CODI: Cornucopia of Disability Information

Sexuality in Males with Spinal Cord Injury

		      Spinal Cord Injury - InfoSheet #3
     "Sexuality in Males with Spinal Cord Injury"   Level - Professional

The following is an Information Sheet developed by the Training Office of The
RRTC in Secondary Complications in Spinal Cord Injury at UAB Spain
Rehabilitation Center.  It contains information and resources on issues and
concerns dealing with sexuality in males with a spinal cord injury.  For
permission to reprint for further distribution, contact Linda Lindsey: via
Internet -
	Lindsey@Sun.rehabm.uab.edu
or write to RRTC Training Office, address and phone listed below.


Published by:
Medical RRTC in Secondary Complications in SCI
Training Office, Room 506, UAB-Spain Rehabilitation Center,
1717 6th Ave. S, Birmingham, AL 35233-7330 
(205) 934-3283 or (205) 934-4642 (TTD only)

Date:  December, 1993

INTRODUCTION

     A spinal cord injury affects a male's sexuality both psychologically and
physiologically.  The type and level of the spinal cord injury determine the
extent that the spinal cord injury affects his sexual functioning.  He may
face changes in his relationships, his sexual performance, and his ability to
biologically father children.  He also can expect changes in his feelings and
concerns about his own sexuality.
     It is important to remember that sexuality includes both emotional and
physical aspects, and may or may not involve a partner.  The physical aspects
of a relationship can involve touching, kissing, or sexual intercourse.  All
aspects of the male's sexuality need to be addressed and understood.
     This information sheet cannot address in detail all the issues related to
male sexuality after SCI.  For additional information, see the resources
listed at the end of this paper.

PHYSIOLOGICAL CHANGES
     The level of spinal cord injury affects a male's ability to have an
erection.  There are two types of erections that a male can have, psychogenic
and reflex.  A psychogenic erection takes place when a message is sent from
the brain, such as, having sexual thoughts or seeing or hearing something
stimulating or arousing.  A reflex erection occurs when there is 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 an erection are located in the sacral segments
(S/2-S/4) of the spine.  Spinal cord injuries that occur above these segments
result in a loss of the ability to have psychogenic erections.  The male with
spinal cord injury 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.
     It is possible for males with SCI to experience orgasm, especially when
concentrating on their partners arousal.
     The ability to ejaculate decreases dramatically after a spinal cord
injury.  The ejaculatory process involves nerves from a number of different
levels of the spinal cord; therefore, it is likely to be affected by most
spinal cord injuries.  Ejaculatory rates vary greatly and are dependent on
several factors.
     The most important factor affecting the ability to father children is the
motility of the sperm.  The average motility rates among males with SCI are
considerably lower than for the average male without SCI.  Because the ability
to father children is often a main concern of males with SCI, other options,
such as artificial insemination with donor sperm, should be discussed. Medical
advice and options for males with SCI, who are interested in fathering
children, should be provided by a fertility specialist experienced in spinal
cord injury.
     
