A RT I S S SYMPOSIUM 2012

Evaluation and Treatmentof Genital Injuries in
Combat Warriors

Sponsored by
Department of Psychiatry, Walter Reed National Military Medical Center
Center for the Study of Traumatic Stress
Department of Psychiatry, Uniformed Services University
Department of Urology, Walter Reed National Military Medical Center

A RT I S S SYMPOSIUM 2012

Evaluation and Treatmentof Genital Injuries in
Combat Warriors

SP ON S OR E D B Y
Department of Psychiatry, Walter Reed National Military Medical Center
Center for the Study of Traumatic Stress
Department of Psychiatry, Uniformed Services University
Department of Urology, Walter Reed National Military Medical CenterFrom the Conference Series:
ARTISS SYMPOSIUM

Evaluation and Treatment of Genital Injuries in Combat Warriors
Editor’s Note: This transcript has been edited, however, as in most transcripts someerrors may have been missed. The editors are responsible for any errors of content
or editing that remain.

IPD 2012 by Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
First Edition
Mary Lee Dichtel, RN
Senior Medical Editor
Educational Support Management Services, LLC
Mary.Dichtel@edusupportsvcs.com

Contents
List of Speakers.....................................................................................................i
Preface..................................................................................................................1
Harold J. Wain, Ph.D.
Welcome...............................................................................................................3
Brett J. Schneider, M.D.
Introduction.........................................................................................................5Charles W. Callahan, D.O.
The Impact of Trauma/Injury on our Veterans and Congressional
Oversight........................................................................................................7
Representative Timothy Murphy
Trauma and its Impact on one’s Psyche and Soma.........................................9Robert J. Ursano, M.D.
Genitourinary Trauma in Combat: Impact on the Wounded Warrior......15
James R. Jezior, M.D.
Testicular Trauma: Managing Sexual function and Fertility.......................19
Robert C. Dean, M.D.
Psychiatric Care of Survivors of Genital Injuries.........................................25
Frederick J. Stoddard, M.D.
Speaker Biographies..........................................................................................31

History of the Artiss Symposium
Kenneth L. Artiss (1913–2001), the namesake of this symposium, was an
Army officer, a research psychiatrist and instructor at Walter Reed Army
Medical Center. Dr. Artiss, who served for 21 years in the Army Medical
Corps retired in 1964 as a Lieutenant Colonel. He was Chief of the Department of Psychiatry in the Division of Neuropsychiatry at Walter Reed’s Institute of Research. His work included development of treatment methods
for combatants with severe psychiatric disorders.
After his retirement from the Army, Dr. Artiss was a senior consultant
for many years to Walter Reed’s psychiatric residency training program. Dr.
Artiss created an award in 1983 to spur military psychiatry residents to conduct high quality research. This award still exists today and was presented at
the conclusion of this symposium.

i

Speakers
Charles W. Callahan, D.O.
COL, MC, USA
Commander
Fort Belvoir Community Hospital
Robert C. Dean, M.D.
COL, MC, USA
Program Director, Urology Residency
Director of Andrology
Walter Reed National Military Medical CenterJames R. Jezior, M.D.
COL, MC, USA
Chief, Department of Urology
Director of Reconstructive Urology
Walter Reed National Military Medical Center
Timothy Murphy, Ph.D.
Congressman, 18th District
Pennsylvania
Brett J. Schneider, M.D.
LTC (P), MC, USA
Chief, Department of Psychiatry
Walter Reed National Military Medical Center
Frederick J. Stoddard Jr., M.D.
Chief, Department of Psychiatry
Shriners Hospital, Boston, MA
Associate Clinical Professor
Harvard Medical School
Continued

ii
Robert J. Ursano, M.D.
Professor and Chair
Department of Psychiatry
Uniformed Services University
Director, Center for the Study of Traumatic Stress
Harold J. Wain, Ph.D.
Chief, Psychiatry Consultation Liaison Service
Walter Reed National Military Medical Center

Conference Organizing Committee
Harold J. Wain, Ph.D., Chairman
James R. Jezior, M.D.
Robert Perito, M.D.
Brett J. Schneider, M.D.
For their support the committee wishes to thank:■■ Ms. Lisa Moore■■ Mr. Vernon Woods■■ Staff at NICoE■■ Our clinicians and support teams for providing the best care to ourwounded warriors.

■■ The Command at WRNMMC for providing a climate where we areallowed the space and creative license to think about complex issues.

■■ Dr. Robert Ursano for his support and encouragement to document

this important symposium.

■■ All the patients that continue to inspire and to teach us.

1

Preface
Harold J. Wain, Ph.D.
This year’s annual Artiss Symposium, “The Evaluation and Treatmentof Genital Injuries in Combat Warriors,” was sponsored by the Department of Psychiatry at the Walter Reed National Military Medical Center(WRNMMC), the Department of Psychiatry, Uniformed Services University and the Department of Urology, WRNMMC, Bethesda, MD.
Over the past 10 years the shattered bodies and psyches of our wounded
warriors have come to the clinical staff at WRNMMC on a daily basis. Mostof us have evaluated and treated patients who have suffered the onslaughtof trauma and its impact on the psyche and soma. Many of us subscribe toassessing and responding to our patients with a biopsychosocial approach
but in doing so we have often ignored the topic of genital injury because of
the taboo associated with talking about this type of injury. As a result of this
symposium, we hope to learn more about and discuss the psychiatric andmedical risks associated with genital injuries in order to better care for patients, their spouses and families. To accomplish these goals many thoughts
and questions must be addressed.
What does it mean to have a genital injury? What is it like? How do wetalk to patients with genital injuries? How do we instill hope in those withdevastating genital injuries? How do we address sexual function and fertility? How do we provide the education and tools to allow wounded warriors
to direct their own healing? When and how can we develop therapeutic alliances so the patient and family feel they have an advocate? How do we collaborate more effectively with our colleagues to insure more effective treatment outcomes? How can we have a voice to help our veterans who needsupport once they leave WRNMMC?
With these questions and others in mind we have organized this groundbreaking symposium and invited experts from the fields of Psychiatry, Psychology, Urology and Congress to learn from each others’ experiences andinsights and to initiate and facilitate dialogue to help patients, families, andchildren. The following pages are a summary of the thoughts and discussion
at this important conference.

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Artiss Symposium 2012

3

WelcomeA Warrior’s Deepest Fears
Brett J. Schneider, M.D.
As part of the opening of the conference, Dr. Schneider read an excerpt
from the Huffington Post that highlights some of the deepest fears our warriors feel as they prepare to deploy.
“Before they went off to fight in Afghanistan, the guys of 3rd Battalion, 5thMarines talked quietly about their deepest fear. Not dying. Not losing a leg
or an arm. It was having their genitals ripped off, burned away or crushed in
the fiery blast of an improvised explosive device. This was no idle concern toyoung men bursting with testosterone. The makeshift bombs known as IEDs
are taking a frightening toll in Afghanistan, the blasts shearing off arms andlegs, ripping through soft flesh, crushing organs and bone and driving dirt,
rocks and filth deep into torn flesh often leaving the genitals shredded or
missing. Some guys said they’d rather be dead. “
Dr. Schneider continued to explain the devastating injuries in Afghanistan presented in the article. “The decade of U.S. combat in Afghanistan
has left Afghans and Americans with a seemingly endless series of woes.
Among the most devastating are the blast wounds that have left more than
16,000 young American severely wounded. Several hundred have sufferedgenial injuries in addition to amputations and burns, leaving them unable
to father children and struggling to engage in something resembling the sex
they used to have often without the aid of what many view as the primarysymbol of their manhood.”
After injury, Dr. Schneider illustrated there can be loss of one’s hoped for“Several hundred have suffered genial injuries in addition to amputations
and burns, leaving them unable to father children and struggling to engage
in something resembling the sex they used to have often without the aid ofwhat many view as the primary symbol of their manhood.”4

