First Things First: What is Human Sexuality?
"In the broadest sense, sexuality encompasses all the feelings, attitudes, and behaviors that contribute to a person's sense of being a man or a woman both publicly and privately. Healthy sexuality represents a natural extension of affection, tenderness, and companionship between two people" (Firestone, Firestone, & Catlett, 2006).
The definition above is not usually what most people think of when they think of sex. And, especially when people have experienced a spinal cord injury (SCI), there are usually many other questions that come up, such as:
- Does my SCI affect my sexual function?
- What kind of physical changes can I expect?
- Will I have orgasms?
- Will I be able to satisfy my partner?
- What do I do with my catheter during sex?
- What about bowel and bladder accidents?
- Will I be able to get an erection?
- Will I be able to have a have a child with my partner?
These are just some of the things that may be on your mind. Throughout this brief introduction to sexual changes after SCI, maybe we can answer some of those questions. The physical act of intercourse isn't all that defines your sexuality. When we talk about sexuality, we mean more than what goes on behind your bedroom doors. Sexuality is the total YOU! It's how you talk to people, what you think about your body, how you get along in the world - everything that says anything about you as a person. Sexuality is everything you are - your personality, your likes and dislikes, your preferences for food, activity and the people you hang out with, the social roles you play in your home and community and, of course, the physical act of sex.
How Is Male Sexual Function Affected by SCI?
A spinal cord injury presents major challenges to many bodily functions, especially those functions that are at or below the level of the injury. You already know that your SCI has affected your bladder and bowel function and has probably also affected your sexual function. For many men, having an erection is one of the first questions on their minds, so let's talk about erections.
Before a SCI, men get erections in one of three ways.
- Psychogenic: This type of erection means that you thought of something you find sexy or attractive. The erection may come from sights, sounds, or thoughts that are arousing. Maybe you remembered a situation with a partner or girlfriend or you were watching a movie with a sex scene or looking through a Playboy magazine and sure enough, an erection occurred.
- Reflexogenic: This type of erection is a direct result of physical touch or stimulation to your penis. Stroking, caressing or sucking the penis will produce this response.
- Spontaneous: If you have ever awakened with an erection because your bladder is full, you’ve had a spontaneous erection. This is from some kind of internal stimulation.
After a SCI, men may get erections in one of three ways.
- Psychogenic: For many men after SCI, having an erection by just thinking about something sexy may not work so well. This is because the area of the spinal cord responsible for erections is located between T11 and L2. Therefore, if your level of SCI is above this level, the message (sexy thoughts) from your brain cannot get through the damaged part of your spinal cord.
- Reflexogenic: Some men with SCI may still get an erection when the catheter is being changed or when their penis is being cleaned or wiped or even by just pulling clothing or blankets over the body. This stimulation to the penis may actually produce an erection even if you really didn't want that to happen. It's important for you to pay close attention to what causes an erection as that may be useful for future occasions.
- Spontaneous: Some men after SCI may still get an erection when their bladder is full. Depending on how long the erection lasts will help you determine its usefulness for sexual activity.
The ability to get a reflexogenic erection or spontaneous erection is controlled by nerves found in the lowest part of the spinal cord segments (S2-3-4).
Men are also interested in the possibility of ejaculation. Like many other functions, ejaculation is also affected by the SCI. The process of ejaculation is even more complex than an erection. It requires a higher degree of coordination and interaction between nerves, the penis, and the brain. Very few men with a complete SCI have ejaculations. A small percentage of men with SCI report the feeling of ejaculation but show no outward sign of semen.
Sometimes the spinal cord injury prevents the bladder neck from closing and seminal fluid (semen) will be ejaculated into the bladder instead of out the penis – this is called retrograde ejaculation.
Your specific ability to have an orgasm after SCI is unknown but many people report they are able to have some form of orgasm after their injury. How that orgasm will feel or how your body will react is really up to you to explore and find out.
Here are a few more details depending on level of SCI.
Men with complete upper motor neuron (T11 and above) injuries:
- Reflexogenic erections from touch are possible in most men at this level of injury; however, psychogenic erections from arousing thoughts, sights, or sounds are not usually possible.
- The ability to ejaculate is rare and less than 10% are able to have normal ejaculations (Johnson & Lanig, 1996).
Men with complete lower motor neuron (T12 and lower) injuries:
- Psychogenic erections from arousing thoughts, sights, or sound may be possible but reflexogenic erections from touch are usually not.
- The ability to ejaculate is usually not possible especially if the sacral nerves are involved (Johnson & Lanig, 1996).
Changes in sexual function depend on your level of injury and how complete the injury is. Each person's function is unique and may not fit into the above descriptions.
