On September 7, 2011, Aaron Causey, an explosive ordnance disposal expert with the United States Army, responded to a call about a suspicious item while on deployment in Afghanistan. The item, he realized as he approached, was not a bomb. It was a decoy, set up so that anyone responding to it would trigger a nearby improvised explosive device (IED). When it went off, the IED destroyed his legs and portions of his hands and studded his shoulders with metal shrapnel. It also ripped into his scrotum, leaving him with only two-thirds of one testicle—and functionally no ability to produce testosterone. As he recovered, he and Kat Causey—whom he married a year before his injury—realized that the limitations presented by his injury and loss of sex drive from his lack of testosterone would change their sex lives forever.
In the past, war wounds like Aaron’s were uncommon, as the trajectory of bullets and shrapnel were likelier to hit soldiers’ upper torsos or heads than their groins. As groups like the Taliban expanded their use of IEDs to inflict maximum damage against their opponents, and as field medicine advanced to help soldiers survive major injuries like Aaron’s, the number of soldiers coming home with genital injuries skyrocketed. According to one study, at least 1,500 Americans involved in wars in the Middle East sustained genital wounds from 2005 to 2017. Many of these injuries occurred between 2009 and 2011, as America initiated a surge in soldiers deployed to and actively patrolling in Afghanistan; in 2010, almost 13 percent of the war wounds Americans sustained involved their genitals, compared to two to five percent in prior wars. At least a third of these injuries were classified as severe. Some call them this war's signature wound.
Genital injuries have lessened among American soldiers in recent years thanks to the development of new forms of groin armor and a drawdown on troop levels in Afghanistan. But they are still incredibly common—if less counted, discussed, and studied—among soldiers and civilians in other conflict zones where IEDs and similar weapons are widely used.
The extent and nature of these injuries vary, sometimes taking out one testicle; sometimes destroying the penis and testicles entirely; and sometimes doing no visible damage, but causing internal trauma to, and atrophy in, genital tissue. (Testicular issues are the most common of these injuries; most genital war wounds appear to affect cis men, given the demographics of the military.) But most IED-related genital wounds are messier than the genital injuries that civilians sustain in accidents, fights, and other everyday tragedies, and so are harder for medical experts to treat or repair.
Every genital injury has the potential to permanently alter how a person has sex. The fear of no longer being able to have sex after a genital injury, combined with the fear of losing part or all of the bits that many men feel define their gender identity, has led some soldiers to say they’d rather die than live without their penis or testicles.
Social taboos around talking about sex after sustaining a genital wound, as well as the fairly limited amount of medical expertise on this topic, can pose serious barriers to people’s efforts to navigate physical intimacy in the wake of a serious genital injury. However, losing part or all of one’s genitals to an IED blast is not necessarily a death sentence for one’s sex life. Hormone treatments and therapy can help restore sexual drive after testicular loss, while reconstructive surgery, strap-ons, and, more recently, the promise of penile transplants can restore the ability to have penis-in-vagina or penis-in-anus sex. People who have sustained genital injuries can also explore non-penetrative sex, stimulation through intact non-phallic erogenous zones (like the prostate, provided an individual has one and it is undamaged), and non-sexual forms of physical intimacy with their partners.
Veterans with genital wounds have started to speak openly about their sex lives, chipping away at taboos and helping experts build up their knowledge and supportive materials. Over the last five years, new resources have emerged for individuals or couples living with these injuries. However, these resources often focus on fertility and rarely contain details about the experience of navigating sex after sustaining a genital war wound.
VICE recently spoke to Aaron and Kat Causey, who advocate for open acknowledgment and discussion of all aspects of life after genital injuries, including sex and intimacy, by sharing their own experiences.
Kat Causey: There was nothing remarkable [about our early relationship]. We had sex. It was pretty standard, white-bread sex. We had no reason to not have sex every day. We were separated by distance a lot, though, so I did appreciate quality over quantity after the first couple days of a reunion. We engaged in all types of sex when we were long distance. We sexted, did videos, dirty emails.
Aaron Causey: We had a good time.
Kat: Things changed before his deployment. I wanted to have more sex leading up to that. But he was training often for 12, 14 hours a day. Then, it was painful. Like, this is the last time we might do this thing or that. Directly before he left, it wasn’t like when we first got together.
Aaron: My job was built around disarming explosives—and probably eventually getting blown up. It was a reality from day one, when I got my initial briefing, that injury was possible. But part of the job is that you don’t think about things like that. When you start to think about those things, that’s when you get injured or killed. We do joke about them after the fact, though.
Kat: Dying was more what we talked about [before he deployed.] We never discussed injury.
Aaron: I had several buddies who’d died or gotten injured. But you more expect to die than to get injured. I hadn’t known anyone [who suffered a groin injury].
Up until this deployment, I had an agreement with every one of my medics that, if I lose one limb, no problem. If I lose two limbs, or [my penis], don’t even [save my life]. I hadn’t had that conversation with my last medic, and I was unconscious right after the injury. They would have ignored the whole thing [and saved my life] anyway, though.
Once I woke up in the hospital, I had no concept of time. I’m not sure how many times they explained what had happened. I know, at one point, they pulled back the sheet to let me see what had happened. I remember a urologist talking to me about the injury.
Kat: As they were taking him into the operating room after he was medevaced, someone hit his gurney on a door frame. The first thing out of his mouth was, "Hey, be careful—I want to have kids someday." Bleeding from open wounds all over, feet and shins blown off—you can’t get more mangled, yet still be conscious, and that’s what we were told he said.
