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 physical act of intercourse is not all that defines your sexuality. When we talk about sexuality, we mean more than what goes on behind your bedroom doors. Sexuality is the intimacy between you and your partner, your preferences, your body image and desires.
The definition above is not usually what most people think of when they think of sex. This is especially true when people have experienced a spinal cord injury (SCI). Some questions that come up are:
- Does my SCI affect my sexual function?
- What kind of physical changes can I expect?
- Will I have orgasms?
- What do I do with my catheter during sex?
- Will I be able to satisfy my partner?
- What about bowel and bladder accidents?
- What are the risks of having sex?
How has SCI affected my sexual function?
A spinal cord injury changes many parts of the body. This is especially true for those body parts that are at or below the level of the injury. SCI can change the way your bladder and bowel function. Your SCI has most likely changed your sexual function as well. This can mean changes in sensation and ability to achieve orgasm. Initially there are also changes in your menstrual period, which can lead to questions about your ability to have children.
Can I still have sex after SCI? What can help?
People after SCI do not lose their sexual desire and can still have a rewarding sex life. 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 also find that there are other parts of sexuality that may satisfy you and your partner more.
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 does not work after their injury tend to have the most success and reported satisfaction.
Many parts of your body can feel good and provide a pleasant sexual response. These areas of the body are called the erogenous zones and are not only in the genital area. Using all of your senses can also be helpful. Instead of focusing on what the body 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.
- Try looking at arousing images.
- Consider using candles, incense or perfume.
- Some people report heightened sensitivity in the areas where they can still feel, explore touch on the head, neck, lips, arms and nipples.
- Some people report increased ability to achieve orgasm through use of vibration. Using sexual devices and vibrators can be modified for people with limited mobility.
- There are many types of vibrators and massagers. They can be helpful to use to explore your sensation and the ability to achieve orgasm.
- Some vibrators that are more readily available include The Fairy Wand, The Magic Wand and The Wahl Massager. For more information about sexual aides and devices, request a copy of the Patient Education document entitled 'Pleasure Able.'
- BE AWARE: the use of vibration can put you at risk for autonomic dysreflexia. Speak with your provider before using vibration. It is important to discuss how to evaluate and manage autonomic dysreflexia.
Orgasm and lubrication
There may be a need for a prolonged period of foreplay before orgasm, but orgasm is still possible. Studies found that 52% of women with SCI were able to achieve orgasm. Orgasm and lubrication depend on level of injury and if the injury is complete or incomplete.
Normally, your vagina will become moist to make intercourse easier. This is called lubrication. Your breasts will also become more sensitive and your nipples will become erect. After a spinal cord injury, your vagina may lubricate less and some women find it takes longer to have lubrication occur. Lubrication can be added by using a water-based, non-petroleum lubricant like K-Y Jelly.
Some water-based lubricants have glycerin in them, which tastes sweet but can sometimes lead to vaginal yeast infections.
Silicone lubricants are another option that are longer lasting and generally feel more natural, less sticky and can be used less frequently. Silicone lubricants do not taste good and should not be used with silicone sex toys as they can bond/stick to the toys. Both of these options are available over-the-counter. Using a lubricant will also help to prevent irritation to the vaginal tissues.
Oil-based lubricants such as baby oil or lotion are not recommended for vaginal use as they can cause bacterial vaginal infections, urinary tract infections and can cause latex condoms to fail.
All of these 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.
What are the risk factors of having intercourse with SCI?
Autonomic dysreflexia (AD): 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 may occur during sexual activity. Here are some ways AD can be triggered:
- Rough stimulation of the genital area
- Using a vibrator for stimulation
- Infection or inflammation of the vagina or uterus
If you experience AD symptoms during sex, immediately stop the activity. Put yourself into a sitting position. Be sure you have also removed all tight clothing, binders and compression hoses. If this does not stop the AD symptoms, call your medical provider or 911. Generally, the AD symptoms will stop after the activity stops.
You may want to discuss AD with your health care provider prior to having sex to develop a plan in case it occurs. If you are prone to AD, it may be wise to have Nitroglycerin Ointment 2% available. Speak with your provider further to get more education on this medication.
Bladder and bowel:
- Be sure to empty your bladder before any sexual activity.
- A suprapubic catheter can be taped to the lower abdomen to keep it out of the way and prevent pulling.
- Stick to a regular bowel program. Do your bowel program before sexual activity so your bowels are empty.
- Use a pillow or wedge under your pelvis to tilt it upward. This will aid in penetration and keep pressure off the bladder and lower bowel.
- Damage to skin from shearing, pressure or rubbing can happen during sexual activity.
- Padding and positioning can help prevent pressure and friction injuries.
- Monitor skin for redness and injury.
- Remove pressure from the area if anything develops.
- Use plenty of lubrication.
- Be sure to wash and dry the genital area with soap and water before and after sexual activity.
Menstrual periods frequently stop for a time after an SCI due to the shock the body has received from the injury. Menstrual periods will usually start again within three to six months. Either tampons or menstrual pads can be used.
