Spinal Cord Injury

Sexual Activity Following SCI:

• Sexuality and return to sexual activity can actually help the individual to cope and come to terms with their new body and life. Depending on your client, their stage of life, and other contributing factors, sexual activity is something that can be discussed early in rehabilitation. (Pritchard, Kordes, & Hoffman, 2012, p. 87)
• For women, a study by found that women thought that sex was 25% less important to them following SCI due to loss of sensation.
  • For these individual who have less sensation, it was more important to them to participate in hugging, kissing, and touching. (Pritchard, Kordes, & Hoffman, 2012, p. 87)
• For men, a decrease in frequency of sexual intercourse is sometime correlated with an increased interest in alternative sexual activities following SCI. (Pritchard, Kordes, & Hoffman, 2012, p. 87)
• In general, for both men and women, their perceptions of both their partners and their own as sexual being was decreased after SCI. (Pritchard, Kordes, & Hoffman, 2012, p. 88)

Arousal

• Psychogenic arousal to elicit an erection starts in the mind but is carried out by the nerves located in the T12-L2 levels of the spinal cord. If injury impacts these levels or the ones higher, it is likely that the person will be unable to experience psychogenic arousal. (Pritchard, Kordes, & Hoffman, 2012, p. 91)
• Reflexogenic arousal occur from physical touch to the labia, clitoris, penis, or other pats of the genital area and are elicited by the nerves int he S2-S4 levels of the spinal cord. (Pritchard, Kordes, & Hoffman, 2012, p. 91)
• Arousal causes an erection in men and lubrication in women, so difficulty with either type of arousal results in inability to elicit an erection or lubrication. (Pritchard, Kordes, & Hoffman, 2012, p. 91)
• Injury-specific arousal abilities
  • Those with complete injuries, particularly men, will be unable to achieve a psychogenic erection, but will be able to achieve an erection via reflexogenic arousal.
  • Men with incomplete injuries reserve the ability to have reflexive erections and some are able to achieve a psychogenic arousal. (Pritchard, Kordes, & Hoffman, 2012, p. 91)
  • Men with complete lower motor neuron injuries affecting the sacral areas, 25% retain the psychogenic erectile function, and none retain the ability to reflexive erectile function. (Pritchard, Kordes, & Hoffman, 2012, p. 91)
  • With incomplete lower motor neuron injuries, over 90% of males will be able to have some type of erectile function, whether psychogenic or reflexive. (Pritchard, Kordes, & Hoffman, 2012, p. 91)
• Women with decreased or loss of sensation will experience lack of lubrication which causes uncomfortable or painful intercourse. (Pritchard, Kordes, & Hoffman, 2012, p. 91)
• Orgasm after SCI can still be experienced, but is experienced more as a "mind thing" or a psychological orgasm, as opposed to a physical response. (Pritchard, Kordes, & Hoffman, 2012, p. 91)
  • Orgasm in men can manifest as muscle contractions, muscle spasms, or a sensation of flushing above the injury site. (Pritchard, Kordes, & Hoffman, 2012, p. 93)

Bowel and Bladder

• Bowel and bladder function are controlled by S2-S5 spinal segment, so injury at or above this level will result in loss of control of bowel and bladder control. Voiding becomes reflexive, so catheterization and bowel and bladder programs become a part of daily life. (Pritchard, Kordes, & Hoffman, 2012, p. 95)
• There are a multitude of catheters and each type will present it's own barrier to sexual activity depending on the method of drainage. (Pritchard, Kordes, & Hoffman, 2012, p. 95)
• Bower and bladder is also an important part of a person's self-esteem and quality of life and should be approached in relation to both sexual activity and as a part of their daily routines. (Pritchard, Kordes, & Hoffman, 2012, p. 95)

Fertility

• Gender differences
  • Males
    • Male fertility is impacted by the location of the injury and it's impact on their ability to achieve ejaculation, which is controlled by T12- L2 and S2-4. But, the inability to ejaculate does not mean that he will be unable to father children. Another option is a procedure called electro-ejaculation where sperm can be collected for fertility. (Pritchard, Kordes, & Hoffman, 2012, p. 93)
  • Females
    • Women can experience amenorrhea, or the loss of a menstruation cycle due to the physical and psychological stress associated with the injury itself. This occurs for an average of 4.3 months, with a range from 1 week to 24 months (Pritchard, Kordes, & Hoffman, 2012, p. 93). Inform your client that, although they are not having periods, it does not mean that they are infertile and they can likely still become pregnant.
      • Risks associated with pregnancy include,
        • Transferring difficulty by added weight and change in center of gravity. (Pritchard, Kordes, & Hoffman, 2012, p. 94)
        • Increased risk of urinary tract infections and bladder management problems. Hygiene and decreased sensation can contribute to the risk, and an added girth due to a women's belly increased difficulty in hygiene and reaching the genital area. (Pritchard, Kordes, & Hoffman, 2012, p. 94)
        • Autonomic dysreflexia is at an increase risk during pregnancy and can present as a spike in blood pressure or a persistent headache that may be life threatening. (Pritchard, Kordes, & Hoffman, 2012, p. 94)
          • Occurs most commonly in injuries at T6 or higher.

