Let's Talk Sex, Learning to Adjust After a Spinal Cord Injury, A Guide for Men
Acknowledgements
Special thanks to our patients and staff at the University of Wisconsin Hospital and Clinics. The sharing of their experiences help to make this book a valuable resource for future patients and families.
A Word About Privacy---For most of us, talking about sex is a private matter. Americans like their right to privacy and will go to great lengths to protect it. While at the hospital, you will meet doctors, nurses, and social workers who will ask you questions about your sex life. You may be asked to share some thoughts and feelings you have never told anyone before. Keep in mind, this information can be useful in helping you and your partner learn to adjust. Yet, if you are uncomfortable talking about your sex life, just let us know.
Learning to adjust after a spinal cord injury (SCI) is an important part of your recovery. A spinal cord injury can affect your feelings about sex and how you perform. Yet, how you adjust sexually after SCI is up to you. Your doctors, nurses, psychologists, and social workers can help you and your partner with this change.
This book goes over basic issues from changes in body image to dealing with feelings of anger, depression, and guilt. It looks at how SCI affects sex and how you might deal with these changes. The book is also designed to help you and your partner begin talking about the many changes and how you can cope.
You and Your Partner
After a SCI, you need to talk with your partner – especially as you rediscover each other in a sexual way. A couple needs to freely discuss changes in their sex life and how they plan to deal with them. Be honest and open in a gentle, caring way. This prevents any wrong ideas that could make you and your partner grow apart.
Talking With Others
Disability is not what you are – it’s something you have. The less you focus on it, the less important it may seem to you and others. People sometimes feel uneasy around someone with a disability. They don't know about them and they are unsure of themselves. Educate people, be yourself, and be casual about your disability. People will likely feel more at ease around you.
Making friends is really no different than before. Find friends where you used to meet people. You could meet that special someone in the same place you would have before your injury. Intimacy is knowing yourself and what you want from a relationship – not just finding the “right person”. Being attractive means more than how you look. It's who you are.
Adjusting After a Spinal Cord Injury
After a SCI, your body goes through many changes. It may look different. This may change how you feel about your body. Adjusting to the changes takes time. There is no set time frame for learning about and dealing with a SCI. Likewise, there is no right or wrong way to cope. Here are some questions to help you to think about yourself, your body, and your ability to adjust. There are doctors, nurses, psychologists and social workers to help you as you and your partner begin to explore these questions.
Role Changes
How has your role in life changed since your SCI? Have you had role changes within your family? At work? While playing or watching sports? If your role as a provider has changed, how have you and your partner been able to adjust? Can your partner do your cares and also be your lover?
Many people find it is hard to adjust to all of these new roles. Learning to rely on others for help can be hard. At first, you may feel more at ease having your partner help with your personal cares. While this may be convenient, it is often hard for partners to switch gears from being caregivers to being lovers. Plus, the drain and time it takes to provide these cares can be overwhelming. Since being your lover should be your partner's priority, you may need to hire someone to help with your cares. It is wise to talk about this option with your partner and with the staff well before you plan to leave.
Sex Role Issues and Expectations
What do you expect in a relationship? What do you expect of your sex life? Can you achieve it? What does your partner expect? Are you afraid of being rejected by a lover? Will this fear keep you from trying sex? Do you feel you are a worthwhile, loving person or do you feel like nobody could love you now? Do you feel like someone would want to have sex with you?
You may feel your roles have changed. Loss of function, dexterity, or mobility to any degree may make it hard to function in the role you were used to. You will need to create new self-concepts and new roles. It will take time to adapt. It may be harder to deal with based upon your cultural background and religious beliefs. Your partner needs to understand and support you as you seek a new balance in your relationship.
Sexual Drive
Has your sex drive changed? Will you still have the same desire for intimacy?
A SCI does not affect one’s desire to have sex. Yet other physical and mental factors can affect your desire. Medicines can decrease your sex drive. Stresses and financial strain can cause distraction and conflict. This can further interfere with sex drive.
Body Image & Self Concept
What are the physical changes that have occurred? How do these changes affect how you feel about yourself and your body? How does the sight of medical equipment – urinary devices, wheelchairs, splints, braces – affect the way you feel?
