Themes in Experiences of PTSD Symptoms and Relationships Among Male Veterans with Risky Sexual Behavior

Abstract

Objective:

US Veterans with PTSD symptoms are at elevated risk for high-risk sexual behavior (HRSB). Although quantitative research has examined relationships between PTSD symptoms and HRSB, qualitative research to understand the lived experiences of Veterans with PTSD symptoms and HRSB has not been conducted.

Method:

Qualitative interviews were conducted with N=29 male Veterans of Operation Enduring or Iraqi Freedom who had PTSD symptoms and reported recent HRSB. The interviews were analyzed using a phenomenological framework.

Results:

Six themes emerged: (1) avoiding social contact due to feeling different since return from service, (2) effortful self-management, (3) supportive relationships, (4) sex as a means to an end, (5) sex, risk, and intimacy, and (6) responsibility and growth.

Conclusions:

Male Veterans with PTSD symptoms and HRSB reported engagement in significant self-management to re-engage in life, and still reported high levels of difficulty in relationships. They described both wanting to avoid perceived risk associated with intimate relationships and wanting to take risks that caused them to feel alive. Implications for treatment include increased efforts to facilitate coping, to recognize and moderate risk-taking urges, and to build intimacy and trust.

Post-traumatic stress disorder (PTSD) is characterized by intrusive symptoms (e.g., nightmares, flashbacks, repeated intrusive memories), avoidance of trauma-related cues, alterations in mood and cognition, and alterations in arousal and reactivity (e.g., increased risk-taking, irritable behavior, sleep disturbance; American Psychiatric Association, 2013). A recent meta-analysis estimated that 23% (+/− 8.4%) of Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) meet criteria for PTSD (Fulton et al., 2015). PTSD symptoms have been associated with risky sexual behavior in male active duty military personnel (Tavarez, Chun, & Anastario, 2011), as well as in treatment-seeking individuals with substance use disorder (Weiss, Tull, Borne, & Gratz, 2013), women in jail (Staton-Tindall et al., 2015), and men with childhood sexual abuse histories (Holmes, Foa, & Sammel, 2005).

Research has shown that Veterans with greater PTSD symptom severity were more likely than those with less severe symptoms to endorse high risk behavior, including high risk sexual behavior (HRSB) such as unprotected sex, sex with casual or multiple partners, sex under the influence of alcohol or drugs with a person who is not an exclusive partner, or trading sex for money or drugs (Strom et al., 2012), or using digital social media to seek a sexual partner (Turban, Potenza, Hoff, Martino, & Kraus, 2017). By this definition, HRSB is associated with increased risk for sexually transmitted infection (STI): for example, sex with multiple partners in brief intervals or overlapping in time (concurrent partners) is a risk factor in human immunodeficiency virus (HIV) epidemics (Kalichman, Cain, & Simbayi, 2011). Men with concurrent partners are more likely to engage in other forms of HRSB, such as having unprotected sex or having sex under the influence of drugs or alcohol (Adimora, Schoenbach, & Doherty, 2007). As PTSD diagnosis was associated with increased risk for STI in OEF/OIF Veterans (Goulet et al., 2014), understanding the associations between PTSD symptoms and modifiable risk factors, like HRSB, is critically important from a public health standpoint. Various hypotheses have been proposed to account for the relationship between PTSD symptoms and higher propensity towards HRSB: sleep disturbance and other hyperarousal symptoms may reduce the ability to control impulsive behavior (Weiss et al., 2013), increased substance use that often occurs with PTSD may facilitate HRSB (Staton-Tindall et al., 2015), or trauma exposure may lead to participation in HRSB due to inaccurate risk perception (Miller, 1999). Despite several quantitative investigations into the relationship between PTSD symptoms and HRSB separately, no qualitative studies of individuals with both PTSD symptoms and HRSB have been published. Qualitative methods can help develop nuanced understanding of the lived experiences of individuals experiencing PTSD symptoms that may facilitate HRSB, and can help identify important areas of unmet need that may require intervention. This study is an analysis of participant responses during an observational study (Black, Cooney, Sartor, Arias, & Rosen, 2018) examining HRSB among male OEF/OIF Veterans with PTSD symptoms.

