Sexuality after SCI
"Will I respond the same as before?"
Every spinal cord injury is different. The impact that a particular SCI has on sexual functioning varies and depends on many factors:
· type of injury (complete or incomplete)
· the level of the injury
· medications used.
There are no definite rules about how a person's sexual response changes after a spinal cord injury.
Generally, when bowel and [bladder control: link to consumer bladder changes section] and genital sensation are affected there will be changes in genital-sexual response.
My main concerns were whether I would be able to satisfy a woman and whether - physically - I would function the same way that I had before. And, could I function in a way that would satisfy me? Would the sensation be the same?
If a complete spinal cord injury has occurred, the following aspects of sexual functioning are likely to be affected:
Genital sensation or orgasm
For women and men with spinal cord injuries that are complete at any level, there is not likely to be any genital sensation or [orgasm: link to male orgasm page and female orgasm page] feelings resulting from stimulation although some people learn to transfer erotic feelings from other parts of their bodies that do have sensation.
Erotic mental and physical feelings
A complete injury -regardless of the level - does not rule out erotic sexual feelings. Many people are able to shift their source of eroticism so that the brain receives sexual signals from parts of the body other than the genitals. The brain learns to react sexually to pleasurable touching in other areas of the body. For example, the ear lobes and the back of the neck can be erogenous areas. This experience will be different than before but can be as fulfilling; some people describe the feeling as less intense or more diffuse. A person's attitude is all-important here. If you are convinced that sex only means intercourse in a certain position, then there may be little room to explore other possibilities. If you are more open and creative, the possibilities are less limited.
Erection to touch (reflex erections)
Men who have injuries that are T10 and above are likely to experience uncontrolled reflex [erections: link to male erection pages] in response to touch on the penis. This happens because the reflex arc (from the penis to the lower part of the spinal cord and back again) functions independently of the brain. This type of erection is often welcomed by men with SCI since it means they can get an erection for sexual activity. Sometimes men with SCI are unhappy with reflex erections because it may happen when they don't want it to - during a catheterization or anytime when the penis is touched. For some men with SCI, the reflex erection may not be completely reliable or may not last long enough for some type of sexual activity; in these cases, some form of [erection enhancement: link to erection enhancement pages] may be used.
When an injury occurs in the lower part of the spinal cord (below T10) reflex erection to touch is not possible. However, purely mental stimulation (a sexual thought or fantasy) can lead to some enlargement of the penis. Some seminal fluid - which can contain sperm -may flow. After this emission of seminal fluid, the erection is usually lost. Men who have a complete SCI below T10 generally choose to use some form of [erection enhancement:
For women, spinal cord injuries can affect [vaginal lubrication: link to section on vaginal lubrication in women's section]. Some women will no longer lubricate when they have sexual thoughts and others will not lubricate when they are touched in this area. These changes will vary. All women have changes to lubrication at different times in their monthly cycle and may experience changes to lubrication following menopause.
Most men with a spinal cord injury - whether complete or incomplete - experience some disruption in [ejaculation: link to male section on ejaculation]. However, ejaculation is a complex response and there can be much variation between individuals.
Incomplete Spinal Cord Injuries
There is no clearly defined way to determine what genital response will be when the injury does not result in a completely damaged spinal cord. Factors such as location of the injury and the amount of sensation and motor functioning can be important in predicting changes to sexual response. If you are able to control both your bowel and bladder that is generally predictive of normal or close to normal sexual functioning.
Sexuality after SCI
Maintaining a healthy sex life after spinal cord injury is an important priority to many people.
Fortunately, over the past few years a large amount of research has begun to be performed in this area. Whereas in the past our knowledge about the field of spinal cord injury was exclusively focused on males and erectile function, recent work has begun to illustrate the impact of spinal cord injury on female sexuality. Moreover, recent gains in the study of infertility after spinal cord injury have allowed professionals to approach the care of newly injured patients with optimism for their potential in sexual functioning.
In this article, I will provide a basic review of what is known about sexual functioning after spinal cord injury and the impact on patients.
