Sexuality - The Male SCI
Sex and relationships...
…are hard to manage when you don’t have a disability. When you have a spinal cord injury (SCI), it’s even harder to “pick up” a woman. It’s not as easy as the image of a woman with her phone number easily accessible!
Common misconception
One common misconception following a 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.
Thousands of people have been married and begun families after a spinal cord injury. Finding a life partner is possible – don’t give up.
Changes to dating and sexThere are some changes in all aspects of dating and sex – taking care of your physical needs (bowel and bladder), accessibility, going to movies and having to sit in the front row where everyone can you see snuggle with your date…
The perks
Despite the drawbacks of having a disability, there are some perks as well. You need to be able to see the good stuff that comes along with the chair as well as the bad – having a sense of humour helps!
What is sexuality?
Sexuality is part of every human’s personality. It can’t be separated from the social, fantasy, gender, emotional, psychological, physiological, cultural and ethnic dimensions of your life. Each of these parts of your life affects the others.
Sexuality is…
- Thoughts
- Desires
- Longings
- Erotic fantasies
- Turn-ons
- Experiences
Sexuality 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. It is almost impossible to ignore. For some people, questions about having sex are the first that are asked after a spinal cord injury. This is normal.
Areas of sexual health affected by spinal cord injury
- Sexual functioning
- Bladder and bowel issues
- Motor and sensory influences
- Sexual drive or sexual interest
- SCI factors
- Autonomic Dysreflexia (AD)
- Spasticity
- Pain
- Medications
- Self-perception/esteem
- Reproductive health
- Partnership issues
1. Sexual functioning
Sexual functioning after SCI depends on:
- The level of injury
- Whether the injury is complete or incomplete.
Generally, the more incomplete the injury, the less change there is in sexual functioning. The main changes experienced by men with SCI include:
- Sensation
- Getting erections
- Ejaculation (producing sperm)
Sensation
Usually after SCI, sensation below the level of the injury is altered. The amount of genital sensation depends on the SCI and the return of function and sensation.
Touch is very important. How do you get excited now if you can’t feel your genitals? “Relocation” is about finding new erogenous zones above the level of your injury – such as the nipple line, the back of the neck, behind the ears, and the chest.
Make use of all your senses!
- Be open to try new things. Compensation and adaptation are often needed.
- Communicate your likes and pleasures – this will help you and your partner.
- Make use of all your senses:
- Sight: use candles or dim light to set the scene
- Smell: scents can be used to stimulate, remind and increase the intensity of the experience
- Taste: use your mouth to explore natural and exotic tastes
- Sound: Make use of music, sounds and talk
Erectile dysfunction
T11 to L2 and S2 to S4 are the most relevant areas of the spinal cord for sexual functioning.
The ability to achieve an erection depends on:
Level of injury
A lower level injury generally prevents one from having an erection. An upper level injury usually means the male can have an erection. In general, the higher the injury, the more chance of achieving and maintaining a complete erection.
Erectile dysfunction is part of most male’s lives. SCI brings additional complications.
Severity
Males with an incomplete spinal cord injury have a better chance to achieve a complete erection.
Type
Males with paraplegia who experience spasticity have a greater chance of achieving an erections compared to those who have flaccid paraplegia. Spasms can help achieve erections but can also cause problems during sex. Be willing to investigate your own body and situation.
Time elapsed since injury
Men who are unable to have an erection shortly after their injury may regain the capability during the first year.
Psychogenic erections
Messages are passed down the spinal cord from the brain to the sacral area. The centre at T11 to L2 controls psychogenic erections (those stimulated in the brain when fantasizing) and release of fluids. You are able to control erections by thinking about it. There is still some connection through the spinal cord.
- 83% of males with incomplete lower level injuries have psychogenic erections
- 26% with complete lesions have psychogenic erections
- 25% with incomplete upper level injuries can achieve psychogenic erections
Reflexogenic erections
Reflexogenic erections result from the direct stimulation of the genital area. They are reflexogenic because they are controlled by a reflex arc between the genital area and the spinal cord. This type of erection is not mentally controlled.
The centre at S2 to S4 controls reflexogenic erections (those stimulated by masturbating, rubbing the inside of the thigh, a full bladder and when catheterizing) and ejaculation.
- 98% of women with incomplete upper level injuries have reflexogenic erections
- 93% with complete upper level injuries have reflexogenic erections
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 – segments T12 to L2 and sacral levels 2, 3 and 4. Nerves that control sexual function are in the sacral part of the spinal cord.
Some men with SCI can ejaculate. According to a research report:
- 70% of men with incomplete lower injuries can ejaculate
- 17% of men with complete lower level injuries can ejaculate
- 29% of men with incomplete upper level injuries can ejaculate and rarely, if ever, in men with complete upper level injuries
However, men with SCI do who do not ejaculate may experience retrograde ejaculation – where the semen goes up into the bladder due to a blocked sphincter. This is not dangerous.
