Academy of Chiropractic’s Lawyers PI Program 279
From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
"SEX; or the Lack Thereof" The Gold Standard of Disability
It was 1980 and I was in clinic as a chiropractic intern. My patient Valerie was sitting in one of my first consultations and was slightly antalgic. Valerie was a liberated woman who was totally uninhibited and also must have realized that I was all of 25 years old, grossly inexperienced in life and as a doctor and gave me a lesson in being a trauma trained specialist. At that time I was trained in almost nothing.
I asked her the textbook required 5 questions "PQRST." When we got to the "S" I asked her what made it worse and her answer was (I will never forget this one) "When I get laid, I like sitting on top and depending upon how big the -----, I like to lean forward. When I do that now the pain is so severe that I can't continue and I can't..." well you get the drift of the rest! I remember being so flustered that when I examined her and had to listen to the heart sounds, she tapped me on the shoulder and asked me if it was protocol to put the stethoscope in my ears when listening. Needless to say, if Facebook was around then, I would have gone viral in a heartbeat!
The sexual habits of patients are real, personal and it is my vast experience now, 32 years later in documenting the sexual ability of the injured or the lack thereof. It is that lack of ability that makes this such a dynamic topic. In my courtroom experience, the lawyers that have had me testify always request that I discuss upon direct examination the alteration in sexual habits of the patient so the jury can get a clinical rationale how the injury is causally related to my patients inability to have the same sexual relationships they had prior to the trauma.
This is the central issue and one that most doctors still miss. It is simply "WHAT CAN THE PATIENT NO LONGER DO THAT THEY COULD PRIOR TO THE ACCIDENT." Sex is on that list and you should urge, in a sensitive way to get the patient to document their sex life, or the lack thereof post-trauma.
Here is how I put the question to the patient; "Mr./Mrs. Jones, it is important to document every aspect of your life so that a judge and jury can realize the full and often devastating negative effect the accident had on your life. One area that jury's, lawyers and judges relate to is your sexual life. Virtually no one lies about such a sensitive issue and I need to document how the accident has altered this aspect of your life. Therefore, simply, has the accident negatively affected your sex life? If so, in generalities and how so?"
At this juncture, most patients do not need prompting and 99% will simply say that they cannot have sex as often secondary to pain in their low back, neck, etc... Occasionally a patient will get graphic, but that will be a rarity.
When communicating to the patient's lawyer, make sure to highlight this issue and allow them to fully understand it, especially when they have to negotiate settlement.
Post Traumatic Stress Disorder and Sexual Dysfunction
People who have experienced a life-threatening event may develop PTSD. Examples of events that may cause PTSD in people can include things such as terrorist attacks, physical or sexual abuse in children, combat or military exposure, car wrecks or serious accidents, and natural disasters; tornados, floods, earthquakes, or fires, for example. Once the event has occurred and a person has endured it they may feel confused, frightened, or angry. Should these emotions worsen or remain unresolved, the person may have PTSD. These symptoms can disrupt the person’s life, making it difficult for them to continue their activities of daily living.
SEXUAL DYSFUNCTION IN PTSD
Symptoms usually develop within 3-6 months of the event but may be delayed. They include:
- Flashbacks , dreams or intrusive memories /images of the event
- Awareness and avoidance of cues that trigger memories of the event
- Partial or total amnesia for the event
- Depression and irritability
- Social withdrawal and relationship problems
- Drug and alcohol problems
- Concentration and memory disturbance
- Sleep disturbance with nightmares
- Sexual Dysfunction
PTSD is a condition that can be difficult to treat and recognize. It is a long-term condition and the patient and their partner will need considerable help and support.
One area that has been poorly understood and addressed is that of sexual dysfunction. In my experience this is an almost uniform feature of sufferers whether male or female. Such dysfunction occurs through several mechanisms:
1) The sufferer will tend to have emotionally withdrawn from their partner and may avoid intimacy at all costs. They may be bad tempered, irritable and possibly even violent- this does not make their loved one feel particularly loving towards them either! Alcohol and drug abuse can worsen the situation.
2) The condition itself is characterized by a state of “sympathetic nervous system hyper-arousal.” This nervous system prepares us for “fight or flight” and is our survival mechanism. People in such a state are not likely to feel sexual and will not be able to become easily sexually aroused- “the last thing you need in a fight or flight situation is an erect penis!” To achieve an orgasm a person needs to “lose control,” even if only momentarily; this is very hard for the sufferer of PTSD who is often unable to “lower their guard.”
3) Many of the drugs used to treat PTSD and any associated depression may cause considerable sexual side-effects. The commonest drugs used are the SSRI antidepressants; these are associated with a reduced libido and delay in orgasm. Tricyclic antidepressants may cause erectile dysfunction and arousal disorder, and major tranquillizers can cause loss of libido, arousal disorder and delay or difficulty in achieving orgasm.
SEATTLE (UPI) -- A large number of trauma patients suffer from sexual dysfunction long after their initial injury, researchers at the University of Washington say.
Nearly one-third of patients who had sustained moderate to severe trauma reported some degree of sexual dysfunction, and most characterized the dysfunction as severe a year after the event, the researchers said.
The study found a total of 3,087 of 10,122 patients who were treated for trauma had sexual dysfunction.
Dr. Mathew D. Sorensen and colleagues said the researchers did not expect to find sexual dysfunction was so widespread among trauma patients.
"Overall, the sexual dysfunction rate in this study is about double what it is in studies of healthy patients. And for patients under the age of 50 years, the rate is about triple," Sorensen said in a statement.
"In fact, we found that a moderate to severe traumatic injury imparts a risk of sexual dysfunction above and beyond the risk that may be imparted by known risk factors for sexual dysfunction, such as increasing age, diabetes and lower socioeconomic status."
The findings were presented at the Clinical Congress of the American College of Surgeons.
Should a patient have this type of issue, it must not only be documented in the "personal functional loss" section of the narrative, the patient should also be referred to a "neuropsychologist" for care in eradicating the root issues of the PTSD and given mechanisms to cope while going through the process.
Sexual dysfunction is real...very real and a very serious physical and emotional disabling issue that has been the effect of many injuries. It must be responsibly documented with every sensitivity afforded your patients.