Sexuality - The Female SCI

Overview of Sexuality

Sexuality is an important part of the personality of every human being. It is a basic need and aspect of being human. It can’t be separated from other aspects of life—including the physical, psychological, social, emotional, cultural and ethical dimensions of sex and gender.

Our sexuality is defined by sexual thoughts, desires and longings, erotic fantasies, turn-ons and experiences. It is the force that empowers us to express and display strong, emotional feelings for another person and is a natural stimulus for the procreation of our species.

A spinal cord injury (SCI) is a life-changing event that can greatly affect how we function and looks at sexuality and intimacy.

Areas of sexual health affected by spinal cord injury
The following aspects of a person’s sexual health are affected by SCI. This presentation explores each of these areas on its own, but it is important to recognize that all aspects of a person’s sexual health are connected.

1. Sexual functioning

The level of injury and whether it is complete or incomplete determines the extent to which a person’s sexual functioning is affected.

• Generally, the more incomplete the injury, the less change there is in function.
• For women, the changes are in sensation (or feeling) and the ability to lubricate (get wet)

Orgasm
A woman with SCI, like men with similar injuries, can achieve normal orgasm if there is some residual pelvic innervation (nerve stimulation), though orgasm is relatively rare.

• Reports show that some women with SCI (and men) are able to experience what has been called “paraorgasm” or “phantom orgasm,” through reassignment of sexual response to areas of the body which are unaffected by the injury. This is commonly known as the “E-zone.”

• After SCI, a woman needs to find new areas of arousal on her body. This can be done alone or with a partner.

• There is more than physical response to orgasm—a person’s mind plays a role in getting excited and stimulated. “Paraorgasm” or “phantom orgasm” is a highly pleasurable fantasized orgasm. It occurs by mentally intensifying an existing sensation from a neurologically intact portion of the body and reassigning the sensation to the genitals.

• After SCI, orgasm is often described as a “psychological response” or a “mind thing” that is just as enjoyable and sometimes even better than before.

Vaginal lubrication
With complete SCI, vaginal secretions are affected.

• If lubrication (getting wet) is a problem, vaginal lubricants can be used. For example, KY jelly is a water-soluble, non-lanolin, over-the-counter product.

• Avoid Vaseline or petroleum products.

• Thinking about being aroused helps to promote lubrication.

2. Motor and sensory influences

Motor/Mobility
Sexual positions will be affected by changes to functional abilities – such as the ability to transfer or turn yourself or your partner – as well as balance and spasms.

• Spasms can sometimes help with positioning or stimulation. It is best to try different positions until you find one that is comfortable and works best for you and your partner.

• If spasms make it difficult to have sex, take prescribed medications an hour before.

• Stretching before you are with your partner might help to decrease spasms.

Weakness can cause problems with maintaining sexual positioning. Certain positions allow more energy for sex with less energy on weight support for women with spinal cord injury. Easier sexual positions include the following:

[illustrations required]

Sensory
Sensation on genitalia or erogenous zones

• The amount of genital sensation depends on the spinal cord injury and the return of function and sensation.

• Usually after SCI, sensation below the level of the injury is altered.

• Find the erogenous zone above the level of injury by experimenting and touching. Increased sensation is often found at the nipple line, the back of the neck (including behind the ears) and at the shoulders.

Pain or paresthesia
• Pain and paresthesia (“pins and needles” or limb “falling asleep”) can affect a healthy sex life. You will need to communicate with your partner so they understand what causes you pain or discomfort, and what is happening with your body.

3. Bladder and bowel function

The nerve that innervates the bladder and bowel are at the same level as the sexual centres on the spinal cord. So there is the possibility to having accidents during intercourse.

• Plan ahead. It is important to empty the bladder and bowel before intercourse.

• For women using indwelling (Foley) catheter, it may be left or removed during intercourse.

- If left in place, tape the catheter out of the way (usually it is taped up to the hip or abdomen), making sure that the urine can drain.
- If removed, have a new one ready to put in after intercourse or keep a urinal close to the bed.
- Use a bed pad in case of incontinence or accidents.

4. Factors specific to the condition

Autonomic Dysreflexia (AD)
• If AD occurs during intercourse, stop and check bladder and bowel to make sure that both are empty. Pain can also be a precursor to AD. AD typically occurs in people who have an injury at T6 and above.

Medications
• Some medications may make it harder to get wet. Review medications with your health care provider to see if any affect sexual functioning.

Pain
• Pain limits activity function and may decrease sexual interest. Exercise and stretching as well as finding a comfortable position can help sexual functioning. Be aware of your body and know what works best for you through trial and error.

 Spasticity
• Spasticity may or may not limit movement and positioning.

5. Sexual drive and activity

Sexual expression in females with SCI is generally less affected in sexual function than with males because it is easier for the woman to adapt a passive sexual role.

Bodily response such as an increase in breathing, pulse rate and blood pressure is the same for a woman with SCI as it is for an able-bodied woman. The clitoris and labia swell in women with SCI as well.

Tips for enjoying intimate time
• Prepare yourself, your partner and your surroundings. Setting the mood will improve the experience and make it more enjoyable.

• Communicate. Talk to your partner about what is pleasing and satisfying. The losses or changes in sensation mean it may take time to get used to new feelings in certain areas of your body.

• Response to clitoral stimulation varies among women. Be aware of how your body reacts to stimulation and talk to your partner about it.

