Relationship Between Post-Traumatic Stress Disorder and Sexual Difficulties: A Systematic Review of Veterans and Military Personnel

Abstract

Background:

Posttraumatic stress disorder (PTSD) is associated with sexual difficulties but the nuances of this relationship remain elusive. Research has increased in recent years, most notably following publication of several reviews in 2015.

Aim:

This systematic review examines the relationship between PTSD and sexual difficulties in veterans/military personnel.

Methods:

A systematic review was conducted using PRISMA guidelines in PsycINFO and PubMed databases for studies examining a diagnosis of PTSD or PTSD severity in relation to a range of sexual difficulties. Forty-three studies were identified that met inclusion and exclusion criteria for this review.

Results:

PTSD was associated with increased risk of experiencing at least one sexual difficulty. PTSD was most clearly associated with overall sexual function, sexual desire, sexual satisfaction, and sexual distress. Results were mixed for sexual arousal, orgasm function, erectile dysfunction, premature ejaculation, sexual pain, and frequency of sexual activity. PTSD symptom clusters of avoidance and negative alterations in cognition/mood were most commonly associated sexual difficulties. Few studies compared results by gender and trauma type.

Clinical Implications:

Clinicians should inquire about sexual health in relation to PTSD symptoms and target avoidance and negative mood symptoms by incorporating sexual exposure assignments and sexual activation exercises when appropriate.

Strengths & Limitations:

This systematic review synthesizes an extensive literature that has grown substantially in the past 5 years and includes studies with low to moderate risk of bias. Limitations of the existing literature include challenges differentiating between PTSD and depression, inconsistent measurement of PTSD and trauma histories, inconsistent operationalization and measurement of sexual outcomes, and largely cross-sectional study designs.

Conclusion:

PTSD is linked to a range of sexual outcomes. The current literature suggests that PTSD is associated with sexual difficulties related to both the sexual response cycle (ie, sexual desire) and one’s emotional relationship to sexual activity (e.g., sexual distress). More research is needed to increase confidence in findings.

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) is one of the most common mental health disorders among United States veterans,¹ and is often chronic and associated with significant functional impairment.² Lifetime prevalence varies across samples, but approximately 7% of veterans in the general population meet criteria for PTSD³ and approximately 13% of active duty military personnel have a current PTSD diagnosis.⁴ Higher rates of PTSD (over 25%) are found among veterans from the wars in Afghanistan and Iraq who seek medical care at the Veterans Health Administration (VHA).⁵ PTSD is associated with a plethora of social and personal health concerns, including personality, mood, anxiety, and substance use disorder comorbidity,³ suicidal ideation,⁶ and interpersonal difficulties.^7,8 Although the link between PTSD and relationship difficulties more broadly has been extensively studied, less is understood about the association between PTSD and sexual difficulties, specifically. This is a critical gap in the literature, given that sexual difficulties are a common clinical complaint among those with trauma histories^9,10 and researchers have implored clinicians to address sexual symptoms in the veteran population.^11,12

POSTTRAUMATIC STRESS DISORDER AND SEXUAL DIFFICULTIES

PTSD may impact a variety of sexual outcomes,¹³ including sexual desire, function (e.g., sexual arousal, orgasm), genito-pelvic pain, sexual satisfaction sexual distress, and frequency of sexual activity. Furthermore, sexual difficulties may not remit with PTSD treatment.¹³ Research suggests that PTSD, not trauma exposure alone, is proximally related to sexual difficulties.¹⁴ However, having a sexually-based index trauma may confer unique risk for sexual difficulties compared to having a nonsexual index trauma.¹⁵ Thus, a more nuanced understanding of how PTSD impacts the sexual lives of veterans and military personnel (V/MP) is paramount to improving the quality of their care.

Indeed, major health systems, such as the VHA, advocate for the use of a “Whole Health” framework of care that integrates patient preference and values and considers multiple domains of health.¹⁶ Moreover, VHA researchers highlight the relationship between PTSD and sexual difficulties.¹⁷ However, in routine clinical practice trauma specialists often neglect to query patients about their sexual experiences. Researchers have examined barriers that providers encounter when discussing sexuality with patients, and findings point to personal discomfort, concern of upsetting patients, and inadequate training such as lack of awareness of comorbidity, among other factors.¹⁸ Despite provider barriers to assessment, sexual health is an important contributor to quality of life,¹⁹ and of high priority to many patients.^18,20

THEORIZED MECHANISMS OF ASSOCIATION

The Diagnostic and Statistical Manual for Mental Disorders, 5^th edition²¹ criteria for PTSD includes 4 symptom clusters: re-experiencing, avoidance, negative alterations in cognition and mood (NACM), and hyperarousal. Researchers theorize the psychological and biological mechanisms through which PTSD and sexual difficulties may be associated. Specifically, PTSD re-experiencing symptoms, which include intrusive images, flashbacks, and associated emotional distress, may occur during sexual activity to the extent that sexual activities can be explicit reminders of trauma even when traumatic experiences were non-sexual.^22-24 A survivor of sexual trauma eloquently recalls, “As I got turned on, images of the abuse appeared; it became impossible to separate then from now,” (Haines, 1999, pg. XXXI²⁵). Indeed, survivors of adult sexual assault frequently report that being reminded of trauma during sexual activity can interfere with sexual functioning and satisfaction, consistent with research on the role of attention in sexual functioning^26-28 and even lead to flashbacks²³ and dissociation.²⁹ One study of civilian women with a history of sexual trauma found that greater re-experiencing symptoms were associated with more difficulties in orgasm function and higher sexual distress.³⁰ In the case of non-sexual trauma, feeling emotionally or physically vulnerable during sexual activity might function as a reminder of traumas in which one felt vulnerable (e.g., of being a prisoner of war), leading to intrusive images and vulnerability-related distress.

PTSD avoidance symptoms (e.g., avoiding situations, stimuli, or emotions reminiscent of trauma) can also negatively impact sexuality. Patients with PTSD often avoid people, places, and activities that remind them of traumatic events, including sexual stimuli.³¹ They may avoid sexual activity altogether, or aspects of sexual activity (e.g., avoiding certain sexual acts, keeping eyes closed), to decrease the likelihood of re-experiencing symptoms and may do so through outright avoidance of sexual behaviors or through the use of alcohol and other drugs prior to sexual activity.²⁵ Emotional processing theory³² suggests that avoidance of sexual stimuli perpetuates negative associations with sexual activity through negative reinforcement, thus maintaining PTSD symptoms and sexual difficulties.

Trauma survivors also describe developing NACM (e.g., “The world is dangerous,” “I am bad,” feelings of sadness, anger, fear, emotional numbing, and decreased interest in activities they used to enjoy). Negative beliefs may include an inability to trust others, including romantic partners, or the dangerousness of sexual activity, among other themes. These NACM can adversely impact multiple aspects of sexuality. Individuals may avoid sexual activity for fear that they will be hurt or amotivation to engage in previously pleasurable activity.³³ Cognitive interference during sexual activity related to these beliefs can also negatively impact sexual function and satisfaction.²⁶ Furthermore, certain antidepressant medications (e.g., selective serotonin reuptake inhibitors; SSRIs) often prescribed to treat this cluster of PTSD symptoms can negatively impact sexual desire, sexual arousal, and orgasm function.^34,35

Lastly, PTSD hyperarousal symptoms include increased startle response, irritability, feeling “superalert,” watchful or on guard, taking risks, and difficulty concentrating, which may make it difficult to be mentally present during sexual activity, interfering with sexual function. Furthermore, hyperarousal symptoms are characterized by an increase in sympathetic nervous system activity. While some sympathetic nervous system activity is necessary for adequate sexual responding to occur, too little, or too much, as in the context of PTSD, can impair functioning.³⁶ Sexual functioning impairments may result from an inability to downregulate the fear response and engage in the inhibitory neurobiological processes necessary for healthy sexual functioning, especially as the physiological arousal becomes paired with threat.¹⁴ Indeed, in a study on civilian women with PTSD, women with hyposexual desire disorder were significantly more likely to meet criteria for avoidance and hyperarousal symptoms in the past month compared to those without hyposexual desire disorder.³⁷ Similarly, in a sample of women veterans who experienced military sexual assault, heightened arousal, particularly symptoms of anger, irritability, and difficulties concentrating and sleeping, was associated with lower sexual function and satisfaction.³⁸ Based on prior research and clinical case study, it appears that PTSD symptoms are each uniquely associated with various aspects of sexuality. However, questions remain regarding for whom and under what circumstances these associations exist and how to best capture these phenomena in research.

PREVIOUS REVIEWS

We are aware of 3 reviews on PTSD and sexual dysfunction.^14,17,39 Although these previous reviews provide important examinations of this research area, they are limited in terms of focus and methodology. Both Bentsen et al (2015)³⁹ and Yehuda et al (2015)¹⁴ either limited or excluded studies that examined PTSD and sexual functioning in women veterans or where PTSD was related to sexual trauma³⁹, likely due to little research on PTSD and sexual functioning within women veterans at the time. Likewise, both Tran et al (2015)¹⁷ and Yehuda et al (2015)¹⁴ did not specify methods for comprehensive article identification. Given the significant increase in research since the publication of these reviews in 2015 (see Figure 1 for number of publications by year), the current review expands upon these previous works, both in terms of comprehensive coverage of recent literature, as well as an expansion in scope to include the examination of PTSD and sexual functioning within women veteran samples.

Figure 1.

Number of publications by year.

