AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Common Causes Of Sexual Dysfunction
• Pathophysiology
• Organic Problems
• Neurologic Issues
• Psychosocial Issues
• Disability-specific Issues
• Solutions
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Common Causes Of Sexual Dysfunction
• Pathophysiology
• Organic Problems
• Neurologic Issues
• Psychosocial Issues
• Disability-specific Issues
• Solutions
• References

Sexual dysfunction in patients with disabling physical or neurologic conditions is often overlooked by medical personnel, but it is a topic of great importance to both the patient and those with whom they share significant relationships. People with disabilities are sexual individuals with sexual desires and concerns that require the attention of health care providers. The largest myth about people with disabilities is that they are less sexual than those without disabilities. Other myths regarding sexuality include the following:

• Sex means sexual intercourse.
• Talking about sex is not natural, proper, or necessary.
• Sex is for younger people.
• Men should initiate sexual activity.
• Sex should be spontaneous.
• A firm penis is a requirement for satisfying sex.
• Quality sex ends with an orgasm.

Too often, physicians overlook aspects of function that may be less obvious than the injury or illness that brought the patient to the rehabilitation team. The quality of personal relationships in general, and sexual ones in particular, exerts great impact on a patient's self-esteem and support network. The multiple physical, psychological, and emotional changes that may occur after catastrophic injury or as a result of congenital disability or chronic illness must be addressed not only in the context of the patient, but also of the patient's support system. The issue of sexuality needs to be addressed during both the acute and long-term rehabilitation processes. Sexual function recovery is no less important than any other aspect of functional rehabilitation from a disabling disease or injury.

COMMON CAUSES OF SEXUAL DYSFUNCTION

Section 3 of 10  

• Authors and Editors
• Introduction
• Common Causes Of Sexual Dysfunction
• Pathophysiology
• Organic Problems
• Neurologic Issues
• Psychosocial Issues
• Disability-specific Issues
• Solutions
• References

Sexual dysfunction, in the presence or absence of disabling conditions, has many causes. Organic/structural, psychological, or relationship issues may need to be considered, regardless of the underlying disability diagnosis.

Structural problems that can contribute to erectile dysfunction or sexual arousal disorder vary widely. These structural problems may involve the circulatory or nervous system or may be associated with anomalies in the spine that impact those systems. The dysfunction also may be of psychological origin. The site of the problem (eg, the nervous or circulatory system) governs the type of intervention needed.

Organic and psychological causes

• Vascular disease
• Endocrine disorders
• Musculoskeletal disorders
• Neurological disorders
• Psychogenic disorders

Erectile dysfunction

See also Spinal Cord Injury, in the section Disability-Specific Issues.

The term impotence was previously used to describe sexual dysfunction in men. The term erectile dysfunction is used currently to connote inability to achieve or sustain sufficient erection for satisfactory sexual function. Estimates suggest that 50% of men aged 40 years or older have experienced some degree of erectile dysfunction.

The clinician should understand that a patient who has sustained head injury may experience erectile dysfunction that is not necessarily related to the head trauma. Consider all possible conditions that may be relevant in assessing the patient's sexual functioning. Patients with undiagnosed diabetes or hypertension may experience erectile dysfunction as one of the first signs of disease.

Atherosclerosis affects the circulatory system, reducing the blood supply to both the heart and the brain. Reduced blood flow also affects many other parts of the body, including the genitalia, and can change the degree of erection or vulvar engorgement and lubrication that occurs. Thus, sexual dysfunction must be viewed as a systemic process, rather than as a local equipment failure. Perform a full diagnostic workup in assessing any patient's sexual functioning.

Sexual arousal

Sexual arousal is defined as increased heart rate, blood pressure, respiratory rate, and lubrication-swelling response associated with erotic psychic and physical stimulation. In women, female sexual arousal disorder is associated with inability to attain or maintain sufficient lubrication/swelling response. Low estrogen levels, as well as negative emotions, such as anger or fear, may inhibit arousal and lubrication.