Sexual Response The effect of spinal cord injury on sexual response is generally discussed based upon the degree of completeness or incompleteness of the patient's injury and whether the neurological damage affecting the individual's sacral spinal segments is an upper or lower motor neuron injury. Whether a spinal cord injury is considered complete or incomplete is determined by whether they have voluntary rectal contraction and whether they have the ability to perceive sensation around their rectum.
As males have external genitalia, questionnaire studies have been utilized to determine the impact on erections and ejaculations, depending on their extent of injury.
In males with complete spinal cord injuries and upper motor neuron injuries affecting their sacral segments, there is a loss of psychometric erectile function in conjunction with maintenance of reflex erectile functions (Boors & Comarr, 1960).
In those males with incomplete upper motor neuron injuries, there is still maintenance of reflex function; however, some of these males may be able to have psychogenic erectile function.
For those males with lower motor neuron injuries affecting their sacral spinal segments, it has been shown that approximately 25 percent of males will have psychogenic erectile function, whereas none of these males will have reflex erectile function.
With incomplete lower motor neuron injuries affecting the sacral spinal segments, over 90 percent of the population will be able to have some type of erectile function.
Previous reports have hypothesized that female sexual function would be affected similarly to male sexual function in that psychogenic and reflex lubrication will be maintained in a comparable fashion to males, depending on the level and degree of the woman's spinal cord injury. Recent laboratory-based research performed at our institution has supported the hypothesis that women with complete spinal cord injuries and upper motor neuron injuries affecting the sacral spinal segments will maintain the capacity for reflex lubrication while losing the capacity for psychogenic lubrication (Sipski and Alexander, 1995a). Moreover, in those women with incomplete injuries and upper motor neuron injuries, research indicates the preservation of the ability to perceive pinprick sensation in the T11-L2 dermatomes may be able to be used as a predictor for the ability of psychogenic lubrication.
Further research to confirm the effects of spinal cord injury on women with injuries below the level of T6 is planned for the future.
Ejaculatory function is markedly decreased in men with spinal cord injuries. This is most likely due to the fact that coordinated neurological impulses from the sympathetic, parasympathetic, and somatic nervous systems are necessary for ejaculation to occur. For instance, the rate of ejaculation in men with complete upper motor neuron injuries can be as low as 4 percent (Bors and Comarr, 1960).
Furthermore, many times men with spinal cord injuries have ejaculation which goes back into the bladder instead of coming out of the penis. Treatment of this inability to ejaculate has recently been used successfully to help men who suffer from infertility.
Treatment of Sexual Dysfunction
Treatment of male sexual dysfunction has been focused at the treatment of erectile dysfunction.
For those males who are able to attain reflex erections but not maintain them, the use of a silicon or rubber ring placed at the base of the penis can be helpful to maintain an erection. These rings may be used for up to 30 minutes, but should not be used on a longer basis due to the risk of insufficient blood flow to the penis causing ischemia and subsequent complications.
If a male is not able to have an erection, a vacuum suction device may possibly be used effectively to produce the erection, followed by the placement of a similar ring. Again, this device should not be used for more than 30 minutes due to the risk of ischemia.
Recently, FDA approval has been obtained to allow for self-administered injections of prostaglandin E1 into the penis. This is followed by an erection which occurs in approximately 5 minutes. Potential complications from prostaglandin include the development of priapism, a condition whereby an erection will not go down; therefore, emergency instructions must be available to the patient, and a system for appropriate treatment for priapism must be in place.
Intraurethral insertion of medication is now also on the horizon as another mechanism to treat erectile dysfunction.
Other male sexual dysfunctions such as inability to have an orgasm, decreased sexual desire, and premature ejaculation have not been well-studied in the male population.
Questionnaire studies have revealed that approximately 50 percent of males with spinal cord injuries can have orgasms and that the ability to have orgasms is not related to the degree of spinal cord injury.