Some feel overwhelmed with their body changes. As you become more familiar with how your body has changed and with the equipment you use, you may find your feelings about your body will change. This will take time. If you feel good about yourself, others will sense that feeling.
Emotional Changes
Along with the SCI comes many feelings. You may feel anger, frustration, depression, and guilt. These changes are normal. We expect them. These feelings need to be dealt with to get life back in order. Here are some questions you might ask yourself as you or your loved one start to make sense of your feelings. As you begin to think about the questions, you may find you need some help. We are here to help you. Just ask.
Anger
Do you feel angry and ask, “Why did this have to happen to me?” Are you upset about the new changes and limitations in your life? Do you miss your previous lifestyle? Do you blame anyone for your SCI? Do you feel anger towards your partner at times? Does that anger affect your relationship with your partner?
It is okay to feel angry. You need to get it out – reduce the anger – and move on with your life. If you keep this feeling bottled up inside of you, it'll affect not only how you deal with your partner, but others, too.
People deal with anger in different ways. Sometimes talking with someone who's not personally involved can help. Find someone you feel comfortable with – a nurse, a psychologist, a social worker, a clergy member, or a friend. Let them know you need help.
Frustration and Resentment
Do you feel frustrated because you need to depend on others for things you’d rather do yourself? Are you impatient when things aren’t done the way you'd like them to be done? Do you feel resentful of others? How do these feelings affect you your partner?
Frustration and resentment are a common part of every spinal cord injured person’s rehabilitation. You need to find ways to deal with these feelings. They can harm relationships with your partner and others. Once you recognize these feelings, you’ll begin to find ways to deal with them. Again, talking to others can help put these feelings aside and help you move on.
Guilt
Do you feel like you are a burden to others? Do you feel guilty that your partner has to take on more responsibilities? Do you feel your partner has had to put their life on hold?
Guilt can be a very common part of adjusting after a SCI too. The person who has had the injury often feels guilty for being a burden. The partner feels guilty for not doing enough. You and your partner may find it tough to discuss these feelings. This guilt can sometimes cause big gaps in communication. To make it even tougher, the guilt is often mixed with anger, frustration, and resentment. If you start to notice communications breaking down, ask for help.
Fear
Are you afraid of being rejected by your partner? Are you worried that things will not go as well as planned? Are you concerned how you'll perform? Will these thoughts keep you from starting or resuming a sexual relationship?
After the SCI, you may find yourself unsure of what to expect and afraid of failure or rejection. Sex will be different. At first, it may not be as wonderful as you want it to be. Do not let this discourage you from trying again. This is a time of adjustment. As you get to know your body again, things should improve with time and practice.
Depression
Do you have a hard time doing all the things you used to enjoy? Do you feel like nothing will ever be right again? Do you feel like your life is over and now you only just exist? Are you depressed about all of the changes in your life? How do these feelings affect you and your partner?
After a SCI, some people become depressed. If you feel depressed, let your doctor or nurse know.
Warning Signs of Depression
- feelings of hopelessness
- poor appetite
- too little or too much sleep
- trouble focusing or concentrating
- general feelings of sadness
- difficulty regaining interest in others
- lack of motivation
- feelings of guilt
- suicidal thoughts
While these things are not sure signs of depression, they are clues that you may need some help and support. Again, if you notice these signs over several days, let us know. We're here to help
Effects on Your Partner
At first, you may not be able to look beyond yourself to see how your partner has been affected. What has happened in your life will greatly affect both you and your partner. As you both adjust, you may be challenged by some of these questions and issues.
Depression, Anger, and Guilt
How do the changes in your life affect your partner? Does your partner miss the way things used to be? How does your partner feel about new roles in life? How does your partner feel about having to take on new responsibilities? How do these feelings affect your sex life?
Just as you may feel depressed, angry, and guilty, your partner might also feel these feelings. If left unnoticed, these feelings can be very harmful. Talking with your partner and keeping your communication open can help. And again, if you feel you need help, ask.
Fear
Is your partner afraid that you could be hurt during sex? Does your partner worry about performance? Does your partner fear something could go wrong?
Most partners fear that they may hurt the person with a SCI. It is highly unlikely that this would happen. Even so, it is common for people to be afraid to start a relationship after having a SCI.
