It’s Not Just Sex

A good approximation of how sex and intimacy is regarded by the U.S. Armed Forces can be summed up in the phrase I heard recently: “If you needed a wife…we’da issued you one.”

These days, the U.S. Army is perhaps the most chaste and constrained military organization on planet earth.  No drinking on duty, no sex, no pillaging, no cavorting…and go easy on the damn swear words.

Contrast this with the Russian Army, and German, which frequently serves beer with lunch; the harder stuff after dinner.  And numerous armies – no joke – provide prostitutes to their deployed troops.  Effectively, a little mini-platoon comprised of practitioners of the world’s oldest profession gets sent to war zones right along with the soldiers.  No doubt this idea  is regarded by these armies as a Godzillian leap up the ladder of human rights.  In the past, when victorious they just raped the women (and men) of their vanquished quarry.  At times, a veritable sexual bonanza was promised as the leading incentive to engage in vicious battle in the first place.

Members of the U.S. Armed Forces by contrast, seem expected to never have sex of any kind.  If sexual organs didn’t come already attached to the bodies of their troops, I’m rather certain the Army would have confiscated all tissue related to human reproduction – and especially the related pleasures of it – on the first day of basic training, relegating every appendage to iron storage boxes next to the gold bars in Fort Knox.  “You can have your clitoris back after your 20, soldier.  Until then, kill stuff.  And like it.”

I’m a happily-married, loyal-to-death-do-us-part, honest-to-a-fault type of husband who, with the perfectly understandable exceptions of Rachel McAdams and Jennifer Connely, can provide infinite assurances to his wife that she has minimal reason to fear infidelity (in kind, if she ever meets Johnny Depp in a smoky, sultry, bean-baggy, beatnik bar…she has my blessing).  That said, I think the “Hooker Platoon” is a great idea.  Presumably, said professionals are well-paid, in control of their lives, and free of drugs.  Like it or not, humans are sexual beings and they go about obtaining it in a myriad of ways.  Might as well make it safe, fair, protected and consensual, even if questionably moral.

But what about the ones who aren’t deployed?  Or the ones who, by choice, remain celibate as they await – with admirable fidelity – their dear lover back home?  What about the people who have returned from over a year’s deployment, waay beyond ready to re-start a healthy, loving sexual relationship with their spouses?

Unfortunately, many soldiers return from war zones with major emotional and physical damage – and major problems having sex.  PTSD, insomnia, chronic pain, depression and anxiety all affect sexual ability.  And these problems are like cockroaches…if you have one, you probably have others.  Worse, the meds used to treat the above problems often severely inhibit sexual function too.  Am I the only one who sees the Faustian irony in “You can be happy…OR you can have sex.  Not both.  Your choice.”  For many (including me), that choice is an oxymoron…emphasis on moron.

While not always the problem, erectile dysfunction is one of the more common issues I deal with.  Given the ubiquitous commercials displaying medically-enhanced virile men, one would think ED wouldn’t be such a problem.  And it is true…a pill can solve the problem sometimes.  Cool, right?  A nice, easy fix.  The problem is that sex is considered by the Army to be something of a sport.  Golf, but morally suspect and generally distrusted.  As if to clarify their position, one of the more odd policies I’ve seen is the meet-you-1/20th-of-the-way idea of providing 6 pills of Levitra per month for up to 3 months for erectile dysfunction.  6.  For 3 months.  Then…good luck.

But 6 pills?  A month?  I know they’re expensive – something like 10 bucks a pill – but who came up with a number like that?  Was he (or she…or it) ever in a loving, happy sexual relationship?  Had it already donated the entirety of its copulation gear to NORAD for weapons testing?  Turns out the decision comes from the Department of Defense.  Yep.  The guys buying fiber-plated bombers and infra-red rifle sights and inventing bombs that suck your inner organs out through your maxillary sinus, are also the ones who decided that 6 sexual encounters a month should keep the average couple happy.

Truth is, for many of my returning soldiers, sex and intimacy isn’t simply a nice addition to their lives after over a year of living in austerity.  It is life.  This seems to be especially true of the committed, married soldiers I work with.  Their marriage, and the love they share within it, is often the only salve on wounds that cover their bodies and souls.  Imagine falling into the yearning arms of your wife after 15 months alone, after encountering horrors on the battlefield you will never describe, only to have to say you’re sorry, you just aren’t the same as you were…even as a lover.

A patient recently said to me (to paraphrase), “My wife and I LOVE to have sex, doc.  It’s an every day thing, if not two or three times a day.  At least, that’s how it was.  Now we spend most of the time we would have spent in bed – or in the kitchen, or in the microwave, or in the neighbor’s tool shed, or on top of the dresser, or under the aquarium, or in the chimney, or dressed up as Tonto and the short curly-haired lady from Cheers – with a counselor, trying to figure out what’s wrong with me.”

Most (not all) healthy, vital, loving relationships are comprised of sex more than just once a week with an occasional “two-fer” on the weekend.  Especially if one of the partners has been gone for over a year.  If returning injured soldiers have anything to look forward to, for many of them it’s their longsuffering, waiting, pent-up, willing spouse.  Divorce is a catastrophe, especially when it’s between a broken soldier and the person who typically is the last one standing in their corner when the world is running down.  Seems to me that we could forgo a couple of those useless air-to-air combat fighters everyone’s arguing about and use the money to give these soldiers as many nights of intimate bliss as we possibly can.

Oh-NineHundred

Nothing makes an Army drill sargent (prounounced something like ‘Sar-Ughnt’) more testy than when a good number of his/her unit skips morning physical training.

I take that back…there’s a veritable Olympics of things competing to be the thing a drill sargent hates the most.  But showing up late for PT is definitely on the list.