Method

This manuscript presents findings from analysis of qualitative data collected for a larger study. The parent project was a study of the association between daily PTSD symptom experiences and risk-taking among post-9/11 male veterans (see details in Black et al., 2018). The parent project examined HRSB, alcohol and other substance use, impulsivity, and risk-taking over a 28-day period using ecological momentary assessment (EMA; Stone & Shiffman, 1994) three times per day. Quantitative results are presented in prior papers (Black et al. 2018; DeViva, Rosen, Cooney, & Black, 2020).

Inclusion/Exclusion Criteria

Participants were recruited by convenience sampling from two Department of Veterans Affairs Medical Center campuses in Connecticut. Participants were male OEF/OIF Veterans who had experienced a military-related trauma and had PTSD symptoms (score of 24/80 or greater on the PTSD Checklist-5; Weathers et al., 2013) and self-reported HRSB in the past 30 days (defined in accordance with U.S. Preventive Services Task Force ([Lee et al., 2016] as behavior increasing risk for sexually-transmitted infection, including at least one instance of unprotected sex, or sex under the influence of alcohol or drugs, with a person who was not a legal spouse or cohabitating and exclusive partner, or, having more than one sexual partner, or, trading sex for drugs or money. Participants were required to provide at least one telephone number that could reliably receive text messages, and to have internet access for completion of daily surveys. Participants were excluded if they reported recent suicidal intent. See prior papers (Black et al. 2018; DeViva et al., 2020) for further detail about study methods. The project was reviewed and approved by the local institutional review board.

Data Collection

Participants attended an in-person meeting with a research assistant to complete an informed consent process, then complete baseline quantitative assessments and receive training in the study’s EMA methods. Over the subsequent 28 days, participants were sent a survey link to their personal cell phones three times daily, for a total of 84 momentary assessment opportunities. Survey links were sent at random times within three fixed 5-hour blocks of time between 7:00am and 10:00pm. Each survey assessed all PTSD symptoms listed in the PTSD Checklist-5 (Weathers et al., 2013), impulsivity, post-traumatic cognitions, and substance use experienced in the past two hours, and all sexual behavior since the last completed assessment, with items to assess whether the sexual behavior met the study definition of HSRB.

Qualitative data collection.

After the 28-day period of daily assessments, participants were asked to attend a follow-up in-person meeting to complete additional assessments and to participate in a semi-structured interview about the experience of study participation and their PTSD symptoms (Appendix B). Qualitative interviews were conducted by the study principal investigator or research assistant, both of whom are female. Interview questions asked what participants did to manage PTSD symptoms, concerns about their sexual behavior, and about their most recent episode of HRSB (using the study definition): how the veteran felt before the HRSB event, how they felt afterward, and whether in the veteran’s opinion the HRSB was related to PTSD symptoms. See Appendix B for full interview.

Qualitative Data Analysis

Interview results were transcribed verbatim. Analysis was conducted by four researchers using the qualitative research principles of phenomenology (Davidson, 2003; Giorgi, 2009; Wertz et al., 2011). Transcriptions were first summarized in narrative form (Sells, Topor, Davidson, 2004), such that one- to two-page narratives were created reflecting the meanings of participants’ stated experiences, using language identical to or closely reflecting the participant’s actual words. These transcripts were then independently coded by four researchers for themes. Each narrative was coded by a researcher who had not created the narrative; one researcher, a qualitative expert, coded all narratives. To permit veterans’ statements to be fully reflected in the data, themes were generated from the interview response as a whole, rather than restricting themes to answers to one specific prompt. Final themes were arrived at by consensus of the four coding researchers in a series of meetings in which themes were proposed and discussed, data were re-reviewed by each researcher between meetings to identify further themes, redundant themes were discarded, and final themes were reviewed for their fit to the data. For this manuscript, our goal was to create a composite portrait, including contradictions, of the lived experiences of veterans with HRSB and PTSD symptoms. These methods have been used in prior qualitative explorations of veterans’ experiences (Desai et al., 2016).

Data availability.