METHOD

We sought to evaluate the full spectrum of literature that included both women and men V/MP and comparison groups of individuals without PTSD to better illustrate associations that are likely attributable to PTSD symptomatology. We chose to focus on V/MP samples, as veterans are an important subpopulation in which to study associations of PTSD and sexual difficulties. Indeed, V/MP have poorer health and health behaviors compared to civilians,^40,41 are more vulnerable to experiencing traumatic events,⁴² and demonstrate higher rates of lifetime PTSD.³ Findings are organized by sexual outcome, given diverging etiologies of sexual problems and their potential to be differentially associated with PTSD symptoms. We include sexual constructs when relevant to sexual functioning difficulties or to participants’ relationship to sexual activity. We highlight patterns of results regarding the basic relationship between PTSD (diagnosis and symptom severity) and sexual difficulties and note proposed mechanisms of the association of PTSD with sexual difficulties.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used in the writing of this systematic review. Sexual outcomes were considered if the constructs characterized participants’ relationship to sexual activity, and/or if they were included in the Female Sexual Functioning Index (FSFI⁴³) or the International Index of Erectile Function (IIEF⁴⁴) (i.e., erectile function, intercourse satisfaction, orgasmic function, sexual arousal, sexual desire, sexual pain, and overall sexual satisfaction), as they are the most commonly used measurements of sexual functioning in research. Multiple studies utilized measures of sexual difficulties that were not the FSFI or IIEF. In those cases, constructs analogous to those measured in the FSFI and IIEF were examined. Constructs that describe an individual’s perceptions of sexual activity include sexual distress (e.g., anxiety related to sexual activity), satisfaction with sexual activity, self-rated importance of sexual activity, and frequency of sexual activity. Other sexual constructs that may be associated with PTSD, such as impulsive and/or compulsive sexual behavior^45,46 or sexual risk-taking behavior,⁴⁷ were not included in order to increase the homogeneity of our review and the consistency in our theoretical explanations of the relationship between PTSD and sexual functioning. Articles measuring the above constructs were included if they (i) examined V/MP; (ii) assessed any of the sexual constructs described above; (iii) assessed PTSD symptoms; (iv) examined the relationship between PTSD symptoms and sexual constructs of interest; (v) reported quantitative data; and (vi) were published in English. To review the widest range of articles, we did not restrict year of publication. The final search was conducted on October 16^th, 2020.

Search terms were created for PubMed and PsycINFO with the aid of a university librarian (see Supplemental Material for search terms). Reference sections were also reviewed. Forty-three (43 studies) were included in the final review out of 278 initial citations reviewed (see Figure 2 for PRISMA diagram referencing reasons for exclusion). The first author determined eligibility of articles, consulting co-authors as needed. The third author independently assessed roughly 15% of the 278 articles for eligibility and inter-rater reliability was 100%. Articles were summarized with regard to their features and findings in several domains (see Table 1).

Figure 2.

Article selection flow chart.

Table 1.