PATHOPHYSIOLOGY

Section 4 of 10  

• Authors and Editors
• Introduction
• Common Causes Of Sexual Dysfunction
• Pathophysiology
• Organic Problems
• Neurologic Issues
• Psychosocial Issues
• Disability-specific Issues
• Solutions
• References

Masters and Johnson describe 4 major stages of sexual response, each of which may be affected by disabling conditions.

Masters and Johnson's 4 stages of sexual response

• Excitation is characterized by increases in heart rate, blood pressure, and respirations.
• Plateau refers to a surge of sexual tension.
• Orgasm is the release of endorphins with ejaculation.
• Resolution is the cool-down period.

Desire may be lessened by reduced ability to visualize, fantasize, or respond to usual cues. Sexual interest overall may be reduced. The plateau phase may be prolonged or shortened by erectile dysfunction or anxiety.

Excitation and orgasm may be hampered by reduced descending signals or by decreased sensory feedback from the genital region, skin, and other areas of arousal. Anxiety may hinder orgasm, or insufficient buildup of excitation may not be possible because of distractibility.

Resolution is the important intimate bonding phase that should draw couples closer together. If the sexual interaction is perceived as too demanding or unsatisfying, however, couples may not be able to enjoy a sense of closeness.

ORGANIC PROBLEMS

Section 5 of 10  

• Authors and Editors
• Introduction
• Common Causes Of Sexual Dysfunction
• Pathophysiology
• Organic Problems
• Neurologic Issues
• Psychosocial Issues
• Disability-specific Issues
• Solutions
• References

Physical or organic problems contributing to sexual dysfunction may include the following:

Adverse effects of medications

• Cross-reactions between drugs or increased sedation may result from certain medications.
• Spasticity that interferes with movement and relaxation can be reduced by medications (eg, Dantrium, baclofen). However, medications may impact stages of sexual function.
• Substances, such as alcohol, cigarettes, and nonprescription drugs, also can impair sexual function.

Depression

• Many patients develop depression after traumatic injury. Depression can be associated with decreased libido and inability to enjoy previously pleasurable activities.
• Antidepressant medications may help depression; however, in some patients, sexual dysfunction can also occur as an adverse effect of medications. Many of the selective serotonin reuptake inhibitors, for example, can cause delayed orgasm or erectile dysfunction.
• According to Schover and Jensell, depression, altered body image, personality/behavioral changes, social distance, anxiety, fear of rejection, fear of inadequate performance, fear of pain/spasticity interference, and bad memories of prior experience can all hamper sexual interest and performance.

Neurogenic problems (eg, autonomic, central, peripheral)

• Autonomic dysfunction, as a result of brain dysfunction or spinal cord injury (SCI), may impact stages of the sexual response cycle. The fight or flight response is generated by the sympathetic nervous system. This impulse can be increased psychogenically by anxiety or from organic lesion in the brain or spinal cord.
• With increased sympathetic tone, excessive constriction of blood flow is common, reducing engorgement of sexual organs and orgasm. Multiple levels of dysfunction can exist. Head trauma, for example, may be accompanied by other injuries (eg, spinal injuries, soft tissue injuries, fractures).

Pain/spasticity as inhibitor

• Pain or limitation of motion from other injuries may depress interest in sex or sexual performance even further.

Traumatic structural changes

• Diffuse or focal brain injury may result in mild-to-severe physical and cognitive impairments that may impact sexual function. Diffuse injury may impact deep hemisphere structures that regulate sexual function, including possible direct injury to the pituitary gland or hypothalamus, which could disrupt normal hormonal functions. Imbalance in available neurotransmitters may disrupt normal function. Thus, the practitioner must be aware that traumatic effects on different areas of the brain lead to alteration of certain functions.
• Several dysfunctions are associated with certain symptoms, such as the following:
  • Amygdala with sexual disinhibition/hypersexuality
  • Brain stem with decreased libido, inappropriate processing of information
  • Hypothalamus with general initiation, dyscontrol of sexual behavior, hormonal regulation
  • Frontal lobes with sexual apathy, loss of initiative
  • Pituitary gland with infertility, decreased secondary sex characteristics, decreased libido
  • Septum with decreased libido, impotence, decreased ability to experience pleasure/orgasm
  • Temporal lobe with diminished responsiveness
  • Thalamus with hypersexuality
• Most often brain injuries are not discrete lesions but represent a combination of involvement of different areas of the brain with overlapping challenges. The main challenges are disinhibited or socially inappropriate behavior demonstrating lack of restraint, lack of initiation, or inability to find a start button to get things going. Sexual dysfunctions (eg, hypersexuality, hyposexuality) may result.