Orgasm
Many people with spinal cord injuries say that orgasm is different but it does occur. 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.
Orgasm is often described following spinal cord injury as a “psychological response” or a “mind thing” just as enjoyable, and sometimes even better. Orgasms are tied to all of your senses – so use your imagination and thoughts to heighten the moment.
Coitus
Not all spinal cord injured men attempt coitus, for a variety of reasons – fear, no available partner, privacy, personal care (bladder/bowel instability), cost, prescription needed, etc. For those who do attempt intercourse, many are successful.
Success rates for men with lower level injuries:
- 90% with incomplete lower level injuries
- 65% with complete lower level injuries
Success rates for men with upper level injuries:
- 85% with incomplete upper level injuries
- 72% with complete upper level injuries
Interventions to enhance and/or maintain erections
Viagra (Sildenafil)
- 30 to 60 minutes prior to intercourse
- Oral
- Erection may last up to 4 hours
- No more than once a day
- 80% success rate
- Men who have low or high blood pressure or vascular disease should not take sildenafil.
- Consult a doctor for a prescription.
- Side effects: headache, blue spots appear, high blood pressure, congestion
Talk to your doctor to get more information on various medications that are available. Viagra is approximately $15 per pill depending on where you get it. The dispensing fee varies for each drug and at each pharmacy.
Cialis (weekender)
- 30 to 60 minutes prior to intercourse
- Oral
- Erection may become present for 3 days
- No more than once a week
- 80% success rate
- Men who have low or high blood pressure or vascular disease should not take sildenafil.
- Consult a doctor for a prescription.
- Side effects: Headache, raised blood pressure, congestion
Cialis has similar side effects to Viagra but different medications affect people in different ways.
Penile injection therapy
Caverect
Involves injecting the pens with medication (such as alprostadil) to produce an injection.
- Must be used exactly as prescribed by the physician.
- 20 to 30 minutes prior to intercourse
- Not recommended to be used more than once a week
- Lasts up to 2-4 hours, no more than once a day
- 80% success rate
Consult your doctor about this medication. It is approximately $15 to $20 a dose. You will need good hand function or a willing partner to work the syringe.
Medicated urethral system erection (MUSE)
A transurethral medication option placed in the urethra where it is absorbed into the surrounding tissue. This is not a popular choice for men with SCI. Consult your doctor for more information.
- Causes the blood vessels to relax and the penis fills with blood causing an erection
- Inserted 5 to 10 minutes prior to intercourse and lasts up to 60 minutes
- Taken no more than twice a day
- 50% success rate
Vacuum pump
A vacuum pump is a mechanical option for producing an erection sufficient for intercourse.
- Penis is placed in vacuum cylinder
- Air is pumped
- Blood is drawn into the erectile tissues
- Erection is maintained by placing a constriction ring around the base of the penis
- It is important to remove the ring after intercourse to prevent skin breakdown
- Lasts for 30 minutes and can be used many times in a day
The negatives include a penis that is cold to touch and discoloured. The positive side is that this method is cost effective.
Surgical implantation
Surgical implantation involves a permanent penile prosthesis.
- Insertion of an implant directly into the erectile tissue
- Rigid, semi-rigid or inflatable
- Used only as a last resort
- 90% success rate of erection after surgery
2. Motor influences
Motor/Mobility
- Ability to transfer or turn oneself or partner
- Balance
- Spasms and tremor
- 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
- Explore various options. If stretching helps your spasms and increases circulation, you might want to do some before an intimate encounter.
- Building a lifestyle and daily routine with activity as a healthy alternative will only enhance your “love life.”
Weakness (maintaining sexual position)
- Some people find lying on their back allows for more energy for sex since less energy is used to support their weight.
- The use of sexual devices helps overcome difficulty in sexual positioning (e.g. Intimate Rider, Body Bouncer, Love Swings)
- You and your partner will need to compromise and agree on new and different approaches to intimacy. With the male on his back, he can conserve energy and has his hands available. Being on top reduces the use of hands and arms because they are holding you up.
Love Bumpers
These products can be purchased but pillows, cushions and bean bags can also be used creatively.
Love Swing
These swings present another option for the couple that wants to experiment.
Body Bouncer
The Body Bouncer supports your body weight and helps maintain positioning.
Intimate Rider
This chair enables the male to be in a more dominant position. The Intimate Rider allows for roles that may have been valued prior to your injury.
The Love Chair
This looks like a simple TV chair and yet it can do so much more.
Cherry Dolls
This is a hot 3D interactive sex game. Choose your girl, choose your location and start having wild virtual sex within moments. Multiple sex positions, erotic 3D audio, lush environments, full camera control and more.