Respiration

• In clients with cervical SCIs, respiration can be compromised. Pneumonia is the most common cause of death following SCI in the first year. (Pritchard, Kordes, & Hoffman, 2012, p. 96)
• Sexual activity frequently causes increased respiration, so client's may become fearful of how sexual activity will impact their ability to breathe. (Pritchard, Kordes, & Hoffman, 2012, p. 96)

Pain

• 84% of people with SCI experience pain, with more prevalence in those with tetraplegia than paraplegia. (Pritchard, Kordes, & Hoffman, 2012, p. 97)
• Clinicians can also become pre-occupied with addressing pain as a barrier in other ADLs and may miss out on addressing pain related to sexual activity. (Pritchard, Kordes, & Hoffman, 2012, p. 97)
• Sexual activity can actually help with pain management and is important to include in the rehabilitation process. (Pritchard, Kordes, & Hoffman, 2012, p. 97)
  • In this case, it is very important to give strategies as pain can be exacerbated with incorrect positioning.

Addressing Sexuality:

• Depending on your client, their stage of life, and other contributing factors, sexual activity is something that can be discussed early in rehabilitation. (Pritchard, Kordes, & Hoffman, 2012, p. 87)
• Open conversation to find out what parts of intimacy are important to the client can guide how you approach sexual activity as a part of their rehabilitation.
• Open up the conversation to alternative methods of sexual participation.
• Remind your client that they can still for relationships, get married, and have families. Men can still father children and women can still bear children. SCI does not mean that they cannot have these things, it just means that they will be done differently. (Pritchard, Kordes, & Hoffman, 2012, p. 88)
• Remind your client that intimacy is more than sexual intercourse. A SCI does not change many of the other parts of being intimate with a partner, including communication, touching, respect, and physiological reactions to their partner. (Pritchard, Kordes, & Hoffman, 2012, p. 88)

Evaluation:

• You can provide your client with a sexuality questionnaire to open up the conversation, which encompasses psychosocial status, physical abilities and limitation, personal values, and communication. (Pritchard, Kordes, & Hoffman, 2012, p. 89)
• You client may be more responsive to a questionnaire than they would be in a face-to-face conversation.
• See Evaluation for more specific assessment tools.

Specific Considerations:

• The effect on sexual activity is effected by, the level of injury, the client's age, co-morbidities, culture, marital status, perceived importance, and numerous other factors specific to the person that should be considered when approaching the topic. (Pritchard, Kordes, & Hoffman, 2012, p. 93)

Specific Suggestions:

• Encourage your client to adhere to their bowel and bladder program, to not only increase their safety, but if they are aware of their schedule, they can utilize this to plan ahead and avoid accidents during sexual activity.
  • Could advise that they complete their bowel and bladder program just prior to sex to make sexual activity more comfortable and reduce the risk of incident.
• With respiratory difficulties, encourage client's to participate in slow and gentle sexual activity in order to maintain safety and their own psychological outcomes.
  • With less respiratory involvement, sexual activity should be performed in a slow and flowing manner.
• For lubrication, suggest the use of over-the-counter water or silicon based lubricating gels or the use of lubricated condoms for the male partner. (99)
  • Water-based lubricants are easier to clean up and this should be mentioned to the client.
• For stimulation, men and women can utilize vibrators or other assistive devices, with use of strapping to their hands if hand dexterity is a problem. (100)
• If erection is not possible, recommend (100)
  • Engaging in sexual activities outside of strictly intercourse.
  • Use of a vibrator to attain stimulation.
  • Use of a vacuum device to facilitate an erection
    • Draws blood to the penis and a ring is placed around the penis to maintain the erection, but the erection will be short-term and your client should be made aware of this.
    • Precautions
      • This requires significant dexterity and cannot be left in place longer than 30 minutes for skin integrity.
    • A partner can be involved in this process if hand dexterity is not available to the client and their relationship warrants this.
  • Surgical implants can be utilized to mimic an erection or partial erection.
    • Are typically last-ditch efforts after trying other means or if vascularity is poor to the penis.
  • Use of pharmacological means of erection.
• For positioning (101)
  • For women
    • Use "man-on-top" positioning, which is a traditional position for sex, but the partner must be mindful not to put too much pressure on her chest for respiratory concerns.
    • Can use their wheelchair while the partner performs sexual activities outside of intercourse, such as tactile or oral stimulation.
    • Laying on their side women would have to allow their partner to be in charge of positioning them and supporting their legs, but could be utilized for intercourse.
  • For men
    • Utilize supportive chair or with support from pillows or bolsters on a bed, while their partner sits on top of them. This allows for the client to be able to look at their partner and engage in kissing. This can also be performed in the client's wheelchair.
  • See Weakness/Paralysis for more information.

References

Pritchard, V., Kordes, T. L., & Hofmann, A. (2012). Spinal cord injury and sexuality. In B. Hattjar (Ed.), Sexuality and occupational therapy. Bethesda, MA: American Occupational Therapy Association.