Neurogenic bowel and bladder

Substance abuse

• Drugs
• Alcohol
• Cigarettes

Cognitive challenges

• Damage to the brain, whether traumatic, vascular, or hypoxic, may result in numerous cognitive changes that may be associated with behavioral changes (eg, anger, compulsion, inconsistency). Reduced memory and organizational skills may result in easy distractibility and inattention to previously observed details. For instance, a couple may have a usual routine, knowing what the other likes, possibly in sequence, or cued with certain gestures or comments. Such a routine may be forgotten or changed by the person with brain injury.
• Lack of interest because of pain, fatigue, or loss of libido may frustrate both partners. Memory impairments and distractibility can be quite challenging for a couple. The partner with traumatic brain injury (TBI) may not be able to recall having sex and may make repeated demands. On the other hand, easy distractibility may interfere with full participation in sexual activities.
• A person with brain injury may not be able to pick up on subtle cues, and the partners may need to start over as if from the beginning of the relationship. Sometimes, memory can be impaired to the extent that there is no recollection of sexual encounters at all, and, therefore, frequent demands for sex are made. Patients with hypoxia frequently manifest this type of behavior. Memory impairment makes the partner feel unappreciated and used, particularly when accused of refusing to participate. Use of a memory book may be helpful. The partner who is not disabled notes dates and times of sexual encounters and can refer back to this record if needed for reference.
• Sometimes a person who was sexually aggressive before sustaining illness or injury may become more passive or forget about sex altogether unless reminded. On the other hand, a sexually passive person may become quite disinhibited. Challenges may develop with emotional lability (eg, crying or laughing not necessarily associated with activities at hand). This behavior could be quite disconcerting in the midst of passionate lovemaking. Insuring adherence to safe sex protocols is a further challenge, as is consistent use of contraceptive methods that require physical coordination and memory.

Communication problems

• Communication problems due to speech and language deficits, such as nonfluent speech, word finding deficits, and memory loss, may aggravate attempts to work out mutually agreeable solutions. Thus, a neutral intermediary, such as a counselor, may be helpful.

NEUROLOGIC ISSUES

Section 6 of 10  

• Authors and Editors
• Introduction
• Common Causes Of Sexual Dysfunction
• Pathophysiology
• Organic Problems
• Neurologic Issues
• Psychosocial Issues
• Disability-specific Issues
• Solutions
• References

Neurologic conditions such as spinal cord injury (SCI), traumatic brain injury (TBI), cerebrovascular accident, and multiple sclerosis present similar challenges. From a physiologic standpoint, certain sexual dysfunctions can be explained based on which parts of the nervous system have been damaged.

Problems in the CNS may be associated with certain symptoms. Symptoms are dependent on the level of involvement of brain, spinal cord, or peripheral nerves and may include the following:

• Spasticity
• Incontinence
• Fatigue/weakness
• Sensory changes
• Cognitive/perceptual changes

PSYCHOSOCIAL ISSUES

Section 7 of 10  

• Authors and Editors
• Introduction
• Common Causes Of Sexual Dysfunction
• Pathophysiology
• Organic Problems
• Neurologic Issues
• Psychosocial Issues
• Disability-specific Issues
• Solutions
• References

Individuals and couples coping with sexual limitations of disability must work to accept those limits and develop options available to them.

