Polytrauma with Sexual Dysfunction in a Female Soldier Following IED Blast Exposure

Combat Medic, by Msg. Henrietta Snowden, courtesy of the Army Art Collection, US Army Center of Military History.

Historically men comprised an overwhelming majority of military forces. As recently as the Vietnam conflict, only 2 % of active duty forces were female [1]. In 2010 that figure had risen to approximately 15 % [1, 2]. The 1994 Department of Defense Direct Ground Combat Definition and Assignment Rule (DGCDAR) prohibited women from serving in infantry or special operations units until recently [2]. So, despite the marked increase in female service members, women’s specific exclusion from serving in units whose primary mission included combat jobs would lead one to expect the morbidity and mortality rates for women to remain very low. However, the amorphous battle space and guerilla techniques used during the Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) conflicts exposed personnel in supporting roles to more combat [1, 3]. In fact, over 160 casualties and 1000 wounded service members from the OIF/OEF conflicts have been women as a result of these shifts in service demography and fighting tactics [4].

Perineal injury and lower limb amputation have been described as the “signature injury” of veterans of the conflict in Afghanistan [5]. The injury pattern has replaced the more historic genitourinary injury of renal trauma in part due to the successful introduction of torso personal protective equipment and the coincident rise in improvised explosive device (IED) utilization by enemy forces [6]. While these injuries have been investigated in male soldiers to some degree, it has yet to be well examined in females. In this chapter, we use a case to discuss how amputation, perineal trauma, and genital injury may affect female veterans . Additionally, we explore the existence and characterization of gender differences in psychological symptoms secondary to combat experiences.

20.1 Case Presentation/History

A 22-year-old single female Army soldier with no prior psychiatric history presented with posttraumatic stress and depressive symptoms in the context of severe physical injuries. Private First Class (PFC) Anderson, a pseudonym, was in her usual state of good psychological health until riding in a convoy that was struck by an IED. She sustained immediate traumatic amputation of her distal lower extremities and injuries to her perineum. She reported a clear recollection of the events. Documentation after the blast indicates that she did not lose consciousness or show signs of altered mental status, until chemically sedated in the field prior to transport. Management of her wounds during progression of the medical evacuation system resulted in bilateral above the knee amputations and pelvic injuries. She had genital scarring but her urinary tract was repaired with only mild residual pelvic floor instability.

Surgical management and stints in the intensive care unit characterized the first two months after injury. During lucid periods she was stolid though adequately participative in care. However, at a major medical center 3 months post-injury, the surgical team managing her care noted low mood, poor participation in physical therapy, crying episodes, variable appetite, irritability, hopelessness, nightmares, irregular sleep cycles, intrusive recollections of the IED blast, and avoidance of reminders associated with the day of injury. She frequently asked her parents to leave her room and angrily refused their help with transfers and other activities despite continued limitations imposed by her injuries.

At the time of consultation she was taking calcium, vitamin D, pregabalin, acetaminophen, and oxycodone as needed for pain, which she described as well managed. Prosthetics had not yet been fitted due to continued wound healing. She later resumed menstrual cycles, although it was unclear if she retained reproductive capacity. The psychiatric consultation team was asked to evaluate PFC Anderson and specifically tasked with managing the psychological symptoms interfering with optimal participation in rehabilitative services.

PFC Anderson had previously been without other medical conditions. She denied a family history of psychiatric disorders. She grew up as the fourth of seven children to an intact family in the Western USA. She denied a history of physical, sexual, or emotional abuse. Among her hobbies, she had enjoyed staying active by jogging and participating in yoga. She completed high school on time with excellent grades. Immediately after graduating she enrolled in community college and worked as a yoga instructor. Her aspirations included becoming an athletic trainer, but first she wanted to attend university to receive her degree in a related field.

Due to the cost of college and her extended family’s history of military service, she enlisted in the Army two years after high school to save money and gain access to education benefits. She intended to complete her initial four-year obligation and then get out of the service in order to raise a family.

This was her first deployment and she had no problems in her unit. She had two previous sexual partners in the context of committed relationships but was not dating at the time of her injury.

Mental status exam revealed a supine female with appropriate hygiene dressed in hospital attire. There were no alterations in her sensorium or abnormal behaviors. She displayed a dysthymic and restricted affect and minimal eye contact. She denied suicidal or homicidal ideations. Labs were normal, including hemoglobin, estrogen, cortisol, and thyroid stimulating hormone (TSH) levels.