3. Sexual drive and activity
Men with spinal cord injury may lose the ability to maintain an erection, ejaculate or experience orgasm
but their sex drive often remains strong.
The trick is to find and maintain a balance between preferences and abilities. Don’t let frustrations overwhelm you in the moment.
Tips for enjoying intimate time
- Prepare yourself, your partner and your surroundings. Setting the mood will improve the experience and make it more enjoyable.
- So…look good, dress to impress, keep yourself and your chair clean, show yourself as a sexual being.
- 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 problems.
- Communication is a big part of intimacy and that only increases after spinal cord injury. Talk about what you can and can’t, will and won’t do with your partner.
Communicate
- Talking to your partner about sex is pleasing and satisfying.
- The loss or changes in sensation mean it may take time to be used to new feelings in certain areas of the body.
- Be aware of what you like now and communicate this to your partner.
- Foreplay helps to get both of you in the mood—and it’s fun!
- Experiment and explore. There are many options for sexual enjoyment.
- Using sexual devices can enhance enjoyment and intimacy.
Other devices
- Go to your local sex shop for assistance.
- In Toronto, Come As You Are on Queen St. East is a great resource for people with disabilities.
4. Bowel and bladder 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 a man using indwelling (Foley) catheter, it may be left in or removed during intercourse.
- If you leave it in, run the catheter along the side of the penis and cover with a condom, making sure that the urine can drain.
- If you choose to remove it, have a new catheter ready to put in after intercourse or keep a urinal close to the bed.
- Also, think about your environment. Do you have personal supplies nearby? Do you have toys that are within reach?
5. 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.
Pressure sores
- Moving in bed can cause shearing of the skin. Be aware of bony body areas to protect your skin, such as knees, elbows, hips, back, etc.
Medications
- Some medications may make it harder to get an erection or get wet. Review medications with your health care provider to see if any affect sexual functioning.
Pain
- Pain limits activity function and you may lose sexual interest.
- Pain may get in the way of your ability to get in the mood. Let your partner know what works and doesn’t work.
- Exercise and stretching as well as finding a comfortable position can help sexual functioning.
6. Reproductive healthy: Fertility
- Men with SCI also experience a change in their ability to biologically father a child—but it is still possible to have kids after spinal cord injury.
Male fertility
- Men with spinal cord injury experience a change in their ability biologically father a child.
- 50% to 90% of men develop some form of erectile dysfunction which makes impregnation unlikely. As a result, about 5% of men with SCI father children.
- The main reason for this is inability to ejaculate during intercourse.
- Another reason is the number and movement of sperm ma be less, which influences fertility.
- Retrograde ejaculation may also occur. This is when the ejaculate travels back up the tube and goes into the bladder.
- Thermoregulation – which means maintaining a fairly steady body temperature within certain boundaries – is important to consider as sperm must maintain a consistent temperature to stay healthy.
Assistive devices for extracting sperm
Penile vibratory system (PVS)
PVS uses a vibrator or massager against the penis to help produce ejaculate.
Rectal probe electroejaculation (RPE)
RPE involves insertion of an electrical stimulation probe into the rectum with controlled stimulation produces an ejaculate.
Minor surgery (testicular puncture)
Can be used to retrieve sperm from the testicles. The sperm is then used in in-vitro fertilization.
7. Partnership issues
SCI happens to the whole family – everyone is affected in some way. Continue to talk to your partner about what is going on with your body, and what you are thinking and feeling.
Many couples experience issues relating to sexuality that may or may not require the services of a qualified counsellor or sex therapist.
While open communication between partners can often resolve many sexual issues, a therapist can sometimes assist with the transition issues following SCI.
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.
Tips/suggestions/solutions
Attraction
- You need to love yourself first.
- Empower yourself through education and support. Ask friends and family what makes you “you”?
- Create social networks (maybe new ones)
- Everyone needs to feel value every day
- Recognize your assets – one man with SCI listed his as great hair, a sense of humour, wheelchair skills/abilities
- Presentation is key, including posture and cleanliness of “all” of you – including your equipment, which is an extension of you
Body image
- With equipment, less is more. The goal is to make the person most visible and the equipment disappear.
- Empower through words: “Scars are natural tattoos with life experience”
- Dress – abdominal binders defend against gravity for “para pot / quad belly”
- Wear longer pants/shirts
- Resources:
Remember
For everything you have missed, you have gained something else;
And for everything you gain, you lose something else.
It is about your outlook towards life. You can either regret or rejoice.
Regret vs. Rejoice
Try to see both sides and then move from a place of regretting into rejoicing the many possibilities in your life.
Celebrate the possibilities
The possibilities are endless – the most important thing is your attitude.