SPINALCORD: Sexuality for Women with Spinal Cord Injury

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SEXUALITY
Sexuality is an expression of one’s self as a woman or man. It is intimate in nature, which means it is personal and private. Sexuality is commonly expressed through physical and emotional closeness. Most people consider sexual activities as a means to express physical intimacy. However, Physical intimacy is more than sexual intercourse. Holding hands, hugging and kissing are good examples of ways to express physical intimacy. Likewise, emotional intimacy is more than feelings that result from physical contact. Emotional intimacy can be a connection with one’s self that results in feelings of self-satisfaction, confidence and self-worth. It may also be a feeling of trust in another person and an openness to share private thoughts and feelings.

ADJUSTMENT
Body image is an important adjustment issue for women with spinal cord injury (SCI) because their feelings can influence their desire to engage in sexual activity. It is natural for women who are newly injured to take time to become more comfortable with their bodies, and a woman who is comfortable with her body before her injury will likely adjust well to her new condition. When a woman sees herself as desirable, it is easy to believe that others also find her attractive. On the other hand, a woman with a negative opinion of her looks before her injury will likely find it difficult to see herself as sexually attractive after injury. Thus, she will be more likely to have a difficult time with sexual adjustment and will likely avoid sexual activity.

One of the main keys to adjustment issues is learning to manage impairment related issues of everyday life. Sexuality is a natural part of life, so healthy adjustment begins with knowing the facts about the impact of SCI on sexual issues. No matter the level of injury, it is normal for women to have doubts, concerns and questions. However, the facts are simple. Women with SCI:

are desirable;
have the opportunity to meet people, fall in love, and marry;
are sexual beings;
have sexual desires;
have the ability to give and receive pleasure;
can, and do, enjoy active sex lives; and
can become pregnant and have children.

Women who accept these facts as true may have questions about relationship issues. Simply put, women who put themselves in a position to meet new people have a greater opportunity to establish a relationship. Then, it does not matter whether a woman is asked on a date or asks someone on a date; the answer will be either “yes” or “no.”

Women who are in a relationship may wonder whether or not they can maintain the relationship. In reality, it is almost impossible to assure the success of any relationship. Lasting relationships depend on a number of factors such as personal likes and dislikes, common interests, communication, and long-term compatibility. Considering that about half of all marriages end in divorce, it is obvious that relationships are not easy whether a woman has SCI or not.

Anytime women with SCI are in a relationship, it is very important for them to remember that their partners also need to understand the facts about sexuality. When a partner understands the issues, sexual adjustment becomes easier for everyone. Plus, women and their partners can talk about issues and work together to solve problems, which is also a great way to build physical and emotional intimacy.

While women and their partners work together to solve problems, it is important to remember that sexual adjustment takes time. There may be many concerns about sexual activity along with unexpected problems or setbacks. The thing to remember is that couples can work together and solve problems if they focus on common interests.

SEXUAL FUNCTION
For women, normal sexual response brings about lubrication of the vagina, clitoral swelling, and an increase in heart rate, respiratory rate, and blood pressure¹. This response typically occurs as a mental (psychogenic) and/or physical (reflex) response to something sexually stimulating or arousing. A mental response occurs with sexually stimulating thoughts, and activities such as touching and kissing are physically stimulating.

Although women with SCI can engage in sexual activity, the impact of impairment on normal sexual response depends on the degree of injury and its location on the spinal cord². Most women with SCI will likely retain their physical response to sexual activity but not their mental response. However, it appears that women who have light touch and pinprick sensation from the waist (T-11) to the thigh (L-2) have a greater likelihood of sexual response to mental stimulation³.

The most significant impact of impairment on sexual response seems to be an inability of some women to produce vaginal lubrication. The purpose for this lubrication is to allow easier vaginal penetration, so a lack of lubrication can result in problems such as vaginal tearing or pain during intercourse. An artificial water-based lubricant can be used by women who can no longer naturally produce lubrication. Oil-based lubricants should never be used.

Most women with SCI will also experience some, or all, loss of vaginal sensation and muscle control. With a loss of sensation, the physical feelings associated with sexual activities are different from women without SCI. The loss of muscle control results in an inability to tighten vaginal muscles, which means there may be less friction during sexual intercourse. Women may try out different sexual positions to help improve vaginal friction. If a lack of friction continues to be a problem, women should talk to their doctor about treatment options.

SEXUAL AROUSAL
Sexual arousal is the process of stimulating excitement and readiness for sexual activity. Although there are individual preferences as to what is considered arousing, some women with SCI may find it difficult to identify physically stimulating areas. Plus, some women may require lengthier foreplay to stimulate physical arousal when compared to women without SCI.

