Military personnel can experience psychosexual difficulties for a variety of reasons. Problems can arise because of psychological trauma, physical injury, consequences arising from pharmacological and surgical complications and social or emotional concerns relating to intrapersonal and interpersonal relationship dynamics. Such individuals might seek to minimise or avoid resolving their pertinent difficulties, while others can experience cultural, personal or organisational barriers to accessing professional help. This paper offers an overview of the development of a national specialist psychosexual therapy service (PST), commenting specifically on the service delivery for male military personnel. It will also consider factors which may support progress in treatment and reflect upon the importance of considering psychosexual functioning in relationships as part of the broader service-life context, which is especially relevant to military personnel.
- genital trauma
- mental health
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Many biological, psychological and social elements are involved in the development and maintenance of psychosexual problems. Some of these issues are associated with physical factors or trauma (eg, operational injuries). In addition, as noted by Dr Frappell-Cooke,1 formerly a member of the Defence Clinical Psychology Service, Ministry of Defence (MoD), UK, operational exposure to improvised explosive devices may result in a devastating impact on bodily integrity. Physical injuries can be significant and entail ‘traumatic amputation of limbs, pelvic fracture, abdominal trauma, extremity fragmentation wounds and genital trauma’ (p. 52). Indeed, military personnel who experience genital trauma can develop overwhelming emotions and complications in the process of adjusting to their injuries. Research has also explored male sexual dysfunction problems arising from cancer and in spinal cord injury.2 3 Other unwanted aetiology can perhaps fracture the degree of intimacy and attachment within a relationship, presenting internal or external challenges to the levels of affection and trust between the parties involved. Primary mental health disorder can also be associated with the onset or perpetuation of sexual dysfunction, such as depression, anxiety and other conditions. Furthermore, Hom et al 4 identify that sexual dysfunction can occur in those who report symptoms related to ‘Gulf War Syndrome’.
It is common to find intimacy and relational difficulties experienced as part of post-traumatic stress disorder (PTSD). Jordan et al 5 estimate that 60% of veterans with PTSD experience marital difficulties and Moore6 discusses the relationship problems presented by PTSD symptoms such as emotional numbing and decreased affectional expression. Goff e t al 7 also note severe sexual problems in some patients with PTSD. Male military personnel can experience psychosexual difficulties that may result in erectile concerns, reduced interest in sexual intercourse, premature ejaculation, orgasm problems, sexual phobia, functional anxiety, delayed ejaculation, pain during intercourse and so on.
The military culture has a reputation for being a masculine arena and men continue to comprise 90% of the UK Armed Forces8. Boldry et al 9 and Mazrui10 noted, in 1977, that all cultures seem to subscribe to the notion that ‘our sons are our warriors’. The melding of military with masculinity is well-documented in Western military history;11 and Mankayi12 produced a recent discourse analysis of masculinity within South African soldiers, indicating it remains a current and universal influence. In 1969, Erikson13 predicted a demasculinisation of warfare by the growing use of technology, but this does not appear to have been borne out, according to Kunashakaran.14 Importantly, many fundamental masculine characteristics are not solely dependent upon social constructions. However, Barrett15 suggests that it might be anticipated that men who are in the military may espouse masculine ideals, perhaps more than the average man, by the fact that they have selected this career. He highlights what is characterised as a sense of idealised masculinity in the US Navy, noting: ‘the military is a gendered institution. Its structure, practices, values, rites and rituals reflect accepted notions of masculinity and femininity’.
Woolacott16 describes a sexualisation of the military male during World War I that led to the term ‘khaki fever’, of which there remains some effect in today’s modern preoccupation with ‘men in uniform’, with this proposition being applied to both service member and the observer.17 Individuals who identify psychosocially, relationally and morally with an excessively rigid and dichotomous notion of their overall understanding of their sexuality may endorse even more strongly with what Zilbergeld18 calls ‘the fantasy model of sex’. In such a conceptual frame, a performance-focussed experience is emphasised and a sexual dysfunction is thus viewed as catastrophic to the individual’s sense of self. Nobre et al 19 have identified that such beliefs may render one more vulnerable to sexual dysfunction. Such archetypal constructs are often observed in those engaging in PST.
The experience of male sexuality that Zilbergeld describes may produce a ‘self-stigma’ effect as it is known, in terms of psychosexual dysfunction and military mental health.20 Thus, the individual is inclined to adopt a harsher view of themselves, although they may not take the same position where the focus is on any other person. This fundamental attribution error is also seen in those with a mental health disorder, who endorse stigma beliefs about such issues, which impacts tangibly on perceived barriers to care. Of note, in this study of mental health stigma, is that junior military personnel are also more likely to experience such stigma, when compared with older and more experienced service members.
