I have been working with combat veterans for two years as a group, individual and mindfulness therapist in our mental health outpatient clinic, the continuing care program, and in the palliative care unit. Among the combat veterans I serve, there is a complex array of experiences in the military theater, personality styles, medical complications, and mental disorders. However, all of the men are plagued by gender role strain, that is, discrepancies between gender role norms and their own personal sense of masculinity, which is further complicated by impotence. There are many evidence-based treatments for combat veterans that target and address distress tolerance, affect regulation, impulse control, anger management, and so forth. One complication of treatment for male combat veterans that is rarely discussed either in the literature or in the clinical realm, is how impotence affects a man’s self-concept, sense of wholeness, and gender identity in relation to his behavior, therapy goals and prognosis.

Writing about the various emotional, psychological and behavioral responses to emasculation and powerlessness are out of the scope of this article, as is discussing other sexual dysfunction disorders. Female veterans’ issues of sexuality, gender role identity and medication compliance are extremely important to address in treatment. However, this article focuses on the unique complications faced by male combat veterans because of impotence. The purpose of this article is to encourage clinicians to consider impotence as more than a secondary medical condition or by-product of psychiatric medication in the mental health treatment of male veterans. Before exploring treatment complications, it is important to understand how the physiological phenomenon of impotence becomes a self-limiting psychological construct.

Readjustment back to civilian life, turning in uniforms and daily disciplined routines, handing in the “license to kill” and “giving up my gun” leaves many of the men feeling powerless, limp, and soft. That shift in self-concept can emerge behaviorally as maladaptive, compensatory strategies that serve a purpose of regaining a lost sense of power. One veteran confessed to killing cats to feel that sense of potency; some react to small triggers and frustrations as if the outcome is “life or death,” and some perpetrate domestic violence. In a mixed group of combat and noncombat veterans on conflict resolution, the words “soften and surrender” arise as potential strategies for dealing with inner tension and interpersonal conflict. These terms always come from noncombat veterans and are immediately dismissed by the combat veterans as clear violations of their military training. Some of the responses to these terms include the following: “There’s no room for a soldier to surrender and soften; I would have died if I did that,” and “Those words make me think of a limp [phallic member], all soft and powerless.” Many of these men also suffer from impotence. They are no longer military personnel with the powerful capabilities of taking life but are now impotent men unable to live up to that constructed image of a man. This can greatly impact their treatment prognosis and medication compliance. 

During group psychotherapy, many of the veterans have reported becoming erect when shooting automatic weapons at enemies in the field. They share vignettes that detail their physiological and sexual response to being in combat, and they even become noticeably aroused in session. When the conversations shift to interpersonal intimacy, the fact that they no longer can perform sexually with their spouse triggers shame, sadness, anger and emotional decompensation that usually end in tears and shaking fists. One patient reported, “I’m no longer a man ... I work just to survive and now I’m just waiting for the end.” Another veteran disclosed, “I can’t perform with my wife; she thinks it’s her fault, I know it’s mine.” I generally rely on gender role strain theory to conceptualize the men’s experiences of the discrepancy between perceived gender roles and their actual experience. Much of their thinking is culturally conditioned, and using gender role strain theory helps reconstruct a sense of masculinity where emotional control, anger, power over others, risk taking, being the playboy and so forth are no longer centralized to a man’s sense of masculinity. However, clinicians must meet these men where they are, and in these instances, these men see themselves as impotent, both physiologically and spiritually.

Sixty percent of the male veterans we see in our outpatient mental health clinic are impotent. The etiology of impotence varies: from vascular disease, diabetes, hormone changes, to more psychological origins, for example, “this is the consequence for having cheated on my wife while deployed,” or experiencing military sexual trauma. Taking some psychiatric medications, like Risperidone, can result in raised levels of prolactin, increasing the chances of erectile dysfunction. Thiazides and other antihypertension medications, beta-blockers, and a host of antidepressants may cause impotence, among other sexual dysfunctions like anorgasmia. In consultation, a behavioral health psychologist reported that some combat veterans who have handled bodies, held comrades who have died, or perpetrated violence against the enemy at close range cannot tolerate the sounds, smells, and sensations involved in sex, leading to erectile dysfunction. While we as clinicians are figuring out the etiology of our veterans’ erectile dysfunctions, the veterans themselves are creating their own medical experiments in hopes of achieving an erection.

One of my patients has been through several treatments for impotence, including the front line medications and the more invasive second line treatments. He reports that none of the treatments have worked, and the injections leave him aching. He confesses to frequently skipping his morning antipsychotic medication in hopes of having an erection. His deep shame for not being able to “be a man and please my wife” becomes more important to him than not hallucinating or dissociating. While his conception of “being a man” is culturally bound and delimiting, his obvious deep-seated emotional distress leaves him sacrificing his psychological stability. This greatly impacts his ability to work and be in relationships.