20.1.1 Clinical Pearls

Establishing rapport is paramount in a consultative role. When a patient has been decimated by injuries, it would seem natural and appropriate to immediately focus on these. Rather, first inquire into and acknowledge their military service as a way of gaining rapport, especially if the mental health provider does not have a military background [7]. Chossing initial topics such as the service member’s branch of service, military occupational specialty, and previous duty stations can facilitate history gathering.

A comprehensive assessment of mental health issues in women post-deployment should include asking about physical injuries as well as explicit evaluation for thoughts about suicide, depression, anxiety, PTSD, alcohol use, sleep disturbances, and military sexual trauma (MST) [2]. As with men, women might not volunteer information unless specifically asked.

20.1.2 Potential Pitfalls

Avoiding sensitive topics out of discomfort or fear of causing increased psychological injury. It is important to evaluate the whole person, including a discussion about sexual activity. Although not extensively studied in veteran populations with genital injury, women with injuries impacting sexual functioning generally expect sex education during rehabilitation [8].

Assuming that because the patient is female she has not been exposed to combat or gone through a life-changing experience. Deployment, separation from family, combat exposure, and a heightened concern of MST are all issues that commonly affect female veterans [2].

20.2 Assessment/Diagnosis

20.2.1 Somatic Polytrauma and the Respective Psychological Implications

Though the full extent of PFC Anderson’s somatic injuries and their sequelae were uncertain, her case represented an increasingly common injury pattern.

20.2.1.1 Perineal injury

In American forces perineal injury from IED blast exposure has yet to be well studied. Prevalence data for this specific injury in the US military population is not readily available. An epidemiological study of musculoskeletal combat wounds from conflicts in Iraq and Afghanistan between 2005 and 2009 does not specifically quantify genital or perineal trauma, but found that soft tissue injuries to nearby regions of the thigh/hip and buttock accounted for 8.6 and 1.3 % of total musculoskeletal combat injuries, respectively [9]. Furthermore, this study found that pelvic fractures, which are often associated with perineal injury, combined with spinal fractures comprised 16.8 % of the total fractures sustained during combat .

One of the many obstacles PFC Anderson faced has been researched in civilians. Perineal injury can result in pelvic floor disorders that seem to have a dynamic relationship with depression and anxiety. For instance, in patients with pelvic organ prolapse, prevalence of depressive symptoms are reportedly high, while body image and multiple measures of quality of life have been found to be low [10–12]. These mental health implications also appear to adversely affect treatment outcomes. A study of 108 women in the UK observed that patients who benefitted most from the intervention of pelvic floor muscle training displayed absent or minimal anxiety or depression using subjective and objective measures of psychological health [13].

20.2.1.2 Sexual/Reproductive Functioning

The psychological impact of genital injuries has also yet to be adequately addressed in the literature. The few articles that address the mental health consequences of genital or perineal injuries exclusively examined men. For example, Lucas and colleagues interviewed thirteen male patients who suffered some degree of genital trauma while serving the British Army in Afghanistan between 2009 and 2011 (eleven with bilateral or triple amputations). Eight of the thirteen described their genital injury as more important than losing their legs. The authors explained this finding by noting that those eight patients felt a loss of gender identity associated with the loss of their testicles [14]. Additionally, the patients’ ability to cope with these injuries depended on whether or not their fertility was preserved, either through sexual intercourse or artificial methods. Also highlighted were the expectations patients had to discuss their genital injuries with health-care professionals, despite the sensitivity of the topic [14].

While the literature on traumatic genital injury in women is lacking, research has shown that patients with spinal cord injury (SCI) face multiple barriers to sexual activity. In their study on Malaysian women with SCI, Julia and Othman noted that psychological factors such as perceived unattractiveness, lack of self-confidence, feelings of dependence, and concerns over satisfying their partners have been found to limit sexual activity more than physical impairments [8].

That study and the Lucas publication on male genital trauma both indicate that patients desired more information on sexually related matters such as fertility. In addition to recommending increased sexual counseling by health-care professionals, Julia and Othman described peer support groups as a “necessary” coping strategy due to the role models for recovery and decreased embarrassment while sharing intimate subjects with women managing the same problems [8].