Results for this analysis are based on data from 29 Veterans who participated in the qualitative interview at study follow-up and had an available transcript of interview results. This sample represents 66% of the 44 Veterans who enrolled in the study and completed baseline assessments, and 83% of the 35 Veterans who participated in the follow-up interview. Six interviews were not transcribed due to missing or poor quality audio-recording.

Sample.

Veterans included in this analysis were male with a mean age of 31.69 years (SD = 5.71; range 22-45 years). Approximately half (n=14; 48.3%) identified as White, not of Hispanic origin, 11 (37.90%) as Black, not of Hispanic origin, 3 (10.3%) as Hispanic, and 1 (3.4%) as Asian. Approximately half (n=14, 48.3%) had never been married, 10 (34.5%) were separated or divorced, 4 (13.7%) were married, and 1 (3.4%) was widowed. Most participants (n=26, 89.7%) self-identified as heterosexual; three (10.3%) self-identified as bisexual. Participants had a mean of 14.59 years of education (SD=1.40, range=12-17 years), had served on active duty an average of 65 months (SD=61.61, range=10-309), and had been separated from active-duty service an average of 51.34 months (SD=42.10, range=less than 1-168 months). Participants’ mean baseline PCL-5 score was 48.62 (SD=12.40, range=26-74). Approximately half (n=13, 44.8%) were taking prescribed medications for a psychiatric problem, and nine (31.0%) had ever been hospitalized for a psychiatric problem. A minority of participants (n=6, 20.7%) reported having a diagnosed traumatic brain injury.

Results

In the qualitative analysis, we identified six themes: (1) Avoiding social contact due to feeling different since return from service, (2) Effortful self-management, (3) The importance of supportive relationships, (4) Sex as a means to an end, (5) Sex, risk and intimacy, and (6) Responsibility and growth.

Avoiding Social Contact due to Feeling Different

Participants described themselves as different or changed after military service and being diagnosed with PTSD. These changes were often experienced in subtle ways and often manifested in participants’ relationships. Aspects of their experience that were once tacit or taken for granted, namely issues related to relationships, identity, and day-to-day coping, were experienced in more overt ways.

Central to feeling different was a sense of being persistently misunderstood, making social engagements difficult. At times, participants avoided social situations altogether. Participants described a loss of feeling at ease around others. For example, participant 47 spoke of the challenges he faced in engaging with family and old friends, despite having been very social before his military service. He felt like he was no longer a “regular” among his friends and felt judged by his family members. He noted wanting to make contact with one family member on a holiday, but clarified:

“But I didn’t go by my mom’s. I didn’t want to be around a bunch of people.… I just couldn’t. I feel like people would look at me sometimes, try to see what was going on with me. I’ve been trying to avoid that.”

In addition to describing difficulties maintaining relationships with family and friends, participants also described avoiding strangers for similar reasons. Participant 2 explained that he kept away from people to avoid the risk of having his behavior misunderstood:

“before PTSD I was more a people-person… even if I didn’t know you I’d say hi and generate a conversation just to try to build some type of relationship. Now I try to stay away… That’s part of me just trying to keep myself together because I feel like if I let everything out I don’t know what judgment you’re going to pass.”

Participant 42 also described avoiding situations where he felt others might misunderstand his behavior:

“I generally withdraw from people and situations as much as possible.… I don’t know if it’s a good way but I think it’s better than having people ask you why you are twitching and sweating.”

Participant 2 explained something similar:

“people are not so nice, as far as they don’t understand what is going on in my brain, so I pretty much try and tell them that yeah, I have a problem with PTSD and I’m working on it and I’m getting medicated, I’m seeing therapists and I’m doing all the stuff but at the end of the day that it’s still this problem and they don’t understand. They think that once you get medicated and once you see a therapist you’re cured. No, it’s not that simple: I’m still living and dreaming every day of the nightmare that I’m going through.”

For participant 4, the sense of being different and misunderstood related to his inability to work, and fear of being seen as lazy by others:

“I get real paranoid and real nervous and that’s part of the reason why I’m not working at the moment and I can’t keep trying to get them to understand that, but nobody really understands that and they just think that I’m sitting around trying to do nothing.”