Psychosexual therapy in the military
There is a dearth of published literature available on the application of PST in the military. Furthermore, there is no identified published evidence-base on a specific psychological intervention for genital trauma.1 Nevertheless, PST has developed a clear theoretical and evidence-base for psychosexual problems in general,21 22 and meta-analyses of approaches are summarised by Carr.23 PST seeks to identify the underlying aetiology of the sexual problem, while the therapist conducts a collaborative therapeutic exploration with the patient of their cognitions, behaviours and related elements that contribute to the dysfunction. This may involve psychological work on aspects of the patient’s developmental, social, medical, mental health, military and relational history; along with their current psychosocial status. Traumas and sexual values and beliefs are also addressed, along with how these are expressed. Treatment therefore entails helping the patient to attain an understanding of the development of their problem, factors that perpetuate the difficulty and issues that might exacerbate such concerns. This care can involve assisting the patient to improve their relationship with themselves and others, while working on their familiarity with their sexual self, bodies and responses. Certain behavioural tasks are often included in treatment to help with these aspects of the dysfunction. This is often integral to the expression of such issues within the patient’s relationship with their partner. Thus, when relationship factors are associated with the emergence and continuation of the sexual dysfunction, treatment seeks to address such conflict and communication within the PST process.
Military personnel can experience various difficulties in engaging with PST. They are subject to frequent separations from their partner, whether for deployments or training exercises. Cohan et al 24 note that there are ‘many casualties of war; marriage being one of them’. The emotional cycle of deployment clearly has a significant effect on the family25 and will likely have an impact on the couple’s relationship and sexual dynamics, while Bey and Lange26 identified impaired communication and decreased intimacy. Although Amen et al 27 highlighted a ‘honeymoon period’ on return from tours, Vormbrock28 also notes elevated divorce rates during this phase of the deployment cycle.
A parallel can be made between the reunion process with Bowlby’s attachment theory and identifies ambivalence, anxiety and anger in spouses, which can manifest as psychiatric symptoms.29 Clearly, the process is complex and although there are some detrimental effects of enforced separation, sometimes there are positive consequences. Burrell et al 30 suggest that it is the perceptions of the impact of the separation for the couple that are important (eg, timing in their lives—such as when a partner is ill, pregnant and so on), rather than any quantifiable characteristics of the separation (eg, duration, frequency). Ultimately, therefore, the implication for PST is that the couple’s emotional needs and coping are of relevance in understanding their response to separations.
As such, the resilience of both the service member and the couples’ relationship should not be underestimated, with some partnerships also being strengthened by the experience of deployment.31–33 Indeed, Fontana and Rosenheck34 discuss a ‘restorative role’ of the homecoming ritual. Hancock35 also notes the common characteristic of adaptability within service personnel, which is a positive therapeutic factor. For example, while many service personnel are young, they are invariably highly motivated with perhaps a ‘work-hard/play-hard’ perspective on their lives. This is commonly associated with a rather flexible and adaptable approach to problem-solving, which is certainly an advantage in PST.
There is an extensive literature on the stigma attached to mental health difficulties36 and this effect is particularly notable in military populations both in the USA37 and in the UK.38 Service members with psychosexual dysfunction may likewise experience stigma. Cultural factors on the impact of sexual dysfunction have been studied in certain African communities, which highlight significant emasculating effects of such dysfunction on male sexual identity.39 Stigma can furthermore result in a reluctance to present for PST interventions.40 41
For those that do present for PST, it can often occur as a result of encouragement and pressure from their spouse or partner.42 During the initial phase of PST, military patients can struggle to disclose certain details of their psychosexual difficulties to the therapist. This may represent another stage in the service members’ experience of a deconstruction of certain intrinsic and often defensive schema, which relates to their notion of self and indeed, their masculinity. As therapy progresses, such patients can also struggle with engaging in tasks as ‘prescribed’.
Therapeutic stages in PST aim to assist the patient in exploring and addressing their problems within their ‘zone of proximal development’. The nature of the therapeutic homework exercises may feel inherently uncomfortable because he is invited to, perhaps, experience sex in a more passive or receptive way, and he may need empathy, patience and support to implement the PST tasks. The therapist seeks to attend carefully to both partner’s experiences and dynamics in this regard, while maintaining the couple’s engagement to reduce the chance of unintended early termination or drop-out from the PST.43
Furthermore, efforts to improve engagement in PST within the military may involve undertakings to reduce the stigma associated with this topic across the AF, such as via educational methods, as is already done for promotion of sexual health behaviour; Forces.net44 reports these are woven into unit health fairs, predeployment briefings and engagement with national campaigns such as from Public Health England,45 for example, the promotion for sexual and reproductive health and HIV Strategic action plan, 2016 to 2019.
