A review article published in the Journal of Sexual Medicine finds that PTSD-related biological and cognitive processes may contribute to the development of sexual dysfunction following traumatic stress.

Sexual dysfunction was previously linked with exposure to sexual trauma, but not traumatic stress in general. But studies on combat veterans and victims of nonsexual crimes has shown that post-traumatic stress disorder can cause sexual dysfunction even when the trauma is not related to rape or sex abuse.

“It is clear that PTSD is associated with sexual problems, even among relatively young people regardless of the type of trauma they experienced,” said co-author Amy Lehrner in a news release. “We need to better understand this relationship and develop new treatments for sexual dysfunction in PTSD that will improve quality of life and promote resilience among trauma survivors.”

The authors said PTSD and sexual desire compete for the same hormonal and neurological networks. Because of this, drugs used to treat sexual dysfunction can result in panic attacks and flashbacks in individuals with PTSD. The substance yohimbine, for instance, increases the release of the hormone norepinephrine. A moderate boost in norepinephrine helps increase sexual desire, but high levels produce a generalized fear response.

“Sexual arousal mimics the physiological experience of fear, and once these associations have been forged in the intense experience of trauma, it can be difficult to uncouple them,” the authors said in their review.

Emotional factors also play a role. After reviewing more than 20 studies, the authors concluded that PTSD can produce sexual dysfunction by rupturing an individual’s sense of safety and the ability to trust and feel connected to others. It may result in an association of arousal with threat.

“Individuals with PTSD may avoid intimacy because it raises feelings of emotional vulnerability, necessitates some degree of physical vulnerability, or is incompatible with constant hypervigilance,” the authors explained. “For trauma survivors with PTSD, the relinquishing of control necessary to achieve orgasm may trigger feelings of helplessness, anger, and fear such that sexual activity becomes paired with negative affect. Emotional numbing and interpersonal disconnection also run counter to sexual desire and function.”

Lehrner and her colleagues said health care providers should be aware of the link between PTSD and sexual dysfunction.

“Given the pervasive and fundamental phenomenon of avoidance in sustaining PTSD, some patients may wish to continue to avoid sex, and may therefore not mention sexual dysfunction as a problem to their providers.”