Treatments discussion

Relying on an interdisciplinary team of psychologists, psychiatrists, primary care physicians and urologists can provide the holistic support that our veterans often need. As complications arise in the course of treatment of mental disorders with medical issues, each team member can offer unique treatment interventions. Some treatments include sexual therapy, psychotherapy and couples therapy. Other treatment options include medication (Cialis, Viagra, or Lavetra), hormone treatments, penis pumps and vacuums. The more invasive treatment options are injections of Caverject or Edex into the side of the penis or inserting tablets of Muse directly into the urethra. However, what is often missed in treatment is a centralized conceptualization of impotence as it impacts the veteran’s self-concept and sense of masculinity.

Many current integrative theories can be relied upon to conceptualize the more behavioral and interpersonal consequences that impotence might have on our male veterans. I present the one I am most familiar with and for which I have seen results. Relational-cultural therapy’s (RCT’s) main tenet is that people are always striving toward connection, while feeling isolated and chronically disconnected. RCT can help clinicians broaden the veteran’s understanding of sexuality and gender role identity to include being attentive, intimate, soft, playful and nonpenetration driven. For veterans learning to unlearn restrictive gender role norms, there needs to be a relational, cognitive shift where they can attend to the needs of their partners as a strategy for feeling connected and supported at the same time. This is an alternative to holding to the restrictive, one-dimensional schema that “I’m less of a man because I can’t penetrate.” This requires both the clinician and veteran to focus treatment on learning new skills that transforms intrapsychic isolation into interpersonal relatedness, that is, shifting from self-absorption to other-focused thinking. In therapy, I often focus my interventions with my male veterans who display aggressive behaviors and emotional restriction with their partners on exploring the possible relationship between anger, shame, and maladaptive behaviors. I wonder out loud how feeling powerless plays out in their relationships. Gender role strain theory formulates that anger and emotional control are two primitive and reactive male responses to conflict. Can the veterans connect their angry behavioral responses to a deeper sense of shame and sadness? The goal of these interventions is not to achieve an erection, of course, but to identify the ways in which impotence impacts their sense of self and their interpersonal strategies for connecting with others.

Another paradigm shift in treatment includes identifying and reconstructing how male veterans relate to sexual activity. If sex is genitally organized, that is, only involves the penis, then issues of masculinity are bound solely to penetration. Therefore, veterans who are unable to become erect are also unable to fulfill their perceived male roles. I have found that most of my patients who are not medication compliant claim that they “would rather be hard, than sane.” Many of the male veterans who complain of losing their libido and their erections report taking medications only occasionally, not taking medications in the morning when they hope to have sex with their partner, and stopping all together in the hopes of achieving an erection. Unfortunately, as seen above, this strategy often leaves the patient disoriented, anxious, hearing voices or experiencing whatever symptoms the medication reduces. In addition, the patient is still physiologically soft and unable to perform sexually. The role of the clinician then becomes split between offering support for their choice to be sexual over stable, while ensuring reality has been tested. This paradigm shift in treatment includes asking the following: Can male veterans learn to offer, enjoy, and see foreplay, cuddling, kissing, and massages as intimate and arousing? Sensate focus is a well-documented treatment in sexual therapy for individuals and couples that focuses almost exclusively on nongenital contact in most of the stages. Learning about global sensate pleasure and nonpenetration intimacy can retrain our male patients to experience themselves as whole beings not limited by impotence. If male combat veterans are skipping doses of their medications in hopes of achieving an erection and being intimate, it then becomes our responsibility to help them reconstruct their relationship to sexuality and to masculinity.

This is clearly not an exhaustive exploration of the relationship between impotence and treatment complications. Hopefully, this article acts as a drawing board for generating future conversations and discussions on this issue. In future literature, research, and APA division Listservs I would like to see issues of masculinity and sexuality discussed as a primary consideration in the treatment of male combat veterans. Whether we as clinicians discuss these factors or not, the men themselves formulate their self-concept based on these sociocultural constructs of masculinity and sexuality. Their treatment prognosis and medication compliance could very well depend on us addressing these very intimate details with the men we serve. It takes both courage and vulnerability on all our parts to handle such a sensitive topic.

About the author:  Michael Sapiro, MA, is completing his PsyD degree in clinical psychology at John F. Kennedy University. He holds a master’s degree in clinical psychology and a master’s degree in English with an emphasis on feminist and social justice pedagogy. He currently trains at a Veterans Affairs (VA) center working with combat veterans with posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and severe mental disorders. He sits on the board of directors for the Institute of Spirituality and Psychology and presents on clinical applications of mindfulness practices for treating PTSD. He is the cofounder and director of Maitri House Yoga.