- Sexuality has a significant impact on interpersonal relationships and psychological well-being.
- Up to 50% of patients with moderate to severe TBI report sexual problems.
- Sexual disorders in TBI are closely dependent on the damaged brain area.
- TBI patients and their caregivers should be provided with information useful to achieve a better sexual health.
Posts Tagged sexual dysfunction
By Kathryn Farris, OTR/L • Marisa King, PT, DPT • Monique R. Pappadis, MEd, PhD • Angelle M. Sander, PhD
Sexual dysfunction is a problem for 25% to 50% of persons with
traumatic brain injury (TBI) at one or more years post-injury
(Downing, Stolwyk, and Ponsford, 2013; Sander et al., 2012).
Dysfunction can occur at the stages of desire (Downing et al., 2013;
Sander et al., 2012; Strizzi et al., 2015), arousal (Sander et al., 2012;
Strizzi et al., 2015), and orgasm (Downing et al., 2013; Sander et
al., 2012; Strizzi et al., 2015). Sexual dysfunction after TBI can result
from damage to parts of the brain involved in regulating sexual
function, including the frontal lobe, temporal lobe, and subcortical
structures (Sandel, Delmonico, and Kotch, 2007). TBI-related
disruption of neurotransmitters and the neuroendocrine system also
impact sexual function (Behan et al., 2008).
TBI-related changes in physical, cognitive, emotional, behavioral,
and social functioning can impact sexuality. Physical changes
include spasticity, hemiparesis, balance/vestibular dysfunction, and
impaired sensation (Gervasio and Griffith, 1999). Cognitive deficits
can also negatively impact sexual function (Aloni and Katz, 2003).
For example, impaired attention and concentration can affect a
person’s ability to stay focused during a sexual encounter or become
aroused. Impaired initiation and planning can affect relationship
building and frequency of sexual activity. Reduced abstract thinking
and cognitive flexibility can limit ability to fantasize, impacting sexual
arousal. Memory impairments can result in an excessive demand for
sexual activity that can be distressing to partners. Impaired social
communication can result in decreased empathy, reduced ability to
read and respond to non-verbal behavior in others, and problems
perceiving emotions (Zupan et al., 2014).
Depression and anxiety, which occur frequently post-TBI (Osborn,
Mathias, and Fairweather-Schmidt, 2014, 2016), can inhibit
sexual desire and arousal. While hypersexuality is not as common
as hyposexuality after TBI (Simpson, Sabaz, and Daher, 2013),
disinhibition and impulsivity contribute to decreased self-monitoring
of sexual behavior in some people (Bezeau, Bogod, and Mateer,
2004). TBI can negatively impact social relationships, leading
to marital dissatisfaction and/or reduced relationship quality
(Hammond et al., Davis et al., 2011; Kreutzer et al., 2007). Reduced
social participation or social isolation is common following TBI and
contributes to sexual dysfunction (Sander et al., 2013).
Medication side effects also contribute to sexual problems. Many
drugs used to facilitate sleep and reduce cognitive and emotional
changes after TBI can have negative side effects on sexual
function (Aloni and Katz, 2003; Moreno et al., 2015) Examples
include anticonvulsants, selective serotonin reuptake inhibitors,
serotonin antagonist and reuptake inhibitors, dopamine agonists,
acetylcholinesterase inhibitors, stimulants, and baclofen.
[Abstract + References] Changes in sexual functioning following traumatic brain injury: An overview on a neglected issue
Traumatic brain injury (TBI) is any damage to the skull and/or the brain and its frameworks due to an external force. Following TBI, patients may report cognitive, physiological and psychosocial changes with a devastating impact on important aspects of the patient’s life, such as sexual functioning. Although sexual dysfunction (SD) occurs at a significantly greater frequency in individuals with TBI, it is not commonly assessed in the clinical setting and little information is available on this crucial aspect of patients’ quality of life. As the number of people with TBI is on the rise, there is a need for better management of TBI problems, including SD, by providing information to patients and their caregivers to achieve sexual health, with a consequent increase in their quality of life. Discussing and treating sexual problems in TBI patients enters the framework of a holistic approach. The purpose of this narrative review is provide clinicians with information concerning changes in sexual functioning and relationships in individuals with TBI, for a better management of patient’s functional outcomes and quality of life.