Artiss Symposium 2012

future. “Who’s going to want to be with me now? wondered a Marine Staff
Sgt, 39, after an IED blast shattered his leg, ripped open his lower torso andsevered most of his penis. It was a legitimate concern. His girlfriend stayedwith him at Walter Reed National Military Medical Center in Bethesda,
MD., through many of his 42 surgeries. But one day he was wheeled back to
his room to find she had gone, leaving a nine-word handwritten note: ‘I can’ttake this anymore. I’m outta here.’”These warriors and others “agreed to share the painful and intimate details of their ordeals in order to spotlight what they feel is a life-altering but
often hidden wound, one that is frequently given inadequate attention andcare within the military health care system. Those who cannot regain theirsexual function or drive are given little understanding or aid, they said. ‘They
weren’t prepared for this,’ ” said one injured warrior of the Walter Reed Staff.
Dr. Schneider summarized the injuries in the past decade as stated in thearticle. “Since 2005, more than 1,500 soldiers and Marines have been carried off the battle field with genital wounds. Since late 2009, when President
Barack Obama ordered a “surge” of 30,000 combat troops into Afghanistan
and approved a new tactic in increased foot patrols, the pace of genital injuries has accelerated. In the year before the surge, 170 combat troops sufferedgenital wounds, mostly from IED blasts. In 2010, according to Pentagon
data, that number leapt to 259.” Last year, the Defense Department counted
299 cases of genital wounds that Dr. James Jezior , one of today’s speakers,
and a urologist who does genital repair surgery at Walter Reed, characterizes
as “devastating.”
Last fall the British military sent two nurses to Walter Reed to learn “fromthe experts.” They came to learn how we manage the sexual intimacy issuesof patients with genital injuries. This experience, which was echoed in the
Huffington Post article, taught us that we at Walter Reed are expected to beleaders in this area.
Today marks one more step in our preparation. Recently the Executive
Command of the Medical Staff unanimously voted its support for a multidisciplinary team that will focus its efforts on sexual health and intimacy
for our wounded warriors and their families. Requests will be submitted forfunding to create this team over the next few months.
References:
Wood, D., Beyond The Battlefield: Afghanistan’s Wounded Struggle With
Genital Injuries. The Huffington Post, 3/21/2012

5

Introduction“Therapuron”
Charles W. Callahan, D.O.
Medical necessity historically has been driven by military necessity. If wego back to the turn of the century we see Walter Reed himself championing and looking for the causes of yellow fever because yellow fever plagued
humanity forever. Some of the issues were taken on by uniformed medicine
and were conquered by uniformed medicine. That is the gauntlet that has
been thrown down today as military necessity drives another area where
Walter Reed National Military Medical Center has the opportunity to leadthe world in expertise.
At the turn of the first millennium the Greek language had words thatwere used for healing. One of them was the word from which we get iatrogenic and iatros which means physical healing. But there was another word,a more robust word, the word that we derived therapy from — therapuron.
Therapuron means much more than to heal. It means to heal, to care for,to serve and to restore. As we think about genital injuries and the devastation they cause, not just physically but on the whole individual including
their surrounding relationships, we face the very unfortunate fact that purephysical healing is beyond our grasp at this time. We focus, instead, on thefact that we serve this patient population as demonstrated by all of us being
here today and that we care for them like any group of patients with chronicand debilitating conditions. Ultimately, our goal is to heal, to care for and torestore our wounded warriors to their maximum potential.
As we think about genital injuries and the devastation they cause, notjust physically but on the whole individual including their surrounding
relationships, we face the very unfortunate fact that pure physicalhealing is beyond our grasp at this time.

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Artiss Symposium 2012

7

The Impact of Trauma/Injury on Our
Veterans and Congressional Oversight
Representative Timothy Murphy, Ph.D.
In any group, but certainly in the military, the topic of genital injury is asource of joking, teasing, mocking, and bragging. It is a sign of courage, cowardice, strength and weakness. It is a sign of masculinity, fertility, attractiveness, unattractiveness but we are not allowed to talk about it. Annual training for us is now not to talk about it. We are told what not to do as opposed
to how to do it. We have to remove the cloak of secrecy surrounding genital
injuries and begin a dialogue.
Approximately, one billion dollars per year is spent on medications forerectile dysfunction and that does not include all the supplements, minerals
and devices used to enhance performance. What happens to soldiers, sailors,
airmen and marines who go off to war after saying their goodbyes not thinking that a genital injury will happen to them?
In talking to a number of servicemen one of the great fears after genital
trauma is abandonment. When we discuss with a family member, spouse,boyfriend/girlfriend what has happened to their loved one we have to understand genital injuries are overwhelming for the injured and for their family members. We have seen spouses that are very caring and loving saying,“I’m never going to forget you. I’m never not going to be your friend. I just
can’t be your spouse anymore.”
On a national scope Congress is so filled with the psyche of embarrassment that they cannot talk about the topic of genital trauma. There are moments of courage, though. A young soldier came home after surviving devastating injuries. His wife said, “I sent this handsome young man to war andI don’t know who came back with his name.” When I asked her what she
was going to do she said, “I made a decision on my wedding day and even if
In talking to a number of servicemen one of the great fears after
genital trauma is abandonment.

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Artiss Symposium 2012

it takes 50 years I’m going to teach him to laugh and love again.” That is an
example of extraordinary courage under fire.
It is important to recognize that we are preparing people for the rest of
their lives as they seek a new identity that they were not prepared for. Issuesof dealing with the injury itself as well as the prolonged recovery time canbe very challenging creating extensive psychological losses and fears. Do wehave adequately trained staff for these patients? Do we have the knowledge
base? There is an absence of written knowledge of long term sequelae.
One of the things Congress is supposed to be good at is dealing withissues with a media perception. I recently screened a number of my colleagues. Not one of my colleagues has ever given a speech on the subject ofgenital injuries. Not one of my colleagues has gone on camera to talk about
genital trauma to help remove some of the stigma or to help start a dialogue.
One colleague said, “You have to be careful what you say on TV. You don’t
want that to show up in a campaign spot.”
Congress has a public leadership role in the area of behavioral medicine.
Do we have therapists trained to address issues of sexual function for our
wounded warriors? Do we have marriage counselors? Do we have NCOs
with some training and level of understanding of psychological first aid andlong term support? What skill set does the VA have to support veterans withgenital injuries? What is Congress doing to promote funding and asking for
research and reports? Congress needs and is asking for information fromthe military in this area. What do you need? What do medical providers
need? What products and other resources do you need and do you have thefunding to get it? How many patients are we talking about? What do we needin the long term? Clearly, we do not have all the answers. Congress is seeking
information from the military. Talk about these questions among yourselves
to seek answers. Include the wounded warrior and his/her family in yourdiscussions. Develop a protocol.
I want you to be challenged by the courage of the soldier’s wife I spokeof earlier. Have courage like her. Help these patients get ready for the rest of
their lives. Have a military and national dialogue.
Congress has a public leadership role in the area of
behavioral medicine.

9

Trauma and its Impact on One’s
Psyche and Soma
Robert J. Ursano, M.D.
We are filled with the feelings of what it is like to work with our patients,
whether we are surgeons, internists, or mental health providers. The reason
we work with our patients is because of what we just felt while Dr. Schneider
read the very moving words of our soldiers. That is what pulls us back. It iswhat makes us come back to the operating room, the clinic, or come backto the two chairs sitting in a room with nothing else present. But empathy is
only one of our tools. My task is to move us from empathy to a broader picture. How do we get from empathy, which is one of our tools, to other tools
to help those we are so concerned about?
DoD leads the nation in trauma informed care. How do we develop systems for this care? How do we deliver the care? What is going on with the patient? How do they recover? So far we have only mentioned men. Two things
were not said today. Women also have genital injury. In fact there is literature on intended genital injury performed on women. The second is not yet
mentioned. It is burn out that providers feel. It does not matter whether you
are a surgeon, internist, primary care physician, social worker, psychologist
or psychiatrist. Burn out happens. Burn out is frequently exemplified by thewife or friend who says, “I’m out of here.” Clinicians also say this. They say it
in lots of ways. They say it by becoming so irritable at home that they cannot
tolerate any more. They say it by becoming tired and depressed. They say it
by making mistakes and errors. All are aspects of burn out. These two topics
have to become a part of the dialogue, as well as many others.
Talking to patients, no matter what setting, provides the opportunity to
My task is to move us from empathy to a broader picture. How do we
get from empathy, which is one of our tools, to other tools to help those
we are so concerned about?

