Sexual dysfunction refers to a series of problems associated with a reduced ability to respond sexually or to experience sexual pleasure. Areas of malfunction include: arousal, pain, orgasm, and satisfaction. There is scarce research into sexual problems in the context of post-traumatic stress disorder (PTSD), although almost 45% of the people who have been raped, experience PTSD after 3 months. The DSM-5 does not refer to sexual problems that may be present within the PTSD diagnostic criteria. The article looked at the potential relevance of sexual problems with regard to any diagnostic criteria for PTSD:
Criterion A: A certain exposure to a traumatic event. According to the article, traumatic events related to sexual violence or abuse can often be linked to the development of PTSD.
Criterion B: Covers intrusive experiences (memories, dreams or flashbacks) as a result of experienced trauma. Sexual contact can also lead to such experiences.
Criterion C: High avoidance regarding the traumatic event. Traumatic experiences with regard to sex can lead to an association between sexual contact and anxiety. For example, a traumatized person can show behaviors such as reduced sexual contact and experiencing emotions such as guilt, shame, emotional and disgust. Someone can also block feelings of love and closeness.
Criterion D: Negative changes in cognition or mood. Many cognitions about sex can change after a sexual trauma (for example: "Sex is harmful and disgusting"), which can be accompanied by difficult emotions such as guilt and shame. Negative thoughts and feelings about sex can hinder positive sexual experiences and have an impact on sexual desire.
Criterion E: There is a clear change in excitement and reactivity. Experienced anxiety and threat can affect healthy sexual functioning.
Since sexual problems are not part of the standard PTSD treatment, they are not identified. Treatment of sexual problems normally takes place after successful PTSD treatment, while it would be possible to combine these two treatments.
Integrating psychological treatment of PTSD and sexual problems
Sexual problems and their treatment are heterogeneous. However, four common elements of psychological treatment could be integrated into the article for comorbid PTSD and sexual problems:
Psycho-education: can help people to understand biological systems involved in PTSD and sexual response, to normalize emotions, to motivate someone to go to therapy and to have open conversations about sex
Relaxation: learning to relax in PTSD can help to reduce the activity in the amygdala and therefore the anxiety
Sensory sensation: this involves concentrating on the sensory sensation of touch, alone or with a partner, through which intimacy is slowly reintegrated.
Exposure: in this phase, someone is exposed to his or her fear, which leads to a reduction in the experience of symptoms related to anxiety
The purpose of this meta-analysis was to quantify the influence of psychological interventions on sexual problems in people with PTSD as a result of sexual trauma.
Studies were excluded from the meta-analysis if they were not published in English and / or if the study was not fully available. Studies were included based on the following criteria:
Adults
The diagnosis of PTSD in relation to sexual trauma
RCT (psychological treatments for sexual abuse)
Outcome measures of sexual problems
There were five studies that fit the included criteria. Out of these five, four studies had available data. The average age was 37.8 and all participants were women (N = 799). Two studies examined adult sexual trauma, child sexual trauma and a combination of both. Two studies were three-armed RCTs: active treatment, active comparison treatment and an inactive control. The other two studies were two-armed: active treatment and active comparison treatment.
Types of meta-analysis
There were two types of meta-analysis that were performed:
Between-groups analysis: Psychological treatment compared which compared both active and inactive controls had no effect on sexual problems. Psychological treatment which compared both active and inactive controls also showed no effect on dysfunctional sexual behavior.
Within-groups analysis: All four studies were included in the within-group analysis for sexual problems. A moderate effect size was found for psychological treatment, before and after treatment, on the subscale of sexual problems. Three studies were included in the within-groups analysis for dysfunctional sexual behavior. In this analysis there was a small effect size of psychological treatment on dysfunctional sexual behavior.
Study comparisons
The meta-analysis found no improvement in sexual problems and dysfunctional sexual behavior in a large range of psychological treatments. This was also somewhat expected since the interventions focused merely on PTSD symptoms. It was emphasized that sexual problems cannot improve as a result of improving PTSD symptoms, but that immediate intervention is required in the case of sexual problems. The treatments often took place in groups. This may be an explanation for the fact that sexual problems were not addressed by the treatment, since it was found to be difficult and uncomfortable to share these sexual problems. Another explanation may be that PTSD treatments are aimed at sexual traumatic memory and to facilitate emotional processing. However, this can indirectly neglect fear-based avoidance. For example, the frequency of flashbacks may have been reduced, but feelings of guilt, shame, or disgust may still prevent sexual contact.
Changes in pre and post treatment
A small to moderate effect of improvement was found on both the subscale sexual problems and psychological treatment. However, this effect cannot be attributed to an effect of the treatment. Given the lack of data to draw conclusions, more research is needed into the changes that are observed in pre-post analysis.
This study is limited by the lack of studies that have measured sexual problems as a result of psychological treatment for PTSD of sexual trauma. The meta-analysis also only contains subscales of measurements of broader trauma symptoms and a limited recording of sexual problems. More thorough measures can lead to a more convincing effect of psychological treatments for sexual problems. Another limitation of the study is that the data that was included in the assessment consists mainly of women participants, without comparable data for men. Men who are assaulted report more sexual problems than women and experience less improvement in sexual dysfunction than women. Although all participants in the samples have experienced sexual trauma, it is not possible to say whether PTSD is specifically caused by the sexual trauma. This is especially true when someone has experienced multiple forms of trauma. The risk of bias is relatively low between studies, however, some studies had heterogeneous samples that reduce the quality of the results in this meta-analysis.
There are people with PTSD after sexual trauma in who sexual problems are not identified or treated immediately. This can hinder the progression of therapy for PTSD and / or be related to other psychosocial problems. The results of this study suggest that it is false to assume that sexual problems will improve directly when symptoms of PTSD improve.
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