Sexual Dysfunction in Male Iraq and Afghanistan War Veterans: Association with Posttraumatic Stress Disorder and Other Combat-Related Mental Health Disorders: A Population-Based Cohort Study



      Mental health disorders are prevalent in the United States, Iraq, and Afghanistan war veterans. Mental illness, including posttraumatic stress disorder (PTSD) with or without psychiatric medications, can increase the risk for male sexual dysfunction, threatening quality of life.


      We sought to determine the prevalence and correlates of sexual dysfunction among male Iraq and Afghanistan veterans.


      We performed a retrospective cohort study of 405,275 male Iraq and Afghanistan veterans who were new users of U.S. Department of Veterans Affairs healthcare from October 7, 2001 to September 30, 2009 and had 2-year follow-up.

      Main Outcome Measures

      We determined the independent association of mental health diagnoses and sexual dysfunction after adjusting for sociodemographic and military service characteristics, comorbidities, and medications.


      Veterans with PTSD were more likely to have a sexual dysfunction diagnosis, be prescribed medications for sexual dysfunction, or both (10.6%), compared with veterans having a mental diagnosis other than PTSD (7.2%), or no mental health diagnosis (2.3%). In a fully adjusted model, PTSD increased the risk of sexual dysfunction by more than threefold (adjusted risk ratio = 3.61, 95% CI = 3.48–3.75). Veterans with mental health disorders, particularly PTSD, were at the highest risk of sexual dysfunction when prescribed psychiatric medications (adjusted risk ratio = 4.59, 95% CI = 4.41–4.77).


      Among U.S. combat veterans, mental health disorders, particularly PTSD, increased the risk of sexual dysfunction independent of the use of psychiatric medications. Breyer BN, Cohen BE, Bertenthal D, Rosen RC, Neylan TC, and Seal KH. Sexual dysfunction in male Iraq and Afghanistan war veterans: Association with posttraumatic stress disorder and other combat-related mental health disorders: A population-based cohort study. J Sex Med 2014;11:75–83.