When you first try sex again, avoid setting expectations that it will be like it used to be. You and your partner may get frustrated and even angry when things don’t work out as planned. This could prevent you from trying again. Therefore, go slow and relax. Be willing to try other approaches. Be patient with yourself and your partner.
Adaptation and Adjustment
Adaptation does not mean acceptance, but instead is a process of making changes in your life. You need to get on with your life. Don’t let your disability get in the way of doing things you enjoy like school, a job, or sports. Control your disability – don’t let it control you.
Change takes time. It affects both partners, yet it may not occur in each partner at the same time. Keep in mind that you may not have the same feelings as your partner all the time. It will help to be open, sensitive, and supportive of your partner.
Counseling may be a good option for you. Sometimes talking with an outside person can help you and your partner to work through these changes.
Physical Changes in Sexual Function
It may be harder to move or position yourself. You may have trouble getting or keeping an erection and ejaculating. During sex, you may have less of a rise in your blood pressure, pulse, and breathing rates. You may have less feeling in your genitals.
Types of Erections
Knowing the 2 types of erections helps you to know how your body may respond after a SCI.
- Reflexogenic – the kind you get by touching the penis.
- Psychogenic – an erection that results from fantasizing or watching something erotic.
The level of injury affects your body’s response. A man with an injury at T12 or above is most likely to get an erection by touching. If you have had a complete injury at T12 or above, it is unlikely that you will be able to get an erection from fantasizing or watching something erotic. But, if the injury is incomplete, it may be possible to be aroused mentally and have some feeling in the genitals.
A man with an injury at T12 or below is most likely to respond to mental arousal, but not to touch. Also, there is a chance that he will be able to ejaculate. And, if your injury is incomplete, there's a chance that you may have some genital feeling.
Obtaining & Maintaining Erections
Many men have trouble getting and keeping an erection during sex. Here is a list of options to help you deal with these problems. You may also want to talk with your doctor to find specific ways to solve your particular problems.
Nonsurgical Treatments – The Preferred Choices
Erectile Dysfunction Medicines
Medicines in this class, such as Viagra, work by increasing blood flow into the penis. The penis still needs to be stimulated to obtain an erection. The difference between medicines is the amount of time the medicine lasts, which can vary between several hours to several days. These medicines can interact with some other medicines, so check with your doctor. They cannot be used if any medicines contain nitrates. Most are well tolerated, but side effects include a mild headache, changes in vision (see a blue/green tint), facial flushing, a stuffy nose, stomach upset, and a chance that the erection may carry over to the next day.
Constriction Ring
This method works well with men who are able to obtain an erection, but cannot keep it long enough for sex. It can be used with other methods like Viagra and MUSE. Once the erection has been achieved, a latex band/ring is placed over the base of the penis to maintain the erection. Do not keep the ring on more than 30 minutes at a time or you could damage your penis. You cannot use this method if you have a latex allergy or a bleeding disorder.
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Self-Injection of Medicine
Self-injection is a common and inexpensive treatment. A medicine such as Papaverine or Alprostadil is injected into the penis to dilate the blood vessels. This can cause an erection to last up to four hours. This treatment can be very helpful. It can be used 1 – 2 times a week. It may cause bruising and, rarely, infection or scarring. You can learn about this method at a clinic visit. The amount of medicine needs to be prescribed by a doctor. Be sure to follow the instructions since too much can cause a painful erection that will not go away. This could result in permanent damage.
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Other Options
Erections can sometimes happen by pulling on pubic hairs, stroking the scrotum, thigh, or rectal area. The “stuffing technique” (stuffing a flaccid penis into the vagina) can also be used. Gentle or vigorous massage of the penis, or use of dildos, vibrators or penis stiffeners may be used to achieve an erection and/or to assist with vaginal penetration. Many of these items often require good hand strength.
Vacuum Device
The penis is placed into a vacuum cylinder. It is then pumped up in order to get an erection. A constriction ring is placed around the base of the penis for no longer than 30 minutes to keep the erection. The vacuum can cause bruising. Though there are various vacuum models, some require good hand strength. A rubber ring can also be used alone for those who are able to get an erection, but need help to keep it. The band is placed at the base of an erect penis. This method is easy to use.
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Surgical Penile Implants
When simple treatments do not work, a final option may be surgical implants. Implants will not improve one’s ability to ejaculate. They can be useful in keeping condom catheters on. Penile implants can result in many severe complications, such as pressure sores and infections inside the penis. We do not recommend their use.