Sample, method, and findings information organized by sexual outcome

Overall sexual function
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Andresen (2019)	671	Low	100	MST	Survey	Sex: FSFI total PTSD: PCL-5	PTSD total	↓
Beaulieu (2015)	247	Medium	10.5	Varied	Survey	Sex: ASEX total PTSD: PC-PTSD	PTSD v. no	NS°
Blais (2018)	1189	Low	100	MST	Survey	Sex: FSFI* PTSD: PCL-5	Re-experiencing, avoidance, NACM, anhedonia, dysphoric arousal, anxious arousal	↓
Blais, Livingston (2020)	833	Low	100	Varied	Survey	Sex: FSFI PTSD: PCL-5	Anhedonia, dysphoric arousal	↓
Blais, Zalta (2020)	426	Low	100	Varied	Survey	Sex: FSFI PTSD: PCL-5	Re-experiencing, avoidance, NACM, anhedonia, dysphoric arousal, anxious arousal	↓
Cosgrove (2002)	90	Medium	0	Combat	Interview Survey	Sex: IIEF-15 PTSD: Diagnostic interview, PCL	(1) PTSD < no (2) PTSD total	(1) ↓ (2) ↓
DiMauro (2018)	255	Low	100	Varied	Survey	Sex: FSFI PTSD: PCL-5	PTSD total	↑
Khalifian (2020)	138	Low	18.8	Varied	Survey	Sex: CSFQ PTSD: PCL-5	PTSD total	NS°
Wilcox (2014)	367	Low	0	Varied	Survey	Sex: IIEF-5 PTSD: PCL-M	PTSD < no	↓
Sexual desire
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Anticevic (2008)	156	Medium	0	Combat	interview	Sex: 1 item assessing desire for select sexual activities PTSD: CAPS, MS-PTSD	(1) PTSD < no: Desire for kissing, masturbation, petting, oral sex, sexual intercourse (2) PTSD+AD < PTSD−AD: Desire for kissing, masturbation, petting, oral sex, sexual intercourse	(1) ↓ (2) ↓
Arbanas (2010)	164	Medium	0	Combat	Survey	Sex: IIEF-D PTSD: CAPS	(1) PTSD+AD v. PTSD−AD (2) SubPTSD+AD v. SubPTSD−AD (3) PTSD < no (4) PTSD+AD <SubPTSD−AD	(1) NS (2) NS (3) ↓ (4) ↓
Badour (2015)	150	Medium	0	Combat	Interview Survey	Sex: BDI item assessing loss of sexual interest in past 2 weeks; IPF item assessing sexual desire in current relationship PTSD: CAPS, PCL	(1) Loss of interest: PTSD < no (2) Desire: PTSD v. no (2) Loss of interest: PTSD dx, PTSD total, re-experiencing, avoidance/numbing, hyperarousal (3) Desire: PTSD total, Re-experiencing, avoidance/numbing, hyperarousal	(1) ↓ (2) NS (3) ↓ (4) ↓
Badour (2016)	45	High	0	Combat	Interview Survey	Sex: IPF item assessing sexual desire in current relationship PTSD: CAPS, PCL	(1) Baseline: PSTD total (2) Change in desire across treatment: PTSD total	(1) NS (2) NS
Badour (2020)	187	Low	9.6	Unknown	Intervention (PE)	Sex: BDI-II item assessing loss of sexual interest in past 2 weeks PTSD: PCL	(1) Initial session PTSD total (2) PTSD nonresponse during treatment	(1) NS° (2) NS
Becirovic (2019)	105	Medium	0	Combat	Survey	Sex: IIEF-D PTSD: HTQ	(1) PTSD < no: no dysfunction, mild, mild-moderate, moderate, severe HTQ total	(1) ↓ (2) ↓
Cosgrove (2002)	90	Medium	0	Combat	Interview Survey	Sex: IIEF-D PTSD: CAPS, PCL	(1) PTSD v. no (2) PTSD total	(1) NS (2) ↓
Garneau-Fournier (2018)	2002	Low	67	MST	Survey	Sex: Lack of sexual thoughts or desire for sex (men) or reduced or absence of interest or pleasure in sexual activity (women) at least 50% of the time in last 6 months PTSD: PC-PTSD	(1) Men: PTSD < no (2) Women: PTSD < no	(1) ↓ (2) ↓
Khalifian (2020)	138	Low	18.8	Varied	Survey	Sex: CSFQ-D/F, CSFQ-D/I PTSD: PCL	(1) D/F: PSTD total (2) D/I: PTSD total	(1) NS (2) NS°
Lehrner (2016)	170	Low	0	Combat	Survey	Sex: BDI item assessing loss of interest in past 2 weeks PTSD: CAPS	CAPS score	↓
Letica-Crepulja (2019)	300	Low	0	Combat	Interview Survey	Sex: IIEF-D PTSD: CAPS, PCL-M	PTSD total, Re-experiencing, avoidance/numbing, NACM, hyperarousal	↓
McIntyre-Smith (2015)	99	Medium	0	Unknown	Interview, Survey	Sex: PHQ item assessing desire or pleasure during sex in last 4 weeks PTSD: PCL-M	(1) PTSD total (2) Intrusive, Avoidance/numbing, arousal	(1) NS (2) NS
Richardson (2020)	543	Low	0	Unknown	Survey	Sex: PHQ item assessing desire or pleasure during sex in last 4 weeks PTSD: PCL-M	(1) PTSD total (2) Re-experiencing, avoidance/numbing, arousal	(1) ↓ (2) ↓
Sexual arousal
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Badour (2015)	150	Low	0	Combat	Interview Survey Chart review	Sex: IPF item assessing sexual arousal PTSD: CAPS, PCL	(1) PTSD v. no (2) PTSD total, re-experiencing, avoidance/numbing, hyperarousal	(1) NS (2) NS°
Badour (2016)	45	High	0	Combat	Intervention (BA-TE)	Sex: IPF item assessing sexual arousal PTSD: CAPS, PCL	PTSD total	NS
Beaulieu (2015)	247	Medium	10.5	Varied	Survey	Sex: ASEX items assessing ease of sexual arousal and vaginal lubrication difficulties PTSD: PC-PTSD	(1) Arousal: PTSD v. no (2) Lubrication: PTSD v. no	(1) NS (2) NS
Khalifian (2020)	138	Low	18.8	Varied	Survey	Sex: CSFQ A/E subscale PTSD: PCL-5	PTSD total	NS
Erectile function
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Anticevic (2008)	156	Medium	0	Combat	Interview	Sex: 1-item assessing sufficient erection for intercourse PTSD: CAPS, MS-PTSD	(1) PTSD < No (2) PTSD+AD v. PTSD−AD	(1) ↓ (2) NS
Arbanas (2010)	164	Medium	0	Combat	Interview Survey	Sex: IIEF-EF PTSD: CAPS	(1) PTSD v. no (2) PTSD+AD v. PTSD−AD (3) SubPTSD+AD v. SubPTSD−AD (4) PTSD+AD < SubPTSD+AD	(1) NS (2) NS (3) NS (4) ↓
Badour (2015)	150	Medium	0	Combat	Interview Survey Chart review	Sex: ED chart dx or ED rx PTSD: CAPS, PCL	(1) ED problem list: PTSD total, Re-experiencing, Avoidance/numbing, hyperarousal (2) ED rx: PTSD total, Re-experiencing, Avoidance/numbing, hyperarousal	(1) NS (2) NS
Beaulieu (2015)	247	Medium	10.5*	Varied	Survey	Sex: ASEX item assessing ease of erection PTSD: PC-PTSD	PTSD v No	NS
Becirovic (2019)	105	Medium	0	Combat	Survey	Sex: IIEF-EF PTSD: HTQ	(1) PTSD < no: no dysfunction, mild, mild-moderate, moderate (2) HTQ total	(1) ↓ (2) ↓
Cosgrove (2002)	90	Medium	0	Combat	Interview Survey	Sex: IIEF-EF (severity and dx) PTSD: Diagnostic interview, PCL	(1) EF: PTSD v. no (2) ED: PTSD > no (3) PTSD total	(1) NS (2) ↓ (3) ↓
Garneau-Fournier (2018)	2002	Low	67*	MST	Survey	Sex: Difficulty getting or keeping an erection at least 50% of the time in the past 6 montds PTSD: PC-PTSD	PTSD v No	NS
Letica-Crepulja (2019)	300	Low	0	Combat	Survey	Sex: IIEF-EF PTSD: PCL-5	Re-experiencing, avoidance, NACM, hyperarousal	↓
McIntyre-Smith (2015)	99	Medium	0	Unknown	Interview, Survey	Sex: IIEF-EF PTSD: Clinical interview, PCL-M	PTSD total, re-experiencing, avoidance/numbing, hyperarousal	NS°
Wilcox (2014)	367	Low	0	Varied	Survey	Sex: IIEF-5 PTSD: PCL-M	PTSD < no	↓
Orgasm
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Anticevic (2008)	156	Medium	0	Combat	Interview Survey	Sex: 1-item assessing difficulty reaching orgasm PTSD: CAPS, MS-PTSD	(1) PTSD v. no (2) PTSD+AD v. PTSD−AD	(1) NS (2) NS
Arbanas (2010)	164	Medium	0	Combat	Interview Survey	Sex: IIEF-O PTSD: CAPS	(1) PTSD+AD v. PTSD−AD (2) SubPTSD+AD v. SubPTSD−AD (3) PTSD v. no (4) PTSD+AD < SubPTSD−AD	(1) NS (2) NS (3) NS (4) ↓
Beaulieu (2015)	247	Medium	10.5	Varied	Survey	Sex: ASEX-O PTSD: PC-PTSD	ASEX-O: PTSD < no	↓
Becirovic (2019)	105		0	Combat	Survey	Sex: IIEF-O PTSD: HTQ	(1) PTSD < no: no dysfunction, mild, mild-moderate, moderate, severe (2) HTQ total	(1) ↓ (2) ↓
Cosgrove (2002)	90	Medium	0	Combat	Interview Survey	Sex: IIEF-O PTSD: Diagnostic interview, PCL	(1) PTSD < no (2) PTSD total	(1) ↓ (2) ↓
Garneau-Fournier (2018)	2002	Low	67	MST	Survey	Sex: Delayed absence of ejaculation or orgasm at least 50% of the time in the past 6 months PTSD: PC-PTSD	(1) Men: PTSD v. no (2) Women: PTSD < no	(1) NS (2) ↓
Khalifian (2020)	138	Low	18.8	Varied	Survey	Sex: CSFQ-O PTSD: PCL	PTSD total	NS
Letica-Crepulja (2019)	300	Low	0	Combat	Survey	Sex: IIEF-O PTSD: PCL-5	PTSD total, Re-Experiencing, Avoidance, NACM, Hyperarousal	↓
McIntyre-Smith (2015)	99	Medium	0	Unknown	Interview Survey	Sex: IIEF-O PTSD: Clinical interview, PCL-M	PTSD Total, Re-Experiencing, Avoidance/Numbing, Hyperarousal	NS°
Premature ejaculation
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Anticevic (2008)	156	Medium	0	Combat	Intervention (PE) Interview	Sex: 1-item assessing premature ejaculation PTSD: CAPS, MS-PTSD	(1) PTSD v. no (2) PTSD+AD < PTSD−AD	(1) NS (2) ↓
Garneau-Fournier (2018)	2002	Low	67*	MST	Intervention (PE) Survey	Sex: Premature ejaculation experienced at least 50% in last 6 months PTSD:PC-PTSD	PTSD v. no	NS
Letica-Crepulja (2019)	300	Low	0	Combat	Survey	Sex: IIEF; PEDT PTSD: PCL-5	Intrusion, avoidance, NACM, hyperarousal clusters	↓
Sexual pain
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Anticevic (2008)	156	Medium	0	Combat	Interview	Sex: 1-item assessing pain during intercourse PTSD: CAPS, MS-PTSD	(1) PTSD v. no (2) PTSD+AD v. PTSD−AD	(1) ↓ (2) NS
Cohen (2012)	71,504	Low	100	Unknown	Chart review	Sex: Chart dx of dysmenorrhea, genital pain, dyspareunia PTSD: Chart dx	(1) PTSD > no (2) PTSD + Dep > no	(1) ↓ (2) ↓
Garneau-Fournier (2018)	2,002	Low	67**	MST	Survey	Sex: Pain or tightening of pelvic muscles during sexual activity at least 50% of the time in tde past 6 months PTSD: PC-PTSD	PTSD v. no	NS
Pulverman (2019)	1,000	High	100	Sexual trauma	Survey	Sex: SWAN item assessing pain during sexual intercourse or penetration PTSD: PSS	PTSD v. no	NS°
Richardson (2020)	543	Low	0	Unknown	Survey	Sex: PHQ item assessing pain or problems during sexual intercourse in last 4 weeks PTSD: PCL-M	PTSD total	NS
Sadler (2012)	1,004	Medium	100	Varied	Interview	Sex: 1-item assessing pain during sexual intercourse or penetration PTSD: PSS-I	PTSD > no	↓
Sexual satisfaction
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Arbanas (2010)	164	Medium	0	Combat	Survey	Sex: IIEF-IS, IIEF-OS PTSD: CAPS	(1) IS, OS: PTSD+AD v. PTSD−AD(2) IS, OS: SubPTSD+AD v. SubPTSD−AD (3) IS, OS: PTSD < no (4) IS, OS: PTSD+AD <SubPTSD+AD	(1) NS (2) NS (3) NS (4) ↓↓
Bachem (2020)	191	Low	0	Combat	Survey	Sex: ISS PTSD: PTSD-I	Re-experiencing, avoidance/numbing, and hyperarousal	↓
Beaulieu (2015)	247	Medium	10.5	Varied	Survey	Sex: ASEX-OS PTSD: PC-PTSD	PTSD v. no	NS
Becirovic (2019)	105	Medium	0	Combat	Survey	Sex: IIEF IS; IIEF-OS PTSD: HTQ	(1) IS: PTSD v. no: no dysfunction, mild, mild-moderate, moderate (2) OS: PTSD v. no: no dysfunction, mild, mild-moderate, moderate, severe (3) IS: HTQ total (4) OS: HTQ total	(1) ↓ (2) ↓ (3) ↓ (4) ↓
Blais (2018)	1,189	Low	100	MST	Survey	Sex: SSS-W PTSD: PCL-5	Re-experiencing, avoidance, NACM, anhedonia, dysphoric arousal, anxious arousal	↓
Blais, Zalta (2020)	426	Low	100	Varied	Survey	Sex: SSS-W PTSD: PCL-5	Re-experiencing, avoidance, NACM, anhedonia, dysphoric arousal, anxious arousal	↓
Breyer (2016)	1,581	Low	50.2	Combat	Interview Survey Chart review	Sex: 1 item assessing satisfaction with sex life PTSD: SCID-IV	(1) Men: PTSD < no (2) Women: PTSD < no	(1) ↓ (2) ↓
Caska-Wallace (2019)	65	Low	0	Varied	Interview Survey	Sex: MSI-R-SEX PTSD: CAPS, SCID*; PCL-M	PTSD < no	↓
Cosgrove (2002)	90	Medium	0	Combat	Interview Survey	Sex: IIEF-IS; IIEF-OS PTSD: Diagnostic interview, PCL	(1) OS: PTSD < no (2) IS: PTSD v. no (3) OS: PTSD total (4) IS: PTSD total	(1) ↓ (2) NS (3) ↓ (4) ↓
Dekel (2006)	214	Low	0	Combat	Survey	Sex: ISS PTSD: Self-report measure of DSM-IV criteria	(1) PTSD < no (2) PTSD total	(1) ↓ (2) ↓
Dekel (2008)	157	Low	0	Combat	Survey	Sex: ISS PTSD: PSTD-I	PTSD < no	↓
DiMauro (2018)	255	Low	100	Varied	Survey	Sex: SSS-W PTSD: PCL-5	PTSD total	↓
Garneau-Fournier (2020)	2,002	Low	67*	MST	Survey	Sex: 1-item assessing satisfaction with sex life PTSD: PC-PTSD	(1) Men: PTSD < no (2) Women: PTSD < no	(1) ↓ (2) ↓
Letica-Crepulja (2019)	300	Low	0	Combat	Survey	Sex: IIEF-IS; IIEF-OS PTSD: PCL-5	(1) IS: Re-experiencing, avoidance, NACM, hyperarousal (2) OS: Re-experiencing, avoidance, NACM, hyperarousal	(1) ↓ (2) ↓
McIntyre-Smith (2015)	99	Medium	0	Unknown	Interview Survey	Sex: IIEF-IS; IIEF-OS PTSD: Clinical interview, PCL-M	(1) IS: PTSD total, Re-experiencing, avoidance/numbing, hyperarousal (2) OS: PTSD total, Re-experiencing, avoidance/numbing, hyperarousal, (3) OS: Bodily pain mediator	(1) NS (2) NS° (3) ↓
Pereira (2020)	138	Low	0	Unknown	Interview	Sex: ISS PTSD: PTSD Scale	(1) PTSD < no (2) PTSD total (3) Re-experiencing, avoidance/numbing, hypervigilance/activation	(1) ↓ (2) ↓ (3) ↓
Suvak (2012)	589	Medium	51	Varied	Survey	Sex: SAS-SR satisfaction PTSD: PCL	PTSD total	NS°
Zerach (2010)	199	Low	N/A	Combat	Survey	Sex: ISS PTSD: PTSD-I	(1) PTSD total (2) Marital intimacy mediator	(1) ↓ (2) ↓
Sexual Distress
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Gobin (2016)	91	Medium	100	Sexual trauma	Survey	Sex: TSI-SC PTSD: PCL-S	(1) European-American women: PTSD total (2) African-American women: PTSD total	(1) ↓ (2) NS
Bhalla (2018)	221	Low	0	Combat	Survey	Sex: MSQ-SA PTSD: PCL-M	Re-experiencing, avoidance, emotional numbing, hyperarousal	↓
Riggs (1998)	50	High	0	Combat	Survey	Sex: FIS PTSD: PCL-M	(1) PTSD+ > PTSD− (2) Re-experiencing, numbing/avoidance, arousal	(1) ↓ (2) ↓
Schnurr (2009)	242	Low	100	Varied	Intervention (PE, PCT)	Sex: TSI-SC PTSD: CAPS	Re-experiencing, avoidance, numbing, hyperarousal	NS°
Multiple sexual outcomes or non-specific sexual outcomes
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Breyer (2014)	405,275	Medium	0	Unknown	Chart review	Sex: Chart dx of sexual dysfunction ICD-9-CM codes, rx PTSD: Chart dx, ICD-9-CM codes	(1) PTSD+ > MH+ (2) PTSD+, MH+, Rx− > no (3) PTSD+, MH+, Rx+ > no	(1) ↓ (2) ↓ (3) ↓
Breyer (2016	1,581	Low	50.2	Unknown	Interview Survey Chart review	Sex: Chart dx of sexual dysfunction ICD-9-CM codes, rx PTSD: SCID-IV	(1) Men: PTSD v. no (2) Women: PTSD v. no	(1) NS° (2) NS°
Cohen (2012)	71,504	Low	100	Unknown	Chart review	Sex: Chart dx of sexual dysfunction ICD-9-CM codes PTSD: Chart dx ICD-9-CM codes	(1) PTSD > no (2) PTSD + Dep > no	(1) ↓ (2) ↓
Hosain (2013a)	3,962	Medium	0	Combat	Chart review	Sex: Chart dx of sexual dysfunction ICD-9-CM codes, rx PTSD: Chart dx ICD-9-CM codes	PSTD > no	↓
Hosain (2013b)	4,755	High	0	Combat	Chart review	Sex: Chart dx of sexual dysfunction ICD-9-CM codes, rx PTSD: Chart dx ICD-9-CM codes	PTSD > no	↓
Helmer (2013)	158	High	13.4	Combat	Survey	Sex: Text analysis using chart PTSD: PC-PTSD	PTSD > no	↓
Nunnink (2010)	197	Medium	11	Varied	Survey	Sex: 2-items assessing impotence/other sexual problems, diminished sexual desire/function PTSD: DTS	(1) DTS mean (2) Re-experiencing, emotional numbing, avoidance, hyperarousal	(1) ↓ (2) ↓
Suvak (2012)	589	Medium	51	Varied	Survey	Sex: SAS-SR sexual problems PTSD: PCL	(1) PTSD total (2) Women v. men	(1) NS° (2) NS
Turchik (2012)	11,410	Low	12.5	MST	Chart review	Sex: Chart dx of sexual dysfunction ICD-9-CM codes PTSD: Chart dx ICD-9-CM codes	(1) Men: PTSD > no (2) Women: PTSD v. no	(1) ↓ (2) NS
Sexual activity participation and frequency
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Anticevic (2008)	156	Medium	0	Combat	Interview	Sex: 2 items assessing frequency and type of select sexual activities PTSD: CAPS, MS-PTSD	(1) Frequency: PTSD < no (2) Frequency: PTSD+AD v. PTSD−AD (3) Sexual fantasies, foreplay, oral sex, sexual intercourse, masturbation: PTSD v. no (4) Sexual fantasies, foreplay, oral sex, sexual intercourse, masturbation: PTSD +AD v. PTSD-AD	(1) ↓ (2) NS (3) ↓ (4) ↓
Breyer (2016)	1,581	Medium	50.2	Combat	Interview Survey Chart review	Sex: Self-report sexual activity in the past 3 months PTSD: SCID-IV	(1) Men: PTSD v. no (2) Women: PTSD v. no	(1) NS (2) ↓
Suvak (2012)	589	Medium	51	Varied	Survey	Sex: SAS-SR sexual frequency PTSD: PCL	PTSD v. no, interaction between PTSD and gender	NS
Importance of sex
Article	N	Risk of bias	Women (%)	Trauma type	Method	Measures	Analysis	Effect
Sadler (2012)	1,004	Medium	100	Varied	Interview	Sex: SWAN item assessing importance of sex PTSD: PSS-I	PTSD < no	↓