Effortful Self-Management

Stemming from feeling different than they did before service, participants described needing to be more thoughtful about how they managed their anxiety than they had in the past. Participants described expending a large amount of effort and resources in coping with day-to-day life. Coping mechanisms included use of medication, attending therapy, avoiding difficult situations, constant mood-monitoring, working out, listening to music, and keeping busy. As participant 34 explained:

“I’m already listening to meditative music and bringing myself down.… it’s proactive not reactive. I’m actively doing things to make sure my mood and temperament stay in control.”

Participant 42 described the work he had put into managing his symptoms:

“I’ve tried a variety of different things; um, it, didn’t really work out for me. I tried the group therapy thing, that didn’t work out for me at all. I’ve tried some other Veteran-run group therapy things… I’ve gone to meditation classes, anger management classes, sleep classes and any other class you can go to.” He added that he is currently receiving therapy and medication, and “it’s helping, it’s a slow process.”

Participant 46 explained how his workout regimen was key to managing his symptoms:

“I have a lot of rage and… guilt that I try to let go. I work out three times a day just to get rid of it. It’s a huge stress reliever for me. I can’t imagine not being able to go to the gym.”

Additionally, some participants spoke about reducing the use of coping strategies that didn’t work well, like alcohol use. Participant 11 explained that alcohol “makes everything worse” and that he was trying to not drink.

The Importance of Supportive Relationships

While the sense of difference (from the veteran’s former self) described above made it difficult for some participants to maintain good relationships, almost all participants recognized the importance of supportive relationships. Participants found support from relationships with family, friends, fellow veterans, romantic partners, Alcoholics Anonymous (AA) sponsors, and therapists. For many participants, the most important relationships were non-sexual; they did not always see sexual relationships as supportive beyond the immediate function that having sex played. Additionally, many participants spoke of deliberately avoiding intimacy with sexual partners, suggesting they feared the vulnerability implied in having an intimate relationship.

When talking about supportive relationships that they valued, participants spoke about the importance of being understood, of having shared expectations, of familiarity, and of being able to depend on those people. Participants described these relationships as more open and honest, and involving dialogue. This stands in contrast to relationships in which they felt misunderstood, which often involved assumptions and judgments rather than effective dialogue. As participant 31 explained, his relationship with his sisters helped him cope because they were honest with him:

“they’re very open with me. And they’re like ‘Hey, calm down. It’s not that serious.’ And I’m like, ‘what’s not that serious?’… I didn’t know I was making it serious. I’m glad they at least feel comfortable enough with me to open up and tell me.”

Participant 2 received valuable support from his therapist and appreciated a sense of reciprocity in this relationship:

“…at the end of the day she is my nag because she has to make sure that I’m okay and that’s her job. So I like that she calls even if she has but two words to say, ‘how you doing’ ‘are you okay’ ‘have a good day’ stuff like that, just to give me a little pick-me-up real quick.… if I need to pick up my phone and she can pick up hers… it’s a two-way street.”

Participant 3 had similarly developed a valued relationship with his therapist, sharing that he felt understood by his therapist in a way that he did not feel understood by others:

“I don’t have anybody that I’m really talking to about my situation, it’s not like I can talk to my brother because he still doesn’t understand why I have so many behavioral issues, or anybody in general. I know I have someone here that I talk to every Thursday, a therapist.”

Some participants explained that due to the shared experience of being a veteran, they felt they could only be honest with fellow veterans. As participant 46 put it:

“[Fellow veterans] are really the ones who can tell.… I let them in just because they know. I’ll be damned if I try to talk to someone and have someone understand what I’m talking about and they have never even done it. I have veteran friends who have been through a lot worse crap than me but when they see I’m having a really hard day – I wouldn’t say they know what to do, they are just there, and that’s all that matters: they know exactly how I’m feeling.”

For similar reasons, participant 28 relied on his AA sponsors for social support:

“I try to call three of them [sponsor from AA, network] from my phone list per day. The days I do that it’s a better day and the days I skip it or have some reason why I didn’t do it or want to do it, they’re worse.”