SEXUAL AIDS AND OPTIONS FOR THE MALE FOLLOWING SCI
     Many males have erections; however, these erections may not be hard
enough or last long enough for sexual activity.  There are several options
available for males to use for achieving erections, including penile
injections, surgical implants, and the vacuum pump.
     Penile injection therapy involves injecting a single drug or a
combination of drugs into the side of the penis.  This produces a hard
erection that can last for one to two hours. These drugs must be used exactly
as prescribed by the physician.  If not used correctly, the result could be a
prolonged erection, called priapism.  When priapism occurs, the blood fails to
drain from the penis.  This can damage the penile tissue and be extremely
painful.  A person who has a history of substance abuse, therefore, would be a
risky candidate for this therapy since its success requires the exact use of
the prescribed drug.
     Penile injections would be a difficult option for an individual with SCI
with limited hand function to use on his own.  He must have a partner who is
willing to learn to give the injections.
     Surgical implantation of a penile prosthesis was the more popular option
for individuals with SCI before the discovery of penile injections.  The
surgical procedure involves inserting an implant directly into the erectile
tissues.  The three types of implants available are semi-rigid or malleable
rods, fully inflatable devices, and self-contained unit implants.
     With implants, there is a risk of mechanical breakdown as well as a
danger that the implant could push out through the skin.  Individuals with SCI
usually do not have good sensation in the genital area.  They would not
experience pain to indicate that the implant has broken through the skin.  All
surgical implants carry a high risk of infection.  If an infection develops,
the prosthesis may need to be removed.  Penile implants are the most expensive
option and some health insurance plans do not cover the costs.
     The vacuum pump is the least invasive aid. It is the recommended
alternative when penile injection therapy is not an option.  It is a
mechanical, non-surgical method of producing penile engorgement and rigidity
sufficient for intercourse in most individuals.
     The penis is placed in a vacuum cylinder.  The 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 any 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.
     There are several models of vacuum pumps from which to choose.  A battery
operated model is available for use by those with limited hand function.
Other models require good hand function to press the pump against the skin,
creating the necessary vacuum.  A prescription is required to purchase the
medical versions of these devices.
     The use of some of the erectile aids may require assistance from one's
partner. The male may find it difficult to admit to his partner that he has
difficulty having an erection and needs assistance.  Sexual counseling can
help the individual learn to communicate his needs and feelings concerning
sexual issues.
     Before using any of the erectile aids discussed above, a thorough
physical exam is neededby a urologist familiar with the benefits and side
effects of each option as related to SCI.  Thetreatment options available for
erectile dysfunction mentioned above WILL NOT affect sexual desire,
ejaculation, orgasm or sensation.  They WILL NOT solve unrelated marital
difficulties.
     
EMOTIONAL/PSYCHOLOGICAL EFFECTS
     Various emotional and psychological issues about one's sexuality need to
be examined and understood after a spinal cord injury.  Following a spinal
cord injury, people are often sensitive about the physical changes which have
occurred in their body.  This may result in a loss of self-esteem, especially
in those who have to depend on others for help.  Throughout history, men have
equated masculinity with sexual functioning.  After a spinalcord injury, it is
common for males to have thoughts like, "I can't be a man if I can't have sex
with a partner in the same way that I did before my injury."  A male's
self-esteem may suffer when this realization occurs.
     An individual who has a partner at the time of injury may believe the
partner is staying in the relationship out of pity.  He believes that his
partner will eventually leave him for someone who is "normal."  Sometimes a
male will actually "run off" his partner with the idea that this way he will
dissolve the relationship before his partner leaves him.  It is a mistake for
the male with SCI to assume that his partner will leave.  Time and trust are
means of testing the permanence of any relationship.
     Males who do not have a partner at the time of injury are concerned with
how to attract and meet a partner.  At first it may be more difficult to get
out and go places where he can meet potential partners.  He needs to be
encouraged to make the effort to continue making social and business contacts,
to meet new people, and develop new relationships.
     Often the male has thoughts, such as, "I will never find someone to
marry."  Most males are surprised to find out that this is not a problem.
Some males who have a spinal cord injury even report having an easier time
meeting females now that they use a wheelchair.  When a male is attracted to a
female who is not interested in him, he naturally assumes it is because of his
spinal cord injury.  This is a mistake.  During his lifetime, a man may be
attracted to a woman who is not attracted to him.  Do not assume that lack of
attraction has to do with the spinal cord injury.  Consider all personal
traits when examining one's relationship, such as, grooming, dress, manner of
speech, and personal interests.