Women with SCI can help identify areas of physical stimulation through sexual exploration with or without a partner. They can experiment with touch or use a vibrator to try to find stimulating areas. It may also help to know what other women find physically arousing. Table 1 ranks areas of physical arousal reported by women with spinal cord injury.

⁴Table 1 - Areas of Sexual Arousal

Mouth and lips
Neck and shoulder
Stomach
Clitoris
Thigh
Feet
Ears
Breast
Buttocks

ORGASM
An orgasm is the intense physical pleasure at the height of sexual arousal. Because orgasms generally vary in type and intensity among all women, it is difficult to determine whether or not a spinal cord injury actually impacts a woman’s ability to achieve orgasm. The evidence shows that about 54% of women with SCI engaging in sexual activity reported experiencing orgasm⁵. Moreover, the feelings associated with orgasm, which usually includes vaginal contractions followed by a feeling of relaxation, seem to be similar for women with and without SCI. Some women, including women with SCI, have reported having orgasms after breast and upper body stimulation⁶.

FERTILITY
Fertility is an issue for women with SCI who are of child-bearing age. It is normal for most women to experience a brief pause in their menstrual cycle after a traumatic injury. This pause may last for as much as 6 months before the menstrual cycle resumes. However, the ability of women to have children is not usually affected once their period resumes⁵. Women whose period does not resume should talk to a doctor about possible treatment options.

AREAS OF CONCERN
Women who are sexually active after injury generally report participating in similar activities such as they did before injury^4,7. However, 87% of women with spinal cord injury report participating in sexual activity before injury compared to 67% participating after injury⁵. Although the likelihood of participating in intercourse after injury increases with time after injury, many women with SCI are sexually inactive.

For women who are hesitant to engage in sexual activities, it is important to understand the source of hesitation. It is natural for women who are newly injured to take time to become more comfortable with their bodies, but women who have prolonged feelings of discomfort will need to identify problems and work to solve them.

Table 2 ranks the ten common areas of concern for women with spinal cord injury. No matter what the concern, women and their partners should learn about potential problems and prepare to manage issues. Once issues are managed, couples will probably become more at ease with sexual activities.

⁸Table 2 - Areas of Concern about Sexual Activity

1    Urinary Accidents
2    Bowel Accidents
3    Not satisfying a partner
4    Feeling sexually unattractive
5    Others viewing me as sexually unattractive
6    Not getting enough personal satisfaction
7    Preparation too much trouble
8    Hurting self
9    Loss of interest
10    Not liking methods for satisfaction

Bladder management is a concern for most women with SCI engaging in sexual activities. There are a number of ways to reduce the chance of urinary accidents. First, women might limit fluid intake if they are planning a sexual encounter. Drinking too much fluid increases urine output and causes the bladder to fill more quickly. Women who use intermittent catheterization for bladder management can empty their bladder before engaging in sexual activity. Women who use a Suprapubic or Foley catheter may have concerns about the tubing. The Foley can be left in during sexual intercourse because the urethra (urinary opening) is separate from the vagina. If the catheter tube is carefully taped to the thigh or abdomen so that it will not kink or pop out, it should not interfere with intercourse. Women also have the option of removing the Foley catheter before sexual activities, but the catheter needs to be properly reinserted following sexual activities.

Bowel management is another concern for women with SCI. The best way to avoid accidents is to establish a consistent bowel management program. Once a routine is establish, women are much less likely to have an accident. They might also reduce the chance for accidents by emptying the bowels and avoiding meals prior to engaging in sexual activity.

Sexual satisfaction may be an issue for some women who wonder whether or not they can be sexually satisfied or satisfy a partner. These concerns are usually the result of a lack of education on available methods for gaining satisfaction. Again, some women may find self-exploration helpful. This not only can help identify sensual areas of the body, but self-exploration can also help build confidence in a woman’s ability give and receive pleasure.

Sexual exploration can also help couples enhance their physical pleasure. The goal is to find sexual activity that is interesting, enjoyable and mutually pleasurable. As couples work together, it may help to try different methods to give and receive physical pleasure. Some couples may find that methods for gaining sexual satisfaction are the same as before injury. However, those “old” methods may not be satisfying. Then, it might be helpful to start sexual exploration with simple acts of hugging, kissing, and touching. As women and their partners express comfort with furthering exploration, they might progress to sexual stimulation, oral sex, vaginal and anal intercourse, or other means of physical intimacy.

