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    Clinical perspective, Spinal Cord Injury

Reclaiming Sexuality After Spinal Cord Injury

Kenneth C. Parsons, MD Paradigm Medical Director

Nearly all aspects of life, including sexuality, are changed by a catastrophic injury. Spinal Cord Injury, in particular, can profoundly alter self-image and sense of worth.
A case manager prepared with knowledge to guide the conversation can encourage any concerns to be spoken and addressed, even in the acute care setting and during the rehabilitation inpatient stay.

Let’s look at this topic in three parts:

  • Psychosocial challenges, which are the most common area of sexual dysfunction for all people with catastrophic injuries,
  • Physiological effects of SCI, and
  • A model for permission giving using PLISSIT and EX-PLISSIT.

Psychosocial challenges

Both genders experience significant psychosocial stress after any catastrophic injury. First, there is the emotional impact of the trauma and a near-death experience. Then, physical impairments change the person’s perception of his or her body image. Many questions arise that are so personal they are often not voiced. “Am I still attractive?” “Will my marriage survive?” Or “Will I be able to meet someone who will love me?” The result is often a loss of a sense of control over one’s life.

Certainly, the loss of privacy during an inpatient stay can contribute alterations of self-esteem. Later on, if the results of the catastrophic injury include wheelchair use, the person in the chair finds that he or she is surrounded by a world of standing people. All these psychosocial issues deserve attention.

Physiological effects of SCI

General effects of neurological disability on sexuality include alterations in bowel and bladder continence, decreased mobility, pain, fatigue, altered sensation, spasticity, and medication side effects. In addition, brain injury and SCI both impact the production of hormones that influence sexual desire and physical functions.

With some awareness of how SCI affects self-image and sense of worth in very powerful ways, let’s look at its physiological impacts. Sexual neurophysiology after SCI involves four aspects of neuro anatomy:

  • loss of sensation in erogenous zones,
  • loss of mobility,
  • impairment of the sympathetic nervous system, and
  • impairment of the parasympathetic nervous system.

The degree of impairment varies by the level and completeness of the injury. Fertility is often severely impaired in men with SCI. After an initial interval of interruption of menstrual cycles, fertility in women is usually unimpaired. So contraception and pregnancy management must be considered.

Bladder or bowel incontinence may cause embarrassment and hygiene issues. Many people with SCI depend on bladder or bowel management. If the injured person must rely on his or her partner for intimate hygiene care, this role change may amplify the upheaval in their sexual lives.

A model for permission-giving

Case managers must be well aware of these psychosocial and neuro physiological effects of SCI for both male and female injured workers. A caring approach to each person encourages those who are reticent to raise the questions mentioned above and many others.

A case manager who is comfortable with the PLISSIT model is prepared to initiate such a conversation. The four progressive degrees of intervention, as described by Jack Annon in 1976, are:

  • Permission: Can you give your client and his or her partner permission to ask questions and make observations about the changes they have noticed?
  • Limited Information: Sometimes your clients just want assurances that they will regain the sense of being a sexual person, or perhaps just some basic information about fertility.
  • Specific Suggestions: Some clients want to know how to correct erectile dysfunction, etc.
  • Intensive Therapy: With the client’s concurrence, make an appropriate referral to a sexual counselor, Ob-Gyn, or urologist.

In 2006, the PLISSIT model was extended by Taylor and Davis to give increased emphasis to the permission-giving step. Their name for their extended model is the EX-PLISSIT model.

  • By giving people explicit permission to discuss any concerns they have about their sexuality, the healthcare professional affirms the individual as a sexual being.
  • Any information or suggestions that follow, are then specific to the needs of that person.
  • The EX-PLISSIT model also requires further permission-giving in the form of “review,” whereby the healthcare professional asks the patient to review the interaction and gives the patient the opportunity to express any further worries or concerns.
  • In addition, this model requires the professional to reflect on their interactions, challenge their assumptions and extend their knowledge.

Discussing the important and intimate topic of sexuality after a catastrophic injury is central to restoring an injured worker’s quality of life. A wise and compassionate case manager can provide safe parameters for the ongoing conversation, as well as the tools and resources to address the needs of the injured worker and his or her spouse or partner.

For more detailed information about the psychosocial and physiological implications of SCI, here are some valuable resources:

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Dr. Kenneth Parsons is a Paradigm Medical Director specializing in spinal cord injury. He is board certified in physical medicine and rehabilitation, has more than 30 years’ experience in caring for patients with spinal cord injuries, and was among the inaugural group of Fellows of the American Spinal Injury Association.