10

Artiss Symposium 2012listen and to observe accurately in a way that can be repeated by others. It
is of no value to you or your patient to make an observation that no one
can repeat. If someone cannot repeat it, it cannot be followed, it cannot bemeasured, and we cannot help the patient with that observation. No matter
how elegant the observation is, and there are many in psychoanalysis thatare very elegant, it does not help others if it cannot be repeated. If you cannot
repeat it, you cannot use it. We enjoy the elegance of our observations but wehave to make the elegance of our observations into tools if our primary goal
is to help people. And I think that is the goal and has been the goal of thisdepartment and this institution with all its capabilities.
So what are we hearing from our warriors about this type of injury? When
we talk about genital injury, particularly from the psyche side, what is it thatis injured? “Who will want to be with me now?” That is a wonderful observation. It means the person has injured intimacy. How do we measure intimacy? We have a literature on intimacy. We can think about how to treat issuesof intimacy. We can measure issues of intimacy. We can also think about how
to restore intimacy in some and in others how to mourn the loss of intimacy.
What about the lost sense of power and energy? We have a literature on theloss of sense of power and energy. It includes depression and decreased motivation. We have ways of measuring these. And of course, identity, “Who am
I?” How do we measure the loss of identity? How do we intervene? Do wehave a therapeutic modality? Do we have medications? Do we have targeted
psychotherapies for restoring identity and other aspects of loss?
What about the loss of “what can I produce?” As I was listening I was
thinking of Erikson’s stages and laying out a grid of what is injured in the
person. And I was also thinking about what Harry Holloway taught me froma wonderful piece of work that he did after an earthquake in Russia. The discussion led to what the community had lost. One of the things they lost was
their children. But what they said was, “We lost our future.” Genital injury
also has to do with something about the loss of future. It is a loss of sense oftime. How has one’s time sense changed? We all confront a shortened lengthof time usually much later in life. If one has genital injury all of a sudden one
is rocketed forward to a much older age in which one is dealing with lost
productivity. How does this transition occur? Can we facilitate it in a waythat is actually healthful?
What do we already know? What are some of the constructs that we have?
My goal today is to present the big umbrella. What do we know about people
that are injured? We know there are differences between human made andnatural traumatic events or intentional and non intentional traumas. It is an
important distinction. We know it generally takes longer to recover fromhuman made/intentional events than from natural/unintentional events.
What we are talking about today is a human made intentional traumaticWRNMMC | CSTS | USU 11

event. So we already begin to know recovery will be long. When there is comorbidity, for example, bodily injuries with brain injuries, the challenges aremuch greater.
Psychological problems, in DoD and in particular the Army and Marines,
comprise the second highest of all the areas of burden of the health caresystem in the military. It is an important part of our health care system that
requires resources to meet the needs of our patients.
There are at least three health responses to trauma and war. The first is amental health illness. As we all know, after an exposure to trauma the most
likely outcome is a resilient outcome. Most people actually do OK even in
facing the worst traumatic events. But where we spend our time is with issues like PTSD, depression and anxiety disorders. Secondly, responses include distress responses. We do not usually give these diagnoses but they
comprise a substantial amount of time in health care delivery. These include
changes in sleep to feeling safe at home, feeling safe driving over a bridge,
or feeling safe at a particular place. The other area of concern is health risk
behaviors. A classic example is increased smoking of either legal or illegal
substances or both. If the sustained increase in smoking continues we see anincreased mortality rate. I often remind our disaster workers that starting asmoking cessation program can be one of the most important interventions
after a disaster. It also allows you to identify people who are at high risk forother types of health risk behaviors.
Perhaps, surprisingly, one of the most important behaviors that helps prevent psychiatric illness is the use of a seat belt. If you have a seat belt on, you
are less likely to have an injury and we know if you have an injury you arefour times more likely to develop PTSD after a motor vehicle accident. What
are the seat belts for combat? Seat belts for combat are frequently training
and body protection. These are behavioral interventions that prevent injury
and, therefore, help prevent PTSD.
There are a vast range of other psychosocial responses to trauma and disaster. Other aspects of psychological responses to trauma injury include an
injured family, not just an injured person. Our group, led by Ed McCarroll,
was the first to document the increased rates of child neglect that occurred in
the Army from the onset of the war. Why is that? If you were to ask what is thehighest predictor of child neglect the answer is single parent families. What
we do when there is a war is the experiment you cannot do. We send one parent off to war. Today we are focused on an injury that impairs the ability to bea parent, and this creates a single parent family even though the parent may
be present. And might there be increased rates of child neglect among injured
soldiers even though they are still in the house? The burden of parenting falls
on one parent. Anyone who has children knows that is a tough job.
The rates of PTSD increase with greater exposure to war. PTSD is not12Artiss Symposium 2012

uncommon after many types of traumatic events. Perhaps nearly all of us
have the acute form at some point. PTSD can develop in people without apsychiatric history. Understanding that PTSD has a wide range of trajectories from mild to severe and debilitating is important. We can have PTSD asa bruise as well as a broken bone. Understanding the different trajectories isvery important. We do not know how to do that yet. How can we predict on
any given day post trauma the trajectory for any given patient? Our prediction ability is not very accurate. We know in the Oklahoma City Terrorist attack about 34% of people within ten blocks developed PTSD, and about 25%
developed depression. Most importantly, of those people, 40% had never hada psychiatric problem in the past. Those with no previous psychiatric illness are at risk. Despite the evidence there is still the belief that if you havea trauma related disorder you had something wrong with you before thetrauma. Let me clarify. This does not mean that people who had problems
before are not at increased risk. But that is very different from saying thateveryone with PTSD now had something wrong before.
We usually think of PTSD as a memory problem. Maybe it is not a memory problem. A cartoon illustrates: Walking beside Zambesi, Congo felt very
happy. “I have a super memory,” he said to himself. “And I will always remember what to forget.” Perhaps PTSD is really a forgetting problem. It is an
impairment in our forgetting process. Forgetting has often gotten a bad rap.
In psychoanalysis we want patients to remember and in medicine we worry
about forgetting because it is associated with Alzheimer’s and other forms ofdementia. But actually, forgetting may be a much more important process
to us than remembering. Remember our brain is taking in information all
the time and if it did not forget it would explode! In PTSD something has
happened with our forgetting ability. It has become impaired. Is what we arereally teaching patients is how better to forget?
A number of year ago we studied body handlers following the gun turret
explosion on the USS IOWA. About 12 % of the body handlers developed
PTSD over a year. Now why is that? Why is working around dead and injured bodies — you are not being shot at, you are not being blown up, andyou are not in a motor vehicle accident — a risk factor for developing PTSD?
Perhaps it has to do with identification. When you think, “It could have beenme,” you are four times more likely to develop PTSD. That cognition — thethought — that it could have been me, increases your risk of PTSD. You allknow that thought. We all know it. It is a part of what we usually think of asa very healthy cognition called identification. We identify with our parents,
our children identify with us and our mentees identify with us. But can identification actually turn against us like an auto immune disorder? Somethingthat is usually very helpful to us has actually become an impairment.
We already know that the brain changes with PTSD: the amygdala, pre-

