Sexuality 201 - Sex After SCI

Overview

This chapter reviews how the body normally works during sexual activity, what changes after a spinal cord injury, and what you can do to improve your responses.

• Introduction & Definitions
• What’s Different Now?
• What Can I Do About It?
• What Do I Need to Know?
• Who Can Help Me?
• Conclusion & Resources

Introduction & Definitions

Desire:

Sexual feelings in your mind. Also known as drive, libido, or, mojo. Desire can be spontaneous, it’s that “horny” feeling you had when you were in your teens. Desire can be also be responsive, which is often more common. Responsive desire arises once sexual play starts. What does this mean? Many people start a sexual encounter without a strong sense of desire but once things begin and they get into it they notice their body starts to respond.

Arousal:

Sexual feelings in your body. Also known as excitement, turned on, fired up, hot. It’s common to start a sexual experience because of sexual motivations that can include things other than arousal. Here is a list of some common motivations:

• partner connection
• wanting to feel pleasure
• fun
• relaxation
• keep you and/ or your partner happy/ satisfied
• feeling “horny”
• curiosity or seeking new experiences

Sexual Response:

This figure shows how sexual response increases during arousal, plateaus, increases sharply during orgasm, and resolves through a gradual decline in sexual response or tension. From Masters and Johnson

Let’s review the body’s normal response cycle now (since not all of us paid attention in science class).

Sexual response is broken down into the following phases:

1. Excitement phase (arousal and initial excitement)
2. Plateau phase (excitement before orgasm)
3. Orgasmic phase
4. Resolution phase

Simply stated, the body starts to respond because there is arousal present (thoughts or feelings about sex, foreplay, visual stimulation), this excitement continues to increase until an orgasmic release occurs. This is followed by a feeling of relaxation and a sense of the body slowing down (i.e. heart rate and breathing slows down, blood flow to genitals decreases).

For the record, sexual response doesn’t always go in this order and the time spent in each phase may vary. Some variations include anejaculation, delayed ejaculation, rapid ejaculation, or multiple orgasms. As well, each stage is experienced differently between men and women.

What’s Different Now?

The spinal cord is the main “highway” for communication between the brain and genitals. After an SCI, your injury may affect this “highway” and cause changes. Your experiences of desire, arousal, orgasm and others may be different than before.

Desire:

It is common for people to say that after their injury they are not as interested in sex. This change can range from a little bit, to a lot. There are many reasons for this. Stress, fatigue, medications, fear, mood, pain, relationship status, and hormones are all factors that can interfere with sexual desire.

Male Arousal: 

Generally men get erections in two ways, either by thoughts and/or by touch. After injury, there is a disconnect between the brain and the penis. The two main issues men experiences after injury are:

1) They can get an erection but it is difficult to keep; OR

2) An erection is difficult to get, period.

This difference is based on your level of injury. Typically, the higher the injury the more likely you will be to have an erection. Alternatively, the lower the injury, the less likely it is that you will experience erections.

Touch is the most common way for men after injury to get an erection but often once the touch goes away the erection does too. The brain can’t send signals down to the penis so sometimes it will react to non-sexual touch (e.g. in hospital nurse assists with a catheter and you get an erection).

For some men, no matter how much you touch or think, your body won’t respond. Don’t panic, this is because of the changes to the nerves from the SCI.

Vaginal lubrication:

This is one of many signs of female arousal, it can occur through sexual thoughts and touch. Every woman is different in the amount of lubrication they produce. Many women don’t really know what is normal for them. What we do know is that vaginal lubrication is often less for women after SCI.

Ejaculation:

Sometimes it will happen, but there is no guarantee. Ejaculation is less likely in men with SCI and this response is much harder to predict. What we do know is that men with injuries above T10 and who have spasticity are more likely to ejaculate.

More stimulus is needed for ejaculation to occur (i.e. your hand might not be strong enough).

You may not have the same orgasmic sensation with ejaculation as pre-injury. Some men say they don’t feel it at all, some men will experience autonomic dysreflexia. Ejaculation can still feel good, even if the sensation itself is different.

If ejaculation occurs, the ejaculate volume can be less, the force at which it comes out of the penis can be less (like a dribble instead of a spurt), or the fluid can go back into the bladder instead of coming out at all. This is called retrograde ejaculation.

If ejaculation does not occur for you, your body will still make sperm. Don’t worry, your testicles will not explode, the excess sperm is reabsorbed into your body.