It may also be necessary for some couples to explore a variety of sexual positions to find comfort during sexual intercourse. This exploration may be needed if spastic hypertonia (muscle spasms or contractures) or pain occurs during sexual activities. If spastic hypertonia or pain is a problem, it is recommended that you talk to a doctor for advice on treatment.

OTHER POTENTIAL PROBLEMS
Autonomic Dysreflexia (AD) is a life-threatening condition for women with level T-6 injury and above. Although sexual activity normally results in a rise in blood pressure, which is one sign of AD, women at risk and their partners should be watchful for other signs such as irregular heart beat, flushing in the face, headaches, nasal congestion, chills, fever, blurred vision, and/or sweating above the level of injury. Women who experience multiple signs of AD during sexual activity should stop immediately. If symptoms continue after stopping, it is crucial to contact a doctor immediately for advice on treatment.

Verbal and physical abuse is an unfortunate reality in some relationships. The chances of getting into an abusive relationship are greater for women who have low self-esteem. Women who are in an abusive relationship can talk to friends, family, doctors or clergy to find local agencies that help women escape abusive relationships.

Sexual Dysfunction in women is gaining interest in the medical community, and it can be a concern for women with SCI. Much of their difficulties are related to a lack of desire to participate in sexual activities9 or a failure to achieve satisfaction. There are treatment options available, so talk to your doctor if you think sexual dysfunction might be impacting the quality of your sex life.

Aging might impact sexuality in many ways. For example, many women have a decline in sexual interest. Some women have a decrease in vaginal lubrication after menopause. Although it is natural to experience some changes in sexuality over time, there is no reason why women cannot continue to enjoy an active sex life late into life.

CONCLUSION
Sexuality does not have to change after spinal cord injury. Woman with SCI can still express sexuality both physically and emotionally. However, it is important for women to learn about how impairment can impact their mind and body. When potential problems are prevented or managed, women can feel comfortable in exploring, expressing, and enjoying all aspects of sexuality no matter their level of impairment.

If needed, women with SCI should not hesitate to get professional advice if they experience problems related to sexuality. For example, a professional counselor can help resolve problems with self-adjustment and relationship issues. A physiatrist (doctor who specializes in rehabilitation medicine) can be a great educational resource for women and help them manage medical issues. Plus, a physiatrist can likely recommend an urologist and gynecologist knowledgeable on issues related to sexual and reproductive health for women with spinal cord injury.

REFERENCES
¹Masters WH, Johnson VE. Human Sexual Response. Boston, Mass: Little, Brown and Co Inc, 1966.
²Bors E, Comarr EE. Neurological disturbances of sexual function with special reference to 529 patients with spinal cord injury. Urol Surv. 1960;110:191-221.
³Sipski ML, Alexander CJ, Rosen RC. Sexual arousal and orgasm in women: effects of spinal cord injury. Ann Neurol. 2001;49:35-44.
⁴Sipski, ML, Alexander, CJ. Sexual activities, response and satisfaction in women pre- and post-spinal cord injury. Arch Phys Med Rehabil, 1993;74:1025-1029.
⁵Jackson AB, Wadley V. A multicenter study of women's self-reported reproductive health after spinal cord injury. Arch Phys Med & Rehab 1999;80(11):1420-8.
⁶McClure, S. Female sexuality and spinal cord injury. Arkansas Spinal Cord Injury Association Fact Sheet #8, 1992
⁷Charlifue SW, Gerhart KA, Menter RR, et al. Sexual issues of women with spinal cord injuries. Paraplegia. 1992;30:192-199
⁸White, MJ et al. Sexual activities, concerns and interests of women with spinal cord injury living in the community. Am J Phys Med Rehabil, 1993;72(6):372-8.
⁹Benevento BT, Sipski ML. Neurogenic bladder, neurogenic bowel, and sexual dysfunction in people with spinal cord injury. Physical Therapy, 2002;82(6):601-12. Review.

Published by: UAB Medical RRTC on Secondary Conditions of SCI
UAB Spain Rehabilitation Center
619 19th Street South - SRC 529, Birmingham, AL 35249-7330
(205) 934-3283 or (205) 934-4642 (TTD only)
Email: rtc@uab.edu

Update: April, 2004
Developed by: Phil Klebine, MA
Contributors: Linda Lindsey, MEd; Patricia Rivera, PhD
© 2002 Board of Trustees of the University of Alabama
The University of Alabama at Birmingham provides equal opportunity in education and employment.

This publication is supported by grant #H133N000016 from the National Institute of Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, U.S. Department of Education, Washington, DC. Opinions expressed in this document are not necessarily those of the granting agency.