A constellation of limiting factors may be involved, such as the following:

• Depression
• Altered body image
• Personality/behavioral changes
• Social distance
• Anxiety
• Fear of rejection
• Fear of inadequate performance
• Fear of pain/spasticity interference
• Negative memories of prior experience

In addition, couples may be challenged by issues like the following:

• Change in role
• Caregiver versus lover conflict
• Communication problems
• Contraception

The impact of a disabling condition on a couple is profound and complex. Role changes can interfere with adult-to-adult relationships. Making the transition from being an anxious observer/caregiver in the initial recovery phase back to being a lover may be difficult. This situation may be exacerbated if the necessary role changes include greater responsibilities (eg, paying bills, working, making decisions that previously were the responsibility of the person with the impairment). Confusion and resentment may develop.

Disagreement over timing of pregnancy subsequent to injury may be a problem, and it may be compounded further by physical or mental challenges involved in using contraceptive devices.

Communication problems associated with speech and language deficits (eg, nonfluent speech, word-finding deficits, memory loss) may aggravate attempts to work out mutually agreeable solutions. A neutral intermediary (eg, a counselor) may be helpful.

Survivors may feel self-conscious about changed physical or mental states. In certain conditions (eg, TBI), individuals may not demonstrate any physical deficits, further compounding the partner's frustration with multiple cognitive changes.

Few opportunities for social interaction may exist, causing patients to feel shy and fear rejection. These individuals may not have had much sexual experience prior to onset of the disabling condition or already may have had problems with sexual dysfunction, now further compounded by effects of the condition. Patients or partners may be fearful of increasing pain or physical damage.

Sexual identity and confusion can cause great consternation. These issues must be handled with sensitivity and compassion to help avoid reduced self-esteem and depression. Recommend discussion of such questions with a knowledgeable counselor or sex therapist, so that successful strategies can be worked out.

DISABILITY-SPECIFIC ISSUES

Section 8 of 10  

• Authors and Editors
• Introduction
• Common Causes Of Sexual Dysfunction
• Pathophysiology
• Organic Problems
• Neurologic Issues
• Psychosocial Issues
• Disability-specific Issues
• Solutions
• References

Traumatic brain injury cognitive changes

• See also Organic Problems
• Memory
• Organization
• Distractibility

Spinal cord injury

• Sexual dysfunction in spinal cord injury (SCI) can result from many factors (eg, ejaculatory failure) because of neuromuscular dysfunction or obstructive changes from recurrent genitourinary infections. Average sperm motility rates among males with SCI are considerably lower than for the average male without SCI. This phenomenon can limit a man's capacity to father children.
• The level of SCI affects a male's ability to have an erection and the female's ability to lubricate and experience orgasm. A male with SCI can experience 2 types of erections, psychogenic and reflex.
• A psychogenic erection takes place as a result of descending stimulation from the brain associated with mental stimulation through fantasy, visual stimulation from viewing erotic materials, or participation in sexually stimulating activities. Psychogenic erections do occur in those with sacral lesions.
• A reflex erection occurs in association with direct physical contact to the penis or other erotic areas such as the ears, nipples, or neck. A reflex erection is involuntary and can occur without any sexual or stimulating thoughts.
• The nerves that control erection are located in the sacral segments (S-2/S-4) of the spine. SCI that occurs above these segments results in loss of the ability to have psychogenic erections. Thus, the male with SCI is no longer able to achieve an erection by becoming emotionally or mentally excited; however, these males may be able to have reflex erections with physical stimulation. Reflex erections are experienced by patients with higher SCI lesions.
• Males with SCI can experience orgasm, especially when concentrating on their partner's arousal. Ability to ejaculate, however, decreases dramatically after SCI.
• Increasingly successful fertility enhancement is seen with electroejaculation techniques. Physiologic limitations include decreased sperm count and decreased sperm motility with increased numbers of abnormal sperm.
• Incontinence (ie, lack of full control of bowel or bladder) can be challenging; however, incontinence can be overcome with timing of catheterization or voiding so that the bladder is emptied prior to sexual relations. Use of certain medications (eg, Ditropan) may help to relax the bladder to improve bladder capacity and reduce irritability.
• Overall education for individuals and couples faced with SCI emphasizes redefining and expanding the boundaries sexual expression. Sensory amplification is a technique whereby the individual concentrates on a physical stimulus to amplify sensation, sometimes to the point of mental orgasm.
• Sexuality in a female patient with SCI is less studied than in male patients. Significant decline in sexual intercourse frequency and impaired ability to achieve orgasm occur postinjury. Females with SCI who are younger than 18 years at the time of their injury are at high risk of not experiencing intimacy compared with women who are older than 18 years at the time of their injury. Most women interviewed concerning this issue received little or no health care provider education concerning the sexual aspect of their catastrophic disability. Female fertility remains intact postinjury and contraceptive methods should be used to prevent unwanted pregnancy.

