Sexual abilities
following physical
disability
By Raul G. Rosales, OTR
Objectives:
 Overview of spinal cord injury (SCI) and sexual health
 Anatomy
 Interventions
 Information on CVA, Cardiac, Orthopedic sexual health
Spinal Cord Injury
 Sexuality is an important aspect of human nature
 According to OT practice framework, sexual
satisfaction is an ADL, and therefore a responsibility of
ours to address it if need be.
 Sexuality relates to everyone’s quality of life.
 It affects self esteem and self concept.
 Its an intrigal part of of human experience.
Sexuality and Sensuality
 Sexual expression is not only the act of intercourse
itself, but may include: talking, touching, hugging,
kissing, fantasizing.
 After a physical disability or when there are physical
limitations, engagement in any type of sexual act
decreases.
 Some individuals may feel like their objects of pitty,
unattractive, asexual, self perception or worth.
 Males may feel loss of masculinity and possibly
threatened in the male role.
 Females may feel loss of parenting abilities, or may
have difficulty with how she perceives herself
attractively.
 As Occupational Therapists, we can assist with
eliminating unnecessary obstacles, overcome
anxieties, and appreciate personal uniqueness.
OT
 OT goals should include:
 Facilitation of self esteem
 Enable client to feel lovable
 Education provided to family members, as many times its
difficult to transition to/from role of caregiver and lover.
 History information should be to learn how a person
thinks and feels about sex and their body
SCI
 Maintaining a healthy sex life after a spinal cord injury
is important to many.
 The effects studied relate to complete spinal cord
injuries, and incomplete spinal cord injuries.
 And if upper motor neurons or lower motor neurons are
affected.
 Simple test to determine if a SCI is complete or
incomplete is whether a person has voluntary rectal
contraction and whether they have the aibility to perceive
sensation around their rectum.
Motor Neurons
 Upper motor neuron: neurons that originate in the
motor region of the cerebral cortex or brain stem and
carry motor information down to the lower motor
neurons.
 Lower motor neuron: motor neurons that innervate
skeletal muscle fibers and act as a link between upper
motor neurons and muscles.
Sexual Arousal
 Sexual arousal leads to increased:




breathing rate
increased heart rate
increase blood pressure
increased blood flow to genitals- in men, this leads to
erections and women lead to lubrication
SCI doesn’t affect what happens in the brain, but it does
affect how one is aroused and that happens in the spinal
cord.
arousal
 There are two types of arousal: psychogenic and reflex
arousal.
 Psychogenic arousal happens in the brain and travels
down to the levels of T11-L2 of SC. This occurs with:
visual stim., smells, thoughts etc.
 Reflex arousal happens in the lower levers of T11-L2
and are a impulses that are received from stimulation
and cause a motor response and synapse in the spinal
cord. This may be from someone brushing your leg, or
stim. to genitals, or placing a hand on your knee.
 After an SCI, most people will retain reflex arousal, but
loose psychogenic.
 There is evidence to support that women who have
light touch and pinprick sensation from waist to thigh
(T11-L2) will maintain psychogenic response to
stimulation.
 If an injury is high up, but a complete lesion, can not
get aroused psychogenic
 If an injury is low or at cauda equina, that might get rid
of reflex, but still get psychogenic.
 Female orgasms and male ejaculations are usually
decreased after SCI though not impossible. This is most
likely due to the fact that coordinated nuro impulses from the
sympathetic, parasympathetic, and somatic nervous
systems are necessary for this to occur.
 Sympathetic nervous system: primary role is to stimulate
body’s fight or flight response and maintain homeostasis.
 Parasympathetic nervous system: primary role is “rest and
digest” and “feed and breed”. Items that occur while body is
at rest especially after eating, sexual arousal, salivation,
lacrimation, urination, digestion, defication.
exploration
 After SCI, its important to explore your body. Do so
before you involve your partner.
 There are a lot of changes after SCI. Some are body
image, bladder and bowel dysfunction, medications,
emotional (depression).
 Always know that arousal and sexual abilities including
pregnancy is possible after SCI.
 Its important to know your body! Though it may not be
exactly the same as before, sexual intimacy and
arousal are still possible.
Treatment
 Most research has concentrated on male erections.
 Women’s difficulties may stay emotional and
psychological. For activity, water based lubricants are
used to avoid tearing or cause pain.