While several participants indicated that they only felt able to share their feelings with fellow veterans, participant 26 explained that his romantic partner had attended a caregivers’ group to learn more about his experience and, as a result, she was more understanding:

“the first week she went she learned a lot and talks to other spouses, and she gets insight and can deal with me better… she understands that I’m not crazy and what my triggers are and the concept of it (symptoms and triggers) and understands there’s a reason and gives me space.” He commented later in the interview that her attending this group “shows me she wants to move forward and she’s doing the best she can.”

By contrast, participant 48 explained that his difficulty trusting people was causing problems in his relationship with his girlfriend, who couldn’t understand his lack of trust:

“I’ll argue with my girlfriend all the time because I stay with her and I can’t really control who comes in and out of her house, but I don’t trust anybody. I explain that to her over and over. She didn’t really understand why I had that trust issue.”

Sex as a Means to an End, or, “It Wasn’t Really About Sex”

Participants described using sex for distraction, comfort, or an “ego boost.” For some participants, like participant 46, sexual behavior arose from the desire to find a distraction:

“During sexual intercourse, that’s another thing where I’m able to let go of everything, I don’t have to think about anything and living in the moment…” He revealed that he sought out sex as a distraction: “I realized it was like if anxiety is going, it’s [sex is] a really easy stress release and after that you’re not dwelling on what was bothering you.”

Participant 23 explained that having sex with ‘random’ partners was an effort to manage his loneliness, and he assumed this was true for others in similar situations. He explained:

“Most of us are just lonely and want someone to talk to and that translates into sex anyway.…Loneliness presents itself in different ways. You can be lonely and sad and look for drugs or look for random sexual partners to make you feel better about yourself. It’s all the same thing, and what you do to deal with it.”

Other participants explained their sexual behavior in terms of power, or an ego boost. Participant 1 explained his tendency to seek out women much younger than himself for sex:

“it’s probably more of like an ego boost, to get a young hot female to take interest.… I was feeling depressed before and this was an ego boost that a female liked me. Feel better about myself. It wasn’t really about sex, it was more about other things.”

Sex, Risk, and Intimacy

In addition to speaking about sex as a distraction, comfort, or ego boost, participants also spoke about how sex outside a committed, intimate relationship avoided the risk of getting close to another person. ‘Risky’ sex of this type allowed participants to feel connected without the vulnerability that comes with intimacy, and specifically the risk of being misunderstood. They also shared that sex without intimacy could be frustrating given the lack of connection.

While almost all participants were sexually active with more than one person, many talked about their efforts to avoid intimacy with those people. In some cases, this took the form of a mutual agreement to stick to companionship and sex without long-term commitment. Participant 3 described his relationship with one of his sexual partners:

“I think it’s mutual. When we are hanging out at her place, it’s just you know just me and her watching a movie and one thing leads to another and it’s always that same scenario, it always starts and ends the same way…She knows I’m busy right now and she probably feels something else. It’s always been two-sided; we know what we want from each other.”

Participant 3 described his discomfort with a second partner, who was interested in greater commitment:

“I was probably over at her house and talking about [holiday] plans and her wanting to meet my family and vice versa. I keep telling her no it’s okay, we’re just friendly, we’re not on that level yet, we’re not girlfriend/boyfriend. You don’t need to meet my family right now, things like that.… I don’t want to put a label on the relationship. I don’t think that I’m boyfriend material just yet.”

Participant 46 differentiated an intimate partner from other partners he sought for sex alone. As he explained:

“Some of the other people I would seek out would be on the basis of, ‘this is what it is and that’s it, and there’s nothing and never going to be anything else’. Then there’s one who can make me upset… I really wouldn’t seek her out all the time but she’s very… I’ve known her for years and it’s that intimate connection.”

While participant 3 described emotional detachment from his sexual partners, he also expressed frustration that those partners were not available for support:

“I don’t have any emotional attachments to these women at all. We’re friends, but like right now they weren’t all there for me during… because that [holiday] weekend was pretty stressful for me and I tried to call them up and they were with their own families doing [holiday] stuff, so they weren’t there, and then after that, they called me right after, like pretty much that week to see if I was okay, if I wanted to hangout, if I wanted to have sex. And I was like no, I don’t want to. You guys weren’t there for me during that time.…I don’t need them for the most part, because they aren’t doing anything for me.”