• Your partner may have a fear of hurting you or causing pain. Assure him/her that you are fine and will tell them if something causes any problems.

• Experiment and explore. There are many options for sexual enjoyment. It is ideal for partners to be free to use whatever activities, fantasies, sexual devices and other sensual expressions that are acceptable and pleasurable to them to create intimacy.

6. Reproductive health

Menstruation
• After spinal cord injury, some women miss cycles of menses (periods). Women with paraplegia or quadriplegia and of childbearing age usually regain their periods in the first few months to first year. Nearly 50% do not miss a single period following injury.

• It is important to know that even without periods, ovulation may be occurring and pregnancy is possible.

Pregnancy
• Women with SCI are able to become pregnant and carry to term, but, depending on the injury, there may be additional concerns or potential complications of pregnancy:
- increased difficult in transferring
- problems with bladder management and urinary tract infection
- premature delivery – in women whose injury occurs during pregnancy and above the T10 level
- higher risk of AD for women with injuries above T6 during pregnancy and labour
- loss of sensation – in the pelvic area, this can prevent the woman knowing that labour has begun

• All of these medical conditions can be managed with good care. If pregnancy is being considered, get more information and ask questions of your doctor and medical team.

Contraception
• Remember that pregnancy can occur even without menses. Always take precautions.

• Your choice of contraceptive method should be discussed with a physician since there are 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 with SCI.

• Oral contraceptives may not be a good combination with medications already being taken for spinal injury. Always check with your doctor to see if an oral contraceptive is the right method for you.

• An intrauterine device (IUD) cannot be felt in the SCI female who has lost sensation in her pelvis, and this may cause medical complications that could go undetected. Some women prefer this method as it doesn’t cause any sexual interruption and is long lasting. This can be a disadvantage for women with spinal cord injury, especially if they have strong spasms (as a foreign body, an IUD can trigger spasms) or if they don’t have any sensation. If an IUD is not fitted correctly or if it injures the uterine wall, the woman with SCI who has loss of sensation, cannot tell. Again, consult a physician about whether it is the right method for you.

• Unlike the IUD, the diaphragm only stays for 6 to 8 hours, reducing any potential risk of bleeding or discomfort. However, his method of birth control can pose a problem though for women with limited hand dexterity.

• Spermacides can be an advantage to some women who prefer easy access to birth control methods as these are easily available in drugstores or supermarkets. A spermacide does not require a prescription or fitting like a diaphragm or IUD. But this method may not be useful for women with SCI who have limited hand dexterity.

• Tubal ligation can be considered for a woman who does not wish ever to become pregnant. This procedure is actually reversible but it depends on the type of procedure originally performed and the amount of damage caused by the procedure. Women whose tubal ligation procedure included either the removal of a small section of the fallopian tubes or those whose tubal ligation was achieved by clips or rings to prevent eggs released during ovulation have a higher success rate of tubal ligation reversal.

Annual wellness exams
After a spinal cord injury, all women should continue to receive annual gynecological exams and health maintenance. This includes:

• Breast exams
• Mammograms
• Pap smears
• Pelvic exam

7. Partnership issues

Many couples experience issues relating to sexuality that may or may not require the services of a qualified counsellor or a sexual therapist.

While open communication between partners can often resolve many sexual issues, a therapist can sometimes assist in the transition issues following SCI.

Fulfilling, loving relationships are still possible and can be very enjoyable.

8. Sexual self: View and self-esteem

A key component of sexuality is how one perceives their body. A person who can see themselves as attractive and desirable is far more likely to engage in a healthy and satisfying sex life.

Some people experience issues of lowered self-esteem and a poor self-image following spinal cord injury. Other factors are:

• Depression and anger
- toward oneself or at others
- loss of self-worth/identity

• Pre-occupation with the body and/or deficits
- concerns of bladder/bowel
- sexual dysfunction

• Alterations in body image
- disfigurement (e.g. atrophy of limbs)
- presence of equipment (e.g. wheelchair, catheter, splints)

• Hopelessness – As a person with SCI adjusts to a new physical reality, it may be difficult to change self perceptions to accommodate the injury in a positive way.


Here are a few ways that you can address body image and sexuality:

• Practice expressing desires sensitively.

• Project a good body image by keeping yourself presentable.

• Choose appropriate clothing.
• Keep yourself fit through exercise and diet. These have positive effects in a number of different areas, not just sex. But remember, everything is connected to everything else!

• Find hope in everything that you do.

• Have candid conversations regarding sex, self image and the body – yours and your partner’s – to express sexual feelings.

• Be open to relationships.


One common misconception following spinal cord injury is that a single man or woman will never find a life partner, or that an existing partner will leave a relationship due to the complications of an injury. This is not the case. Thousands of people have been married and begun families after a spinal cord injury.



Recapping…

Remember:

• Sexuality is positive and enriching. It’s about how we communicate, and accept and give love.

Illustration: Man kissing a woman (see PowerPoint)

• Sexuality means having the ability to enjoy and control our sexual and reproductive behaviour without guilt, fear or shame.

Illustration: Couple in a wheelchair (see PowerPoint)

• Sex is not just physical but an expression of yourself and your relationships throughout life.

Illustration: Couple in a wheelchair (see PowerPoint)

• Don’t fear. Explore. Love yourself.

Illustration: Woman with thumbs up (see PowerPoint)