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Summary: Experts raise awareness of neurosexuality challenges faced by patients with neurodisabilities, including members of the LGBTQIA+ community, and provide guidance for healthcare providers and caregivers.
For people with brain disorders, whether from injury or disease, rehabilitation is a complex process. Neurosexuality is an emerging area of study and practice that focuses on the relationships between brain and sexual function in individuals with and without neurological disorders. Experts on the subject, reporting in NeuroRehabilitation, discuss how sexuality can affect neurorehabilitation in patients suffering from a range of conditions, from stroke and spinal cord injuries to sexual behavior in patients with dementia.
Research addressing the relationship between sexuality and the brain has a long history in neurological and behavioral sciences. This increased awareness has led to a better understanding within the scientific community regarding the importance of sexuality as a health outcome to promote the quality of life of individuals with neurodisabilities.
“This thematic issue of NeuroRehabilitation emphasizes that neurosexuality care should be driven by a transdisciplinary approach to appraise the evidence base of the potential negative consequences of different neurodisabilities on sexuality and to build upon sound treatment strategies to address these complexities,” explained guest editors Alexander Moreno, PhD, Caron Gan, RN, MScN, RP, AAMFT, and Nathan D. Zasler, MD.
An important contribution to this issue advocates for changing the culture of neurodisability through language and sensitivity of providers in order to create a safe place for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and people with other sexual orientations and forms of gender expression (LGBTQIA+). “The particular needs of LGBTQIA+ individuals living with a neurological disorder are neglected in clinical practice and research. The invisibility of LGBTQIA+ individuals with neurological disorders reflects the historical exclusion of marginalized identities and creates disparities of access to healthcare,” explained Alexander Moreno, PhD, Faculty of Human Sciences, Department of Sexology, Université du Québec à Montréal (UQÀM) and the Center for Interdisciplinary Research in Rehabilitation of Greater Montreal, Ari Laoch, MS, Virginia Commonwealth University, and Nathan D. Zasler, MD, Concussion Care Centre of Virginia, Ltd. and Tree of Life Services, Inc. (VA).
The invisibility of LGBTQIA+ individuals with neurological disorders translates into diminished quality of care or inappropriate care, lack of recognition of all family configurations, exclusion of family caregivers, and violations of human rights (e.g., the right to be treated with dignity). Shedding light on the diversity of individuals with neurological disorders has the potential to improve healthcare by helping rehabilitation professionals to be sensitive to the particular needs of LGBTQIA+ individuals. In addition, the results of this study help promote the inclusion of sexual and gender diversity in the curricula of future practitioners and delineate future directions for research. Most importantly, the current study provides concrete clinical recommendations aiming to orient healthcare professionals wanting to improve their practice.
The authors surveyed the literature concerning neurological disorders affecting LGBTQIA+ individuals. They found that the relative neglect of LGBTQIA+ individuals with neurological disorders in clinical practice and research is striking. Healthcare professionals working with individuals with neurological disorders have the responsibility to create safer spaces in their clinical practice, including the use of inclusive language, the modification of admission forms to reflect diverse realities, the inclusion of sexual orientation and gender identity in their institutional policies, and participate in continuing education to challenge misconceptions, stereotypes, and negative attitudes. The authors provide 20 recommendations to guide clinicians, researchers, and policy professionals about the care of the LGBTQIA+ community.
Moreno, Laoch, and Zasler emphasized that “being part of a positive change in the rehabilitation of LGBTQIA+ people with neurodisabilities is part of our obligation as healthcare providers who are self-reflective, critical, and willing to improve the quality of the services provided in an ethical framework.”
Additional contributions to the issue cover a variety of important topics.
Sexual Health After Pediatric Acquired Brain Injury (ABI)
The authors reviewed over 2000 studies and found that literature about sexuality in children and adolescents with ABI has mainly addressed physical issues (e.g., precocious puberty), with positive sexual health needing further development in topics such as body image, sexual orientation, and social competence including flirting, dating, and romance.