Participant 32 explained how his inability to be emotionally engaged prevented his relationships from developing:

“the girl I was seeing completely broke it off and accused me (well, it’s true) I was emotionless and didn’t seem to care about anything and it’s true.”

Participant 20 explained that while some sexual encounters included an emotional attachment which he found positive, other encounters were quickly followed by ‘bad thoughts’:

“if I have any sort of feelings toward the person then [after sex] it’s still relatively on a high. If I just have sex with them to have sex, I want them away from me and it sometimes brings me lower, all that desire and thought is out of my head and it leaves room for bad thoughts thinking about overseas stuff.”

Responsibility and Growth

Several participants discussed successful steps towards managing their symptoms and reestablishing relationships. In some cases, they talked about how their treatment and self-management had paid off. As participant 34 explained,

“…there is a level of being really bad that I no longer really reach because – and it’s nothing magical – it’s become things that are part of my routine.”

While participants described struggling with intimate relationships, they highlighted the importance of relationships that enabled them to successfully take responsibility. Participant 46 noted that other veterans with whom he participated in a program stayed connected with him, and indicated a sense of commitment to checking in with them as well:

“people I was in the program with, they ask how are you doing? Just making sure.… It does [help]. You can be there for someone all you want in an inpatient program, but it’s a struggle when you get out. There’s no structure… you make that structure. I double tap a couple guys who I care about every day, just to make sure they’re doing all right.”

Participants also reflected on their valued relationships with children. Participant 2 explained that taking responsibility for his children was making a difference:

“I put my daughters on the bus in the morning and that’s pretty much like my therapy, letting them know that I’m here, I’m trying to fix myself so that we can get better. As long as I see them and they give me a nice little pep talk, ‘hey dad, we’re okay as long as you’re okay,’ then I’m good to go.”

Participant 25 explained how being responsible for a child had changed his tendency to be reckless:

“It’s toned down a lot. I put things in perspective, my son, things I have to live for, and I’m not getting younger and it’s time to be an adult. Now, I’m not going to fight somebody and risk going to jail because I don’t want to raise my son from behind the glass.”

Participant 47 described the pain of not being able to provide all the things he wanted to provide for his children following his trauma experience:

“I wanted a gift for my children. I was about to say, but more for me. I’ve been so used to being the provider and stuff. And now dealing with all the stuff I’m dealing with, it’s just harder, you know, you can’t do it. I’m not saying that’s what my children want, but it’s what I want to do. And the fact that I can’t do it makes it harder.”

Discussion

This qualitative investigation of male veterans with past-month HRSB and military-related PTSD symptoms who participated in daily monitoring of their PTSD symptoms and risk taking behavior yielded six major themes: avoiding social engagement due to feeling different since returning from the service, engaging in effortful self-management, identifying supportive relationships as important, sex as a means to an end, issues of sex, risk, and intimacy, and responsibility and growth. While the interview questions asked explicitly about management of PTSD symptoms and experiences of HRSB, the conversations that ensued departed from a narrow consideration of those subjects to other issues related to managing life with PTSD symptoms, with a particular focus on managing relationships of all kinds, sexual and non-sexual.

An underlying theme connecting many of the participants’ experiences was feeling profoundly different after returning from service. This often meant feeling misunderstood by people they had existing relationships with, by new acquaintances, or indeed by society in general. This is consistent with prior qualitative analyses of treatment-seeking veterans who described feeling misunderstood (Desai et al., 2016; Fischer et al., 2015). Prior studies of OEF/OIF veterans have reported veterans’ feeling that the only people who could understand them were other veterans (Rozanova et al., 2016), feeling isolated from their civilian family and friends, and feeling isolated from the military social support networks they had relied on during deployment (Koenig, Maguen, Monroy, Mayott, & Seal, 2014). In this sample, some veterans indicated they could only disclose their experiences to fellow veterans, although one veteran noted his relationship improved when his partner attended a caregivers’ support group.