      Key words

      To read this article in full you will need to make a payment
      ISSM Member Login
      Login with your ISSM username and password.
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Department of Veterans Affairs Epidemiology Program PDHSHG
        Office of Public Health.
        Analysis of VA Health Care Utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans. 2012
        • Hoge C.W.
        • Terhakopian A.
        • Castro C.A.
        • Messer S.C.
        • Engel C.C.
        Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans.
        Am J Psychiatry. 2007; 164: 150-153
        • Andersen J.
        • Wade M.
        • Possemato K.
        • Ouimette P.
        Association between posttraumatic stress disorder and primary care provider-diagnosed disease among Iraq and Afghanistan veterans.
        Psychosom Med. 2010; 72: 498-504
        • Letourneau E.J.
        • Schewe P.A.
        • Frueh B.C.
        Preliminary evaluation of sexual problems in combat veterans with PTSD.
        J Trauma Stress. 1997; 10: 125-132
        • Cosgrove D.J.
        • Gordon Z.
        • Bernie J.E.
        • Hami S.
        • Montoya D.
        • Stein M.B.
        • Monga M.
        Sexual dysfunction in combat veterans with post-traumatic stress disorder.
        Urology. 2002; 60: 881-884
        • Hirsch K.A.
        Sexual dysfunction in male Operation Enduring Freedom/Operation Iraqi Freedom patients with severe post-traumatic stress disorder.
        Mil Med. 2009; 174: 520-522
        • Kubin M.
        • Wagner G.
        • Fugl-Meyer A.R.
        Epidemiology of erectile dysfunction.
        Int J Impot Res. 2003; 15: 63-71
        • Cohen B.E.
        • Maguen S.
        • Bertenthal D.
        • Shi Y.
        • Jacoby V.
        • Seal K.H.
        Reproductive and other health outcomes in Iraq and Afghanistan women veterans using VA health care: Association with mental health diagnoses.
        Womens Health Issues. 2012; 22: e461-471
        • Helmer D.A.
        • Beaulieu G.R.
        • Houlette C.
        • Latini D.
        • Goltz H.H.
        • Etienne S.
        • Kauth M.
        Assessment and documentation of sexual health issues of recent combat veterans seeking VHA care.
        J Sex Med. 2013; 10: 1065-1073
        • Hosain G.M.
        • Latini D.M.
        • Kauth M.
        • Goltz H.H.
        • Helmer D.A.
        Sexual dysfunction among male veterans returning from Iraq and Afghanistan: Prevalence and correlates.
        J Sex Med. 2013; 10: 516-523
        • Maguen S.
        • Ren L.
        • Bosch J.O.
        • Marmar C.R.
        • Seal K.H.
        Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in veterans affairs health care.
        Am J Public Health. 2010; 100: 2450-2456
      1. Diagnostic and statistical manual of mental disorders: DSM-IV.
        4th edition. American Psychiatric Association, Washington, DC1994
        • Kessler R.C.
        • Berglund P.
        • Demler O.
        • Jin R.
        • Merikangas K.R.
        • Walters E.E.
        Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication.
        Arch Gen Psychiatry. 2005; 62: 593-602
        • Cummings P.
        Methods for estimating adjusted risk ratios.
        Stata J. 2009; 9: 175-196
        • Zou G.
        A modified poisson regression approach to prospective studies with binary data.
        Am J Epidemiol. 2004; 159: 702-706
        • Litwin M.S.
        • Nied R.J.
        • Dhanani N.
        Health-related quality of life in men with erectile dysfunction.
        J Gen Intern Med. 1998; 13: 159-166
        • Kalmbach D.A.
        • Ciesla J.A.
        • Janata J.W.
        • Kingsberg S.A.
        Specificity of anhedonic depression and anxious arousal with sexual problems among sexually healthy young adults.
        J Sex Med. 2012; 9: 505-513
        • Feldman H.A.
        • Goldstein I.
        • Hatzichristou D.G.
        • Krane R.J.
        • McKinlay J.B.
        Impotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging Study.
        J Urol. 1994; 151: 54-61
        • Kockott G.
        • Pfeiffer W.
        Sexual disorders in nonacute psychiatric outpatients.
        Compr Psychiatry. 1996; 37: 56-61
        • Byers A.L.
        • Covinsky K.E.
        • Barnes D.E.
        • Yaffe K.
        Dysthymia and depression increase risk of dementia and mortality among older veterans.
        Am J Geriatr Psychiatry. 2012; 20: 664-672
        • Player M.S.
        • Peterson L.E.
        Anxiety disorders, hypertension, and cardiovascular risk: A review.
        Int J Psychiatry Med. 2011; 41: 365-377
        • Bleich A.
        • Solomon Z.
        Evaluation of psychiatric disability in PTSD of military origin.
        Isr J Psychiatry Relat Sci. 2004; 41: 268-276
        • Schnurr P.P.
        • Spiro 3rd, A.
        • Paris A.H.
        Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans.
        Health Psychol. 2000; 19: 91-97
        • Drescher K.D.
        • Rosen C.S.
        • Burling T.A.
        • Foy D.W.
        Causes of death among male veterans who received residential treatment for PTSD.
        J Trauma Stress. 2003; 16: 535-543
        • Ahmadi N.
        • Hajsadeghi F.
        • Mirshkarlo H.B.
        • Budoff M.
        • Yehuda R.
        • Ebrahimi R.
        Post-traumatic stress disorder, coronary atherosclerosis, and mortality.
        Am J Cardiol. 2011; 108: 29-33
        • Yaffe K.
        • Vittinghoff E.
        • Lindquist K.
        • Barnes D.
        • Covinsky K.E.
        • Neylan T.
        • Kluse M.
        • Marmar C.
        Posttraumatic stress disorder and risk of dementia among US veterans.
        Arch Gen Psychiatry. 2010; 67: 608-613
        • Arbanas G.
        Does post-traumatic stress disorder carry a higher risk of sexual dysfunctions?.
        J Sex Med. 2010; 7: 1816-1821
        • Spivak B.
        • Maayan R.
        • Mester R.
        • Weizman A.
        Plasma testosterone levels in patients with combat-related posttraumatic stress disorder.
        Neuropsychobiology. 2003; 47: 57-60
        • Vasterling J.J.
        • Proctor S.P.
        • Amoroso P.
        • Kane R.
        • Heeren T.
        • White R.F.
        Neuropsychological outcomes of army personnel following deployment to the Iraq war.
        JAMA. 2006; 296: 519-529
        • Cameron R.P.
        • Mona L.R.
        • Syme M.L.
        • Cordes C.C.
        • Fraley S.S.
        • Chen S.S.
        • Klein L.S.
        • Welsh E.
        • Smith K.
        • Lemos L.
        Sexuality among wounded veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND): Implications for rehabilitation psychologists.
        Rehabil Psychol. 2011; 56: 289-301
        • Hutchinson J.W.
        • Greene J.P.
        • Hansen S.L.
        Evaluating active duty risk-taking: Military home, education, activity, drugs, sex, suicide, and safety method.
        Mil Med. 2008; 173: 1164-1167
        • Hidalgo R.B.
        • Davidson J.R.
        Selective serotonin reuptake inhibitors in post-traumatic stress disorder.
        J Psychopharmacol. 2000; 14: 70-76
        • Rosen R.C.
        • Lane R.M.
        • Menza M.
        Effects of SSRIs on sexual function: A critical review.
        J Clin Psychopharmacol. 1999; 19: 67-85
        • Seal K.H.
        • Maguen S.
        • Cohen B.
        • Gima K.S.
        • Metzler T.J.
        • Ren L.
        • Bertenthal D.
        • Marmar C.R.
        VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses.
        J Trauma Stress. 2010; 23: 5-16
        • Harpaz-Rotem I.
        • Rosenheck R.A.
        Serving those who served: Retention of newly returning veterans from Iraq and Afghanistan in mental health treatment.
        Psychiatr Serv. 2011; 62: 22-27
        • Cohen B.E.
        • Gima K.
        • Bertenthal D.
        • Kim S.
        • Marmar C.R.
        • Seal K.H.
        Mental health diagnoses and utilization of VA non-mental health medical services among returning Iraq and Afghanistan veterans.
        J Gen Intern Med. 2010; 25: 18-24