Survey results regarding traumatic brain injury and sexuality

From 1998-1999, an anonymous sample of patients with TBI was surveyed, requesting their frank input about relationship changes after TBI. Two mailings were sent out, one to a list of clients still in treatment, and the remainder of the forms was included as part of a quarterly journal for patients with brain injury. A total of 29 responses were received, from 23 patients and 6 partners.

The preliminary survey results are as follows:

• Most patients with head injuries and their partners were older than 30 years (93%), with 34% of those responding older than 50 years. Male respondents totaled 53%, and 45% were female (less than 100% due to nonresponse). All of the respondents were at least a year out from injury, and 83% had been in relationships at the time of injury.
• While most patients (95%) and partners (83%) described their relationships as great or good prior to head injury, by 6 months after head injury, a shift had occurred with 72% of survivors describing the relationship as poor or terminated.
• Interestingly, approximately one half (56%) of survivors who were married described their relationships as poor 1 year out from the injury; yet, 83% of the married partners described their relationships as great or good.
• One hundred percent of survivors and their partners were sexually active prior to the injury. Half of the partners considered that the sexual performance of the partners with head injury had changed, and 82% of patients felt that their own performance had changed since the injury.
• The following 4 major problem areas were cited by both survivors and partners in regard to changes in sexual performance:
  • Fatigue: 78% of survivors felt it was a problem; 83% of partners noted it.
  • Decreased interest: 60% of survivors and 50% of partners remarked on it.
  • Easy distractibility: 60% of survivors and 66% of partners noted it.
  • Changed sensations: 60% of survivors cited it, as did 33% of partners.

Additional areas of concern included pain, erectile dysfunction, and physical changes.

Stroke and sexuality

Post–cerebrovascular accident (CVA), a significant decline in sexual activity occurs due to psychologic rather than medical reasons. Partners also play a role in that they are apprehensive regarding the possibility of a stroke relapse, for example. More than half of male patients report erectile dysfunction. Impaired sexual function post stroke is not correlated to gender, hemisphere involved, marriage duration, level of education, or depression.

Limb amputation and sexuality

Although a limb amputation is a rare direct cause of sexual dysfunction, amputees report reduced libido postamputation. Both the site of amputation and the etiology have negligible impact on the sexuality of the amputee. Because sexual function in amputees is preserved, most of the patient education and counseling involves psychologic issues rather than neurologic impairment. Rehabilitation professionals should be more sensitive to the sexuality of disabled patients without a neurologic impairment such as patients with limb amputations.

SOLUTIONS

Section 9 of 10  

• Authors and Editors
• Introduction
• Common Causes Of Sexual Dysfunction
• Pathophysiology
• Organic Problems
• Neurologic Issues
• Psychosocial Issues
• Disability-specific Issues
• Solutions
• References

Team approach

Health professionals who assist in diagnosis and treatment of sexual dysfunction and relationship problems may include physiatrists, urologists, gynecologists, internists, psychologists, and certified sex therapists.

Physical examination and history

Before the patient resorts to using erectile aids or other interventions, perform a thorough physical examination and implement a coordinated team approach to assess for possible accompanying medical conditions.

Take a complete history of both partners and perform a complete physical examination, including genitourinary examination. Order basic laboratory screening (eg, blood pressure, chemistry panels) to rule out hormonal or metabolic imbalances. Ask male patients whether they wake up with an erection. If so, some physiological function is intact. Conduct medication review with the treating physician or pharmacist to rule out intolerable side effects or cross-reactions.

Counseling

Sexual counseling can help the individual learn to communicate needs and feelings concerning sexual issues. Implementation of strategic solutions may require assistance from the partner. The person who is disabled may find it difficult to admit to sexual dysfunction and to ask for assistance.