Sexual health after traumatic brain injury (TBI) in younger and older adults Sexual problems were more likely for older (average mid-40s) patients with TBI than for younger (average 30s) patients. Older patients showed lower sexual desire and suffered more from anxiety and depression. Younger patients did not exhibit these symptoms to the same degree, suggesting that clinicians should be aware of age differences when treating their patients.
Stroke and Sexual Functioning
A literature review of post-stroke sexual functioning describes how various dysfunctions are related to stroke location, laterality, and physical and psychological changes. Three programs are presented to address post-stroke rehabilitation.
Multiple Sclerosis (MS) and Sexual Dysfunction
For patients with MS, assessment and treatment of sexual dysfunctions are described, including sexual assessment tools especially for MS. The authors also explore related topics including relationships, fertility, pregnancy, and parenting issues. They emphasize that, like other neurological disorders, there is a need for more collaboration among providers in addressing sexual concerns in MS.
How perceptions of sexuality in individuals with amyotrophic lateral sclerosis (ALS) can affect care
Surveys of both patients with ALS, also known as Lou Gehrig’s disease, and ALS care providers revealed uncomfortable feelings when the subject of sexuality was raised. The authors call for more education among ALS specialists in sexuality and a policy change that guarantees the inclusion of sexuality in their guidelines.
Sexual Concerns After Spinal Cord Injury (SCI)
SCI can impact sexual response, male infertility and its treatments, as well as pregnancy issues. The authors emphasize the importance of providing education and specific sexual recommendations based on the individual’s remaining sexual potential, and to include their partners, when available. They also present basic and advanced treatments for sexual dysfunctions and discuss other challenges in the management of sexual dysfunction of individuals with SCI.
Studying Intimacy And Sexuality In Clients With Dementia
Obtaining consent to study individuals with cognitive impairment is a controversial topic. In the environment of a residential care facility, the authors propose a multi-step approach involving authorized representatives (e.g., family caregivers), professional caregivers working in the facility, a pre-consent phase, a consent presentation phase, and a final consent before data collection. Their reflections and suggestions illuminate the ethical challenges involved in the study of sexuality and intimacy in individuals with severe cognitive impairment.
In summary, the guest editors write, “We hope that this thematic issue provides an impetus for rehabilitation and other health professionals, students in the health sciences, and researchers to develop their competence and awareness of the importance of sexual neurorehabilitation in persons with neurodisabilities.”
- Neurosexuality Needs to Be Better Addressed in Patients with Neurodisabilities – Experts raise awareness of neurosexuality challenges faced by patients with neurodisabilities, including members of the LGBTQIA+ community, and provide guidance for healthcare providers and caregivers.
- Trump Administration Proposes to End Data Collection on LGBT Elders and People with Disabilities – Proposed removal of sexual orientation question from National Survey of Older Americans Act Participants and sexual orientation and gender identity fields.
- Title IX Retaliation Lawsuit Against School In Disabled Student Wrongful Sexual Assault Investigation – Drake University wrongfully expels disabled male student then retaliates against father for speaking out.
- IntimateRider Sex Aid for People with Disability – IntimateRider products are designed for adults with physical disabilities, including spinal cord injuries, muscular dystrophy, cerebral palsy or arthritis.
- Landmark Transgender Case Challenges Constitutionality of ADA Exclusion – Constitutionality of Americans with Disabilities Act is being challenged in court regarding exclusion of transgender people.
- From our LGBT Disability section – Full List (7 Items)
[ARTICLE] Effectiveness of a structured sexual rehabilitation programme following stroke: A randomized controlled trial – Full Text
Background: Sexual activity is an integral part of life; it is important to address sexual health after stroke, but this is often poorly done.
Objective: To assess the effectiveness of a structured sexual rehabilitation programme compared with written information alone regarding sexual and psychological functioning (anxiety, depression, stress), functional independence and quality of life in an Australian stroke cohort.
Methods: A total of 68 participants were randomized to a structured sexual rehabilitation programme (treatment group; n = 35) or to written information alone (control group; n = 33). Outcome measures included: Sexual Functioning Questionnaire Short Form; Depression, Anxiety Stress Scale; Functional Independence Measure, and Stroke and Aphasia Quality of Life Scale-39 Generic. Assessments were performed at baseline, 6 weeks and 6 months after the intervention. Participant’s preferences regarding how they would like to receive information, who from, and how frequently, were collected at baseline.