 Men’s difficulties are with erection. They might be able
to get one but not maintain.
 Oral medication: Viaga, Cialis, Levitra.
 These should not be used with nitrates eq: imdur.
 Nitrates are vaso dilators and combination of the two will
cause severe hypotension.
 Oral medications may cause: headache, fllushing,
stuffy or runny nose, indigestion, upset stomach,
dizziness.
 Some people may take nitrates for heart problems or
dysreflexia.
 Autonomic dysreflexia is a severe condition that
requires immediate medical emergency attention.
 Occurs most often in individuals with lesions above T6
and as low as T10. It’s a response that is triggered by
overstimulation.
 Its characterized by paroxysmal hypertension (severe
onset of high blood pressure), throbbing head aches,
profuse sweating, nasal stuffiness, flushing of the skin,
slow heart rate, anxiety, and sometimes cognitive
impairments.
 Autonomic Dysreflexia occurs when something is
wrong. For example kinked catheter, constipation with
impaction.
tx. cont.
 Other treatment may include:
 Injections: though overuse may cause scar tissue and
cause penile deformities including priapism
 Medicated urethral system rerections (muse): medicated
pellets placed into urethra where its absorbed
 Electrical stimulation
 Vacume pumps and rings: most commonly used form of
treatment for erections.
 For those that can attain reflex arch erections but have
difficulty maintaining, a silicone rubber ring is used. Should
not be used for over 30 min. as insufficient blood flow to
penis can cause ischemia.
 If a male can not effectively produce and erection, then
vacume pumps are used to produce the erection and a ring
is used to maintain.
 Last resort are penile prosthesis.
 If after prosthesis are used, and complications arise like
loss of feeling or UTI’s, the prosthesis will need to be
removed.
 http://youtu.be/ZIQtKtsjDQY
Sex activity
 Re-establish routines
 Talk to partner
 Allow time for bowel and bladder programs
 Explore Explore Explore!
 Positions for activity.
 Sitting up: http://youtu.be/HatRXFL1TxQ
 Women: http://youtu.be/fUd8aUb20W0
 Can a person with SCI have an orgasm? Regardless
of the injury, you should be able to have one. It’s a
reflex. Reflex happens around T12-S1.
 Ejaculation is not an orgasm. Orgasm is a feeling, witch
depending on the level and severity of injury, may
lessen the intensity. S
 Women with complete S2-S5 injury are less likely to
achieve orgasm
 http://youtu.be/vOFJXgNCBr8
How to address Sexuality
 P-LI_SS_IT
 This is a basic framework developed by Annon (1976) to
assist OT practitioners and other health care
professionals in developing the interpersonal skills
needed to approach and address such a sensitive matter.
 Permission- you are giving the permission to be sexual
beings. This may include reassuring that their not the
only ones. This area may also give patients the right not
to engage in sex or conversations.
 Limited information- allows the therapist to address
sexual concerns with factual information. Present
information like: fertility, contraception, community
resources, ED, AD, body image, etc. And do only to their
needs.
 Specific Suggestions- requires that the therapist obtain a
sexual health history to gain specific information. This
may include current problems and goals. Examples:
positioning techniques, bowel and bladder mgt., adaptive
equipment, alternate methods of pleasure, pressure relief.
 Intensive therapy- If suggestions given by therapist are
not helpful, IT should be considered. At this point a
patient is referred to a specialist.
Stroke after a CVA
 Just as with SCI, sex is not a performance. You don’t
have to fail or succeed. It doesn’t have to be perfect
every time. Explore!
 Talk and communicate with your partner.
 Talk about feelings after stroke, especially body
changes, spasticity, sensation, or any other difficulties.
cva
 Practical problems can be overcome.
 Lie on your affected side so that your dominant side will
be free and active.
 Talk to your doctor about difficulties with emotions or
depression. As well as erection or lubrication difficulties.
 Bowel and bladder programs will assist with ensuring no
accidents will occur during activity.
 If your constantly fatigued, activity in the morning will
assure you are rested.
Sex after hip replacement
 Always speak to your surgeon regarding precautions.
 Precautions may include avoid bending hip past 90
degrees, avoid moving operated leg across midline, avoid
rotating the toes of operated leg inward.