Dr. Annon describes a system known as PLISSIT, which includes the following:

• Permission
• Limited information
• Specific suggestions
• Intensive therapy

Care providers can provide significant impact on a patient's recovery process. Inclusion of sexual history as part of the evaluation and treatment process validates or gives the patient permission to include healthy sexual functioning as part of overall functional goals.

When possible, ask both partners to share information regarding sexual functional status before and after the disability. They need to think in terms of both physical and mental changes and work together, possibly with a counselor, to devise solutions or optimal coping strategies for those problems. The level of information provided should be tailored to the couple's level of comprehension.

Couples are encouraged to use a desensitization approach, returning gradually through each stage of the sexual response cycle. Advise that they first get used to sleeping together again. After awhile, they should practice minimal intimacy such as kissing, fondling, and hugging. Discuss how that went, and, when they are ready, have them proceed through each subsequent step. This eliminates the goalpost mentality of having to reach orgasm each time, while permitting enhancement of the quality of interaction that is comfortable for both participants.

For excellent patient education resources, visit eMedicine's Erectile Dysfunction Center. Also, see eMedicine's patient education articles, Impotence/Erectile Dysfunction, Causes of Erectile Dysfunction, and Erectile Dysfunction FAQs.

Addressing organic issues

Once specific areas of dysfunction are identified, make suggestions to address those dysfunctions. For example, pain and limitation of motion may limit interest or affect performance adversely.

Timing

Choosing more appropriate times, such as the morning or after a warm shower or bath, can minimize the factors that encourage one partner to avoid physical contact. Relaxing massage may be incorporated into foreplay to reduce pain, spasms, and anxiety. Side-lying positions sometimes are tolerated better. Strategic placement of cushions or pillows may enhance the experience for both partners.

Taking advantage of the best time of the day may lessen the effects of fatigue. The morning may be a better time than the evening. The beginning of the week may be better than the end of the week. A quiet day may be better than a busy day.

Fatigue

Strengthening and endurance training as part of the overall rehabilitation program also can help improve physical function and endurance during sexual relations. The conditioning program designed for the patient also should address mental and physical stress reduction, as well as energy conservation during sexual relations.

Sensory changes

Partners need to communicate about sensory changes. What previously was pleasurable may be irritating, and vice versa. Reduced sensation may be a problem in parts of the body; thus, advise that foreplay activities be directed to areas with better sensation. This adaptation could mean the difference between lying on one side or the other to optimize body contact and stimulation.

Longer foreplay may be needed to achieve sufficient stimulation, which could be frustrating for a person with TBI who has reduced attention or easy distractibility. Discussion between partners in a relaxed manner about what has changed and working together creatively to optimize remaining potential may lead to better physical relations.

Erectile dysfunction (ED)

Many males have erections; however, these erections may not be firm enough or last long enough for sexual activity. Several options are available for males to achieve erections, including penile injections, surgical implants, the vacuum pump, and oral medications.

Penile injection therapy involves injecting medications into the corpus cavernosum of the penis to relax smooth muscle and promote blood flow by inhibiting sympathetic tone. Such medications include papaverine, phentolamine, and prostaglandin E1. Use of these medications can produce a hard erection that can last for 1-2 hours. Severe adverse effects (eg, prolonged erection, priapism) may result if not used correctly. Pain and ischemic damage to the penile tissue can result from improper use. Penile injections may be difficult for a patient with limited hand function secondary to SCI. He must have a partner who is willing to learn to give the injections.

Before introduction of penile injections, surgical implantation of a penile prosthesis was used commonly for individuals with SCI. The irreversible surgical procedure involves inserting an implant directly into the erectile tissues. The 3 types of implants available are semirigid or malleable rods, fully inflatable devices, and self-contained unit implants. Risks include skin breakdown in an insensate patient and infection.