^*No women were included in this specific analysis.

^**No men were included in this specific analysis.

^°Results changed in statistical significance after covariates were included in statistical model.

Constructs bolded in the analysis column were statistically significant in the model at P < .05 unless otherwise specified in the article.

ASEX = Arizona Sexual Experiences Scale; ASEX-O = Arizona Sexual Experiences Scale, Orgasm subscale; ASEX-OS = Arizona Sexual Experiences Scale, Orgasm Satisfaction subscale; CSFQ-O = Changes in Sexual Functioning Questionnaire, Orgasm completion subscale; CSFQ = Changes in Sexual Functioning Questionnaire; DTS = Davidson Trauma Scale; MST = military sexual trauma; FSFI = Female Sexual Function Index; PTSD = posttraumatic stress disorder; ↓ = Negative effect; PCL-5 = PTSD Checklist for DSM-5; NS = non-significant; PC-PTSD = Primary Care PTSD Screen; FSFI* = Female Sexual Function Index, no satisfaction items; NACM = Negative alterations in cognitions and mood symptoms; IIEF-15 = International Index of Erectile Function, 15-item version; PCL = PTSD Checklist for DSM-IV; IIEF-5 = International Index of Erectile Function, 5-item version; PCL-M = PTSD Checklist-Military version; CAPS = Clinician-Administered PTSD Scale for DSM-IV; AD = antidepressants; Arbanas (2010) assessed SSRI use specifically; MS-PTSD = Mississippi Scale for Combat related PTSD; IIEF-D = International Index of Erectile Function, Desire subscale; SubPTSD = Subthreshold PTSD; BDI = Beck Depression Inventory – II; IPF = Inventory of Psychosocial Functioning; HTQ = Harvard Trauma Questionnaire; CSFQ-D/F = Changes in Sexual Functioning Questionnaire, Desire/Frequency subscale; CSFQ-D/I = Changes in Sexual Functioning Questionnaire, Desire/Interest subscale; PHQ = Patient Health Questionnaire; CSFQ A/E= Changes in Sexual Functioning Questionnaire, Arousal/Excitement subscale; IIEF-EF = International Index of Erectile Function, Erectile dysfunction subscale; ED = Erectile dysfunction; Dx = Diagnosis; Rx = Prescription; IIEF-O = International Index of Erectile Function, Orgasmic function subscale; PE = Prolonged exposure; PEDT = Premature-Ejaculation Diagnostic Tool; Dep = Depression diagnosis; SWAN = Study of Women's Health Across the Nation; PSS = Posttraumatic Symptom Scale; PSS-I = PTSD Symptom Scale Interview; IIEF-IS = International Index of Erectile Function, Intercourse satisfaction subscale; IIEF-OS = International Index of Erectile Function, Overall satisfaction subscale; ISS = Index of Sexual Satisfaction; PTSD-I = Post Traumatic Stress Disorder Inventory; SSS-W – Sexual Satisfaction Scale – Women version; SCID = Structured Clinical Interview for DSM-IV; MSI-R-SEX = Marital Satisfaction Inventory-Revised, Sexual Dissatisfaction subscale; military traumas; SCID* = Structured Clinical Interview for DSM-IV-TR, research version; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4^th edition; SAS-SR = Social Adjustment Scale - Self-report; TSI-SC = Trauma Symptom Inventory, Sexual concerns subscale; PCL-S = Posttraumatic Stress Disorder Checklist-Specific; MSQ-SA = Multidimensional Sexuality Questionnaire, SA subscale; FIS = Fear of Intimacy Scale; MH = Mental health; ICD-9-CM = International Classification of Diseases, 9^th Edition, Clinical Modification.

Studies were evaluated for risk of bias at the full text review and study feature abstraction phase by the third author. We used a modified version of the Newcastle-Ottawa Quality Assessment Scale^48,49 to enable a granular rating of studies’ overall quality and in regard to specific domains related to sample selection, study comparability, and outcome assessment. Quality ratings were obtained for each study and summed across domains, resulting in an overall quality score for the study ranging from 0-100%. In cases where domains were not applicable for a particular study, the denominator of the overall quality score was adjusted in order to avoid unfairly penalizing these studies. Overall quality scores were coded as “low risk of bias” (>75%) “medium risk of bias” (50-75%), and “high risk of bias” (<50%), and are presented in Table 1. Quality ratings were not used to exclude studies from the review but rather to provide an overall assessment of the literature in this area and identify areas for improvement.