 Precautions should be maintained 4-6 weeks after
surgery.
 http://www.recoversex.com/hip-replacement/sexualpositioning-following-total-hip-replacement - prettyPhoto
 Missionary Position – This is generally a comfortable
position for either a male or female with a new hip. The
female assumes the bottom position. If she has a new hip,
she can bend her knees slightly with her feet on the
bed. Pillows can be used to support the legs on the
outside. If the male has a new hip, he can stretch his legs
out behind him. He can place a pillow between his knees to
keep his operative leg from crossing the midline of the
body. He supports his weight with his arms.
 Face-To-Face Position – This position can be used for
either a male or female. The person with the new joint
is on the bottom and can recline on pillows propped
behind the back. A female can bend her knees slightly
with her feet on the bed. A male can put a pillow
between his knees to keep the operative leg from
crossing the midline of the body.
 Sitting Position – This position can be used for either
a male or female. In all cases, the male sits on the
chair with his knees pointing away from the midline of
his body and his feet on the floor. The female sits on
his lap. She must be able to have her feet planted on
the floor, particularly if she has a new joint. She must
avoid leaning too far forward to prevent the hip from
bending more than 90 degrees.
 Kneeling Position – This position can be used for either a
male or female. The female with a new hip lies on her back
with her buttocks near the edge of the bed. Feet must be
firmly planted on the floor with knees pointing away from the
midline of the body. If the male has a new hip, he can
assume the position of kneeling in front of his partner. For
comfort, he can use pillows under his knees. He must keep
his back straight and avoid leaning over his partner to
prevent the hip from bending more than 90 degrees.
 Side Lying Positions – This position can be used for
either a male or female. In the spoon position, the
person with a new hip can lie on either side. For a
female with a new hip, pillows can be used to support
the upper leg. A male with a new hip can drape his
upper leg over his partner.
 Other Side Lying Positions – This position can be
used for a female with a new hip. With her partner on
his side, she can lie on her back and drape both legs
over his body, with legs apart to keep the operative leg
from crossing the midline of the body. The female can
also lie on her back and drape her non-operative upper
leg over her partner’s body
 Other Side Lying Positions – The partners can also
face each other. The person with a new hip can lie on
either side. The upper leg can be draped over the
partner’s legs.
 Standing Position – This position works for either a
male or female. If the female has the new joint, she
should lean on something firm and stay fairly upright to
avoid bending the hip more than 90 degrees. If the
male has the new joint, he should also avoid bending
the hip more than 90 degrees.
Cardiac conditions
 Remember that sex is a workout
 If you are healthy enough to walk up two flights of stairs
without difficulty, you are healthy enough for sex.
 After a heart attack—Patients should avoid sexual activity
for 1-4 weeks after a heart attack, depending on their heart
health and symptoms with exertion.
 After a stent implant—Patients should avoid sexual activity
for 1-2 weeks after the implant—to make sure the stitches in
the groin area have healed enough. During these implants,
a catheter is inserted through a small incision in the upper
thigh or groin.
 After a cardiac device implant—most patients decide
to avoid sexual activity for about 1 week. While their
incision is healing, patients should avoid supporting
their weight with their arms during sexual activity.
 After bypass or heart valve surgery——Patients are
limited by the fact that it takes 6-8 weeks for the chest
incision to heal. Keep in mind that pushing or pulling
motions with the upper body should be avoided until
the chest has healed. That includes supporting their
weight with their arms during sexual activity.
 After heart failure diagnosis—usually there are no
limitations on sexual activity except in advanced cases.
If symptoms are a problem, do not to support their
weight with their arms, since that makes the heart work
harder.
 http://www.allinahealth.org/ac/METchart.pdf
work cited page
 Internet resources:
 Allina Health System Press, Helping Your Heart, cvs-ahc-90648 (5/05), third
edition, ISBN 1-931876-11-8
 Recover sex-pleasure http://www.recoversex.com/hip-replacement/sexualrelations-after-total-hip-replacement
 Sex after stroke
http://www.stroke.org.uk/sites/default/files/F31_Sex%20after%20stroke.pdf
 Annon, J. (1976) The PLISSIT model; a proposed conceptual scheme for the
behavioral treatment of sexual problems. Journal of sex education and
therapy, 1-15.
 Sexuality and spinal cord injury. www.spinal-injury.net/sexuality-spinal-cordinjury.html
overview
 Sexuality doesn’t have to change
 Take time for you and your partner
 Don’t be afraid to explore and express
 Learn how the injury affects your mind and body
 Work to prevent and solve problems