Preparing for Sex
Setting the Mood
Following SCI, getting ready to have sex can take time. You will need to allow extra time for bladder care and to remove your clothes and get into bed. You may want to use these events as a part of foreplay.
Bladder and Bowel Care
The same reflex that is triggered during sex also controls the bladder. To prevent accidents, it’s best to plan ahead. Try to limit the amount of fluids you drink for three to four hours before having sex.
If you use intermittent catheterization, do so just before sex. (This may be useful since it causes an erection in some men and can be used as a part of foreplay.)
If you have an indwelling catheter, place a condom over it to prevent irritation and use extra tubing so you have plenty of room to move.
Condom catheters can either be removed or folded over with a regular condom placed over it.
Sex can also trigger your bowels to move. If you perform regular bowel care, this shouldn’t be a problem.
In case of accidents, pad the bed well with a waterproof pad. If you have an accident, you can just remove the soiled linen and keep going.
Medicines
In general, sedatives, pain relievers, blood pressure medicines, muscle relaxants, and major tranquilizers may decrease sexual response. Caffeine, alcohol, and tobacco also affect your response. Talk with your doctor if you have any specific questions.
Spasms
You may need to experiment to see if spasms interfere or help with positioning or movement during sex.
If your spasms interfere, try a warm tub or shower, warmer room temperature, range of motion, relaxation, whirlpool, and deep breathing.
If spasticity helps with movement, avoid medicines used for depression and spasms.
Autonomic Dysreflexia
Although it is rare, sex or stimulation can cause dysreflexia in those who have an injury T6 or above. If it occurs, stop, sit up 90 degrees and treat as appropriate. After this episode is resolved, you may continue with sexual activity.
Contraception
Even though you may have trouble with the mechanics of sex, you could still have fertile sperm and should use a form of birth control. Condoms should be worn to prevent pregnancy. They also help to avoid contracting AIDS, sexually transmitted diseases, and urinary tract infections. You may also wish to consider a vasectomy, a permanent form of birth control.
Movement and Positioning
To save energy, you will want to try a variety of positions. You might also want to use pillows, cushions, and folded blankets to keep you in place. Couples must be willing to experiment to find out what works best for them. Here are some suggestions to help you get started.
- Place yourself beneath your partner to allow your hands to be free and your partner’s hips and pelvis to thrust.
- Try having sex in a wheelchair. Remove the wheelchair arms and have your partner straddle over you.
- Lie side-by-side or face-to-face to allow your arms and hands to move freely and to lessen any problems with balance.
- Sit up with your legs wrapped around each other. Use pillows to help keep your position.
- Lie on top of your partner with your partner’s knees bent to your chest. Rocking movements will provide thrusting motions and let your partner’s hips move freely.
- For a paraplegic with good arm strength, use this strength to do a push-up to perform a pelvic thrust. Place your knees apart and shift your weight in a rocking motion. It will also give your partner room to move the hips.
Sexual Excitement
Sex drive is not affected by SCI, but spontaneity is. This may be due to concerns about mobility, bowel, and bladder. You can include these issues into foreplay. Use the time to increase your excitement for what’s ahead.
Within your comfort level, beliefs, and values, you may try fantasy, massage, use of sexual toys, oral sex, caressing, holding, or kissing instead of or in addition to intercourse to enhance the experience for both of you.
Use light and mirrors to help you to watch your partner’s reactions. Don’t forget to include all areas of your body even if you can’t feel them. Use your eyes to follow the movements. Use the memory of how those areas used to feel, along with the sights and sounds to heighten your excitement. Talking to one another about sensations may intensify them.
After spinal cord injury, you may not feel the same feelings from your genital area that you felt before your injury. Concentrate on feelings you get from your erogenous zones (nipples, earlobes, neck, underarms, area just above your level of sensation) while caressing and amplify it mentally to increase its intensity. You also may be able to transfer a sensation from a less sensitive area to an area of retained sensation and intensify it in your mind. Using imagination may increase sensations.
