Although it is not a requirement for diagnosing a woman with Post-Traumatic Stress Disorder (PTSD), about 90% of them report sexual dysfunction, according to Rachel Yehuda, Ph.D. at the conference for the International Society for the Study of Women’s Sexual Health (ISSWSH) I attended recently in San Diego. Many therapists who have clients with PTSD make the assumption that this shows up when women have “psychological” reasons to have low sexual desire and activity. They often think that if the traumatic event was sexual in nature (such as sexual exploitation or rape), of course there would be a sexual difficulty. But, it turns out that loss of libido is present regardless of the type of upsetting event that happened.
Yehuda went on to explain why. In the brain, the amygdala is involved in the emotion of perceiving an event. For example, one might think, “A tiger! I’m afraid!” But, also in the brain is the hippocampus which is involved in assessing the context of an experience. So, one would adjust one’s response but noting, “Oh, but this tiger is in a zoo. I’m safe.”
In the brain, substances called catecholamines affect what one thinks about a situation. Those thoughts can trigger distress. And, as it turns out, distress can trigger more catecholamines, which can trigger more thoughts and, in turn, more distress. Yehuda stated that if catecholamine levels are too high, this may result in what she called an “over consolidation” of memory and that leads to PTSD. This happens if the event is very distressing or if normal coping mechanisms are not engaged.
It’s difficult to engage “normal coping mechanisms” when an event happens that is highly unpredictable and cannot be controlled. These two factors contribute to the occurrence of PTSD. So, the overconsolidation occurs.
So, where does sex fit into all of this?
A woman who can think about a life event and say, “These things happen,” will not develop PTSD. But, a woman who after a life event says, “I’m not going to be the same,” will develop PTSD.
Women who have PTSD are in a state of being numb. They tend to avoid the feelings of general arousal (not sexual, but more what we think of as alertness and vigilance) because it takes them out of their numbness. That is stressful and exhausting.
Arousal (the sexual kind) is required for sexual interest and response, but it is very difficult for women to choose to be aroused since it requires that they not be numb. It can also bring them closer to the memory in the amygdala of feeling afraid. And, it turns out, they are lacking a safety context because during the stressful event, safety was very much in doubt for them. So, staying numb feels like a safer choice and that makes sex out of the question.
In addition to this dynamic, people with PTSD may also have sleep disturbance, medication side effects, chemical dependency and abuse, and other psychiatric conditions that do not easily predispose a person to choose to be sexual. All in all, sexual lack of interest caused by PTSD must be treated with an understanding of the brain structures and neurotransmaitters, the nature of sexual arousal’s similarities to general arousal, and other difficulties that can develop as a result of a traumatizing event.
I received an email inquiry about therapy yesterday from an Iraq War soldier and I have a hunch that I’ll be putting Dr. Yehuda’s ideas into practice.