- Tampons: Many women prefer tampons because they do not cause skin irritation. They can also provide better protection from leaking during transfers. If you use tampons, change them often, at least three times a day. This will help lessen the risk of toxic shock syndrome. Toxic shock syndrome is a dangerous illness caused by not changing tampons often. If you are having trouble inserting a tampon due to limited hand function or vaginal dryness, try using a lubricated tampon or have a caregiver assist you.
- Menstrual pads: If you use pads, check regularly for signs of skin irritation and pressure marks between your legs. Keep your skin clean and dry to prevent skin breakdown. You will need to be careful with the hygiene products you use.
- Over-the-counter douche products are not recommended. They rinse away normal bacteria that protect your body/vagina from infection. If you have a vaginal infection, an over-the-counter douche can push the infection further into the vaginal canal, even into the cervix and uterus. This could result in a more serious infection.
- Vaginal hygiene sprays are also not recommended. The chemicals in them can irritate the skin and make infections or skin breakdown more likely.
- Vaginal discharge in small amounts is normal. Always report heavy, discolored or foul-smelling discharge to your health care provider.
Birth control and SCI
Women are able to get pregnant after a spinal cord injury, with pregnancy rates similar to the non-injured population. If you do not want to get pregnant, using birth control is a good idea. There are many different types of birth control available and it is recommended that you speak with your gynecologist to discuss the option that is right for you.
- Condoms: When used correctly, condoms can be up to 98% effective in preventing pregnancy. Condoms are the only form of birth control that can also protect against sexually transmitted diseases. These can be used safely for a person with SCI.
- Birth control pills: Birth control pills can be taken after SCI and many women use them. When taken correctly, birth control pills are generally between 91% and 99% effective in preventing pregnancy. However, it is important to know that birth control pills have been linked to a higher risk of developing blood clots in the non-SCI population. Individuals with new onset SCI have a high risk of developing blood clots. This risk decreases after 3 months of being injured. It is not often recommended that combination birth control is used within the first three months of injury, but after this time, it may be an option for you. Other things that make your risk for blood clots high are smoking, obesity and/or being older than age 35. In these cases, your health care provider may recommend a different birth control option.
- NuvaRing: The NuvaRing is a vaginal ring that is inserted into the vagina. It is changed once a month. The NuvaRing is between 91% and 99.7% effective in preventing pregnancy.
- IUDs: Intrauterine devices (IUDs) are implanted plastic or copper T-shaped devices that are inserted into the uterus. On average IUDs are over 99% effective in preventing pregnancy. Your periods can be affected by the type of IUD you use. IUDs have a higher risk of causing pelvic inflammatory disease than other birth control options. Being sexually active with multiple partners may increase this risk. Because you may not be able to detect pain as readily as before SCI, it may be harder for you to know if the device has become dislodged or if there is pelvic pain suggestive of infection. This does not mean this is not the birth control option for you. Discuss your situation with your health care provider to determine what makes the most sense for you.
- Implanted hormonal devices: Implanted hormonal delivery systems are over 99% effective in preventing pregnancy. These devices are small rods containing a form of the hormone progesterone. They are effective in preventing pregnancy for three years. The risk for blood clots is lower than that of birth control pills, but there is still a risk.
- Depo-Provera injection: Injected hormonal birth control option that is given every 12 weeks and is usually injected at your health care provider's office. It is 99% effective in preventing pregnancy. This can increase your risk for blood clots but the risk is less than when taking some birth control pills. Regardless of age, women who use Depo-Provera can experience a loss of bone mineral density that can lead to osteoporosis (which is already prevalent in spinal cord injury).
All women should see a gynecologist for a yearly exam of the cervix, vagina, uterus, ovaries and breasts. This exam will monitor for changes, problems and cancer. When you call to schedule an appointment, ask if the office and examination table are wheelchair accessible. Also ask if staff members can assist with transfers, positioning and preparation for the exam. It is important to know that you can still get pregnant and you can still get sexually transmitted diseases such as herpes, syphilis and AIDS — so use protection!
If you are planning a pregnancy or are pregnant, look for a gynecologist (OB/GYN) who is willing to work with you. Help them understand the causes and treatment of AD so that any AD issues can be managed by this doctor during your pregnancy. (see Pregnancy After Spinal Cord Injury)
- Consortium for Spinal Cord Medicine: Prevention of venous thromboembolism with spinal cord injury. Clinical practice guidelines for health care providers, 3rd ed. Top Spinal Cord Inj Rehabil 2016; 22(3): 209-240
- Sipski M et al. Orgasm in Women with Spinal Cord Injuries: A Laboratory-Based Assessment. Arch Phys Med Rehabil 1995; 76: 1097-102.
- Van Hylckama VA, Helmerhorst FM, Rosendaal FR. The risk of deep venous thrombosis associated with injectable depot-medroxyprogesterone acetate contraceptives or a levonorgestrel intrauterine device. Arterioscler Thromb Vasc Biol. 2010 Nov; 30(11): 2297-300.