One of my jobs is to set up patients with this Army thing called a Profile.  THE profile.  After a few months here, I can say in all certainty that the profile is my own personal battlefield.  Everything I do seems to revolve around this paean to administrative oversight.

Simply put, the profile defines what an injured soldier can and can’t do.  They get very specific: Soldier may mix cocktails, but d/t a herniated C-4 disk, he may not tip his head back to drink them.

Oh MAN...we can't come in 'till 9. Super tired...

One of the big reasons I see patients is to “review the profile.”  Read between the lines, and typically, the visit is really about the patient trying to get some other restriction put on their profile.  Restrictions that will make most soldiers ecstatic and drive a drill sargent nuts.

The most ubiquitous profile restriction is the “0900 work call”.  Prounounced “Oh-9 call”.

Droopy-eyed private: “Uh, man, sir, uh.  Need an Oh-9 profile.  TONS of sleep meds. Can’t get up for 0630 PT.  Help.  Desperate and all that.”

Me, Dr. Naive:  “Ok.”  Fill out form.

Private: “THANKS, man.  Can I get Oh-9 profiles for the rest of my X-Box buddies.  Now that I can stay up all night playing Soldier of Fortune, I need my buddies cuz we compete against each other.”

“Soldier of Fortune…isn’t that pretty bloody.”

Evil smile, “YEAH, totally.  We just run around shooting everybody.”

“K.  Why are you on meds again?”

“Can’t sleep.  PTSD.  Keep seeing people get shot when I close my eyes.”

Embellished only slightly, I’m coming to the point where I can’t see a SINGLE medical reason to approve someone for 0900 work call.  Sleep meds don’t last forever.  If you take them at 7pm and are in bed by 0800, you should be able to get up in time for PT.

I’m asking around to doctors I know:  Any medical reason you can think of to allow someone to come in at 0900 rather than 0630?

If I’m Not Depressed, Why Am I Sleepy?

I have a pt. who is taking more than one anti-depressant. At one point, she was so depressed she could barely come to the office to ask for more help. I think if she could have arranged for tube feedings, she would have just laid in bed for the rest of her life.

sis.jpgDepression is a crazy thing. You can have just gotten married, have a good job, be generally healthy, have some friends – like my patient – but still be totally depressed. You’d think that all this stuff would protect a person from major depression, but it doesn’t. The best definition I’ve ever heard about depression is “socially-acceptable rage”. Depression is often angst about the way things are. It’s about perception of what is. It is a habitual analysis of reality that regularly leads to unhappy conclusions. You can have a lot of cool things in life and still think about life in dark themes.

One of the bright spots in depression treatment is…depression treatment. Didn’t use to have much for the problem at all except shocking the hapless patient’s brain (shock therapy is still used, actually, but rarely). Often it is said that medicine created the “magic bullet” when antibiotics were invented but haven’t thought up something as brilliant since then. In truth, antidepression meds are are the magic bullets of our time. They really have changed lives…arguably as well as cardiac catheterization or colonoscopies or CT scans. Just one little pill, and life gets better.

There are side-effects, most notably, antidepressants mess with sexual function. I even saw one guy who had to have a penile amputation because he had antidepressant-caused priapism (constant erection) and he didn’t get treatment for it for too long. The irony of this – the guy was trying to be happier in life, mind you – is hard to miss. But aside for these horror stories, antidepressants are pretty great.

Another problem for some people, is how antidepressants affect the “sleep center” of the brain. This is different from the short-lived insomnia that most people have when just starting out on anti-depression meds. When we sleep, we need to essentially phase through a number of different stages. Each stage should happen more than once. Sleep physiologists identify each stage by noting the different shapes of brain waves that show up on an EEG machine. Often, for some reason we don’t understand, people on antidepressants don’t create “delta” waves when they sleep. So, they go to bed tired, sleep for 10 hours, and wake up wondering how long until they can go back to sleep. They fall asleep on their way to work, in the morning after a solid night’s sleep.

I remember reading lots of Greek myths as a child, and one of the most vexing was the story of Sisyphus. He was this guy who was punished by Le Gods for being a punk (and he was a punk, so don’t feel sorry for him). Ol’ Sis was condemned to roll a huge boulder up a steep mountain, only to see it roll back down to the bottom every time he was just about to the top (note picture above: guy with HUGE thighs holding uncomfortable-sized boulder). Being a myth from The Odyessy, of couse he was condemned to do this for ALL ETERNITY. No breaks. No lunch. No smoking. No benefits, vacation, vision or dental.

Often, trying to sleep while on antidepressants is a little like life might be for Sisyphus. You get all this sleep, but you never get rest. Day after day, you sleep for 8-10, maybe 12 hours, and wake up feeling like you haven’t slept in months. Strangely, you don’t feel depressed at all. Things are good. The world is relatively beautiful…if you could just see it through your drooping eyelids.

There IS an answer. No, not colloidal minerals (apologies to the lady who left the commercial disguised as a comment on one of these posts – yur blocked). Not blue-green algae. Well, maybe that stuff works. But in the M.D. world, we have a fix too…yet another antidepressant! But it’s an older class that we don’t use to treat depression anymore. Called the tricyclics, one of the main reasons we quit using them is because, would you believe, they made people so daaang tired. Why? Well, they seem to have a strong effect of the sleep center of the brain, and seem to cause delta wave formation in many of those same brains.

triathlon_1.jpgSo, my patient is experiementing with these right now. She gave me permission to talk about her here. I don’t know if 3cyclics will help her or not. She may have the “Sisyphean” Task of finding a way to sleep and not be depressed. But I’m hoping she will soon come larking back into my office wondering why I don’t do triathlons and opera like she does these days. My reply, assuredly, will be that I’m just too tired.