The private scars of war

Mike Mills didn't look in a mirror for two months after a land mine blew him out of his truck near Kirkuk, Iraq, in June 2005, cracking his clavicle, shattering his hip "like a jigsaw puzzle" and burning off half of his face. When he did, only one word came to him: "Freak."

Recovering at Brooke Army Medical Center in San Antonio, Mills worried about his two kids in Freeport, Minn. He worried about making a living. Mostly, he worried about Suhanna -- Suki -- his wife of nearly 20 years, who would surely leave him.

"How can I expect her to stay with me anymore?" said Mills, 43, a member of the Minnesota Army National Guard for 18 years. "She's not going to want to be intimate with a freak. Elephant Man. That's the way I saw myself."

Suki, 43, didn't leave.

"I'm too old to train in another one," she joked.

She changed her husband's pus- and blood-soaked bandages, and helped him relearn how to shave and brush his teeth.

As the Mills family moves forward, the U.S. Defense and Veteran's Affairs departments are acknowledging that the physical and emotional scars that troops carry home present a sensitive challenge: sexual intimacy and body-image issues that most couples' therapists are ill-prepared to treat.

In addition, the war's ubiquitous battleground and multiple deployments have left an estimated 40,000 troops with post-traumatic stress disorder (PTSD), a syndrome unequivocally tied to marital distress, as well as brain injuries, burns and loss of limbs -- horrific injuries that, because of protective Kevlar vests, are no longer fatal.

The number of people returning with disabilities, is an "enormous problem ... an astonishing problem," said Eli Coleman, director of the Program in Human Sexuality at the University of Minnesota. "Combined with the fact that returning vets are usually older and partnered, this is having a devastating effect on relationships."

Maureen Kennedy, a licensed psychologist with the Polytrauma Program at the Minneapolis Veterans Affairs Medical Center, agrees.

"Women will say, 'He doesn't even touch me. He doesn't want to come close to me'" Kennedy said. "The man will say, 'I don't even feel like having sex anymore.' He has been conditioned to not feel emotions and may experience hypervigilance or anxiety when touched. ... Emotional detachment is a hallmark of PTSD."

No increase in divorces

The short-term effect is evident. The Minneapolis VA Medical Center, which already provides couples therapy, has expanded to focus on sexual and combat trauma for couples, and is refining that treatment with data being collected from 50 military couples, said VA researcher Christopher Erbes.

Its work, among the first of its kind in the nation, is modeled after a successful treatment program at the VA National Center for PTSD in Boston. And sex was front and center at the Wounded Troops and Partners conference in Washington, D.C., in May.

While sexual problems might seem like a curious concern during wartime, the conference brought home the urgency: A failed intimate relationship was the reason cited for nearly three-quarters of last year's military-related suicides, said Mitchell S. Tepper, of the Center of Excellence for Sexual Health at Morehouse School of Medicine in Atlanta.

"The mirror is such a powerful experience," said Tepper, who is pushing for a national dialogue about how to support healthy intimacy among military couples. "The first time you see the reflection of your changed body, whether sitting in a wheel chair, or severely disfigured because of facial burns, it is shocking. People who are not married look down and ask, 'Will anyone ever be interested in me?' If they are married, they wonder, 'Will my partner still find me sexually attractive?' Facing issues of body image and sexual self-esteem are pretty universal."

Abby Jackson, 25, understands. Her Iowa National Guardsman husband, Robert Jackson, 27, returned home from Iraq with both legs amputated below the knee.

Hardly. Candice Monson, deputy director of the Women's Health Sciences Division of the VA National Center for PTSD, said sleep disturbances are yet another problem for partners.

Sleep disturbances

"He had dreams that he didn't realize he was having," said Jennifer Suarez, 43, a dental hygienist married for 18 years to Maj. Eduardo Suarez, who has done two tours in Iraq with the Minnesota Army National Guard. "He was much more active during these dreams. Nothing that would keep me up but, yes, there was a part of him he couldn't control."

While the Suarezes remained in the same bed and are aggressively working to stay close, Monson worries about couples with fewer resources.

Without effective and targeted couples' therapy, Monson said, "this war can result in separate bedrooms and sexless, loveless marriages 25 years down the road."

Even faced with physical disfigurement or an amputation, Kennedy said, "many couples are resilient and their relationships last, or may even be strengthened." The adjustment can be tougher for younger couples, she said, who might have less maturity and experience.

But all couples can benefit from support and guidance. Monson is beginning a two-year trial, funded by the National Institute of Mental Health, designed to strengthen couple relationships and treat PTSD. Part of her process includes helping spouses avoid the easy way out.

"One woman sends her husband to the 'bunker' in the basement," Monson said. While understandable, "it's inadvertently sending a message that he can't handle it. Now he's less and less in the family picture. ... I ask, 'How are you together going to defeat PTSD? You, as a couple.'"

Hanging in there can pay big dividends. The Jacksons of Iowa did regain their intimacy, evidenced by a busy 2-year-old and a 6-month-old joining their two older children.

The Mills, parents of Aaron, 18, and Kenzie, 13, also continue to draw strength from each other. Three years after his traumatic injuries, Mike looks in the mirror now and says with a smile, "I was good looking before and I'm better looking now."

"My safe spot," she said.