Pando J, et al. 2008. Relationship between loss of libido and signs and symptoms of depression in a sample of Puerto Rican middle-aged women. Puerto Rico Health. Sci. J. 27, 85–91. [PubMed] [Google Scholar]
  3. Badour C, Feldner M 2018. The role of disgust in posttraumatic stress: A critical review of the empirical literature. Journal of Experimental Psychopathology, 9, doi: 10.5127/pr.032813. [DOI] [Google Scholar]
  4. Badour C, Gros D, Szafranski D, et al. 2015. Problems in sexual functioning among male OEF/OIF veterans seeking treatment for posttraumatic stress. Compr. Psychiatry. 58, 74–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Baggett L, Eisen E, Gonzalez-Rivas S, et al. , 2017. Sex-positive assessment and treatment among female trauma survivors. J. Clin. Psychol. 73, 965–974. [DOI] [PubMed] [Google Scholar]
  6. Beck A, Steer R, Brown G 1996. Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation. [Google Scholar]
  7. Blake D, Weathers F, Nagy L, et al. 1995. The development of a Clinician-Administered PTSD Scale. J. Trauma. Stress. 8, 75–90. [DOI] [PubMed] [Google Scholar]
  8. Chrousos G, Gold P 1992. The concepts of stress and stress system disorders: Overview of physical and behavioral homeostasis. JAMA. 267, 1244–52. [PubMed] [Google Scholar]
  9. Chudakov B, Cohen H, Matar M, et al. , 2008. A naturalistic prospective open study of the effects of adjunctive therapy of sexual dysfunction in chronic PTSD patients. Isr. J. Psychiatry Relat. Sci. 45, 26–32. [PubMed] [Google Scholar]
  10. Eftekhari A, Ruzek J, Crowley J, et al. , 2013. Effectiveness of national implementation of prolonged exposure therapy in veterans affairs care. JAMA. 70, 949–955. [DOI] [PubMed] [Google Scholar]
  11. Foa E, Hembree E, Cahill S, et al. 2005. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics. J. Consult. Clin. Psychol. 73, 953–964. [DOI] [PubMed] [Google Scholar]
  12. Foa E, Hembree E, Rothbaum B 2007. Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. New York: Oxford University Press. [Google Scholar]
  13. Foa E, Riggs D, Dancu C, et al. , 1993. Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. J. Trauma. Stress. 6, 459–473. [Google Scholar]
  14. Frohlich P, Meston C 2000. Evidence that serotonin affects female sexual functioning via peripheral mechanisms. Physiol. Behav. 71, 383–393. [DOI] [PubMed] [Google Scholar]
  15. Hamilton L, Rellini A, Meston C 2008. Cortisol, sexual arousal, and affect in response to sexual stimuli. J. Sex. Med. 5, 2111–2118. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Higgins A, Nash M, Lynch A 2010. Antidepressant-associated sexual dysfunction: Impact, effects, and treatment. Drug Healthc. Patient Saf. 2, 141–150. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Hinton D, Hofmann S, Pollack M, et al. 2009. Mechanisms of efficacy of CBT for Cambodian refugees with PTSD: Improvement in emotion regulation and orthostatic blood pressure response. CNS. Neurosci. Ther. 15, 255–263. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Kelmendi B, Adams T, Yarnell S, et al. 2016. PTSD: from neurobiology to pharmacological treatments. Eur. J. Psychotraumatol. 7, 31858. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Kennedy S, & Rizvi S (2009). Sexual dysfunction, depression, and the impact of antidepressants. J. Clin. Psychopharmacol. 29, 157–164. [DOI] [PubMed] [Google Scholar]
  20. Kotler M, Cohen H, Aizenberg D, et al. 2000. Sexual dysfunction in male posttraumatic stress disorder patients. Psychother. Psychosom. 69, 309–15. [DOI] [PubMed] [Google Scholar]
  21. Lee D, Scragg P, Turner S. 2001. The role of shame and guilt in traumatic events: A clinical model of shame-based and guilt-based PTSD. Br J Med Psychol, 74, 451–66. [DOI] [PubMed] [Google Scholar]