20.2.1.3 Traumatic Amputation

As of 2014 more than 1500 US military personnel lost limbs in Iraq and Afghanistan [15]. The vast majority of amputees have been men, but dozens of women have also suffered from these injuries [7]. A qualitative study conducted by Cater has begun to shed some light on how women may cope with being affected by traumatic amputation. In her interviews with six soldiers who lost one or more limbs, four psychosocial adjustment variables were identified as important: grieving, body image, personal safety factors, and coping with the attitudes of others. These themes should be explored in patients like PFC Anderson. Factors that appear to aid in recovery included positive attitude, social support, personal courage, resiliency, military training, humor, and finding meaning in her limb loss [7].

While global quality-of-life measures are on average lower in the amputee community, the Cater study also touched upon the idea that traumatic limb loss is not necessarily a net negative experience for patients [7]. Several women reported that surviving the loss of a limb gave them new courage and made them stronger. Similarly, Benetato explored posttraumatic growth (PTG)—a positive psychological change experienced as a result of a struggle with a difficult life challenge—among OIF/OEF veterans who suffered combat-related amputation. She found a small but statistically significant correlation with higher levels of social support and a moderate-sized correlation between PTG and “rumination,” defined as the “process of re-examining the beliefs that characterize one’s assumptive world in light of an unexpected trauma [16].” Thus, fostering a supportive environment, in which the patient is encouraged to cognitively process the traumatic event and the resulting injury, is considered an important element of recovery and growth. As will be discussed in the treatment course, the consulting team’s formulation of this patient directly informed the role of facilitated rumination for PFC Anderson.

Mental health professionals working with amputees should also be familiar with the process of emotional adaptation to limb loss. As noted by Belon and Vigoda in their review on this topic, grief is a natural and normal emotional response experienced by all amputees [17]. As such, grief resolution is a primary area of focus in treatment. They endorse the following coping strategies: relaxation training, proper diet and exercise, having an adequate support network, developing awareness of and addressing negative self-talk, and pacing physical recovery.

It is noteworthy that the authors proposed eye movement desensitization and reprocessing (EMDR)—an APA-endorsed treatment strategy for patients with PTSD—as a self-talk technique for reducing the power of emotionally charged memories [18]. Two small, uncontrolled studies have also demonstrated promising effects for using EMDR in the treatment of phantom limb pain [19, 20]. In patients with comorbid PTSD, traumatic amputation and phantom limb pain, EMDR is a reasonable treatment choice.

20.2.2 Gender Differences with PTSD

As previously noted the OIF/OEF conflicts represent the first time that military men’s and women’s occupations have overlapped to such an extent that their posttraumatic stress characteristics could be effectively compared. Overall, the limited number of available studies in veterans or active duty personnel have shown few consistent conclusions about gender differences in the development and manifestations of PTSD. The studies tend to be hampered by limitations, including using self-report data collection and cross-sectional design. Furthermore, while statistically significant differences have been noted, the clinical relevance of the variations is debatable. Table 20.1 summarizes recent findings comparing the etiology, rate of development, and presentation of PTSD symptoms for military personnel.

Table 20.1

Suggested but inconclusive gender differences in PTSD trauma, susceptibility, and manifestations for veterans and military service members

	Women	Men
Primary trauma(s)	Sexual trauma, including MST [2, 21, 22]	Combat exposure/violence [22]
Primary trauma(s)	Combat exposure [2]
Rate of PTSD development	Equal for those with similar levels of overall combat exposure or recent deployment [3, 23, 24]	Active duty has a higher rate for those exposed to military sexual trauma [23]. This has not been the case in veteran populations [21]
Rate of PTSD development	Higher than overall active duty personnel [23]
Individual PTSD criteria and symptoms of other disorders	Symptoms including concentration problems and reminder distress may be more common [24]	Symptoms including nightmares, emotional numbing, and hypervigilance may be more common [23, 24]
Individual PTSD criteria and symptoms of other disorders	Higher levels of all factors for those exposed to the most violent aspects of wartime stressors, especially injury [22, 23]	Externalizing behaviors including alcohol abuse is more common [22]

In the current military population, women are more likely than men to develop PTSD as a result of sexual assault, while men are comparatively more likely to have combat exposure as their index trauma [21, 22]. MST can be defined as “sexual harassment and sexual assault that occurs in the military environment,” and meets the “A” criterion for PTSD when accompanied by violence or a threat of violence. A threat of violence may be more common in MST because military personnel often have combat training and access to firearms.

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