WRNMMC | CSTS | USU 13

frontal cortex and hippocampus. We can identify people with PTSD byshowing them angry faces they do not even know they are seeing because
we show them in fewer than 300 milliseconds. We also know that the brainchanges with treatment. It is not a question of whether there are brainchanges with PTSD.
Behind all this are our genes. But genes are not the whole story. The grape
has more genes than we do. The grape has about 30,000 genes and the human has somewhere in the 22,000 range. We have begun to identify whatgenes are related to PTSD.
There are now perhaps a half dozen genes including the serotonin transporter gene which has been looked at in a number of studies. Epigentic
changes are important to PTSD. Epigenetics is the study of how your genes
change. Remember, you are born with a set of genes. Now ask yourself why
did your brain become a brain and your liver become a liver? They have thesame genes. How did that happen? It happened because some of them areturned on and some of them are turned off. The real story is not what genes
you have. It is which ones are turned off and which ones are turned on. And
that is how we get a gene environment interaction.
We began talking about empathy and how it is only one of the tools that
we have to help those we are concerned about. The broader picture encompasses all aspects of trauma informed care. Talking to our patients and making accurate observations that can be repeated by others is a very important
tool. We talked about some of the constructs we know about people whoare injured. We know it generally takes longer to recover from human madeor intentional traumatic events. Psychological problems comprise the second highest of all the areas of burden in the military health care system. We
know one of the most important behaviors that helps prevent psychiatricillness is the use of a seat belt. We also know that PTSD is not uncommon
after traumatic events and it can develop in people without a psychiatric history. Understanding that PTSD has a wide range of trajectories is important.
We know the brain changes in people with PTSD and we have begun to
identify how that happens. Identifying and using all our tools to addresses
the topic of traumatic injuries in our warriors is a great challenge. Ultimately
it will help to address the question, “Who will want to be with me now?”
Identifying and using all our tools to addresses the topic of traumatic
injuries in our warriors is a great challenge. Ultimately it will help toaddress the question, “Who will want to be with me now?”14

Artiss Symposium 2012

15

Genitourinary Trauma in Combat:
Impact on the Wounded Warrior
James R. Jezior, M.D.
Historically, throughout the history of warfare, about 5% of injuries are
genitourinary in nature. At the end of 2007, we saw a marked decrease in
numbers as the war shifted to Afghanistan. In the Afghanistan Theater ofOperations (ATO) the most dramatic changes in 2010 were the increased
numbers of bilateral thigh amputations, triple and quadruple amputations,and associated genital injuries. “When those who sustained major lower
limb amputations were matched with those who also sustained genital injuries, the correlation approached 90 percent.” This was a new battlefield injury
for us. A task force was convened to look into this new type of injury. It was
defined as a dismounted complex blast injury which is an explosion induced
battle injury sustained by a war fighter on foot patrol that produces a specific pattern of wounds that includes traumatic amputation of at least one
leg above the knee, a severe injury to at least on other extremity, and pelvic,
abdominal or urogenital injury.
In 2011, in order to look at our own numbers, we conducted a retrospective review of surgical cases performed by the Department of Urology at
Walter Reed and the then National Naval Medical Center from October
2003–February 2011. The American Association for the Surgery of Trauma(AAST) categorizes most organ systems with a grading system of I-V, with
V being the most severe injuries. We chose patients with injuries categorized
between III and V. These patients would have had at least partial urethra
disruption, laceration of greater than 25 % of scrotal diameter, laceration of
the tunica albugineal of the testes with parenchymal loss, skin avulsion of
the penis, glans laceration and segmental cavernosal defect. In that group of“When those who sustained major lower limb amputations
were matched with those who also sustained genital injuries, thecorrelation approached 90 percent.”

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patients we found 135 pelvic trauma cases and of those 77 % were caused
by improvised explosive devices, 13 % were caused by gunshot wounds, 5 %were caused by rocket propelled grenades and 3 % were caused by motor vehicle accidents. Of those patients with genital injuries 49 % had scrotal injuries, 30 % had unilateral testicular injury or loss, 13 % had bilateral testicular
injury or loss, 21 % had urethral injuries, 24 % had penile soft tissue injuries
and 4 % had penile amputation. Most of the genital injuries were associatedwith other significant non genital injuries. We saw four common injury patterns: (1) soft tissue injury to the scrotum with or without testicular injury or
loss; (2) soft tissue injury to the penis, anterior urethra, scrotum and testes;(3) perineal injury, bulbar urethral transaction, rectal injury and proximal
corpus cavernosum injury; and (4) penile amputation, scrotal loss, bilateralorchiectomy, and lower abdominal injury.
We have developed protocols for penile injury, perineal injury, and scrotal injury. The first thing we do is preserve as much tissue as possible. That
concept is also translated back into theater where we do everything we canto preserve testicular tissue and any of the important penile structures. We
do this by evaluating the wound under anesthesia.
One of the more common injuries is a glans injury. Not only is the glansa critical feature as far as sexual function and feeling and sensation, it is alsoa very cosmetic part of the penis. We found that if less that 50% of the glans
is lost it can be re-shaped and re-modeled to its original conical appearance.
Penile Replacement
The only approved methods for penile replacement in the United States
use the individual’s tissue configured into the shape of a penis which istransposed to the groin. It is flap related care which means tissue is takenfrom one part of the body and transposed to another part. Opportunities are
becoming available for penile replacement in the civilian world but they arestill in the research phase.
Limitations
There are several important limitations to genitourinary trauma reconstruction. Combat wounds often involve donor locations. Abdominal andgroin wounds can obliterate common recipient vessels. Future sexual function requires a penile prosthesis if and when sensation is established. Significant complications can occur from strictures and fistula formation andtissue can atrophy over time changing the cosmetic appearance of the penis.
Future Directions
The Armed Forces Institute of Regenerative Medicine (AFIRM) is amulti-institutional interdisciplinary network working to develop advanced

WRNMMC | CSTS | USU 17

treatment options for severely wounded servicemen and women. AFIRM
has five major research programs: (1) Burn Repair; (2) Compartment Syndrome Repair; (3) Craniofacial Reconstruction; (4) Limb and Digit Salvage;and (5) Scarless Wound Healing. One deficit is the absence of a research
program for genital injuries. In April 2012, AFIRM launched a program thatallows research for genital injuries. Hopefully, protocols will be developed tohelp us move forward.
Tissue Engineering
Tissue engineering must have a scaffold plus seeded human cells and thepresence of bioactive factors. Biomaterials are used to replicate the biologic
and mechanical function of the native extracellular matrix (ECM) to form ascaffold for cell anchorage. Materials can be naturally derived like collagen,acellular tissue matrices or synthetic polymers like polygycolic acid (PGA)
and polylactic acid (PLA). Animal studies to re-grow the penis have been
done in rabbits with some success. We are hopeful that this can be done
in humans but at this time it is still very complicated and more research isneeded.
Penile transplant is another area of increased interest but requires lifelong
immunosuppression regimens similar to those used in kidney transplantation. The universal concern with immunosuppression regimens is their potential to predispose a patient to opportunistic infections, end-organ damage, diabetes, and lymphoma. The question becomes does the risk outweighthe benefit even in someone in their twenties who has lost their genitalia?
One penis transplant reported in the literature in China was removed after
two weeks for psychological reasons. The group that performed the transplant went on to make some very general recommendations.
Guiding Principles for Penile Transplantation
Penile transplantation should only be performed in patients with severe
damage to the penis at appropriate institutions under protocols approvedby institutional review boards. Institutions should have surgical and transplantation expertise with comprehensive multi-disciplinary support. Appropriate selection criteria should be established and the risk/benefit must
be considered for each individual patient with detailed informed consent
explaining the risks, benefits, alternatives and the innovative nature of theprocedure. Candidates for penile transplantation should undergo a thorough psychiatric and psychological evaluation, including evaluation of their
psychosocial support system.
How do we protect our warriors?
In 2011, the first “ballistic underwear” was distributed in theater. Tier 1

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ballistic underwear is made of ballistic silk material coated in an anti-microbial agent to decrease wound infection and deflect particulate debris. Tier 2
ballistic underwear has Kevlar sewn between the layers of the ballistic silkaround the inner thighs, colon, and groin area. This provides more protection from penetrating fragments.
In a study conducted by the Army Office of the Surgeon General war
fighters who suffered one or more lower extremity injuries from February
2010–February 2011 were evaluated. The study compared 61 war fighters
without the pelvic protection with 63 war fighters who had pelvic protection. Their findings showed there was a 72 % chance of genital injury for
those without the protective garment versus a 38 % chance of injury with thegarment. Testicular rupture occurred in 34 unprotected soldiers versus 22
solders with protection. Additional studies are needed to determine the full
benefit of ballistic underwear in preventing genitourinary injuries.
As a way to bridge future discussions an article reporting on small scalequalitative study using interpretative phenomenological analysis was briefly discussed. Nine patients underwent partial or complete penectomy forpenile cancer. The study highlighted the patients’ issues of “grappling withthe reality” of their injury and their issues of coping with the effects of thesurgery. Significant changes in self-image that adversely affects relationships
with a spouse and family were also discussed. Soldiers with genitourinary
trauma often have the same altered self-image issues.
We have developed protocols for penile injury, perineal injury,and scrotal injury.