Another prominent theme was the effort participants engaged in to manage themselves. Adjusting to the new sense of self required intense self-management. Many veterans in this sample had participated in mental health treatment. Some had tried many different types of treatment. In addition to engaging in treatment, participants described deliberately using coping strategies like music, exercise, spending time with loved ones or children, and using sex as a coping tool, consistent with prior studies indicating that coping behaviors used for PTSD symptoms are likely to vary considerably (Lazarus & Folkman, 1984).

It was clear from the way that participants spoke about the people in their lives that, despite the difficulties they faced in maintaining existing relationships and creating new ones, they highly valued what they considered supportive relationships – including family, friends, romantic partners, peers, and clinicians. Previous qualitative studies with mental health care-seeking veterans with PTSD symptoms have identified veterans’ desire for greater trust in others. In one study, the vast majority of veterans reported they would like to be able to trust other people more, and would like to have friends or family understand their experiences during and after deployment (Fischer et al., 2015). One veteran illustrated how much it meant to him that his romantic partner had attended a caregivers’ support group, demonstrating her commitment to understanding him.

In discussing their HRSB, some of the participants described how this type of sex served a short-term purpose – a fleeting distraction, avoidance or escape from loneliness, or a need to feel powerful, consistent with HRSB’s association with sensation seeking in young adults (Charnigo et al., 2013) and similar to how pornography use functioned as an avoidance behavior in a veteran with PTSD symptoms (Larsen, 2019). In the context of relationships, it became clear that many of the participants sought out sex with people they either did not know, or had no commitment to beyond the sex act, as a way to meet an immediate need and avoid the risk that comes with a longer-term intimate, committed relationship. A prior study on propensity towards risky sexual behavior demonstrated a positive correlation with fear of intimacy (Taubman-Ben-Ari et al., 2004). Another reason for the apparent paradox of desiring support and intimacy and engaging in short-term HRSB to avoid intimacy may be PTSD symptoms, which can include feelings of estrangement from others and emotional numbing (American Psychiatric Association, 2013). Experts and empirical data have suggested that individuals with PTSD symptoms may become hyperresponsive to stimuli that elicit negative emotions, and may therefore require more intense stimuli (such as short-term, no-strings-attached sex) to elicit positive emotions (Flack, Litz, Hsieh, Kaloupek, & Keane, 2000; Litz & Gray, 2002). Finally, if sexual behavior functions in some cases as avoidance of intimacy, gradually reducing that behavior during the course of trauma-focused treatment may permit the development of more closeness in relationships, as in the case of a veteran with PTSD symptoms who developed more closeness with his wife as he participated in trauma-focused treatment and gradually reduced pornography use (Larsen, 2019).

Finally, participants described taking responsibility, often for others, and personal growth, consistent with descriptions of posttraumatic growth or positive changes that may occur after a traumatic event (Tedeschi & Calhoun, 1995). Of note, growth can occur concomitantly with PTSD symptoms (Shakespeare-Finch & Lurie-Beck, 2014). Several participants highlighted relationships with children as a prominent reason to continue their growth.

Limitations and Future Research Implications

One limitation of these data is the focus on the experiences of male OEF/OIF veterans with PTSD symptoms and HRSB. Results may not represent the experiences of women veterans, male veterans of other eras, or veterans without PTSD symptoms or HRSB. Other limitations include some missing data (17% of the 35 Veterans who participated in qualitative interview) due to recording error. Further study should expand on these findings by examining the lived experiences of other groups of veterans with PTSD symptoms and HRSB. As PTSD symptoms may include detachment or estrangement from others (criterion D-6) and reduced ability to experience positive emotions (criterion D-7), further study should examine whether the use of HRSB to attain satisfaction while avoiding intimacy is reported in other samples of individuals with PTSD symptoms and HRSB. If replicated, this finding indicates further assessment is needed of veterans’ interpersonal goals to inform further treatment development. For example, if veterans are interested in resolving emotional detachment so they can pursue intimate relationships, treatment developers may wish to increase efforts on relationship building in treatment; if veterans prefer to continue avoiding intimacy, a harm reduction approach could be taken to facilitate attaining satisfaction while reducing risk.