     
RELATIONSHIP ISSUES
Partner Perspective
     The difference between how the female views sex and how the male views
sex plays an important role in any relationship.  A female typically places as
much, or more, interest in the emotional and romantic aspects of a
relationship as she does the physical relationship.  After a spinal cord
injury, the male needs to consider this in his relationship with his partner.
She may not be as concerned as he is about the physical changes resulting from
the spinal cord injury and how these changes will affect their sexual
relationship.  Some women even report relief that sexual intercourse will no
longer be the most important part of the relationship.
     The male can learn ways to be romantic and intimate with his partner. If
the sexual relationship was mutually satisfying before the injury, the
readjustment often does not present a problem.  A female may first blame
herself for not being able to "turn on" or arouse her partner, even though she
was told the spinal cord injury was the cause of her partner's lack of
erections.  The male may need to reassure his partner that the physical
aspects of their relationship are satisfying to him.
     Both partners need to understand there will be changes in their sexual
relationship and there are many considerations to building a strong
relationship.  The couple can explore and experiment with different ways to be
romantic and intimate that are sexually stimulating and fulfilling for both
partners.

Jealousy
     In any relationship, jealousy can lead to anger and resentment between
the partners.  Insecurity following a spinal cord injury often leads to the
male falsely accusing his partner.  An example would be that whenever the
partner is away longer than expected, he becomes jealous, assuming infidelity.

Depression
     Going home from the rehabilitation center after an SCI often results in a
temporary state of depression for both the male and his partner.  Withdrawal,
crying, anger, and a lack of interest in sex may be signs of depression.  The
partner may misinterpret these signs.  Usually the anger is directed at the
partner, creating additional problems in the relationship.  The partner may
try to ignore these displays of anger because of pity for the male with the
spinal cord injury.  If the signs of depression continue in either partner,
professional counseling should be sought.

Arguments
     Money is a primary cause of arguing in most relationships; this may be
magnified after an SCI.  Hospital bills and the permanent or temporary loss of
an income creates financial insecurity.  Sometimes there are also role changes
in the family.  The partner may now have to work to support the family.  he
male with an SCI may have to take over the parenting and housekeeping roles.
If each family member has a rigid view about his or her role, this may become
the source of many arguments.

Verbal or physical abuse
     Verbal or physical abuse should not be excused.  Having an SCI does not
give the male permission to be physically or verbally abusive to his partner.
If either partner in the relationship feels this is happening, they should be
encouraged to contact a professional in the community for help.  The
psychologist, counselor, or social worker at the rehabilitation center are
examples of professionals who could work with the couple on these behaviors.
Local community mental health centers and private licensed counselors are also
available in most communities.

Bowel/Bladder Accidents
     Another physical concern is having a bowel or bladder accident.  The fear
of an accident may be enough to keep the male from pursuing a physical
relationship.  He should alert his partnerto the possibility of a bowel or
bladder accident.  Maintaining a regular bowel and bladder program is an
important factor that can help prevent accidents.  This can eliminate the fear
of accidents and relieve anxiety.

PROFESSIONAL COUNSELING
     Establishing a healthy sexual relationship may require professional help.
Couples or individuals who get sexual counseling can learn effective ways to
communicate feelings.  Studies show that males with SCI want information about
sexual issues.  Those who receive the proper information have more positive
sexual relationships.
     It may be difficult to locate a professional trained in sexual counseling
who is also knowledgeable about the changes in sexual functioning after SCI.
The American Association of Sex Educators, Counselors and Therapists (AASECT)
has set standards for certification of professionals working in the field of
human sexuality.  AASECT can provide a list of qualified professionals in your
area.  [See: Resources]

SAFE SEX
     Today, everyone needs to take precautions to protect himself and his
partner from any sexually transmitted diseases (STDs) .  STDs include diseases
such as gonorrhea, syphilis, herpes, and the HIV virus.  These STDs can cause
other medical problems, such as, infertility, urinary tract infections, pelvic
inflammatory disease (PID), vaginal discharge, genital warts, and AIDS.
     If individuals are not sure that either partner is disease free, each
should be tested by a health care professional.  The safest, most effective
routine to follow to prevent sexually transmitted diseases is to use a condom
with a spermicidal gel that contains the ingredient Nonoxynol-9.  The condom
must be used correctly every time partners have sex.  The condom is often used
as a method for birth control.  Even if the female partner is using another
form of birth control, a condom still needs to be used to protect against
STDs.
     STDs can be the cause of many problems if not properly treated.  Some
STDs can be treated with antibiotics.  Others, such as AIDS, have no current
cure. The best means to prevent infection is to first be tested.  If either
party has doubts about being disease free or having any STD, they should use
protection in their sexual relationship.
  
