SEXUALITY IN SPINAL CORD INJURY

The Spinal Cord Injured Male

• Erections
• Ejaculation, Orgasm, and Coitus
• Sexual Drive and Activity

The Spinal Cord Injured Female

• Orgasm
• Fertility, Childbirth, and Contraception
• Sexual Behavior and Activity

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ERECTIONS

Erections

     A male with SCI may, or may not, be able to achieve erection. The level, severity, time elapsed, and type of the injury may determine this.

• Level: Generally, a complete lower level injury precludes the ability to have erections. However, persons with an upper level injury usually can have erections. In general, the higher the injury, the more chance of achieving and maintaining a complete erection.
• Severity: If the injury is incomplete, there is a better chance for a complete erection.
• Time Elapsed Since Injury: Men who are unable to have an erection shortly after the injury may regain the capability during the first year.
• Type: Spastic paraplegics, for example, have a much greater chance of achieving an erection than individuals with flaccid paraplegia.

There are two types of erections:

• Psychogenic erections result when messages are passed down the spinal cord from the brain to the sacral area. Depending on the level and completeness of the injury to the spinal cord, men with SCI may or may not experience psychogenic erections.

       In men with lower level injuries, researchers report that up to 83% with incomplete lower level injuries had psychogenic erections and up to 26% of men with complete lesions have psychogenic erections.

       In men with incomplete upper level injuries, up to 25% can achieve psychogenic erections.

• Reflexogenic erections result from direct stimulation of the genital area. They are called reflexogenic because they are controlled by a reflex arc between the genital area and the cord.

  In men with upper level injuries, researchers report that up to 98% of men with incomplete upper level injuries have reflexogenic erections and up to 93% of men with complete upper level injuries have reflexogenic erections. 7% do not have erections.

Spontaneous erections may be experienced by spinal cord injured men.

EJACULATION, ORGASM, AND COITUS

     Ejaculation is a motor function which cannot take place if the particular nerves and parts of the spinal cord that control ejaculation are injured. The ability to ejaculate is controlled by nerves, which originate in the lowest part of the spinal cord; that is, segments T-12 to L-2, and sacral levels, 2, 3, and 4.

     Some spinal cord injured men can ejaculate. In men with lower level injuries, most researchers report that ejaculation occurs in up to 70% of men with incomplete lower injuries, and in up to 17% of men with complete lower level injuries. In men with upper level injuries, most researchers report that ejaculation occurs in up to 29% of men with incomplete upper level injuries, and rarely, if ever, in men with complete upper level injuries.

     SCI men who do ejaculate may experience retrograde ejaculation. Orgasm does not necessarily accompany ejaculation. Due to sensory loss, few spinal cord injured men are able to reach and experience pre-injury-type orgasm. Heightened spasticity has been experienced by some men at the point of ejaculation.

     Not all spinal cord injured men attempt coitus, for whatever reason. However, for those who do, many are successful.

     For men with lower level injuries, researchers report that 90% of the men with incomplete lower level injuries who attempted coitus were successful, and 65% of men with complete lower level injuries were successful.

     For men with upper level injuries, researchers report that 85% of men with incomplete upper level injuries who attempted coitus were successful, and 72% of men with complete upper level injuries were successful.

SEXUAL DRIVE AND ACTIVITY

     Although spinal cord injured men may lose the ability to maintain erection, ejaculate, or experience orgasm, their sex drive often remains strong.

     If you are a paraplegic male, with practice, you can learn to have intercourse in the "on-top" position using the "stuffing" technique. The man can assume the top position and, with his fingers, tuck his flaccid, soft penis into the vagina. By thrusting her hips and using the muscles of her vagina, his partner takes the soft penis into her vagina with a sort of pulling, sucking movement. While the flaccid penis gives a sensation of penetration that can be very satisfying in itself, the motion of the hips and the muscle action of the vagina often cause a reflex erection.

    A male with a high level injury may also use the "stuffing" technique. His able-bodied partner can kneel over him and use her fingers for tucking the penis into her vagina.

    A catheter may be worn during intercourse, but it should be taped in place and/or a condom should be worn to keep it in place. Sufficient lubrication will be needed under these conditions. Take care not to anchor the catheter down while the penis is still soft. It should be allowed to slide in the penis as the erection is taking place. If you plan to use no urinary application during sexual activity, it is wise empty the bladder before beginning. It is a good idea to keep a urinal receptacle near the bed.

     A commonly used means of sexual expression for the spinal cord injured male, is the use of the mouth to excite and give pleasure to his or her partner.

Assumptions to Sexuality

• Whatever seems satisfying and pleasurable to a couple is acceptable as long as they mutually agree.
• Is important for people to experiment and discover what is satisfying.
• It is important for couples to communicate to each other what they have found pleasing and satisfying

ORGASM

     A woman with SCI, like men with similar injuries, can achieve normal orgasm if there is some residual pelvic innervation, though orgasm is relatively rare. It is also reported that some SCI men and women are able to experience what has been referred to as "paraorgasm" or "phantom orgasm", through reassignment of sexual response to areas of the body which are unaffected by the injury. It has been described as "a highly pleasurable fantasized orgasm (which occurs by) mentally intensifying an existing sensation from some neurologically intact portion of their body and reassigning the sensation to their genitals."

FERTILITY, CHILDBIRTH, AND CONTRACEPTION

     Women with paraplegia or quadriplegia and of childbearing age usually regain menses; nearly 50% do not miss a single period following injury. Pregnancy is possible, and if pelvic measurements are adequate, most spinal cord injured women can have normal vaginal deliveries.

     A SCI woman may be subject to certain complications of pregnancy and should discuss these with her physician. Among potential complications are premature delivery in women in whom injury occurs during pregnancy and above the T-10 level and autonomic dysreflexia (high blood pressure, sweating, chills, and headache) during labor. The problem is also greater during pregnancy. Loss of sensation in the pelvic area can prevent the woman's knowledge that labor has begun. With a low level injury, the woman can assist in childbirth.

     Choice of a contraceptive method should be discussed with a woman's physician, since there are some special considerations related to the spinal cord injury. Oral contraceptives are linked to inflammation and clots in blood vessels and the risk of these is greater SCI. Intrauterine devices cannot be felt in the SCI woman, who has lost sensation in her pelvis, and may cause medical complications that would go undetected. Use of diaphragms and spermicides can be difficult for the woman with impaired hand dexterity. Tubal ligation can be considered for the woman who does not wish ever to become pregnant.

SEXUAL BEHAVIOR AND ACTIVITY

     Sexual expression in the SCI female is generally less affected in sexual function, than the male, because it is physically easier for the woman to adapt a passive sexual role. A low self-concept and poor body image may interfere with sexual behavior.

     In complete SCI, vaginal secretions are affected and some literature suggests vaginal lubricants be used. Breathing, pulse rate, and blood pressure increases in the SCI woman just as they do in the able-bodied woman. The clitoris and labia swell in women with SCI as well.

Some positions for intercourse are as follows:

• Female on back, male on top; pillows can be placed under woman's leg for support.
• Partners on their sides, facing each other
• Partners on their sides, male entering from rear
• Female on back, holding legs up and back, male on top
• Female on top, pulling with arms and hands around partners neck and shoulders
• Female on stomach, partner entering from rear
• Females on male's lap, using a rocking motion.

     It is ideal for partners to be free to use whatever activities, fantasies, artificial devices, and other sensual expressions that are acceptable and pleasurable to them. Mutual masturbation, hugging, oral stimulation of feeling areas, or any other form of pleasurable stipulations, may be included in the expression of sexuality.

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