  22. Letourneau E, Resnick H, Kilpatrick D, et al. 1996. Comorbidity of sexual problems and posttraumatic stress disorder in female crime victims. Behav. Ther. 27, 321–36. [Google Scholar]
  23. Lorenz T, Harte C, Hamilton L, et al. 2012. Evidence for a curvilinear relationship between sympathetic nervous system activation and women’s physiological sexual arousal. Psychophysiology. 49, 111–117. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Meston C, Frohlich P 2000. The neurobiology of sexual function. Arch. Gen. Psychiatry. 57, 1012–1030. [DOI] [PubMed] [Google Scholar]
  25. Monson C, Gradus J, Young-Xu Y, et al. , 2008. Change in posttraumatic stress disorder symptoms: Do clinicians and patients agree? Psychol. Assess. 20, 131–138. [DOI] [PubMed] [Google Scholar]
  26. Monson C, Taft C, Fredman S 2009. Military-related PTSD and intimate relationships: From description to theory-driven research and intervention development. Clin. Psychol. Rev. 29, 707–714. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Najavits L (2015). The problem of dropout from “gold standard” PTSD therapies. F1000Prime Rep. 7, 43. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Nishith P, Duntley S, Domitrovich P, et al. , 2003. Effect of cognitive behavioral therapy on heart rate variability during REM sleep in female rape victims with PTSD. J. Trauma. Stress. 16, 247–250. [DOI] [PubMed] [Google Scholar]
  29. Powers M, Halpern J, Ferenschak M, Gillihan S, & Foa E (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30, 645–641. [DOI] [PubMed] [Google Scholar]
  30. Rauch S, Grunfeld T, Yadin E, et al. , 2009. Changes in reported physical health symptoms and social function with prolonged exposure therapy for chronic posttraumatic stress disorder. Depress. Anxiety. 26, 732–738. [DOI] [PubMed] [Google Scholar]
  31. Sand P, Goldberg R, Dmochowski R, et al. , 2006. The impact of the overactive bladder syndrome on sexual function: A preliminary report from the Multicenter Assessment of Transdermal Therapy in Overactive Bladder with Oxybutynin trial. Am. J. Obstet. Gynecol. 195, 1730–1735. [DOI] [PubMed] [Google Scholar]
  32. Schubert C, Schreckenbach M, Kirmeier T, et al. 2019. PTSD psychotherapy improves blood pressure but leaves HPA axis feedback sensitivity stable and unaffected: First evidence from a pre-post treatment study. Psychoneuroendocrinology. 100, 254–263. [DOI] [PubMed] [Google Scholar]
  33. Sripada R, Rauch S 2015. Between-session and within-session habituation in Prolonged Exposure Therapy for posttraumatic stress disorder: A hierarchical linear modeling approach. J. Anxiety Disord. 30, 81–87. [DOI] [PubMed] [Google Scholar]
  34. Stein D, Ipser J, Seedat S. 2006. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst. Rev. CD002795. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Tran J, Dunckel G, Teng E 2015. Sexual dysfunction in veterans with post-traumatic stress disorder. J. Sex. Med. 12, 847–855. [DOI] [PubMed] [Google Scholar]
  36. Weathers F, Huska J, Keane T 1991. PCL-M for DSM-IV. Boston, MA: National Center for PTSD - Behavioral Science Division. [Google Scholar]
  37. Wilkins K, Lang A, Norman S 2011. Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depress. Anxiety. 28, 596–606 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Yang E, Kim S-W, Heo C-Y, & Lim J-Y. 2011. Longitudinal changes in sexual problems related to cancer treatment in Korean breast cancer survivors: A prospective cohort study. Support Care Cancer. 19, 909–918. [DOI] [PubMed] [Google Scholar]
  39. Yehuda R, Lehrner A, Rosenbaum T 2015. PTSD and sexual dysfunction in men and women. J. Sex. Med. 12, 1107–1119. [DOI] [PubMed] [Google Scholar]
  40. Yehuda R Status of glucocorticoid alterations in post-traumatic stress disorder. 2009. Ann. NY. Acad. Sci. 1179, 56–69 [DOI] [PubMed] [Google Scholar]

RESOURCES