19

Testicular Trauma: Managing Sexual
Function and Fertility
Robert C. Dean, M.D.
There is very little long term data on the management of sexual function
and fertility after testicular trauma. In the past soldiers did not survive thesetypes of injuries.
Medical Capabilities in Theater
Many more soldiers are surviving devastating injuries on the battle field
because of the many advances in care in the past 10-15 years. Urologists
and other specialized surgical teams are now operating in theater which has
increased survival rates. There is now a higher survival rate among thoseinjured — the highest in any conflict in history.
Wound Patterns
Pelvic and perineal traumas from improvised explosive devices (IEDs)
are the most common combat injury requiring combat care. The improved
survival rates from these wounds have resulted in caring for patients withvery challenging pelvic injuries. The dismounted IED blasts can produce
very devastating injuries. The common injury patterns seen are: (1) Soft tissue injury to the scrotum with or without testicular injury or loss; (2) Softtissue injury to the penis, anterior urethra, scrotum, and testes; (3) Perineal
injury, bulbar urethral transaction, rectal injury and proximal corpus cavernosum injury; (4) Penile amputation, scrotal loss, bilateral orchiectomy,
and lower abdominal injury. The non- trauma related urologic admissions
numbers remind everyone that urologists at Walter Reed still care for urology problems not related to trauma.
There are substantial long term issues of genitourinary injuries
including sexual function and fertility. Early therapy is important…
Therapy in the first four months is paramount.

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Combat Genital Trauma: A Case Study
The patient was a special operations soldier injured by anti-personnel
mine in the mountains of Kandahar Province and was treated by the Forward Surgical Team. He had bilateral AKAS, degloving injuries to his left
thigh and sacrum, a rectal injury with an exploratory laparoscopy and diverting colostomy and perineal soft tissue injuries with loss of a segment ofbulbar urethra and anterior rectum. The patient arrived at the National Naval Medical Center in the fall of 2009 for definitive care after stops at Landstuhl Regional Medical Center where he also received care. After admission
to WRNMMC he had his wounds managed, had prosthetic limbs fitted, had
his rectum repaired, and he had the mitrofanoff procedure which createda tube in the abdomen through which he could urinate. One year later thepatient ran a marathon.
Common Therapies
There are substantial long term issues of genitourinary injuries including sexual function and fertility. Early therapy is important. Patients needto have erections early on to promote good blood flow and to keep collagenelastic. Therapy in the first four months is paramount. For prostate cancer
patients the goal is to regain sexual function almost immediately after surgery. This same guideline is used for patients who have had traumatic genital
injuries. For some of the genital trauma injuries patients have to wait but
sexual therapies should begin as soon as possible.
Barriers to identifying erectile dysfunction (ED) are present for both thepatient and for the physician. Patients can be reluctant to discuss erectile
dysfunction because of embarrassment, shame or ignorance about normal
sexual functioning. The patient may have a cultural belief that prohibits
them from discussing sexual behaviors and many patients have a general
discomfort discussing any aspects of their sexual functioning. The physician
may have a fear of offending the patient or causing discomfort. They may
have a lack of confidence in diagnosing and treating ED. Some physicians
may have interpersonal differences with the patient (cultural, religious, andethnic) while others may have a concern with being “overly interested” inthe patient’s sex life. It is important for physicians to find a way to address
ED early on so treatment can begin.
Oral treatments for ED include the PDE5 inhibitors such as Viagra, Levitra and Cialis. The PDE5 inhibitors can improve endothelial function andglucose tolerance for diabetics is improved. Patients can experience improved levels of self-esteem and can have improved quality and quantity ofsexual encounters. There is very little downside to using oral medications.
However, if they are not working other things must be considered. How doyou manage oral treatment failure?

WRNMMC | CSTS | USU 21

The use of vacuum erection devices is an old therapy made better over
the years. These devices are externally applied and mechanically effect penile
blood engorgement. For the patient who has had genital trauma this might
not be an appropriate option but for the patient who has had a spinal cord
injury this might be considered. Penile injection therapy is another option.
Smooth muscle relaxing medication is injected directly into the penis. Three
medications are injected, papaverine, phentolamine and PGE 1 and while it
may seem to be an alarming injection in reality it is not. Patients are taught
how to inject themselves and report that it is not that painful. They quickly
get over the idea of a needle and they get a very good erection. Injection
therapy works in patients with complete nerve loss with an intact penis andoften is one of the therapies used right after traumas or surgeries to keep
the erectile bodies erect and full. Medicated urethral system for erection(MUSE) is another therapy used. A suppository is inserted to the urethra
that relaxes the smooth muscles and mimics the physiology of an erection.
This therapy is more painful than the injection/needle discussed earlier
and some patients are reluctant. Penile prosthesis implantation is anothertherapy that can be used once all reconstructions have been done. There aredifferent devices that are malleable or somewhat rigid. Mechanical rods canbe inserted and there are inflatable devices that can be used. The inflatabledevices are by far the most commonly used in the United States.
Testosterone Supplementation
Testosterone is needed for the preservation of libido, muscle and bonemass, energy and cognition. Testosterone is not the enemy when it is kept
within a normal range. Generally, when testosterone is low (less than 300
mg/dl) clinical signs can include erectile dysfunction, infertility, small/soft
testes, low energy, depression, sleep disturbance, poor concentration andmemory, breast discomfort or enlargement, loss of male body hair, muscle
wasting and increased body fat. At WRNMMC patients with genital injury
have testosterone levels measured upon arrival and afterwards levels aremeasured monthly to follow trends in recovery. For elevated testosterone
levels the treatment is observation. For low testosterone levels treatment isbegun at the start of the patient’s physical therapy.
The Joint Taskforce Trauma Registry (JTTR) reviewed cases under IRB
approval from 2001 to 2011 to study what happens to patients’ testosterone
levels. Patients came from both wars and surgery records were reviewed forextent of injuries. There were 15 control patients with no testicular injury, no
scrotal injury but who suffered trauma. In these patients it took an averageof 9 months for testosterone levels to return to normal levels. There were 121
trauma patient groups and they were further divided into categories basedon how much trauma they had to their testicular volume: (1) 60 patients

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had scrotal exploration with no testicle loss; (2) 3 patients had lost half of
their testicular tissue; (3) 29 patients had lost one testicle; (4) 9 patients had
lost one and a half of their testicular tissue; and (5) 12 patients had complete
bilateral testicular loss. Most of the trauma patients had suffered IED blasts.
In the first group of 60 patients the average time to testosterone replacement
was 75 days with 15 requiring replacement (25 %). In the second group of
3 patients the average time to testosterone replacement was 292 days with 1
requiring replacement (33 %). In the third group of 29 patients average timeto testosterone replacement was 57 days with 16 requiring replacement (55%). In the fourth group of 9 patients average time to testosterone replacement was 40 days with 5 requiring replacement (56 %). In the fourth groupof 9 patients average time to testosterone replacement was 40 days with 5
requiring replacement (56 %).
The general rule for those patients in the middle groups is to wait andmake assessments when they become more mobile, for example, when they
begin physical therapy. That is the time patients need testosterone if they are
not recovering it on their own. Opiods and other pain medications given topatients also lower testosterone so it is important to evaluate their medical
management before making final decisions about testosterone replacement.
Genital Protection
Research complied by the Operations Research and Systems Analysis
Division of Combined Joint Task Force confirmed that those war fighters
who wore the protective pelvic undergarments (PPU) had greater testicular
protection.
Fertility
The importance or value of a man having children is quite high in oursociety. Americans take quite a bit of stock in making babies and making afamily. Our government rewards those with children with added tax benefits
and there are numerous government programs for the care of mothers andchildren. There is also high media representation of the American family
and those serving in uniform receive pay increases for dependents as well as
increased living allowances.
A study done in England in 2004 by Bartlett looked at the benefits for theindividual and the effects of fatherhood. Basically, Bartlett was looking at thequestion of how happy were men being fathers? He studied married men
with children, single men with children and men with no children. The study
showed that the men with no children had more illness. They had poorer
health with increased days in bed and more health care visits per year. Perhaps there is some benefit to men’s health by having children? The study also
reported that as men became older the health benefit increased.