RESULTS

Articles were initially organized by sexual outcome, including: (i) overall sexual function, (ii) sexual desire, (iii) sexual arousal, (iv) erectile dysfunction, (v) orgasm functioning, (vi) premature ejaculation, (vii) sexual pain, (viii) sexual satisfaction, (ix) sexual distress, (x) variety/nonspecific, (xi) sexual activity participation and/or frequency, and (xii) importance of sex. We first present results pertaining to the sexual response cycle (eg, overall sexual function, sexual desire, sexual arousal, orgasm)⁵⁰ and then present results of other relevant sexual constructs. Results are further organized with regard to gender of samples studied, type of PTSD measurement used, and use of the DSM-IV⁵¹ or DSM-5²³ for measurement of PTSD, as each of these factors has the potential to explain differences in findings. Risk of bias within studies were mostly deemed to be low to moderate with only a minority of studies scored at higher risk of bias.

Of note, various factor structure models of PTSD isolate emotional numbing symptoms into a separate PTSD symptom cluster,⁵² though they are now included as part of the NACM PTSD symptom cluster in DSM-5. Dysphoria has also been isolated as a separate PTSD symptom cluster in some factor models,⁵³ with symptoms spanning the new hyperarousal and NACM clusters in DSM-5. Additionally, some studies use a six-factor “anhedonia” model based on DSM-5, which specifies an anhedonia symptom cluster (loss of interest in activities, social disconnection, and lack of positive emotion), a dysphoric arousal symptom cluster (irritability, risky behavior, concentration difficulties, and sleep difficulties), and an anxious arousal symptom cluster (hypervigilance and jumpiness).⁵⁴ These symptom clusters and factor models have been used in research reviewed in this study, and thus are specified where relevant.

OVERALL SEXUAL FUNCTION

Studies were included in this section if they utilized a comprehensive measure of sexual functioning (e.g., FSFI⁴³ or IIEF⁴⁴). Of the nine studies that examined the association between PTSD and overall sexual functioning, six demonstrated that PTSD was weakly to moderately associated with worse sexual functioning.^19,38,55-58 Additionally, 2 studies demonstrated a non-significant association after covariates were included.^59,60

There were 3 studies that examined the relationship between PTSD diagnosis and overall sexual functioning among men veterans. Results demonstrated a significant negative relationship, such that both total PTSD severity⁵⁸ and a DSM-IV PTSD diagnosis^19,58 were each associated with worse overall sexual function. There was one study that originally demonstrated a negative association between total PTSD severity and overall functioning; however, this relationship was no longer significant when associations were tested in a mixed gender sample using a statistical model that accounted for covariates.⁵⁹ There were 5 studies that examined the relationship between PTSD and overall sexual functioning among women V/MP. Results demonstrated a significant negative association, such that higher total PTSD severity was associated with worse overall functioning.^55,61 Analyses of PTSD symptom cluster severity using a 6-factor model of PTSD revealed that anhedonia⁵⁷, as well as anhedonia and dysphoric arousal³⁸ were uniquely related to increased sexual dysfunction. In a separate analysis that only examined anhedonia and dysphoric arousal, only anhedonia was uniquely linked to increased sexual dysfunction.⁵⁶ Both studies that examined the association between a DSM-IV PTSD diagnosis⁶⁰ or total PTSD symptom severity⁵⁹ and sexual functioning in mixed gender samples initially demonstrated a negative relationship between PTSD and sexual functioning. However, these associations were no longer significant when accounting for covariates, such as depression.

Summary of Overall Sexual Functioning

Overall, results across men, mixed gender, and women samples suggest a negative relationship between PTSD and sexual functioning. In some studies,^59,60 but not all^55-57 this negative association was accounted for by covariates, such as depression.

SEXUAL DESIRE

Sexual desire is variably defined,⁶² but often conceptualized as the motivational state for sexual activity that may or may not result in overt sexual behavior.⁶³ Most of the studies included herein assessed sexual desire specifically; however, some assessed changes in sexual desire (e.g., loss of sexual desire). Among the 13 studies identified, nine studies demonstrated a significant, negative association between PTSD diagnosis and/or symptoms and sexual desire with mostly moderate effect sizes^{64,65,58,66-71}; however, 4 studies did not demonstrate this relationship.^59,72-74

PTSD Diagnosis, Symptoms, and Individual Clusters

There were 5 studies that demonstrated a significant and mostly moderately-sized negative relationship between probable or confirmed DSM-IV PTSD diagnosis and sexual desire.^64-68 However, one study did not demonstrate a significant relationship between DSM-IV PTSD diagnosis and sexual desire⁵⁸ and Badour et al (2015)⁶⁷ found that PTSD was associated with an increase in loss of sexual desire but found no difference between those with and without PTSD when frequency of sexual desire was measured. Several studies also demonstrated a moderately-sized relationship between greater total PTSD symptom severity and lower sexual desire.^58,67-69,71 However, 2 studies did not demonstrate a significant association.^59,72 Notably, Khalifian et al (2020)⁵⁹ found a significant negative association between total PTSD symptom severity and sexual desire for men specifically; however, as was the case when examining overall sexual functioning, this association was no longer significant when examined in a mixed gender sample and accounting for covariates, such as depression symptoms and antidepressant use. There were 2 studies that demonstrated a unique effect of avoidance and/or numbing symptoms (using DSM-IV criteria) on sexual desire^67,71 in men veterans. Additionally, Letica-Crepulja et al (2019)⁷⁰ found a unique effect of NACM symptoms on sexual desire, using DSM-5 criteria. However, McIntyre et al (2015)⁷² did not find significant unique relationships between any PTSD symptom clusters and sexual desire.

PTSD Treatment

In the context of PTSD treatment, Badour et al (2016)⁷⁴ found that total PTSD severity at baseline did not predict changes in sexual desire across behavioral activation and therapeutic exposure treatment⁷⁵ for veterans with comorbid PTSD and depression. Similarly, Badour et al (2020)⁷³ found that sexual desire did not change over the course of prolonged exposure treatment for PTSD³² in a mixed gender sample.

Women Samples

In the sole study that focused on sexual desire for women veterans, Garneau-Fournier et al (2018)⁶⁵ found that a probable DSM-IV PTSD diagnosis was negatively related to sexual desire or pleasure.

Summary of Sexual Desire Findings

Overall, a majority of studies demonstrated a negative association between PTSD diagnosis and symptom severity and sexual desire. Among studies that assessed individual symptom clusters, 3 of 4 studies found effects for avoidance, numbing, and NACM. Moreover, these associations did not appear to change as a result of participating in PTSD treatment or as a function of other mental health comorbidities, such as depression. This suggests that a subjective state, such as sexual desire, can be significantly influenced by the severity of PTSD symptoms. However, only one study each addressed the relationship between PTSD and sexual desire for women and mixed gender samples of V/MP.

SEXUAL AROUSAL

Sexual arousal refers to the complex interplay among physiological and psychological responses to sexual stimuli. Difficulties with sexual arousal typically concern achievement and maintenance of sexual arousal.⁷⁶ Four studies in our review focused on the relationship between PTSD and sexual arousal with largely nonsignificant findings.^59,60,67,74

There were two studies demonstrating nonsignificant associations between PTSD diagnosis and/or symptoms and sexual arousal for men veterans.^67,74 Specifically, Badour et al (2015)⁶⁷ initially found a significant, negative relationship between numbing and/or avoidance symptoms (using DSM-IV criteria) and sexual arousal; however, this was no longer significant after accounting for total PTSD severity, severity of other PTSD symptom clusters, race, severity of combat exposure, and social support. Consistent with these studies, 2 studies with mixed gender samples also did not find any significant associations between PTSD and sexual arousal.^59,60

Summary of Sexual Arousal Findings

The limited results available suggest a nonsignificant association between PTSD (diagnosis and severity) and sexual arousal. Notably, no studies have examined the relationship between PTSD and sexual arousal in samples of solely women V/MP.

ERECTILE FUNCTIONING

Erectile functioning refers to the attainment and maintenance of rigidity in the penis (American Psychiatric Association, 2013, p.582²³). There were 10 studies assessed relationships between PTSD and erectile functioning with 4 studies demonstrating a significant, negative relationship with medium to large effect sizes^19,66,68,70; however, 5 other studies did not demonstrate this relationship^{64,65,60,67,72} and one study demonstrating mixed findings.⁵⁸

PTSD Diagnosis, Symptoms, and Individual Clusters

Of the eight studies that focused on the association between DSM-IV PTSD diagnosis and erectile functioning, 3 studies demonstrated a negative association that was moderate to large in size^19,66,68 and a fourth found that men veterans with a DSM-IV PTSD diagnosis were more likely to have an erectile dysfunction diagnosis.⁵⁸ However, 4 other studies demonstrated that the erectile functioning of men with and without a DSM-IV PTSD diagnosis did not significantly differ^64,65,58,60 and a fifth found no significant differences in erectile dysfunction diagnoses and prescriptions as a function of DSM-IV PTSD diagnosis.⁶⁷ Finally, 2 studies found that those with a DSM-IV PTSD diagnosis who were using antidepressants had similar erectile functioning to those with a PTSD diagnosis who were not using antidepressants.^64,66 However, those with a PTSD diagnosis who received antidepressants reported lower erectile functioning than those with subthreshold PTSD who received antidepressants and this association was moderate in size.⁶⁴

Of the 5 studies that assessed the relationship between PTSD symptoms and erectile functioning, 2 studies demonstrated a moderate negative relationship between total PTSD severity and erectile functioning,^58,68 and a third study demonstrated a moderate relationship between the NACM symptoms and erectile functioning.⁷⁰ Although a fourth study demonstrated negative relationships between erectile functioning and both total PTSD severity and the avoidance and/or numbing symptoms of PTSD, these findings were no longer significant when the statistical model included covariates, such as other mental health symptoms.⁷² The fifth study failed to find a significant association between total PTSD symptom severity or DSM-IV PTSD symptom cluster severity and erectile dysfunction diagnosis or erectile dysfunction prescriptions.⁶⁷

Summary of Erectile Functioning

In sum, results appeared evenly mixed with as many studies demonstrating significant relationships between PTSD (both total score and avoidance and/or numbing or NACM symptom clusters) and erectile functioning as those that did not.

