ADVANCE-CIRCUIT: Combat injury-related challenges to sexual intimacy

Sexual dysfunction comprises the various ways in which adults may have difficulty experiencing personally satisfying, non-coercive sexual activities.  It is associated with reduced quality of life, increased mental ill health and decreased work productivity in men.  As a result, sexual dysfunction can impose a substantial emotional burden on individuals and an economic impact on employers.

Investigations into sexual dysfunction among male military personnel from European countries are limited in number and scale, with none stemming from the UK. Using quantitative data, this project will provide accurate prevalence rates of sexual dysfunction, longitudinally, in a cohort of ~1200 UK Armed Forces (UKAF) personnel who deployed to Afghanistan between 2003-2014.

Few civilian men seek assistance for sexual dysfunction, suggesting a high level of unmet need. Reluctance to seek help for sexual dysfunction is exacerbated by cultures of hypermasculinity; and military culture has a reputation for being a masculine arena. Furthermore, currently, UK support service providers do not routinely ask injured veterans if their injury has affected their sex life. 

Co-designed interventions are suggested to be the cornerstones of accessible and effective treatment for sexual dysfunction, as they promote beneficiary engagement. This project will co-design intervention principles in partnership with UKAF personnel and UK healthcare service providers, to inform a population-centred, evidence-based, health systems response.

This study has one overarching objective: that individuals who sustain occupational injuries which lead to the development of sexual dysfunction are enabled to lead the most fulfilling lives possible.

The specific aims of this study are: 1) To provide accurate prevalence rates of sexual dysfunction, longitudinally, in a cohort of ~1200 UKAF personnel, approximately half of whom sustained combat injuries. 2) To determine the risk factors and mental health outcomes associated with sexual dysfunction in a cohort of combat-injured UKAF personnel. 3) To understand the experiences, help-seeking behaviours and support needs of UKAF personnel with sexual dysfunction. 4) To co-design intervention principles in partnership with UKAF personnel with sexual dysfunction and UK support service providers, to inform a population-centred, evidence-based, health systems response.

• Work Package 1 (Prevalence). Summary statistics will be captured at the first three time points (spanning approximately six years) in both the injured and uninjured groups. A mixed effects Poisson regression model will be used to test the association between injury status and sexual dysfunction longitudinally.
• Work Package 2a (Risk Factors). A mixed effects regression model will be used to ascertain association between sexual dysfunction and injury type (e.g. traumatic brain injury, genitourinary injury and spinal cord injury). 
• Work Package 2b (Mental Health Outcomes). Association between sexual dysfunction at the first time point and common mental health disorders at third time point will be calculated (data from qualitative interviews will be used to ascertain attribution).
• Work Package 3 (Experiences and Support Needs). ADVANCE participants whose injuries have negatively impacted their sex lives will be invited to interview to understand their experiences, help-seeking behaviours and support needs.
• Work Package 4 (Co-Designing Intervention Principles). UK support service providers working in military health will be invited to take part in an online focus group discussion to explore the barriers and facilitators they experience in providing support in this area. Data from Work Packages 3 and 4 will be analysed inductively and deductively, using Framework Analysis.

• RQ1: What is the prevalence, longitudinally, of sexual dysfunction in male UKAF personnel who sustained a serious combat injury whilst deployed to Afghanistan (and in a frequency-matched comparison group)?
• RQ2a: Which physical injuries increase risk for sexual dysfunction in combat-injured UKAF personnel?
• RQ2b: What are the mental health outcomes associated with sexual dysfunction in combat-injured UKAF personnel?
• RQ3: What are the experiences, help-seeking behaviours and support needs of UKAF personnel with sexual dysfunction?
• RQ4: Which intervention principles should shape a population-centred, evidence-based healthcare response? 

• Quantitative Work Packages 1 and 2: ADVANCE study participants (injured and uninjured, frequency-matched, UKAF personnel who deployed on combat operations to Afghanistan), n ~ 1200;
• Qualitative Work Package 3: ADVANCE study participants, n ~ 15;
• Qualitative Work Package 4: UK healthcare service providers, n ~ 8.