Having Children and Fertility Issues After SCI
While it is possible for men with spinal cord injury to father children through intercourse, some may struggle. If you and your partner are trying to get pregnant and are having difficulty, consult with your doctor or a fertility expert. Most problems with fertility for men after SCI are related to ejaculation. Working with a fertility specialist will help identify the exact problem and then you can develop a plan to move forward. If this is of interest to you, please contact your doctor for a referral to a fertility specialist for more information and guidance.
Can I Still Have Sex After SCI? What Can Help?
Using Your Brain...
The most important thing to remember is that sexual function and pleasure is mostly psychological. Human beings can experience a great deal of physical damage without losing their sexual desire. People after spinal cord injury can still have a rewarding sex life as they did before injury... unless you tell yourself you can't.
Having sex after spinal cord injury is a lot like having sex for the first time all over again. People who approach sex with an open mind and a willingness to experiment to find out what works and doesn't work after their injury tend to have the most success and reported satisfaction.
There are many parts of your body which can be aroused and provide a pleasant sexual response. These areas of the body are called the erogenous zones and are not limited to the genital area. Some people report the area of their body at the level of their injury is most sensitive and provides stimulation. Using all of your senses can also be helpful. Instead of focusing on what the penis can and cannot do, try experimenting with all of your senses.
- Verbal expressions, sounds or music can set the mood. Imagination can also be powerful. Consider sharing fantasies with your partner.
- Consider watching your partner touch themselves or touch you where you may not be able to feel (a mirror may be necessary). Or try looking at arousing images.
- Consider using scented lotions, candles, incense or perfume.
- Tastes can also be arousing with kissing or oral stimulation. Some people also find certain foods arousing, such as strawberries, chocolate or whipped cream.
- Some people report heightened sensitivity in the areas where they can still feel; explore touching on the head, neck, lips, arms and nipples. Using sexual devices and vibrators can be modified for people with limited mobility.
- For more information about erectile dysfunction, request the Craig Hospital Patient Education Document: Erectile Dysfunction Options for Men with SCI.
- For more information about sexual aides and devices, request a copy of the Patient Education Document: Pleasure Able.
Autonomic dysreflexia (AD) is a rise in blood pressure resulting from a stimulus below your level of injury. You are at risk if you have an injury at T6 and above.
AD is possible during sexual activity. Here are some ways AD can be triggered:
- Rough stimulation of the genital area such as stroking, squeezing, or sucking.
- Using a vibrator for stimulation. Use plenty of lubrication and be gentle.
- Ejaculation, infection, or inflammation of the testicles.
If you experience AD during sex, immediately stop the activity. Call your doctor or 911 if the symptoms do not resolve. You may want to discuss AD with your health care provider prior to having sex to develop a plan in case it occurs.
Care of Bladder and Bowel Issues
- In order to avoid incontinence during sexual activity, don't drink too many fluids beforehand.
- Be sure your bladder is emptied before any sexual activity.
- Stick to a regular bowel program and be sure bowels are taken care of prior to sexual activity.
Damage to skin from shearing, pressure or rubbing can happen during sexual activity. Avoid additional pressure or weight from your partner by proper positioning and padding. Monitor your skin for redness and injury and remove pressure if anything develops. Use plenty of lubrication and be sure to wash and dry the genital area with soap and water before and after sexual activity.
Male Sexual Health After SCI
All men should have regular exams of the penis, prostate and testicles yearly to monitor for changes, problems and cancer. When calling to schedule an appointment, ask if the office and examination table are wheelchair accessible and if staff members can assist with transfers, positioning and preparation for the exam. Remember that sexually transmitted diseases such as herpes, syphilis, and AIDS are still possible - so use protection!
Fears over changes in sexual function after SCI and concerns about satisfying your partner may decrease as you become more comfortable with your body and more aware of your own sexuality. You may find that there are other parts of sexuality that may satisfy you and your partner more. The physical act of sex may not be as important as other aspects of sexuality. Being aware of your partner's likes and dislikes and being able to express yourself are very important to having good communication – an important key to you and your partner having a satisfying sexual experience.
Learn more about Sexual Function for Women After Spinal Cord Injury.
- Firestone, R.W., Firestone, L.A., and Catlett, J. (2006). Sex and love in intimate relationships. American Psychological Association, Washington D.C. Johnson, K.M.M., Lanig, I.S. (1996). Promotion and maintenance of sexual health in individuals with spinal cord injury. In I.S. Lanig (Eds.), Practical guide to health promotion after spinal cord injury (171-202). Gaithersburg, Maryland: Aspen Publication.