Clinical Implications

Prior quantitative work has identified HRSB as a concern for veterans (Strom et al., 2012; Turban et al., 2017). Clinicians working with veterans should assess for HRSB, including condom-unprotected sex, sex under the influence of drugs or alcohol (which increases the risk for condom mis-use), or traded sex, with a sexual partner who was not an exclusive, cohabitating partner, or having more than one sexual partner.

Participants were clear that they had changed since their service in the military, and that they were now engaged in serious efforts to manage life in the civilian world. Most veterans indicated clearly that they felt misunderstood, or feared being misunderstood, in many social relationships and by strangers. Clinicians working with veterans with PTSD symptoms and HRSB should be sure to explore the changes an individual veteran has noticed and to validate the reported difficulty of adjusting to non-military life. This may be particularly useful in early treatment, when rapport-building and engagement are high priorities and when a treatment provider could easily be viewed as yet another person who doesn’t understand the veteran’s experience. Participants were also clear that supportive relationships were important to them, highlighting the potential role that clinicians can play in the lives of veterans with PTSD symptoms and HRSB. Findings on supportive relationships also underscore the potential importance of involving supportive friends or family in the care of veterans with PTSD symptoms and HRSB, as highlighted by the veteran who emphasized how his partner’s involvement in a caregiver support group had improved his outlook and their relationship. These findings indicate support for continued investment in caregiver outreach or support efforts. Finally, for veterans who indicate they can only connect with other veterans, helping veterans connect to peer specialists or to social opportunities with fellow veterans may facilitate supportive relationships. This may be useful in outpatient treatment settings, and in discussing how to maintain gains made during inpatient or residential care, as in the example provided by the veteran who continued to be in daily contact with others he met in residential care.

As HRSB seemed to function to reduce loneliness while still avoiding intimacy for some veterans, clinicians working with veterans with PTSD symptoms and HRSB should be careful to assess how HRSB functions uniquely for each veteran. Veterans who are using it to seek connection while avoiding intimacy may benefit from learning less risky ways of having human connection or companionship that carries less risk of disease transmission. Those who are seeking a ‘high’ or distraction may benefit from finding alternative activities that provide a ‘high.’ Finally, clinicians working with veterans with PTSD symptoms and HRSB should evaluate and explore any themes of responsibility and growth, noting that posttraumatic growth may occur even while a veteran experiences PTSD symptoms or difficulties in some areas and that actively identifying growth may allow clinicians to reflect clients’ capacity to manage challenges (Shakespeare-Finch & Lurie-Beck, 2014).

Clinical Impact Statement:

Veterans with PTSD symptoms are more likely to have high-risk sexual behavior (HRSB). We interviewed these veterans to learn about their experiences. Veterans described six themes: (1) avoiding social contact due to feeling different since return from service, (2) effortful self-management, (3) supportive relationships, (4) sex as a means to an end, (5) sex, risk, and intimacy, and (6) responsibility and growth. Clinicians supporting veterans with PTSD symptoms and HRSB should help facilitate coping, identify the function of HRSB for each veteran, and help the veteran identify additional mechanisms of satisfying the HRSB function.

Appendix A: Data Transparency

The data reported in this manuscript were collected as part of a larger data collection. Findings from this dataset have been reported in separate manuscripts. This manuscript is unique in that prior publications have used quantitative data. This is the first manuscript from this dataset to examine the qualitative data. This manuscript contains demographic data for sample description, but no other quantitative data.

Prior quantitative publications from this dataset, using quantitative data only:

Manuscript	Variables
Black, Cooney, Sartor, Arias, & Rosen, 2018	PTSD symptoms, alcohol use, trait impulsivity
DeViva, Rosen, Cooney, & Black, 2020	PTSD symptoms, sleep

Prior qualitative publications from this dataset: None. We plan to submit a separate manuscript focusing on participants’ subjective experiences of the ecological momentary assessment research method, focused on perceived benefit and bother of participation in this type of research.

Manuscript	Variables
Enclosed	Experiences of PTSD symptoms, relationships, risk, intimacy, self-management, and growth
Planned	Subjective experiences of the ecological momentary assessment research method including perceived benefit and bother