The vacuum pump is the least invasive erection aid. This mechanical, nonsurgical device produces penile engorgement and rigidity sufficient for intercourse in most individuals. The penis is placed in a vacuum cylinder. Air is pumped out of the cylinder, causing blood to be drawn into the erectile tissues. The erection can be maintained by placing a constriction ring around the base of the penis. This ring also can prevent urinary leakage that can occur in the individual with SCI who has not emptied his bladder before sexual activity or anyone who has a reflex bladder. Pumps are available in manual and battery-operated models.

Oral medications for ED, such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra), are phosphodiesterase 5 (PDE5) inhibitors that relax smooth muscle by enhancing the nitric oxide effect and promote effective erectile function. These oral medications are convenient to use and do not require any preparation, which may delay and detract from the enjoyment of the sexual activity. Men who take nitrate medication for coronary artery disease should not take PDE 5 inhibitors due to associated hypotension. Another reported adverse side effect is sudden decrease or loss of vision in one or both eyes when taking these medications. Sildenafil citrate (Viagra) and vardenafil (Levitra) have been found to be effective management for ED in patients with SCI in both complete and incomplete lesions as reported in randomized controlled studies. No adverse side effects, such as autonomic dysreflexia, have been reported.

Summary

In summary, people with disabling conditions are human beings, just like everyone else. They have human needs just like everyone else. Although they may have changed after their injuries, they have not been rendered asexual. Patients and their partners have a right to know about every aspect of their bodies, the changes that have taken place, and useful solutions to overcome those changes. Physicians need to ask open-ended questions and be prepared to discuss some of the pathophysiology of sexual dysfunctions to educate and reassure the patient and his/her partner.

Case examples

Case 1: JS was a healthy man in his late 30s who sustained a severe facial blow with frontal lobe dysfunction. He suffered from recurrent headaches, disinhibition/anger and impulse dyscontrol, and problems with memory and concentration. JS and his wife worked out a schedule for energy conservation to optimize his helping out around the house and with childcare.

JS and his wife included time-outs when things escalated, so he could either work off frustration or collect himself in a quiet environment. He also found spiritual support and deep breathing helpful. Through regular scheduled communication sessions with a mediator, they were able to discuss their different concerns clearly and honestly. Through relaxation techniques, gradual return to sexual interaction, regular exercise, and use of anti-anxiety medication, they reestablished their relationship sufficiently to conceive a child. They report good rapport and a positive relationship at this time.

Case 2: IR was a man in his late 50s who sustained polytrauma in a motor vehicle accident and suffered orthopedic problems in the neck, back, leg, and head. Challenged with memory deficits, concentration problems, headaches, dizziness, circulatory problems, spinal pain in neck/back/leg, he and his wife were unable to bridge communication challenges and separated. She was unable to accept that his significantly changed behavior was not deliberate, and he was unable to recover sufficiently to previous level of function to maintain the relationship.

Case 3: MM is a 50 year-old married female classified with a C-6 America Spinal Injury Association (ASIA) A (complete) spinal cord injury. She was originally injured in a diving accident at aged 20 and met her husband at aged 25. Postinjury, she required intensive education and counseling regarding SCI lifestyle and sexuality. Her partner was willing to accommodate her severe level of disability. They maintained a satisfying and successful relationship that resulted in a lasting marriage because both partners were enlightened and willing to be flexible concerning each partner's needs and desires. MM became a counselor for female patients with SCI to help them resume lifestyle activities including participation in sexual activities.

Resources

Information Center for Individuals with Disabilities - Fort Point Place, First Floor, 27-43 Wormwood Street, Boston, MA 02210-1606, (800) 462-5015; TDD (617) 345-9743

Sexuality Information and Education Council of the United States (SIECUS) - 130 West 42nd Street, Suite 350, New York, NY 10036, (212) 819-9770

American Association on Mental Retardation, Special Interest Group on Social and Sexual Concerns - 444 North Capitol Street NW, Suite 846, Washington, DC 20001, (202) 387-1968; (800) 424-3688

Sexuality and Disability Training Center - University Hospital, 75 East Newton Street, Boston, MA 02118

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Common Causes Of Sexual Dysfunction
• Pathophysiology
• Organic Problems
• Neurologic Issues
• Psychosocial Issues
• Disability-specific Issues
• Solutions
• References

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Article Last Updated: Sep 27, 2006