Intimacy post-injury, administering to the mental health needs of detainees in war, and seeking tran

A few men's heads turned last night when Col. (Ret.) Elspeth Cameron Ritchie and I sat, chatting in the Daiquiri Bar at the Army Navy Club in downtown DC.

I don't think it was because we were the only women in the joint, but because we were discussing what happens when you lose certain important things in war...things you need if you're planning on having children or intimate relations.

Something I learned in talking with Cam is that earlier this year Sec. of Defense Ash Carter okay'd coverage for military personnel to freeze their sperm or eggs prior to deployment, just in case they do happen to lose something important while in-country.

Even with the possibility for IVF (and getting past the disparities in service personnel coverage for the technique), and perhaps even after reconstructive surgery, complications can remain, causing mental distress.

If you're a physician who treats these service personnel, these are important issues to consider. Many soldiers returning from deployment with lower body injuries, particularly those who are younger and still interested in starting families, and those who simply want to remain intimate with their partners, end up at higher risk for suicide, depression, and other mental conditions. They also have higher divorce rates, according to Col. Ritchie. She's just written a book about the topic, Intimacy Post-Injury (Oxford University Press).

Cam makes the case that since veterans and other military personnel who are prescribed SSRIs for depression or PTSD, find their sex lives take a real hit once they go on their meds, this can lead to more depression because they can't enjoy intimacy, and so goes the vicious cycle. But, because there are medication strategies such as combining bupropion (Wellbutrin) with sildenafil citrate (Viagra), mindfulness and other nonpharmaceutical techniques, talking with patients is the place to start.

"Doctors don't really want to ask about these things, but if they do, they might be able to help prevent a lot of heartbreak," Cam said. "The taboos get in the way and can make it harder to lessen the depression, anger, and relationship troubles."

Cam's book uses composite case studies based on actual histories, and offers clinical teaching points. Intimacy Post-Injury will be out in October.

Also on Cam's radar is a look at how political detainees are treated by our military's medical officers.

"There's the Hippocratic Oath, but that's only a code for doctors. Then there's the fact that we might be at war with the patient's country, so they might be injured from being roughed up by one of your own," Cam explained. And as for the care actually delivered, how good is it?

The Geneva Convention requires "necessary" medical attention, not necessarily state-of-the-art. And it doesn't really address mental health issues. That's the part that I grilled her on: while we're potentially responsible for that person's trauma, how do we then mitigate it while it continues? It's the Rubik's Cube of morality that is military medicine. (Here's Cam telling me about when moral injury results from being ordered to kill.)

Another something to ponder: many detainees appreciate their time in captivity, according to Cam. "They get three hots and a cot. And during the Iraq war at least, they felt safer."

Something else to consider: many suicide bombers, at least during the Iraq War, were persons with serious mental illnesses like schizophrenia, who were not receiving their necessary medications, and so were easily manipulated by rebels into their awful demise, according to Cam.

A book on these ethical dilemmas is forthcoming from Cam, who was part of the forensic team at Abu Ghraib, and who has been sent to observe conditions at Guantanamo Bay and conduct sanity boards on several occasions...

As is a book on the experiences of gay psychiatrists in the military. I hadn't realized there were so many, but those who've served have stories to share, as do transgender personnel. If you'd like more information, or to offer to contribute your own stories, contact Cam.

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