Kim et al 46 note that one of the most common beliefs that results in a barrier to accessing mental healthcare in the military is the belief that ‘I ought to be able to handle it on my own’. The use of educational approaches to addressing such individual and organisational barriers for PST would thus mirror the benefits seen in targeting the stigma relating to other mental health concerns. Indeed, McFarling et al 47 suggest that stigma in this context can only be reduced by influencing policy, education and leadership, which targets the pertinent prevailing ‘culture’. In considering the problem of stigma in mental health in the military, Pols and Oak48 advocate a population-based approach, embedding mental health support within primary care, which may also be a useful model for PST. In addition, Monson et al 49 advocate behavioural conjoint family therapy, emotionally focused couple therapy and a chaplain-led retreat programme as examples of multifaceted approaches to care for this population.
A new PST approach
Frappell-Cooke et al 1 outline the development in recent years of a genital injury care pathway for the UK’s Role 4 battlefield casualties, which was linked with the Royal Centre for Defence Medicine (RCDM) and the Defence Medical Rehabilitation Centre (DMRC). This resulted in the establishment of a new clinical psychology service for such personnel, with the lead author of this current article serving as consultant on the care pathway for this specialist provision at that time. She collated specialist research and literature on similar clinical challenges (drawn from psychological consequences of prostate and penile cancer, limb amputation, acquired infertility and acquired disability) as a base from which to adapt and apply for this population. It also entailed collaboration and liaison with key stakeholders across the academic and healthcare pathways to provide psychoeducation. In the absence of an existing evidence base, Frappell-Cooke et al 1 concluded the need to monitor for the longer term needs and outcomes of this population.
The development of the above Role 4 service underscored the importance of addressing the needs of wounded, injured and sick (WIS) personnel through clear and robust pathways. The possibility of later presentation of need for PST provision led to the consideration of a way to meet this requirement, where WIS patients had now returned to their families and were dispersed across the UK. This discussion of PST provision also drew attention from others across the UK’s Defence Medical Services and Medical Officers in primary care settings were among those who expressed an interest in referring active service members from their caseloads for PST. As a result, the lead author initiated a UK national specialist clinical psychology service for PST, employing a partly remote model of service delivery.
Referrals are provided with an in-depth initial assessment (ca. 4–5 hours), which usually involves the service member and their partner/spouse. The session is conducted with the individual service member, then their partner, along with a ‘round table’ discussion and shared formulation. This process of intensive assessment is designed to facilitate couple engagement and bring to the fore any potential factors that could impair engagement and progress at the outset. At the end of the assessment, they are invited to opt into a PST programme if appropriate: some couples express that the in-depth psychological formulation of precipitating, maintaining and protective factors has been sufficient for them to develop a dialogue together about their psychosexual difficulties. Others require relationship support initially to overcome these difficulties prior to engaging in PST, so were referred to, for example, local Relate services (ie, the UK's national relationship counselling charity). Other couples again may not be suited to the format of remote therapy, so may be advised to seek traditional face-to-face PST from their local services (ie, specialist civilian providers or supervised military clinicians).
If a therapy programme of PST is consensually initiated, the psychological formulation informs a shared treatment plan, which is delivered and monitored remotely. It follows the classic cognitive behavioural therapy PST50 format of weekly homework tasks (deployments and exercises, allowing) with remote support by which ever means the couple prefer (telephone, VTC or joint email discussions). This developed initially to accommodate the location challenges faced by a national specialist service and the difficulty in justifying regular time away from duty/work for two individuals. The therapeutic homework tasks may be ‘condensed’ into periods of time at home, perhaps akin to a battle rhythm. There is also an explicit acknowledgement of the emotional processes around separation and then the realignment and restoration of the couple attachment. Such concerns can arise in terms of longer-term disruption presented by operational tours, along with shorter-term interruptions presented by training and exercises.
Cooper and Marcus51 detailed the benefits of harnessing the internet to improve sexual relationship. In addition, Hall52 presented favourable outcomes of a purely online model of PST. Indeed, Althof53 states this to be one of the key innovations of the last 20 years in sex therapy. Rapid developments of online therapy in other areas have demonstrated excellent outcomes (see, eg, a meta-analysis by Bee et al 54). As such, this MoD specialist service combines elements of face to face and remote working to best meet the needs of this population.
Psychosexual difficulties arise for a variety of biological, psychological and social reasons. These can include factors such as operationally related genital injuries, psychological trauma, mood or anxiety disorders, surgical and/or illness consequences, pharmacological complications and partner-relational problems. The implications of such concerns can result in medical and psychological adversities, social, relational and occupational conflicts and commensurate negative outcomes for the military and wider society. The resilience and operational readiness of service members are significantly influenced by their social relationships, along with the degree of stability concerning their psychological wellbeing. This is particularly evident and manifested in marital, familial and intimate partner relationships, in which sexual contact is a fundamental component of the couple’s relationship. As such, there is clear utility in addressing the needs of military couples, where psychosexual dysfunction is present.55 56
Contributors The subject of the paper was provided by CC, and MM provided additional advice to focus on males, formatting and restructuring advice. CC will act as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.