Sex and Disability

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Sexuality and Spinal Cord InjuryState of the
Science April 2007

• Stanley Ducharme, Ph.D.
• Rehabilitation Medicine and Urology
• Boston University Medical Center

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The Emergence of Sexuality and Fertility into
Rehabilitation Medicine

• The influence of Rehabilitation Physicians in the
  1970s specifically with the support of The
  Academy of Physical Medicine and Rehabilitation
  and the ACRM.
• The introduction of sexuality curriculums in
  medical schools.
• Pharmaceutical involvement in the field and
  the development of new fertility
  techniques.
• Demands for services from people with
  disabilities.
• Involvement of urologists and the
  development of the penile prosthesis.

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The Importance of Sexual Rehabilitation

• Retrospective studies dating back to 1982
  indicate that there is a gap between services
  desired by patients and the services actually
  provided.
• Kennedy 2006 reported a large study of 350
  respondents over 4 European countries that
  identified sexual activity as the area of
  greatest unmet need for persons with spinal cord
  injury.
• 
  (Reitz et
  al, 2004)

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The Needs of Women With Spinal Cord Injury

• Forsythe and Horsewell, (2006) found that women
  desired more information during their inpatient
  rehabilitation and wanted continued opportunity
  for sexual counseling post discharge. They
  believed that sexual counseling should be
  initiated by the clinic not the patient.
• The same study indicated that they regarded peer
  counseling as extremely useful in their sexual
  adjustment. Women also expressed high anxiety
  about the lack of information regarding
  gynecological and obstetric issues.

Spinal Cord, 44, 2006
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Interventions and Models

• Studies do support the need for sexual education
  during rehabilitation but no studies investigate
  the effectiveness of interventions on sexual
  satisfaction.
• (Fisher, 2002)
• 12 months after discharge most people have not
  mastered their sexual adjustment and sexual
  satisfaction is lower for both men and women.
• (Schuler,
  1982)

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Recent Studies in Sexuality and SCI
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Oral MedicationsSidenafil (Viagra)

• Men with SCI report headache 10 to 15 and
  flushing 6 to 10.

• Sildenafil
• A review of 1000 men in 7 Randomized Control
  Trials reported in the literature show efficacy
  of Viagra to be 79 with a range of 75 to 85.

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Oral MedicationsVardenafil (Levitra)

• 22 with placebo felt that their erections lasted
  long enough for satisfactory intercourse.

• Guiliano 2006 reported a RCT of 418 men with sci
  demonstrated 76 ( vs 41 with placebo) had
  erections firm enough for penetration. 59 felt
  that their erections lasted long enough for
  satisfactory intercourse.

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Sildenafil ( Viagra) vs Tadalafil (Cialis)

• The advantage of Tadalafil over Sildenafil is not
  influenced by degree or level of lesions in SCI
  men.

• Del Popolo 2004 did a comparison study of
  Tadalafil vs Sildenafil and found that Tadalafil
  allowed the majority of men to achieve erections
  up to 24 hours post dosing.

Spinal Cord, 42, 2004
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Male Fertility
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Vibrostimulation vs Electroejaculation

• Vibrostimulation has gained popularity among
  patients and urology clinics.
• Less invasive.
• Usually results in better semen quality.
• Can be used at home to produce ejaculation.

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Women and SCI
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How Women with SCI Conceptualize Sexuality

• 63 women received packets in the mail. A total of
  24 women agreed to participate.
• Subjects were outpatients at 4 rehabilitation
  hospitals in the Midwest
• Between 3 and 10 years post injury
• No cognitive impairments

Ruth Leibowitz et al Rehabilitation
Psychology Feb 2007
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Women with SCI-Conceptualizations of Sexuality

• Most women conceptualized their sexuality in a
  way that transcended the physical and genital
  aspects of sexuality.
• Most women discussed relationships,
  communication, trust, concerns related to
  physical changes and lost independence.
• Women noted the importance of physical closeness
  and intimate touch regardless of whether
  intercourse was still
  enjoyable.

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Female Sexual DysfunctionPotential Treatment
Options

• Oral Medications
• Sipski (2000) evaluated the use of Sildenafil in
  50 SCI Women. She reported promising increases in
  subjective arousal when combined with visual and
  manual stimulation.
• 2005 Pfizer, Bayer and Lilly-ICOS stop trials of
  Viagra, LeVitra and Cialis on non disabled women.
• Androgens
• Testosterone gels and creams currently being
  explored.
• Used off label in conjunction with oral
  medications.
• No clinical trials at present time on women with
  SCI
• Clitoral Stimulators
• Received FDA approval in May 2000
• May be difficult with limited hand movement

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The EROS device is placed over the clitoris. The
device provides three levels of gentle vacuum
suction.The EROS is designed to increase blood
flow to the clitoris to assist a woman to achieve
clitoral engorgement and ultimately enhance
arousal
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Female Sexual Arousal after Spinal Cord Injury

• Women with complete SCI have been self-reporting
  orgasm that seemed physiologically impossible,
  (Richards 1997).
• Whipple (2002, 2004) with functional MRIs
  documented the presence of vaginal-cervical
  perceptual awareness and orgasm. The vagus nerves
  were thought to be the spinal cord bypass pathway
  that facilitates these responses.
• Sipski (1995, 1996, 2001) noted that women with
  LMN injuries (S2-5) were less likely to have
  orgasms that women at other levels.
• Sipski (2002) also noted that women with SCI are
  less likely to experience orgasm than an able
  bodied control group.

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Psychological and Relationship Issues
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Different PatientsDifferent Needs

• Not all patients are ready to hear about issues
  such as sexual positions, orgasm and the
  specifics of sexual intercourse.
• Some patients may have never been sexual prior to
  injury.
• For some patients, social skills, communication
  and dating are more relevant
  and appropriate.

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Successful Sexual Adjustment Depends on

• Losses must be grieved and depression must be
  resolved by patient and partner.
• The extent that the individual can value new
  sexual abilities. Let go of old notions of sex.
• The individuals ability to communicate.
• Ability to face fears and to trust each other.
• The individuals ability to take
  emotional risks and be vulnerable.
• Successful resolution of any pre-
  injury difficulties or sexual dysfunction.

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Sexual Education

• Relationships and emotional readiness.
• Discuss treatments for erectile dysfunction.
• Discuss fertility issues for men and women
  including options for birth control.
• Sexual positions.
• Discuss the importance of learning about ones
  body and the need to be creative.
• Sexually transmitted disease.
• Provide resources for the future.

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Whats Ahead?

• 2005 - The Agency for Healthcare Research and
  Quality (AHRQ) completed the evidence report on
  Sexuality and SCI.
• 2006 Development panel selected.
• 2007- Panel of the Consortium on Spinal Cord
  Injury began writing the Clinical Practice
  Guidelines on Sexuality and Reproductive Health.
• 2008 - The clinical practice guidelines and a
  consumer handbook will be released by PVA.

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Web Sites with Information
on Sexuality
and Spinal Injury

• www.sexualhealth.com
• www.siecus.org
• www.scifertility.com
• www.newshe.com
• www.isswsh.org
• www.sciwire.com
• www.bumc.bu.edu/sexualmedicine
• www.stanleyducharme.com

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Thank You !