ORGASM FUNCTIONING

Orgasm function is defined as one’s ability to achieve (or ease and frequency of) orgasm, a feeling of intense sexual pleasure accompanied by physiological reactions such as involuntary muscle contractions.⁷⁷ Premature ejaculation is discussed separately in this review, as its etiology and treatment diverges from delayed or difficulty achieving orgasm.^78,79 There were nine studies that tested the association of PTSD with orgasmic functioning, with 4 studies demonstrating significant, negative associations with largely medium effect sizes,^58,60,68,70 2 studies demonstrating consistently nonsignificant relationships,^64,66 and two studies demonstrated that significant associations were no longer significant when accounting for covariates, including other mental health symptoms.^59,72 Furthermore, in one study, results differed based on gender.⁶⁵

PTSD Diagnosis, Symptom Severity, and Individual Clusters Among Samples of Men

Among men veterans, two studies demonstrated a significant and large negative relationship between DSM-IV PTSD diagnosis and orgasm functioning^58,68; whereas, 3 other studies did not demonstrate significant differences.^64-66 Notably, Arbanas et al (2010)⁶⁴ found that those with a DSM-IV PTSD diagnosis taking antidepressants reported greater difficulty reaching orgasm compared to those with subthreshold PTSD taking antidepressants and this effect was large in size. Results were somewhat similar for total PTSD severity, with two studies demonstrating a significant and moderate negative association between total PTSD severity and orgasm functioning^58,68 that was no longer significant when tested in models that accounted for covariates, including other mental health symptoms.^59,72 In contrast, a study by Letica-Crepulja et al (2019)⁷⁰ found a unique association between the DSM-5 NACM cluster and slower orgasmic functioning, above and beyond other PTSD clusters.

PTSD Diagnosis, Symptom Severity, and Individual Clusters Among Mixed Gender and Women Samples

There were 2 studies that demonstrated a significant negative relationship between probable DSM-IV PTSD diagnosis and orgasm functioning in mixed gender⁶⁰ and women veteran samples.⁶⁵ However, results from a third study did not suggest a significant association between total PTSD severity and orgasm functioning for women veterans.⁵⁹

Summary of Orgasm Functioning

Overall, results suggested a largely mixed relationship between PTSD and orgasm functioning, with some studies demonstrating a significant, negative association and other studies demonstrating a null association or an association that was accounted for by other covariates, such as depression. A single study demonstrated that the NACM symptoms were largely responsible for the association of total PTSD severity with orgasm functioning. Furthermore, the majority of studies relied on exclusively men veteran samples.

PREMATURE EJACULATION

Premature ejaculation is typically defined as ejaculation that occurs within one minute or no more than 3 minutes of sexual activity.⁸⁰ There were 3 studies that examined the relationship between PTSD and premature ejaculation among men veterans.^65,66,70 Results were largely mixed, with 2 studies demonstrating a nonsignificant relationship between DSM-IV PTSD diagnosis⁶⁶ or a probable DSM-IV PTSD diagnosis⁶⁵ and premature ejaculation, respectively. However, results from one study that examined PTSD cluster symptom severity using DSM-5 criteria suggested that NACM symptoms were moderately associated with premature ejaculation and this relationship.⁷⁰ Additionally, those with a PTSD diagnosis who were prescribed antidepressants were moderately less likely to report problems with premature ejaculation, compared to those with PTSD who were not prescribed antidepressants.⁶⁶ Overall, given the limited evidence available and mix of findings, it is difficult to glean clear conclusions about the relationship between PTSD and premature ejaculation.

SEXUAL PAIN

Sexual pain (also referred to as genito-pelvic pain) refers to pain experienced in the genital and/or pelvic regions during sexual activity.⁸¹ Of the 6 studies that examined the relationship between PTSD and sexual pain, 3 demonstrated a significant, negative association with mostly medium to large effect sizes.^66,82,83 However, 3 studies did not demonstrate this association after accounting for covariates, like depression.^65,71,84

In one study of men veterans, those with a DSM-IV PTSD diagnosis reported more sexual pain compared to those without PTSD with a small to medium effect sizes and this association did not differ based on antidepressant use.⁶⁶ However, a second study did not demonstrate a significant relationship between total PTSD severity and sexual pain when accounting for demographic and clinical covariates.⁷¹ Results from 2 studies of women veterans demonstrated that a DSM-IV PTSD diagnosis was significantly related to increased sexual pain⁸³ and pain-related conditions (for example, dysmenorrhea⁸²). Furthermore, women diagnosed with PTSD and comorbid depression reported more pain-related conditions, as compared to women only diagnosed with PTSD.⁸² These significant associations were medium to large in size. However, other studies demonstrated different findings when depression was included as a covariate in statistical models. For example, Pulverman et al (2019)⁸⁴ initially found a significant, negative relationship between probable DSM-IV PTSD diagnosis and sexual pain; however, this association was no longer significant after accounting for a depression diagnosis. Likewise, Garneau-Fournier et al (2018)⁶⁵ did not find a significant relationship between a probable DSM-IV PTSD diagnosis and sexual pain when accounting for demographic and clinical covariates, including depressive symptoms.

Summary of Sexual Pain

Overall, findings regarding the relationship between PTSD and sexual pain across both men and women samples are mixed. Furthermore, some of the significant associations appear to be accounted for by covariates, specifically depression.

SEXUAL SATISFACTION

Sexual satisfaction refers to the individual’s subjective evaluation of the positive and negative aspects of one’s sex life.⁸⁵ There were 18 studies that tested the relationship between PTSD and sexual satisfaction, with 15 of these studies demonstrating a significant, negative association that was moderate to large in size.^{31,38,57,58,61,68,70,86-93} However, there were 2 studies that did not demonstrate this association^64,72 and three additional studies that found that this association was no longer significant when accounting for covariates, like depression.^60,72,89

PTSD Diagnosis, Symptom Severity, and Individual Symptom Clusters in Samples of Men

Among studies of men veterans, a clear majority of studies demonstrated a negative relationship between DSM-IV PTSD diagnosis and overall sexual satisfaction of moderate to large size,^{58,68,86-88,91-93} as well as satisfaction with intercourse specifically.⁶⁸ In contrast, Arbanas et al (2010)⁶⁴ found that veterans with a DSM-IV PTSD diagnosis reported similar levels of overall sexual satisfaction and satisfaction with intercourse compared to those without PTSD; although those with subthreshold PTSD reported higher sexual satisfaction than those with more severe PTSD after accounting for anti-depressant use. Furthermore, Cosgrove et al (2002)⁵⁸ did not find a significant relationship between a DSM-IV PTSD diagnosis and satisfaction with sexual intercourse.

Several studies examined the relationship between total PTSD severity and sexual satisfaction^{58,68,86,88,90} or satisfaction with intercourse,^58,68 overall demonstrating that PTSD severity was moderately associated with lower satisfaction. However, a study by McIntryre-Smith et al (2015)⁷² did not find a significant relationship between total PTSD severity and intercourse satisfaction, and the association between total PTSD severity and overall satisfaction was no longer significant after accounting for other mental health symptoms. Moreover, there were 2 studies that examined mediation models of total PTSD severity predicting sexual satisfaction. McIntyre-Smith et al (2015)⁷² demonstrated that bodily pain weakly mediated the association between total PTSD severity and overall sexual satisfaction. Additionally, Zerach et al (2010)⁹⁰ demonstrated that marital intimacy partially mediated the association between total PTSD severity and sexual satisfaction.

There were no clear trends in the relationship between PTSD cluster symptom severity and sexual satisfaction. For example, Pereira et al (2020)⁸⁸ demonstrated that all DSM-IV PTSD symptom clusters were uniquely associated with sexual satisfaction; however other results suggested that only the avoidance and/or numbing (using DSM-IV criteria³¹) or NACM symptoms (using DSM-5 criteria⁷⁰) were independently associated with sexual satisfaction, respectively, and with moderate to large effect sizes. Letica-Crepulja et al (2019)⁷⁰ also found that NACM symptoms were associated with intercourse satisfaction specifically. In contrast, McIntyre-Smith (2015)⁷² found that DSM-IV PTSD symptom clusters were not significantly associated with intercourse satisfaction. Although they originally found a significant negative relationship between avoidance and/or numbing and hyperarousal symptoms and overall satisfaction, these relationships were no longer statistically significant after including other covariates, such as mental health symptoms.⁷²

PTSD Diagnosis, Symptom Severity, and Individual Clusters Among Mixed Gender and Women Samples

A majority of the 5 studies that examined the relationship between PTSD and sexual satisfaction in women veterans demonstrated a significant negative association. Women with a DSM-IV PTSD diagnosis were slightly less likely to report and endorse lower sexual satisfaction compared to women without a PTSD diagnosis.^87,91 Additionally, a study by DiMauro et al (2018)⁶¹ demonstrated a significant and large negative association between total PTSD severity with sexual satisfaction. Finally, results from 2 studies by Blais et al (2018, 2020) that used a six-factor model of PTSD symptom clusters suggested that NACM and anhedonia,⁵⁷ as well as NACM, anhedonia, and dysphoric arousal³⁸ uniquely predicted lower sexual satisfaction, even when accounting for covariates such as depression. Of the two studies that examined the relationship between PTSD and sexual satisfaction in mixed gender samples, Suvak et al (2012)⁸⁹ initially demonstrated a significant negative correlation between total PTSD severity and sexual satisfaction. However, both studies demonstrated non-significant relationships between total PTSD severity⁸⁹ or DSM-IV probable PTSD diagnosis⁶⁰ and satisfaction after accounting for covariates, such as depression.

