as bupropion or cyproheptadine.
Family practice and other physicians are very familiar with phos-phodiesterase inhibitors, such as
sildenafil, tadalafil, and vardenafil.
Although these medications have
AEs and are very expensive, they
work well for impotence.
Other solutions are nonphar-macologic: Setting aside time for
intimacy can be crucial. Gels and
creams can help with lubrication.
Communication with providers and
between partners and families is the
most important ingredient.
ASKING ABOUT SEXUAL HEALTH
I encourage all medical personnel
who treat active-duty service members or veterans to (1) discuss sexual
health with their patients; ( 2) learn
the basics of how to evaluate, treat,
or refer ED, including SSRI AEs; and
( 3) understand how to discuss the effects of physical injury, pain, and disability on sexual functioning.
The conversation should touch
on sexual activity, satisfaction with
intimacy, exposure to sexually transmitted diseases, and if appropriate,
previous sexual abuse. The appropriate time and place for a conversation about sexual health depends
on the setting. In the outpatient setting, I bring up the subject after I ask
about sleep and appetite and before
I ask about suicidal and homicidal
thoughts; others may choose elsewhere in the patient history. However, asking about sexual issues may
or may not be appropriate in an
emergency department situation.
Providers often are uncomfort-
able with asking about sexual issues,
perhaps more so if they are young
and female and the patient is older
and male. Therefore, I encourage ex-
panded training in medical school
and throughout residency.
In the military, the suicide rate
has been rising from about 10 per
100,000 per year in 2004 to about
20 per 20,000 in this decade. 4, 5 According to the VA Office of Suicide
Prevention, about 20 veterans commit suicide daily. 6 One question that
has received little attention is the
relationship between sexual difficulties and suicide. Although there has
been an important focus on causes
of suicide in the military and veterans, little is known about the important issue of how many service
members commit suicide because of
We do know a lot about the big
picture as to why service members
commit suicide. In about two-thirds of the completed suicides,
there were relationship issues. In
addition, there are often legal, occupational, and financial difficulties. About two-thirds of service
members commit suicide using
firearms. Jumping and strangulation are other common methods. 4, 5
But there is much we do not
know. What percentage of relationship difficulties are related
to sexual dysfunction? Is ED the
straw that breaks the camel’s back
and leads to the shot to the chest?
Other subjects outside the scope
of this column (but included in
Intimacy Post Injury) include sexual therapy, fertility, adaptations
for those with disabilities, reproductive AEs of toxin exposure,
and surgeries that include penile
My hypothesis is that sexual
problems, specifically ED or im-
potence, contribute to feelings of
failure and inadequacy and thus to
suicidal or homicidal thoughts.
Health care providers do not always talk to patients about their
sexual health and may barely mention the sexual AEs of psychiatric
or other medications. In whatever
setting you practice, you should
not neglect asking questions about
sexual health, as it is a critical
issue for many of our patients and
should be for us. ●
The author reports no actual or potential conflicts of interest with regard to this article.
The opinions expressed herein are those
of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the
U.S. Government, or any of its agencies.
1. Committee on the Assessment of Ongoing Efforts
in the Treatment of Posttraumatic Stress Disorder,
Board of Health of Selected Populations. Treatment
of Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington,
DC: National Academies Press; 2014.
2. Ritchie EC, ed. Intimacy Post-Injury: Combat
Trauma and Sexual Health. New York: Oxford University Press; 2016.
3. Higgins A, Nash M, Lynch AM. Antidepressant-associated sexual dysfunction: impact, effects and
treatment. Drug Healthc Patient Saf. 2010;2:141-150.
4. Black SA, Gallaway S, Bell MR, Ritchie EC.
Prevalence and risk factors associated with suicides of army soldiers 2001-2009. Mil Psychol.
5. Ritchie EC. Suicides and the United States army:
perspectives from the former psychiatry consultant to the army surgeon general. Cerebrum.
6. U.S. Department of Veterans Affairs. Suicide
among veterans and other Americans 2001-
/2016suicidedatareport.pdf. Published August 3,
2016. Accessed December 27, 2016.