Orgasm:

The experience of orgasm is different for everyone (male and female). In simple terms it is the brain’s interpretation of pleasure during a physical release. Scientists, doctors, and researchers can’t agree on a definition of orgasm, thus this is a complicated topic. After injury, your experience of orgasm will likely be different. Unfortunately, it is difficult to say how it will be different. It may or may not be possible depending on whether or not you were able to experience it before.

Sensation:

After injury, your body’s ability to sense touch is different. It can be that some areas have full sensation, some have no sensation, less sensation or are very sensitive. This change in sensation can interfere with sexual arousal and response (all of the stuff above) because the touch you’re used to may not work in the same way. This can be frustrating and even a bit distracting! Check out the Sensory chapter for more on this topic.

What Can I Do About It?

The first thing is to take some time to explore how your body works now. Starting off on your own can be helpful for this process regardless if you have a partner or not. If you are partnered, communication is an important ingredient to add to the mix. It is common that people can be uncomfortable with the idea of using tools, aids, or medications to assist with their sexual lives. But there is no harm in trying; you may be surprised with how much fun you can have in the process.

The following is an overview of strategies and options that people often have questions about.

Erection Enhancement:

There are several possibilities here. Pills, pumps, injections, rings, or a combination of these used together. Lets take a closer look.

Medications:

Otherwise known as PDE5 inhibitors. You might be familiar with the commercial names of these medications: Viagra, Cialis, etc. These medications require a doctor’s prescription and need arousal for them to work (e.g can’t take a pill and then watch hockey and wait for it to “kick in”). You need to have sexy thoughts or touch to make it work. Check out our handout for more detail on PDE5 inhibitor medications.
Also, your body has to have some response already for these medications for work (e.g. if you do not get erections the medications won’t take you from 0-10). What they do is enhance what you have (i.e. make your erection firmer and last longer). These medications typically work well for men with SCI whose main complaint is that their erection is difficult to maintain.

The Pump:

Otherwise known as the vacuum erection device (VED) or as Austin Powers calls it the “Swedish made enlarger pump”. This device can be used as a form of physiotherapy for the penis. Say what? — Yes, your penis should go to physiotherapy too! It can be used on its own or in combination with other therapies. This device can enhance the effectiveness of medications. It works through vacuum suction to pull blood into the vessels of your your penis creating an erection. The old proverb warns: if you don’t use it, you lose it! If you haven’t had an erection in over a year, your vessels start to lose their elasticity and can stiffen (like an old balloon that is difficult to blow up). If you regularly stretch the vessels, they become more flexible over time (just like a balloon, you need to stretch it a few times and then it is easier to blow up).

You must be careful and take this slow. Bruising can occur if you pump too much too fast. If you have sensation, there will be an aching feeling as a warning. If you don’t have sensation you will need to take a tentative approach. Slow and steady wins the race here.

Some men report penile shrinkage after SCI. This can be due to the loosening of abdominal muscles creating a bigger belly, weight gain and not having regular erections. The VED can be helpful for this.

Constrictor Bands:

Otherwise known as tension bands or cock rings. These bands hold blood in the penis using tension or pressure once you have an erection. These bands can safely be left in place for a maximum of 30 minutes. There are different sizes, types and materials. Consulting a professional to make the right choice is strongly recommended.

Intracavernosal Injections:

Most men freak out when they learn about this option. You want me to put a needle where?? This reaction is valid but that being said, this method has been used for decades and is effective and more affordable then some of the other options. It works by injecting a medication directly into the tubes of the penis that typically fill with blood during an erection. Because this is a localized treatment, it bypasses the brain and it doesn’t require arousal to work (although arousal is still helpful). Some men find this a weird option. But most men get over their initial reactions when they see it working. A doctor’s prescription is needed and should be consulted prior to use to decrease the chances of a prolonged erection (otherwise known as priaprism).

Combination Therapy:

Consulting a medical professional is strongly advised for this.

Lubricants:

The use of lubricants is very individual. For some people lubrications can increase sensation but for others it can decrease it. They can be beneficial to protect the sensitive skin of the genitals during friction. There are lots of different options of lubrication depending on the activity. Water-soluble and fragrance free is preferred because it is less likely to cause irritation or infection and they are condom-friendly.

Mindfulness:

Mindfulness can be used a way to increase your awareness of your body, limiting your judgments about your body and staying present in the moment. All of these are all helpful for sexual activity. Visit the Sensory page to learn more about how to be mindful.