RESOURCES

Books:
Becker, Elle Friedman. (1991).  Love, Where to Find It, How to Keep It.  
Bloomington, IL: Accent Press.

Cole, Sandra S. (1993). Reproductive Issue for Persons with Physical 
Disabilities.  Baltimore: Brooks Publishing Company.

Cole, T., Chilgre, R., and Mooney, T.  (1975).  Sexual Options for Paraplegics
and Quadriplegics.  Boston: Little and Brown.

Cornelius, D.  (1982).  Who Cares: A Handbook on Sex Education and Counseling
Services for Disabled People.  Baltimore: University Park Press.

Ferguson, Gregory M. (1974).  Sexual Adjustment: A Guide for the Spinal Cord
Injured.  Accent on Living, Inc.

Hammond, M.D., Margaret, C., et al. (Eds.) (1989).  Yes, You Can!  Chapter
14-Sexuality.  Washington, DC: Paralyzed Veterans of America.

Kroll, L. and Klein, E. (1992).  Enabling Romance: A guide to love, sex and
relationships for disabled people (and the people who care about them).  New
York: Crown.

Maddox, Sam.  (1993).  Spinal Network (2nd ed.) .  Boulder, CO: Spinal
Network, pp.323-347.

Neistadt, M.E. and Freda, M.  (1987).  Choices: A Guide to Sex Counseling with
Physically Disabled Adults.  Malabar, FL: Robert E.  Krieger.

Rabin, Barry J. (1980). The Sensuous Wheeler.  Long Beach, CA.

Sipski, Marca, MD and Glick, Tonnie, (Eds.) (1992) Spinal Cord Injury Manual.
Chapter 8-Sex after Spinal Cord Injury.  Northern New Jersey Spinal Cord
Injury System, Kessler Institute for Rehabilitation.

Sandowski, Carol L. (1989).  Sexual Concerns When Illness or Disability
Strikes. Springfield, IL: Thomas.

VIDEOS

Evaluation and Management of Sexual Dysfunction in Spinal Cord Injured Males.
(1988).  Presented by Dr. L. Keith Lloyd, MD and J.  Scott Richards, PhD.
Birmingham, AL: UAB-Spain Rehabilitation Center.

Sexuality Reborn.  (1993).  Produced by Dr. Craig Alexander and Dr.  Marca
Sipski. West Orange, NJ: Kessler Institute for Rehabilitation.

Male Reproductive Function after Spinal Cord Injury: An Overview of Progress
in the Field.  Fact Sheet No. 10.  (1988).  National Spinal Cord Injury
Association.

Sexuality after Spinal Cord Injury. Fact Sheet No. 3.  (1987).  National
Spinal Cord Injury Association.

Male Spinal Cord Injury and Fertility.  (1992). Shirley McCluer, MD.  Arkansas
Spinal Cord Commission.

Vibrator Technique for Ejaculation. (1992).  Shirley McCluer, MD.  Arkansas
Spinal Cord Commission.

ASECT 

The American Association of Sex Educators, Counselors and Therapists.  
435  N. Michigan Avenue, Suite 1717 
Chicago,  IL  60611
(312)644-0828

SIECUS
The Sex Information and Education Council of the U.S.
130 W. 42nd St, Suite 2500,
New York, New York  10036
Information Service available Noon til 5pm (EST)
Mon-Fri.   (212)819-9770 

Developed by:
Jane Brown, MA, LPC, AASECT
Linda Lindsey, MEd, Media Specialist
c   1993  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 in part by a grant (#H133B80012) from the
National Institute on Disability and Rehabilitation Research, Dept of
Education, Washington, D.C. 20202.  Opinions expressed in this document are
not necessarily those of the granting agency.