WRNMMC | CSTS | USU 23

How can we help patients with genital injuries who wish to become fathers? As of April 2012, money became available for in vitro fertilization(IVF) treatment for wounded warriors through an extension of TriCare
benefits. Some may ask why this was not done sooner and why it took solong to adopt the policy. TriCare benefits are congressionally mandated law
and changes to the law require a congressional vote. The IVF service at Walter Reed (ART Institute of Washington, Inc.) is in the top 10 % of the country for pregnancy rates. One can compare the WRNMMC IVF facility to any
other in the United States at the web site SART.org. More than 450 cycles per
year are done at WRNMMC. The average cost of IVF with ICSI is approximately $7200.00.
Basic IVF is the process of fertilization by manually combining an egg
and sperm in a laboratory dish. Embryos form within three days and eggs arestimulated to grow with gonadotropins. Risks of ovarian stimulation for the
woman include: (1) Severe ovarian hyper-stimulation syndrome that occurs
in 1–2 % of cases with potentially fatal thromboembolisms; (2) Mild ovarian
hyper-stimulation syndrome that occurs in 25 % of patients causing increasein ovarian size and abdominal discomfort. When women of child bearingage (under the age of 42 years) are stimulated 3-20 eggs are retrieved. Once
fertilization has occurred the embryos are analyzed and graded and that information is used to tell the physician how many eggs should be placed backinto the uterus. WRNMMC has a policy where no more than 3 embryos canbe returned to the uterus.
We know from data from the Israeli that sperm retrieved from a patient
within three days can be used for IVF. Jarrow’s work (1996) showed that viable sperm can be found in the seminal vesicles for five days following ejaculation. Some trauma patients are able to undergo seminal vesicle aspirationand successfully retrieve motile sperm. When this can be done quickly witheveryone on board, including the IVF Center, these patients will have theopportunity to go through the IVF process with their own sperm.
Conclusions
IED related lower extremity, perineal, genital, and scrotal trauma require
extensive involvement by urology. Advanced Field Medicine has increased
survival rates. Trends in urological care are evolving. Developing an understanding of sexual, social and reproductive outcomes is essential to providing the best care to our patients.
IED related lower extremity, perineal, genital, and scrotal trauma require
extensive involvement by urology. … Developing an understanding of
sexual, social and reproductive outcomes is essential…

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25

Psychiatric Care of Survivors of
Genital Injuries
Frederick J. Stoddard, M.D.
Work with burn patients can inform our understanding of patients withgenital injuries. Genital injuries are complex psychiatrically, surgically andin rehabilitation. In these ways they are similar to some disfiguring burns.
Early behavioral health evaluation and treatment of psychiatric conditions improves the patient care plan. There are three post injury phases:
acute, intermediate and recovery. The history of psychiatry in burn care includes studies of disasters such as the Coconut Grove Nightclub Fire in 1942
that was the founding event for burn care in WWII. Erich Lindemann, Stanley Cobb, and Alexandra Adler were important to this work. Dr. David Hambug wrote about burn patients in Korea from the ego psychosocial point ofview. His work is still relevant today. Norman Bernstein, Walter Meyer andothers wrote in the area of child psychiatry. Samuel Perry was a pioneer inteaching us about the under-treatment of burn pain. His work and efforts
have impacted all of medicine.
There are six models of Post Injury Adaptation: (1) ego/ psychosocial;(2) sociological/adaptational; (3) crisis/psychopathological; (4) existential/
developmental; (5) neurobiological; and (6) evidence-based/evaluative.
There is likely protective psychological benefits for soldiers in the choice
to serve and from their resilience training. This may help decrease their risk
from devastating combat injuries. The present war highlights that the violence and carnage of genital injuries are much greater now and there are no
isolated genital injuries. Genital injuries are not new to war.
In the psychiatric assessment of patients with genital injuries
physicians need to use all of the tools that are available:
Developmental, descriptive, biological and psychodynamic,
cognitive-behavioral, and pharmacological.

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Some of the etiologies of genital injuries include circumcision complications, infant scalds, house fires, motor vehicle accidents, electrical burns,
ritual genital mutilation, self-mutilation and industrial accidents. In addition, genital injuries also come from cancer, other diseases and infections,and war. From 2001–2009 in the Iraq and Afghanistan wars there were 887
genitourinary injuries. Studies indicate this type of injury included injuries
to the scrotum (29 %), penis (14.2 %), testicle (9.1 %), and pelvic fracture (14%). Pictures done by patients at Walter Reed and published in the New YorkTimes (5/27/12) can tell an important story of injured combat warriors.
Peripheral organ and brain interactions occur in burn injuries. The surgeries to recover are also traumatic. They include excision and grafting ofwounds, amputations, removal of shrapnel and other foreign bodies, andrelease of contractures. Dressing changes relating to the surgeries can also
cause severe pain. The goal is always to preserve function and to have thebest cosmetic result. Consent is not always possible at the time of the trauma
and the awareness of complicated surgery may emerge much later.
In the psychiatric assessment of patients with genital injuries physiciansneed to use all of the tools that are available: Developmental, descriptive,
biological and psychodynamic, cognitive-behavioral, and pharmacological.
The anatomy of the injury, infection and pain control affect psychologicalrecovery. Psychological and social factors will inform acute care and influence long term adaptations. It is important to assess over time the patient’s
level of pain, anxiety, grief, guilt, depression, resilience, courage and hope.
Psychiatrists can gain understanding by going to the operating room to
see the surgeries and also by attending dressing changes to see what the patient is experiencing. Some patients use words to describe their pain andanxiety and some do not. Some teams report soldiers talking about what to
do if they lose their “junk.” After injury, some patients avoid talking about
genital injuries while others ask directly. It is important to let patients to talkat their own pace.
In talking with patients it is helpful to state you are there to help. State
your physical observations and ask if the patient has questions. Inquire
about locations and levels of pain using a scale of 0-10 with 10 being themost pain. Suggest a range of possible interventions. Consider sharing thatno one should have to endure such pain and suffering. Consider sharing thatthey are fortunate to have survived. Provide reassurance that questions arenormal for everyone with severe injuries.
Speaking to the patient as a member of the medical care team reducesanxiety in acutely injured patients. Explaining to patients that psychologicalexplanations and support are an essential part of their medical and surgicalcare is critical to their successful recovery. Psychiatrists, psychologists, nurses, social workers, in collaboration with others who are part of the medical

WRNMMC | CSTS | USU 27

team, may share in discussions about appearance related to attractivenessand the function of the injured body part.
Psychological aspects and psychoeducation include supporting emotional shock, assessing and relieving pain, reassuring that genitals do not represent the person, being alert to concerns about gender identity and beingalert to concerns about the ability to satisfy a sexual partner. Assessments
also include identifying strengths and threats to self-esteem, clarification
about what plastic surgery techniques can and cannot do, and supporting
the religious beliefs of the patient.
A case vignette of 17 year old male who sustained a 40 % burn including leg amputations and genital loss from contact with power lines was discussed. This young man considered penile reconstruction with an implantof the type discussed earlier. The result would be a cosmetic penis and not
one used for urination. Issues of his leg prostheses were discussed as they
related to his overall condition and progress. He benefitted from the ongoing
discussions and he learned he had a place to talk about his concerns. This
intervention is a cognitive oriented therapy.
There are many risk factors for severely injured patients. These include
delayed admission, mental disorders, abuse, substance abuse, very young orvery old age, pre-existing medical conditions, malnutrition, poverty and thelack of social supports.
Many diagnoses are associated with trauma patients. These include delirium, pain syndromes, sleep disorders, body image disorder, and other psychiatric disorders associated with traumatic events.
During the recovery phase it is important to be aware that injuries may
profoundly affect body image, self-esteem and interpersonal relations. Body
image disturbance is not inevitable. There are people who adapt and who
are flexible enough to modify their personalities and appreciate who theyare. Others are unable to adapt or do not readily adapt. Plastic surgery andreconstructive surgery that is chosen by the patient is often beneficial psychologically.
The effect on self-esteem of genital, facial, hand and other disfigurement
should be assessed over time, since this may lead to social stigmatization.
Social adaptation is aided by functional recovery, family support, psychotherapy, support for positive coping skills and re-entry to work or school.
How do we understand body image? What is the definition? Schilder,(1950), described body image as, “That (mental) picture or scheme of ourbody involving the interpersonal, environmental and temporal factors.” Thisdefinition does not coincide with the objective body. The neurology of body
image is also important.
Each procedure that is performed on a patient affects body image andthe emotional implications can be positive and negative. Cosmetic and re-28