He was inpatient for two-and-a-half months. At first, he was like, "Everything’s going to be fine, and we’re going to be able to have sex however we want, and to have kids." I don’t know what happened, but then, one day, he said, "Hey, I get it now." There was this understanding that he might not recover fully, compared to how things were when he was an able-bodied person.
Aaron: For the first year [after the incident,] I was on so many narcotics and in and out of surgery so often—even after going [into] outpatient, I was in surgery once every three months, at least—that I don’t have a lot of memory of that time. I have to get a lot of transposed memories about stuff from my family. One of the best recollections I have is waking up one morning, and my penis was hurting. I had gotten a hard-on for the first time—with a catheter in. It was regressing and getting stuck on the catheter. [Kat and I] celebrated, like, " It works! It works!"
I had some alone time [in inpatient], so I tested the waters [by masturbating]. Normal ejaculation looks one way. But I ejaculated a bunch of blood, and it was scary as hell. I had to sit down with a urologist after that—and he was like, "Oh, just keep going."
Kat: You need to masturbate and have sex [after these injuries] so you can tell the doctors about what’s going on. I have a pretty good sex drive, so I was game, even if we could just have sex for a few minutes. It wasn’t about orgasming, or even intimacy, as much then as, How is this going?
We figured out pretty quickly that we could still have penetrative sex like we used to. But, as time went on, we realized that the drive wasn’t there [as much, due to his testosterone loss].
Aaron: We learned very quickly that there are positions we can’t do. I’m physically unable to do them anymore. I had to go through a learning period of accepting my body and not being able to do things I used to be able to do, like throwing her around the bedroom.
Kat: We had to unravel what the injury meant for our sex life over years. There were questions we should have been asking, but that we didn’t know how to ask. Our medical team didn’t worry about us because we seemed like the perfect patients. You think you’re getting everything from us. But we didn’t know what we didn’t know. At that time, it wasn’t like [someone could tell us], "Here are the statistics [on how this injury will affect your sex lives], here is what you can do, and here are other people like you."
Aaron: We had a good relationship with our urologist and our nursing staff. It was all very blunt conversations—but we brought up sex more than it was brought up with us.
Kat: My advocacy on this [for medical professionals] is: Make sure there’s literature in the room, [and] that you bring sex up, even if your patients don’t bring it up.
Something I wish someone had said much sooner to us: "Do not compare this to your able-bodied, before-injury sex life, because it’s not going to be that." It probably took us a year to accept that disabled sex [is different]. It took about four years for us to be really good at being a disabled couple dealing with the stresses of life—a lot longer than people think, because we’re so communicative.
Aaron: Those first four years, I was on a lot of pain meds. I wanted to have sex, but the meds were bad for erections. Then, figuring out the testosterone and going through fertility treatments [so we could conceive]. I was on fertility drugs and off of testosterone. When you remove the testosterone, you remove my drive. I’m lazy, lethargic. I put on so much weight. She’d hit that point like, "Hey, let’s go." And I’d be like, "But do I really have to?" It was annoying, because I have this fucking hot wife. Why am I not wanting to hit this all the time?
Kat: We couldn’t get the testosterone levels right until our daughter was over one year old.
Aaron: When you do the testosterone injection, it’s immediately a lot of testosterone. That first day I take my shot, she’s like, "Leave me alone—you turn into a 14-year-old horndog."
Kat: There have been times when I’m feeling assertive and feisty, and [his] nerve pain has ruined the moment. Or his amputations will start to twitch. There’s nothing we can do about that.
We’re nine years [into our relationship] this September, and we still have all the regular long-term relationship issues anybody faces. For some people, a trip to a [sex] toy store or a good night out at a strip club will spice things up. But how do you spice things up when you’re already so limited?
When I talk to caregiver friends who are baby boomers, we share some of the same issues. It’s like [Aaron and I] showed up to the AARP reception 20 years early. That’s not fun. That feels really shitty. It’s not Aaron’s fault. It’s not my fault, either. But I can get really angry about it.
I also never wanted to enter a parent-child relationship. I’ve seen that develop between spouses [when one of them has a disability]. I’m like, Whatever it takes, we won’t do that.
Aaron: She’ll go stay with a friend for a night or two just to get that separation now and then.
Kat: We’re willing to have hard conversations. There are things I enjoyed about sex that aren’t possible for us anymore. We’d never talked about that until recently. But I accepted there are things I’ll never get to do again.
We go into weird territory a lot quicker than most couples, [like entertaining the idea of opening our marriage if he loses his sexual drive or ability permanently in the future.] We have no boundaries. Christ, we should have set boundaries somewhere, at some point. But when one of us says, "Hey, let’s try something new…" So far so good, I guess.
Aaron: We will still figure out a new position now and then. There’s no being shy. You’ve just got to discuss things.
Kat: We are too dumb to quit. Oh, we should have quit 100 times, for many reasons. But we’re adaptive people. Not being together has never been a serious conversation for us.
People should set boundaries for whether a marriage should continue. I don’t care how selfish it seems. If a woman wants penetrative sex and can’t get it anymore, [it can be a real difficulty within a relationship].
We’re not a perfect couple. We’re not always a happy couple. We just got put in a situation. I was always just one to try… We’re willing to hurt each other’s feelings, sometimes, but also still willing to try the next day.
Aaron: As long as you’re willing to try—and we have had some hard days, sometimes.
Kat: Years. Hard years.
Aaron: We’ve never woken up not wanting to try.
Kat: At least not enough days in a row to really consider it.
Aaron: For the record, Kat’s smoking hot. So that helps. You are smoking hot. And amazing.
Follow Mark Hay on Twitter.