Summary of Sexual Satisfaction

Overall, most results for both men and women samples demonstrated a negative relationship between PTSD diagnosis or PTSD symptom severity and sexual satisfaction that was moderate to large in size. Furthermore, the DSM-5 NACM symptom cluster (including when emotional numbing and dysphoric arousal were measured as their own constructs) commonly accounted for these effects. In some instances, however, results were attributable to comorbid depression severity.

SEXUAL DISTRESS

Sexual distress has been defined as worry, frustration, and anxiety regarding sexual activity.^94,95 Of the 4 studies that examined the relationship between PTSD and sexual distress, results for men samples supported a positive association,^96,97 with medium effect sizes, whereas results for women samples were mixed.^98,99

Among men veterans, higher total PTSD severity was associated with higher fears of intimacy,⁹⁶ with emotional numbing symptoms (using the DSM-IV 4-factor emotional numbing model⁵²) accounting for this effect in one study⁹⁷ and avoidance/numbing symptoms (using DSM-IV criteria) accounting for this association in a second study.⁹⁶ Among a sample of European American women veterans, total PTSD severity was associated with worse sexual distress.⁹⁸ In a sample of African American women veterans,⁹⁸ a combination of PTSD and depression symptoms was associated with worse sexual distress, despite PTSD and depression not being uniquely correlated with sexual distress. In a sample of both African American and European American women veterans, both avoidance and/or numbing and hyperarousal symptom clusters were individually associated with sexual distress.⁹⁹ However, Schnurr et al (2009)⁹⁹ found that the associations with the avoidance and/or numbing and hyperarousal symptom clusters (using DSM-IV criteria) were no longer significant when all scores were examined together, regardless of trauma type (ie, sexual vs non sexual). Additionally, Schnurr et al (2009)⁹⁹ compared effects of prolonged exposure therapy and present centered therapy¹⁰⁰ and found that individuals who no longer met criteria for a DSM-IV PTSD diagnosis after participating in either treatment had significantly lower posttreatment sexual distress and this effect was maintained six months after treatment.

Summary of Sexual Distress

Studies largely demonstrated a positive association between total PTSD severity and sexual distress for men veterans, such that PTSD severity was associated with increased sexual distress. However, the pattern of results was varied for women veterans, likely due to the inclusion of depression in statistical models and decisions regarding the measurement of PTSD (e.g., diagnosis vs total and individual symptom clusters). Overall, there appears to be an absence of research in mixed gender samples and a wide range of sexual distress measures, potentially contributing to disparate findings across groups.

MULTIPLE SEXUAL OUTCOMES OR NON-SPECIFIC SEXUAL OUTCOMES

Studies included in this section measured sexual difficulties either by the presence of a variety of relevant chart diagnoses (e.g., erectile dysfunction, premature ejaculation, dyspareunia, and hypoactive sexual desire disorder) or in a nonspecific manner (e.g., asked about sexual difficulties broadly without administering a comprehensive measure for a total sexual functioning score). Of the 7 studies that tested the association between PTSD diagnosis and sexual difficulties, 5 studies suggested that a PTSD diagnosis was significantly associated with increased likelihood of endorsing sexual difficulties.^82,101-104 However, in one study,⁹¹ results did not consistently support this conclusion and in another study,¹⁰⁵ results differed based on gender. Two studies examined the relationship between severity of PTSD symptoms and sexual difficulties. One found a significant relationship¹⁰⁶ and one did not.⁸⁹

Among studies of men veterans, a majority of findings suggested that those with a PTSD diagnosis (according to DSM-IV⁵¹ or ICD9-CM criteria¹⁰⁷ were significantly more likely to also have a sexual dysfunction diagnosis or have a prescription for a sexual problem, even when accounting for demographic and clinical covariates.^101-103,105 However, although one study initially demonstrated a negative relationship, this finding was no longer significant after accounting for covariates, such as depression.⁹¹ Of the 3 studies that examined the relationship between PTSD and sexual dysfunction among women, 2 studies demonstrated large, positive associations between a DSM-IV PTSD diagnosis and chart diagnosis of sexual dysfunction.^82,91 However, these findings were no longer significant when accounting for covariates, such as depression.^91,105

Among mixed gender samples of V/MP, those with a probable DSM-IV PTSD diagnosis were moderately more likely to report “sexual health issues” during medical encounters.¹⁰⁴ Similarly, those with higher total PTSD severity were more likely to report multiple sexual difficulties¹⁰⁶ and further analysis revealed that emotional numbing symptoms (using the DSM-IV 4-factor emotional numbing model⁵²) minorly contributed to this relationship. Another study also found that more severe PTSD symptoms were associated with higher likelihood of having sexual difficulties,⁸⁹ but this association became nonsignificant with the inclusion of covariates. The one study that examined gender differences in sexual difficulties among men and women initially demonstrated that PTSD severity was associated with lower likelihood of endorsing sexual difficulties in women but not in men.⁸⁹ However, authors suggested that multicollinearity may be a concern and, indeed, the interaction became nonsignificant without the other predictors in the model.

Summary of Multiple Sexual Outcomes or Non-Specific Sexual Outcomes

Results suggest that PTSD predicts higher likelihood of experiencing at least one type of sexual difficulty, although findings appear to differ largely based on gender and comorbid depressive symptoms. Specifically, the relationship between PTSD and multiple or non-specific outcomes was at least partially accounted for by depression in women, but not men.

SEXUAL ACTIVITY PARTICIPATION AND FREQUENCY

There were 3 studies that demonstrated mixed effects between PTSD and sexual activity participation and frequency^66,89,91 that ranged from medium to large in effect size. One study demonstrated that DSM-IV PTSD diagnosis was significantly associated with lower frequency of sexual activity, and antidepressant use did not influence this association,⁶⁶ whereas another study did not find this.⁹¹ Anticevic and Britvic (2008)⁶⁶ also demonstrated that men veterans with PTSD were less likely to report sexual fantasies, as well as engagement in foreplay, oral sex, and sexual intercourse as compared to men veterans without PTSD; however, there were no significant differences in masturbation. In the single study conducted with a sample of women veterans, there was a significant and negative association between DSM-IV PTSD diagnosis and frequency of sexual activity.⁹¹ In the sole study conducted with a mixed gender sample, researchers did not find a significant association between total PTSD severity and sexual frequency.⁸⁹

Summary of Sexual Activity and Frequency

Of the 3 studies in this area, two found significant negative associations between PTSD and sexual frequency and participation in specific sexual activities, while one did not.

IMPORTANCE OF SEX

Only a single study was identified that explored the importance of sex. Sadler et al (2012)⁸³ demonstrated that women with a DSM-IV PTSD diagnosis were slightly more likely to rate sex as not important in their life, compared to women without a PTSD diagnosis. More research on this outcome is critical to better understand the relationship between PTSD and perceived importance of sex.

DISCUSSION

This systematic review found that PTSD was most clearly associated with decreased overall sexual function, sexual desire, sexual satisfaction, and sexual distress. Moreover, results suggested that PTSD was associated with an increased likelihood of experiencing at least one type of sexual difficulty. There was also a strong relationship between PTSD and importance of sex, but this construct was only examined in one study. Results were mixed when examining relationships between PTSD and sexual arousal, orgasm function, erectile dysfunction, premature ejaculation, sexual pain, and frequency of sexual activity. Taken together, the studies suggest that post-traumatic stress symptomatology appears to be linked to cross-cutting difficulties in a wide range of sexual outcomes. Notably, significant associations exist between PTSD and outcomes that are both related to the sexual response cycle (i.e., sexual desire) and one’s emotional relationship to sexual activity (e.g., sexual distress), with clearer findings for one’s emotional relationship to sexual activity.

When studies examined the association between specific components of PTSD and sexual function, PTSD symptom clusters of avoidance and NACM were most commonly associated with sexual difficulties. Re-experiencing and hyperarousal were largely unrelated to sexual difficulties across studies. Hyperarousal, specifically, was no longer significantly associated with sexual difficulties when all PTSD symptom clusters⁹⁹ or additional mental health symptoms⁷² were included in statistical models. These results suggest that sexual difficulties may be differentially related to PTSD symptoms.

Associations between PTSD and sexual difficulties varied in some instances by gender, but no clear synthesis can be made for the literature as a whole. Although the extant literature examining women veterans has grown by 11 articles since this literature was last reviewed in 2015,^14,108,39 only 43% of studies in the present review recruited all women samples or separately analyzed results by gender, and only one directly examined gender differences within the same study.⁸⁹ Additionally, for some outcomes such as sexual arousal and orgasm functioning, few, if any, analyses were conducted using women samples. Women represent the fastest growing group of VA users¹⁰⁹ and women veterans experience the highest rates of PTSD compared to men veterans and civilians,⁴² underscoring the need to study the impact of PTSD on sexual outcomes for women. Specifically, outcomes might vary by gender for constructs that are socially conditioned by gender (e.g., expectations of sexual frequency or importance of sex). Additionally, in some cases (e.g., orgasm functioning), the disproportionate number of studies conducted in solely men samples makes it inappropriate to draw conclusions about women’s sexual functioning in the context of PTSD. Future research should also investigate these questions in transgender and nonbinary V/MP as well as in those who identify as a sexual minority.