Ejaculation and Orgasm
Ejaculation is not the same as orgasm. They are two separate functions of the body. You are able to orgasm, however it might not be like the orgasms you had before your SCI. Orgasm is the mind's interpretation of physical sensations. It has been described as a warm sensation, either above or below your level of injury. The feeling might be the same as or stronger than it was before. You can also orgasm by stimulating erogenous zones. Whether you are able to ejaculate or not, you should be able to orgasm.
Be creative to find and enjoy new areas of sensation.
Fertility Issues
Men with a SCI usually have a very low fertility rate. Although the amount of sperm in the body remains the same, the sperm is of poorer quality due to low motility (or slow movement). After SCI, sperm motility drops from 60% to 5-10% for unknown reasons. The shape of sperm and its ability to move are the most important predictors of fertility.
Other Factors Affecting Fertility
- Inability to ejaculate
- Inability of the scrotum and testes to control temperature. Sperm can only survive at a constant temperature.
- Medicines, especially long term use of antibiotics
- Retrograde ejaculations into the bladder. Sperm cannot survive in an acid environment.
- Repeated urinary tract infections. This affects the ability of the testes to produce sperm and the ability of the sperm to swim and penetrate the egg.
- Type of bladder management. Fertility is best if you are on intermittent catheterization.
Sperm quality cannot be evaluated until six months after SCI.
Assistive Reproductive Methods
If you and your partner want to have a baby, several methods may help. These methods help a man to ejaculate. They can be dangerous to your health though, and should be discussed first with your rehabilitation doctor.
In order to achieve the best sperm quality, your bowel and bladder should be emptied just before the procedure. You should be free of any urinary tract infections. The amount and quality of sperm also improves with repeat ejaculations.
Most men who are at least six months after injury can ejaculate by massaging or using a vibrator. These methods work best for men with injuries above T10 and have been successful 60% of the time. They are the most successful, cheapest, easiest, and least stressful way to ejaculate because it can be done at home.
Massage – Apply continuous vigorous massage to the shaft of the penis. Massage for one minute, then rest one minute. Repeat this cycle 6 – 7 times and then wait 1 – 2 days before trying again. Check the skin on your penis carefully for any blisters or sores. If you have doubts about the condition of your skin, stop until all areas heal. Try this process for about 3 – 4 weeks. If you haven't had any success, try a different method.
Vibration – You might want to use a vibrator or a massager. They can be bought at a local drugstore. You or your partner can apply the vibrator or massager to the shaft and head of the penis. Some men feel they have a better response if they operate the vibrator themselves.
Since vibratory massage can cause autonomic dysreflexia (A.D.), it should be tried first in a doctor’s office so that the A.D. can be treated, if necessary. Medicines can be prescribed to prevent A.D. in the future. After your first try, you will want to start by using the vibrator for one minute, then resting one minute. Repeat the cycle 6 – 7 times and wait 1 – 2 days before trying again. Don’t give up. Keep trying. Check your skin. If any skin breakdown occurs, stop using the vibrator until your skin has healed. If A.D. occurs, remove the vibrator until it resolves.
Taking 30 – 60 mg. Pseudoephedrine (Sudafed) 30 minutes before using the vibrator may enhance your body’s reaction. If you have retrograde ejaculations, you will need to perform vibromassage at the clinic so your doctor can collect the sperm from your bladder and treat them before inserting them into the woman.
Electroejaculation – If the other two methods do not work, electroejaculation is an option. A probe is inserted into the rectum and a low electrical current stimulates the nerves that control ejaculation. This method has a 90% success rate within six months. However, it is expensive and must be done in a doctor’s office. If you have any genital sensation, anesthesia is used since the procedure can be painful. Other side effects include autonomic dysreflexia and rectal bleeding.
Fertilization
After you ejaculate into a cup, you can collect the semen into a small syringe and have the woman inject it into her vagina. Or, place the semen on a diaphragm or cervical cap and insert it into the cervix. The woman should then lie down with her hips propped up on a pillow for thirty minutes. Other options include artificial insemination or in vitro fertilization. You and your partner could talk with an obstetrician or infertility specialist about these choices.
Important Numbers to Know
UWHC Rehabilitation Clinic (608) 263-6540
UWHC Inpatient Rehabilitation Unit: (608) 263-8388
The information provided should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Any duplication or distribution of the information contained herein is strictly prohibited.
Last Updated: 01/28/2010
Copyright © 01/28/2010 University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Department of Nursing. UWH #4907
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