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constructive procedures may be done to almost any body location, especiallythe scalp, face, hands, breasts, axilla, arm, genitals, anus, leg and foot. Typesof surgery include release and grafting, the use of tissue expanders, flap procedures and laser surgery.
There is little research on the psychiatric outcomes of genital injuries.
Most research on severe disfiguring burns shows a majority of patients, treated and followed in centers of excellence, cope well. Studies done in the past
25 years show these patients to be functioning normally on many measures.
This is not always what we expect and it is important to keep in mind when
we see someone who is not doing well. Visible disfigurements are the mostsocially stigmatizing and data shows they are the most difficult for patients.
More resources, reconstructive procedures and psychiatric and rehabilitative treatments are improving outcomes but may not be easily accessible.
A case vignette of a 10 year old boy who suffered large electrical burns
with the loss of his penis was discussed. The child had a remarkable longterm recovery that included many reconstructions with cosmetic penile reconstruction with artificial testes. He later became an EMT, a scuba diver,married a woman who had smaller burns and became a father via artificial
insemination. When last seen as an adult his mood was very positive.
It is important to be alert to the responses of staff caring for patientswith genital injuries, particularly those who are young. These include medics, technicians, nurses, surgeons, radiologists and rehabilitation specialists.
Some of the ways to enhance staff resilience and reduce burn out were discussed. Stress and secondary traumatization can be great even though staff
tends to be resilient and “hardy.”
Some psychiatric and psychotherapeutic interventions prior to surgery
were discussed. The most important piece was collaborative consultation
with the surgeon and allied staff. An intervention called Social Skills Interaction Training (SSIT) was described. SSIT is a cognitive behavior methodthat patients with facial burns are taught to help present themselves in social
situations. The program was developed in Great Britain and has been usedsuccessfully with adolescent and adult patients.
Adolescent patients can be of particular concern since their vulnerability
is magnified by adolescent psychosocial development and “adolescent invulnerability.” Their body self, narcissistic ideal fantasies and self-esteem are impacted by peer comparisons, prowess and the media. Increasing their skills
allows for cognitive mastery of their injury and surgery, optimally modulating feelings of fear, vulnerability and depression.
Patients in young adulthood are in the prime of their lives with the goals
to love and to work. The body self is more distinct from the identity of theself as a person. For example, the loss of a body part is possibly less likely
to mean loss of self. Their vulnerability may be limited by compensatory

WRNMMC | CSTS | USU 29

skills they have learned, their achievements and by their intimate relationships. These capabilities may aid in their adaptation to losses of appearance
or function.
In mid-life patients may struggle with issues of generativity versus stagnation. Generativity refers to the protective concern for all the generations
and social concerns. The virtue to care coalesces during this phase of life,
further strengthening personhood and buffering the effects of injuries.
There are many different causes of body image (BI) disorders. These include congenital abnormalities, those secondary to brain damage, neurologically based and reality based disorders, those induced by disease, substanceabuse or medication induced, post traumatic based, and disturbances in perceptions. Strategies to improve body image include encouragement of family
affirmation and support, surgical interventions, the anticipation of changes
in recovery, surgical interventions, patient education, visitation by screened
survivors, referrals for psychiatric consultation and encouragement to continue a hopeful approach.
Seeing one’s own disfiguring body can be emotionally traumatic. Usually
patients have seen themselves without staff awareness but planning to lookat a time when supportive people can be present may reduce the emotional
stress.
Ethical issues were briefly discussed. The decision to survive, possiblywith a tourniquet is an ethical choice. There has been consideration in burncare regarding the ethics of providing choice of survival or not after massive
burns. And, as in military medicine, the ethical consensus is to support survival and to provide medical care that seeks to improve outcomes.
Dr. Elvin Semrad said, “Find out what the heart says and where in the
body the feelings are.” The goal is to seek to understand and help the patient.
There is little research on the psychiatric outcomesof genital injuries.

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Speaker Biographies
Charles W. Callahan, D.O.
COL Charles (Chuck) Callahan graduated from Rutgers College with acommission as Second Lieutenant in the Infantry. After attending Infantry
Officer’s Basic Course he graduated from the New Jersey School of Osteopathic Medicine in 1984. Dr. Callahan did his pediatric residency at Walter
Reed Army Medical Center and completed a fellowship in pediatric pulmonology at St. Christopher’s Hospital for Children in Philadelphia, PA. Dr.
Callahan served as the Pediatric Consultant to the Surgeon General from
July 2003 to 2007.
In 2004, Dr. Callahan deployed in support of Operation Iraqi Freedom
as the Chief of Professional Services for the 8th Medical Brigade. He served
as the Deputy Commander for Clinical Services at Walter Reed Army Medical Center and later commanded the DeWitt Army Community Hospitaland Health Care Network at Ft. Belvoir. In July 2010, Dr. Callahan became
the first Army officer to serve as Deputy Commander at the National Naval
Medical Center, Bethesda, MD. In August 2011, he became the first Chief ofStaff of the new Walter Reed National Military Medical Center under the
Joint Task Force Capital Medicine. In July 2012, he assumed Command of
the new Fort Belvoir Community Hospital.
Dr. Callahan’s awards include the Legion of Merit with three oak leaf
clusters, the Bronze Star, the Meritorious Service Medal with four oak leaf
clusters, the Order of Military Medical Merit and the “A” Proficiency Designator from the Army Medical Department. In 2004, he received the Lewis
Aspey Mologne Award from the Surgeon General for Academic Excellencein the Army Medical Corps. Dr. Callahan is board certified in pediatrics
and pediatric pulmonology and a professor of pediatrics at the Uniformed
Services University in Bethesda, MD. He is a Fellow of the American Academy of Pediatrics. Dr. Callahan has received numerous teaching awards andauthored more than one hundred articles on subjects including pediatrics,
pulmonology, leadership and parenthood.

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Robert C. Dean, M.D.
Dr. Dean is a graduate (Class of 1985) of the University of Rochester,N.Y. with a Bachelor of Science Degree in Cell Biology. After receiving his
M.D. degree from Uniformed Services University of the Health Sciences in
Bethesda, MD in 1989, he completed an internship at Tripler Army Medical
Center in Honolulu, HI.
Dr. Dean graduated from his Urology Residency at Walter Reed Army
Medical Center in 2000. He gained additional urology training in Andrology (Male Sexual Health and Infertility) at the University of California,
San Francisco and completed his fellowship in 2005. In 2003, Dr. Dean was
deployed for 12 months in support of Operation Iraqi Freedom with the28th Combat Support Hospital from Ft. Bragg, NC. Dr. Dean is currently
the Program Director for the Urology Residency and the Director of Andrology at the Walter Reed National Military Medical Center, Bethesda,
MD. Dr. Dean is also an Assistant Professor of Surgery at the Uniformed
Services University, Bethesda, MD. His interests include treatments forerectile dysfunction, medical management for erectile preservation, peyronie’s disease, and male infertility. Dr. Dean’s present research projects
involve pathological analysis of prostate tissues, testosterone therapy, andneurovascular preservation of erectile function.
James R. Jezior, M.D.
Dr. Jezior graduated from the United States Military Academy, West Point,
NY in 1985 with a Bachelor of Science and Engineering. He earned his M.D.
at the Uniformed Services University of the Health Sciences in Bethesda,
MD and completed an internship and urology residency at Tripler Army
Medical Center in Honolulu, HI. In June 2001, he completed a Fellowshipin Adult and Pediatric Reconstructive Urology at Eastern Virginia Medical
School, Norfolk, VA.
Dr. Jezior was deployed for 12 months in support of Operation Iraqi Freedom with the 28th Combat Support Hospital and while there was Chief of theGeneral Surgery Service and then Deputy Commander for Clinical Services.
Dr. Jezior is currently the Chief of the Urology Service, Director of Female
and Reconstructive Urology and serves on the faculty residency program at
the Walter Reed National Military Medical Center, Bethesda, MD. He is alsoan Assistant Professor of Surgery at the Uniformed Services University of
the Health Sciences, Bethesda, MD.
Representative Tim Murphy, Ph.D.
In January 2011 Congressman Tim Murphy began serving his fifth term inCongress representing the 18th district of Pennsylvania. Congressman Murphy relies on his three decades as a psychologist to advocate for meaningful