Vibratory Devices:

Can be used to crank up the volume of stimulus on the genitals when sensation is limited. These devices can be used to achieve ejaculation (depending on the level of your injury) and to increase pleasure with sexual play. That being said, caution needs to be taken when experimenting with these devices because they can cause AD, skin breakdown, or other injuries. There are lots of devices on the market and it can be confusing to decide which device would work best for you. Consultation with a medical provider initially is recommended.

Positioning tools: 

Use this helpful handbook to switch things up in the bedroom and find out what works best for you!

What Do I Need To Know?

Here are some terms that are useful to know when you start exploring your sexuality.

Priapism: A medical emergency! It is defined as an erection that lasts longer than 3 hours. Even though it might sound awesome to have an erection for 3 hours, it is actually dangerous and can permanently damage the blood vessels in your penis. If this happens to you, you need to go to the emergency room. This can occur if you are using any of the erection enhancement options.

Autonomic Dysreflexia (AD): A medical emergency! If your level of injury is above T6, you are probably quite familiar with AD. AD is defined as a sudden increase in blood pressure above 150mmHg systolic (the top number of your blood pressure). Typical symptoms of AD are: severe headache, feelings of anxiety, sweating above level of injury, flushed face, goose bumps, blotching of the skin, blurred vision, nasal congestion, feeling generally unwell. AD can be caused by sexual play (genital stimulation, arousal, ejaculation and/ or orgasm). If AD is experienced during sex, stop activity immediately and sit yourself up. If your blood pressure remains elevated for longer than 5 minutes, medical intervention is necessary.

Medication Side Effects and Contraindications: Just like with any medications there are things that need to be reviewed with you before taking them. These include potential side effects and how other medications you take interact with the new medication. Specific side effects should be reviewed with you by your prescribing doctor, family doctor, or physiatrist.

Caution with Medication Dosing: Some people think that double the dose equals double the fun — this isn’t the case with erection enhancement medications. This can put you at risk for priapism (see above) and is also very expensive. If the prescribed dose of the medication is not effective, see you doctor for alternative options.

Lubricants and Condoms: Certain lubricants and condoms don’t work together. Lubrications made for self-stimulation tend to be petroleum based (i.e. Vaseline) so they last longer. They cannot be used with latex condoms because the petroleum breaks down the latex and can cause the condom to break during sex.

There are lots of different types of lubricants available: flavours, warming, tingling, liquid, gel, silicone based, water based, petroleum based, and the list goes on. The fancier the lube the more likely it is to cause irritation.

If either you or your partner have a latex allergy, there are non-latex options for condoms. Sold at most major retail outlets by Durex, Lifestyles, Trojan, and more.

My Role

Your role is to become familiar with how your body responds to sexual stimulation post-SCI. This can help you better understand what is working well and what areas you may need some help with. Use the information on this page to get you started, investigate the options provided, and experiment to find what works best for you.

Who Can Help Me?

The Sexual Health Rehabilitation Service can help you apply the content of this website into your own life. It’s a place where you can talk in person with a nurse clinician to assist you in your sexual health journey.

if you’re not in Vancouver, contact your local rehabilitation physician or family physician. Some rehabilitation clinicians such as Occupational Therapists (OTs), Physiotherapists (PTs), and nurses can also be helpful in addressing some of the specific complications of SCI that relate to sexual health.

Conclusion

Learning about your body can have its ups and downs (no pun intended). Exploring your body and how it responds sexually post injury can give you valuable information and confidence to get you on your way to a fulfilling and enjoyable sexual life. Remember to stay open minded, positive, and enjoy yourself during this process.

Sexuality 201 Resources

Clinical Resources

AD Wallet Card - A small card to share with a healthcare provider or emergency responder on how to diagnose and treat autonomic dysreflexia - Spinal Cord Injury BC

Autonomic Dysreflexia: What You Should Know - A guide to understanding AD - Consortium for Spinal Cord Medicine.

PleasureAble - A Sexual Device Manual for People With Disabilities - DHRN/VCH (PDF)

Sex Position Handbook - Use this helpful guide to switch things up in the bedroom and find what works best for you!

Articles

How I Have Sex as a Quadriplegic - Rachelle Friedman, Cosmopolitan.

Videos

The Big "O" - Sexuality After SCI 

Effects of SCI on Sex - Sexuality After SCI 

Erections - Sexuality After SCI 

Facilitated Sex - Sexuality After SCI 

Pre-Injury Factors - Sexuality After SCI 

Check out the Sexuality 201 Video Playlist!