Furthermore, it has been documented that both sexual satisfaction and frequency of sexual activity decrease after spinal cord injury. As the focus changes from merely production of an erection to improving the quality of feeling in male sexual response, the reasons for the ability of some males to attain orgasms and others not to will need to be elucidated.
Furthermore, treatment protocols for other male sexual dysfunctions will need to be developed.
Similar to male sexual functions, females with spinal cord injury have been shown to have the capacity to achieve orgasm approximately 50 percent of the time, and this has not been found to be related to the degree of injury. This has also recently been confirmed via laboratory-based research (Sipski & Alexander, 1995b).
Similar to males, women with spinal cord injury have been shown to have decreased sexual satisfaction in addition to decreased frequency of sexual activities postspinal cord injury. Treatment of inability to have orgasms, decreased sexual desire, and arousal disorders has not been attempted in a standardized fashion in women after spinal cord injury. Because some women with spinal cord injury may be able to be orgasmic, the use of sex therapy techniques similar to those utilized in the nondisabled population may be an appropriate treatment in the future for women with spinal cord injuries.
Treatment of Male Infertility As ejaculation is greatly decreased after spinal cord injury, it follows that infertility can become a problem (Sipski & Alexander, 1992). In addition to the inability to ejaculate, males with spinal cord injury have decrease in the quality and quantity of sperm which occur in the first few weeks postinjuries.
Production of ejaculation via electroejaculation (electrical stimulation in the area of the prostate which produces ejaculate) followed by either in utero insemination (insertion of the semen in the woman's uterus), in vitro fertilization,2 or intracytoplasmic sperm injection3 has emerged as a viable option for treatment of male infertility after spinal cord injuries. Whereas the use of these techniques has been able to produce pregnancies in the partners of men with spinal cord injuries, these techniques must be performed in a clinic setting and can be somewhat costly.
An alternative method to remediate male infertility has been the use of electrovibration applied to the penis. Due to the risk of autonomic dysreflexia,4 this technique is initially performed in a clinic setting, but may also be performed at home, and has been done so in Europe and other countries around the world. Electrovibration, similar to electroejaculation, is coupled with artificial insemination of the female.
Women with spinal cord injuries suffer from temporary loss of their menstrual periods after their injuries. After this, there is generally resumption of periods, which most times return similar to their previous fashion. Menstrual pain is still present after spinal cord injury and there is generally not a decrease in the ability of a woman with a spinal cord injury to conceive. For this reason, the need to use birth control must be emphasized with women who have spinal cord injuries. For those women who become pregnant after spinal cord injury, it is important that their gynecologist is aware of the potential complications associated with pregnancy and spinal cord injuries.
These can include anemia, problems with transfers due to weight gain, urinary tract infections, pressure sores, and, most significantly, autonomic dysreflexia, which frequently occurs during labor in women with injuries above the level of T6. Unfortunately, confusion of autonomic dysreflexia with preeclampsia5 still occurs and the gynecologist who works with a woman with spinal cord injury must be able to differentiate between these two conditions in order to properly treat dysreflexia in the woman with spinal cord injury.
Some studies have shown an increased risk of caesarean section in women with spinal cord injuries; however, more recent works have not shown this increased incidence.
Conclusion Sexual activity and the ability to remain a sexual being persists in both males and females after spinal cord injuries. As such, it is important to provide the patient with information about how their sexual response and sexual functioning can be affected after spinal cord injuries and for healthcare professionals to know where to refer patients who are in need of further information. In our rehabilitation hospital, this information is supplemented by the presentation of our patient education video, "Sexuality Reborn" (Alexander & Sipski, 1993). The video includes various couples speaking about their sexual functioning after spinal cord injury and demonstrating various sexual techniques. Building upon these two instructional presentations, the patient may also be referred to a sexuality clinic for further information about their sexual potential or remediation of problems which may occur. It is important that in this time of change in the healthcare system, the need to maintain healthy sexuality in persons with spinal cord injury not be ignored. Recent advances in our understanding of this area can be utilized to educate and counsel patients and optimize their level of sexual health.