LIMITATIONS OF THE EXISTING LITERATURE

Comorbidity of PTSD and Depression

In the current review, results were mixed regarding whether PTSD symptoms were associated with sexual difficulties over and above depression symptoms. Disagreement exists over whether researchers should account for depression when examining PTSD as an independent variable, given that depression and PTSD are commonly comorbidly diagnosed and have overlapping symptom constructs.¹¹⁰ Additionally, most studies did not account for antidepressant use although SSRIs are known to cause sexual dysfunction^111,112 and are considered a first-line treatment of PTSD.¹¹³ However, it is notable that the PTSD symptom cluster most commonly found to be associated with sexual difficulties was NACM, which includes “changes in beliefs about oneself, others, and the world” and “strong negative feelings such as fear, horror, anger, guilt, or shame” as listed in a self-report measure of PTSD.¹¹⁴ These two items include the experience of thoughts and emotions that are both depressive and anxious in nature, making it difficult to determine the extent to which associations with sexual outcomes are driven by depressive or anxious symptoms, or both. This is alleviated somewhat by studies using factor models, such as the anhedonia model,^38,57 that parse out depressive symptoms of PTSD, and find that these symptoms are most robustly associated with sexual functioning. However, few studies used this model and thus more research is needed to disentangle the association of sexual functioning with the disparate symptoms comprising the NACM cluster.

Inconsistent Operationalization and Measurement of Sexual Outcomes

Sexual difficulties are operationalized in a variety of ways, challenging comparisons across studies. In this review, studies were organized by sexual outcome due do the varying etiologies of different sexual problems and the potential for differential associations with PTSD symptoms. However, this potentially creates an artificial divide between constructs that some argue are indistinguishable (e.g., sexual desire and sexual arousal¹¹⁵) or at least highly related (sexual arousal and erectile function). Relatedly, the commonly-used FSFI does not adequately distinguish between women’s cognitive and/or subjective and physiological aspects of sexual arousal.¹¹⁵ Although this review distinguished between subjective sexual arousal and erectile function for men, no such categories existed for women in this literature (e.g., vulvar vasocongestion and vaginal lubrication). Measurement of women’s physiological sexual arousal function through self-report (e.g., subjective experience of genital vasocongestion) and physiological assessment (e.g., photoplethysmography¹¹⁶) would be welcome additions to the field.

Sexual outcomes also varied widely in terms of assessment tools, sometimes with no overlap between studies. For instance, measures of sexual desire in the current review included both level of sexual desire⁶⁸ as well as change in level of sexual desire.⁷⁴ Additionally, questions on the IIEF assess frequency of orgasm and ejaculation during sexual encounters (e.g., almost always or always during sexual stimulation) while the CSFQ asks about frequency at the daily level (e.g., never to every day). Thus, someone who has an easily attainable orgasm once per week could score highly on the IIEF but not on the CSFQ. Though the difference is subtle, these inconsistencies complicate the comparison of findings across studies.

Relatedly, some studies measured whether participants met criteria for probable sexual dysfunction via chart diagnosis while others measured the sexual outcome itself. Given that providers often report barriers to discussing sexual concerns with patients,¹⁸ using chart diagnosis is likely a poor proxy for actual rates of sexual difficulties. The process of diagnosing sexual dysfunction is also fraught with problems. For example, variations are found across versions of the DSM. Unlike DSM-IV, a new stipulation in DSM-5 prohibits the diagnosis of sexual dysfunction when secondary to a “non-sexual mental disorder,”²¹ such as PTSD. Thus, if one is correctly using the DSM-5 to diagnose a sexual dysfunction, a chart diagnosis would not be found when the difficulty is secondary to PTSD, hindering researchers’ abilities to use chart diagnoses to examine the relationship between PTSD and sexual dysfunction. For these reasons, results from studies that used chart review to measure sexual dysfunction should be interpreted with caution.

Finally, behavioral avoidance of sexual activity often precludes thorough assessment of sexual dysfunction. In order to complete measures of sexual function, participants need to be currently engaging in sexual activity. That is, a participant cannot tell us how their sexual arousal is functioning in the past month if they have not attempted sexual activity in that timeframe. It is possible that in attempt to collect data on sexual dysfunction, studies may inadvertently recruit samples for whom PTSD has had less of an impact on sexual well-being and exclude those with more severe PTSD-related sexual dysfunction. Furthermore, the results from these studies may be less generalizable those who avoid sexual activity altogether.

Inconsistent Measurement of PTSD and Trauma Histories

Measurement of PTSD varied by assessment modality, with some studies using clinician interviews and others relying on self-reported PTSD symptoms. Research has shown good concordance between self-report and interview-based measures of PTSD,¹¹⁷ but differences could impact findings. Moreover, different factor models of PTSD may emphasize certain symptoms of PTSD (e.g., emotional numbing symptoms), thereby allowing for differential associations to occur across studies depending on factor model selected. Lastly, changes across diagnostic manuals and factor structures impact how symptom clusters are defined, further limiting conclusions across studies.

A minority of studies in this review identified participants’ index traumas or conducted a comprehensive assessment of trauma history, limiting our understanding of the extent to which trauma type may moderate the relationship of PTSD with sexual functioning. Although one study observed that among military women, sexual traumas were associated with greater sexual dysfunction compared to nonsexual traumas, and this association was mediated by higher NACM and nonsomatic symptoms of depression,⁵⁷ the dearth of other research exploring index trauma in this area tempers confidence in this result.

Cross-Sectional Study Design

Research included in the present review is also limited by (i) largely cross-sectional study designs that (ii) did not assess mechanisms of the simple associations between PTSD and sexual outcomes, and (iii) were analyzed at the group level, potentially obscure existing relationships between PTSD and sexual difficulties at the individual level. Proximal (e.g., ecological momentary assessment) and distal (e.g., longitudinal) methods may help clarify how PTSD and sexual difficulties interact within a day or a week and across time. Qualitative data collection and person-specific data analysis (e.g., profile, cluster, or idiographic analyses) may be necessary to answer more nuanced questions, such as, “for whom and under which circumstances does PTSD affect sexual functioning.”

CLINICAL IMPLICATIONS

Clinicians should inquire about sexual health, including sexual functioning, distress, satisfaction, and frequency, and specifically ask about PTSD symptoms experienced in relation to sexual activity, as part of comprehensive intake assessment. Additionally, individual clinical interventions that address the anhedonic symptoms of PTSD, such as behavioral activation, could include sexual activation exercises where appropriate. Exposure-based treatments for PTSD, such as prolonged exposure therapy,³² could also incorporate sex-related behavioral in vivo exposure assignments. Finally, some dyadic interventions for PTSD, such as cognitive behavioral conjoint therapy for PTSD,¹⁰⁸ ask traumatized individuals to create an “approach activity” list, and clinicians would do well to encourage physical intimacy and sexual activity on that list knowing the likelihood of problems in this domain.

FUTURE DIRECTIONS

This systematic review highlights several important directions for future research. First, this literature would benefit from more sophisticated longitudinal and ecological momentary data collection that could provide more nuanced assessment of the dynamic interplay between PTSD symptoms and sexual difficulties. Additionally, mixed methods studies could use a combination of quantitative and qualitative data to help clarify and operationalize key constructs related to sexual dysfunction and provide context for some of the anecdotal patient reports of links between symptoms and functioning. Future research would also benefit from the use of validated measures, consistent definitions of constructs, and the inclusion of physiological measures such plethysmography.¹¹⁶ Given the challenges of measuring sexual dysfunction among individuals who avoid sexual activity altogether, it is critical for future research to also more explicitly assess for trauma-related behavioral avoidance and assess perceived changes in importance and frequency of sexual activity. Finally, researchers should inquire about antidepressant use, given that the depressive causes of sexual dysfunction could be synergistic (e.g., depression, dysphoric symptoms of PTSD, and antidepressants). Such alterations to existing assessment procedures should substantially improve the accuracy of measurement of sexual functioning in the context of post-traumatic symptomatology.

We advocate for an additional systematic review to examine studies using civilian samples in order to compare results to the present findings. We sincerely hope that research substantially expands to explore these associations in sample of transgender and nonbinary V/MP, as well. This literature is rapidly growing and the field will greatly benefit from not only an increase in studies exploring the relationship between PTSD and sexual difficulties, but also improvement in research methods to truly advance our field’s understanding of the complicated and important interplay between trauma-related symptoms and sexual difficulties.

SUMMARY

PTSD symptoms are consistently associated with a range of sexual difficulties in V/MP. The relationship between PTSD and sexual difficulties was most consistent in the present review among studies measuring overall sexual function, sexual desire, sexual satisfaction, and sexual distress. This relationship was more mixed among studies measuring sexual arousal, orgasm function, erectile dysfunction and premature ejaculation in men, sexual pain, and frequency of sexual activity. PTSD was associated with sexual difficulties related to both the sexual response cycle (i.e., sexual desire) and one’s emotional relationship to sexual activity (e.g., sexual distress), with a clearer association with the latter.

Results of the systematic review suggest that depression significantly contributes to, and in some instances explains, the relationship between PTSD and sexual difficulties. This is consistent with our finding that the NACM PTSD symptom cluster, which has strong conceptual overlap with depression (e.g., beliefs about being a failure, decreased interest in previously enjoyed activities) was one of the most commonly found to be associated with sexual difficulties. The anxious symptoms of PTSD are also implicated in the avoidance and NACM PTSD clusters as these subscales capture fear-based avoidance (i.e., avoiding reminders of trauma and associated memories and emotions) and changes in cognition (e.g., “men are dangerous”). There were few gender differences in the relationship between PTSD and sexual difficulties, but research among women V/MP continues to be in the minority.

Mixed findings in this review likely reflect methodological limitations of the available literature. Studies included herein inconsistently operationalized and measured sexual difficulties and were highly variable in their assessment of PTSD symptoms, confounding results and challenging our ability to draw strong conclusions about the relationship between PTSD and sexual difficulties. Almost all of the available studies used cross-sectional designs and simple analytical methods that preclude us from better understanding the complex interplay between PTSD symptoms and sexual difficulties. Thus, mixed findings in this review are not definitive and instead highlight a need for more rigorous study design, construct measurement, representation of non-men veterans, and stronger consideration for putative moderators and mediators such as gender, depression, and sexual trauma history.