WRNMMC | CSTS | USU 33

reform in the U.S. healthcare system. As one of only a handful of membersof Congress with a background in healthcare, he quickly established himself
as a leader in the issue. He is Co-Chair of the Mental Health Caucus and
GOP Doctors’ Caucus, giving him a platform to educate other members ofCongress and the public on ways to make healthcare more affordable andaccessible for all families.
Legislation accomplishments include authoring the Seniors Access to
Mental Health Act, which ended the discriminatory practice of charging
higher co-pays to seniors on Medicare seeking mental healthcare. The legislation became federal law as part of the Medicare Improvements for Patientsand Providers Act on July 15, 2008.
Before coming to Congress, Congressman Murphy served in the Pennsylvania State Senate from 1997-2002. There he penned the state’s historic
Patient Bill of Rights and increased funding for medical research, while consistently supporting responsible fiscal management of government to promote job creation and reduce the tax burden on families.
Congressman Murphy also serves as a Lieutenant Commander in the U.S.
Navy Reserve Medical Service Corps, working with wounded warriors withtraumatic brain injury and post traumatic stress disorder.
Congressman Murphy earned a bachelor’s degree from Wheeling Jesuit
University, a master’s degree from Cleveland State University and his Ph.D.
from the University of Pittsburgh.
Brett J. Schneider, M.D.
Lieutenant Colonel (P) Brett J. Schneider, M.D. is currently serving as theChief of Psychiatry at Walter Reed National Military Medical Center. He
also serves as the appointed Child and Adolescent Psychiatry Consultant
to the US Army Surgeon General. Dr. Schneider graduated from Creighton
University with a co-major of Biology and Philosophy. He attended Creighton University School of Medicine and after graduation he did his psychiatry
residency and a child and adolescent psychiatry fellowship at Walter Reed
Army Medical Center.
Upon completion of training, LTC(P) Schneider served as the Division
Psychiatrist for the 1st Infantry Division in Vilseck Germany for two years
before returning to Walter Reed to do a fellowship in Forensic Psychiatry.
He served two tours in Iraq for Operation Iraqi Freedom. Dr. Schneider
served as the Chief of Telepsychiatry and the Chief of Child and Adolescent
Psychiatry prior to being named the first Chief of Psychiatry at the new Walter Reed National Military Medical Center in Bethesda, MD.
Frederick J. Stoddard Jr., M.D.
Frederick J. Stoddard Jr., M.D. is Associate Clinical Professor, Harvard

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Medical School at the Massachusetts General Hospital (MGH), heads psychiatry at the affiliated Shriners Hospital for Children, and is a senior attending psychiatrist at the MGH Burn Center. Born in Ann Arbor, he received his B.A. from Bowdoin College, his M.D. from Case Western Reserve
University, and trained in adult and child psychiatry at Harvard hospitals.
He served in the Public Health Service in the Job Corps, and at the NIH in
the Biological Psychiatry Branch. His consulting and teaching are multidisciplinary with medical students and psychiatry residents, trauma surgeons,plastic surgeons, pediatricians, nurses, other allied staff, and administrative
personnel.
Dr Stoddard is an expert in burns, body image including genital injuries,
PTSD, grief, and bioethics. He is a mentor for aspiring child and adult psychiatric researchers, and leaders. His research and teaching focus on pain,
depression, resilience, disaster psychiatry, and health professionals’ self-care.
He is active in the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, the Group for Advancement of Psychiatry, the International Society for Burn Injuries, and the American Burn
Association. His book, Disaster Psychiatry, edited with Anand Pandya andCraig Katz, received the 2012 British Medical Association’s High Commendation as one of the best books in Psychiatry.
Robert J. Ursano, M.D.
Robert J. Ursano, M.D., is Professor of Psychiatry and Neuroscience andChairman of the Department of Psychiatry at the Uniformed Services University of the Health Sciences, Bethesda, Maryland. He is founding Directorof Center for the Study of Traumatic Stress. In addition, Dr. Ursano is Editor of Psychiatry, the distinguished journal of interpersonal and biologicalprocesses, founded by Harry Stack Sullivan. Dr Ursano completed twenty
years of service in USAF Medical Corps and retired as Colonel in 1991. He
was educated at the University of Notre Dame and Yale University Schoolof Medicine and did his psychiatric training at Wilford Hall USAF Medical
Center and Yale University.
Dr. Ursano served as the Department of Defense representative to the National Advisory Mental Health Council of the National Institute of Mental
Health and is a past member of the Veterans Affairs Mental Health Study
Section and the National Institute of Mental Health Rapid Trauma and Disaster Grant Review Section. He is a Distinguished Life Fellow in the American Psychiatric Association. He is a Fellow of the American College of Psychiatrists. Dr. Ursano was the first Chairman of the American Psychiatric
Association’s Committee on Psychiatric Dimensions of Disaster. This work
greatly aided the integration of psychiatry and public health in times ofdisaster and terrorism. Dr. Ursano was an invited participant to the WhiteWRNMMC | CSTS | USU 35

House Mental Health Conference in 1999. He has received the Departmentof Defense Humanitarian Service Award and the highest award of the International Traumatic Stress Society, The Lifetime Achievement Award, for “outstanding and fundamental contributions to understanding traumatic stress.”
He is the recipient of the William C. Porter Award from the Association of
Military Surgeons of the United States, and a frequent advisor on issues surrounding psychological response to trauma to the highest levels of the U.S.
Government and specifically to the Department of Defense leadership.
Dr. Ursano has served as a member of the National Academies of Science,
Institute of Medicine, Committee on Psychological Responses to Terrorism,
Committee on PTSD and Compensation and the Committee on Nuclear
Preparedness; and the National Institute of Mental Health Task Force on
Mental Health Surveillance After Terrorist Attack. In addition, he is a member of scientific advisory boards to the Secretary of Health and Human Services and the Centers for Disease Control. In 2012, Dr. Ursano was awarded
the William C. Menninger Memorial Award for distinguished contributions
to the Science of Mental Health by the American College of Physicians. Dr.
Ursano has more than 300 publications. He is co-author or editor of eightbooks.
Harold J. Wain, Ph.D.
Harold J. Wain, Ph.D., is the initial selected Chief of the Integrated Psychiatry Consultation Liaison Service at Walter Reed National Military Medical
Center. Previously he had been Chief and Director of the Psychiatry Consultation Liaison Service at Walter Reed Army Medical Center. He is also a professor in the Department of Psychiatry at the Uniformed University Schoolof Health Sciences School of Medicine. Earlier in his career he had been
Chief of the Psychology Department at Walter Reed Army Medical Center
Dr. Wain completed nine years of active duty and twelve years in the U.S.
Army Reserves. He received his degrees from Brooklyn College, The University of Nebraska and Columbia University. He did his formal clinical training at Walter Reed Army Medical Center.
Dr. Wain has published widely, lectured and presented numerous workshops both nationally and internationally focusing in the areas of pain,
hypnosis, somatoform spectrum disorders, psychosomatic medicine andtrauma. He has received several recognition awards for his teaching andacademic contributions. Dr. Wain has been privileged to have had significant leadership roles in the professional organizations where he has held
membership and/or fellowship. He has been on several task forces as well
as a consultant in his area of expertise. Dr. Wain has also been a reviewer
for several journals, and was the associate editor of the American Journal of
Clinical Hypnosis. In addition, he has edited three books.

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Center for the Study of Traumatic Stress
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road, Bethesda, MD 20814-4799
Tel: 301-295-2470 | Fax: 301-319-6965
www.CSTSonline.org