Results: There was no difference between groups for any outcome measures. Half of the participants (51%) wished to receive information and were divided equally into preferring written information vs face-to-face counselling, with the majority (54%) preferring information after discharge from an inpatient setting.
Conclusion: Provision of written information alone appears to be as effective as a 30-min individualized sexual rehabilitation programme in an inpatient setting. Further research is needed regarding longer term outcomes and outpatient settings.
Stroke is a leading cause of death and disability (1). Sexual dysfunction is common after stroke, and has multifactorial causes: damage to the brain (causing decline in sexual desire/interest and coital frequency for both sexes, decline in vaginal lubrication and orgasm in females, and in erection and ejaculation in males, and physical changes, such as hemiplegia with resulting impairment of mobility) together with medical issues, such as medications and premorbid medical conditions (diabetes, hypertension, cardiac issues) and psychological factors (fear of new stroke, loss of self-esteem, role/relationship changes) are major contributors (2–5).
Sexuality is a broad concept and may be experienced and expressed in a variety of ways; including thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles, and relationships (6). Sexual activity is an integral part of life and the importance of addressing sexual health after stroke is well accepted (7). Despite this, it is common for sexuality to be poorly addressed, not just in stroke, but also in other neurological conditions, such as spina bifida (8) and spinal cord injury (9). The 2012 Australian National Stroke Audit Rehabilitation Services Report (10), which included 2,789 post-stroke patients across 111 Australian public and private hospitals, showed that only 17% of patients received information on sexuality. This is despite the opportunities provided through the staffing complement in rehabilitation settings. In practice, allied healthcare providers could have a primary or secondary role in sexual rehabilitation; they could be the sole providers of intervention or provide further intervention in their specific areas of expertise, such as physiotherapy training to optimize mobility in bed for sexual positioning, nursing education for catheter management, and dyspraxia training with speech therapy for sexual activities such as kissing. In addition, although current guidelines recommend the assessment and management of post-stroke sexual dysfunction (7), it is unclear what types of intervention (timing, content, intensity, setting) should be provided and how effective they are. The only intervention study currently available in the literature that addresses the impact of intervention on sexual activity following stroke suggests that a sexual rehabilitation intervention programme prior to hospital discharge increased sexual satisfaction and frequency of sexual activity one month post-discharge, but did not promote sexual knowledge (11). This study was conducted with culturally homogenous 40–49-year-old Korean couples and had significant methodological limitations (generalizability, pre-post design, and short follow-up). Patient’s preferences relating to sexual counselling, such as the timing of such counselling, also varied, creating further challenges for optimization of care (12, 13). Some studies show that most participants feel overwhelmed in the early adjustment period and that the best time to address sexual adjustment issues is towards the end of an acute rehabilitation hospitalization or shortly after discharge. In a pilot randomized controlled trial (RCT) conducted in 2014, the feasibility and importance of providing sexual rehabilitation following stroke was demonstrated; however, the “pilot” nature of the study did not allow for conclusive findings to be drawn (14).
The primary aim of this RCT was to assess the effectiveness of a comprehensive structured sexual rehabilitation programme compared with written information alone, on sexual and psychological (anxiety, depression, stress) function, and on functional independence and quality of life in an Australian stroke cohort. Building on the previous pilot RCT, to our knowledge this will be the first adequately powered RCT in this area. The findings will provide evidence that may lead to improved care.
[Abstract] A Multicenter Study of Sexual Functioning in Spouses/Partners of Persons With Traumatic Brain Injury.
To investigate sexual functioning and its predictors in spouses/partners of persons with traumatic brain injury (TBI).
Inception cohort survey.
70 persons with complicated mild to severe TBI admitted to one of six participating TBI Model Systems inpatient rehabilitation units and their spouses/partners who were both living in the community and assessed 1 year after injury.
Main Outcome Measures
Derogatis Interview for Sexual Functioning Self-Report (DISF-SR); Global Sexual Satisfaction Index (GSSI).
20% of spouses/partners of persons with TBI reported sexual dysfunction and 44% reported dissatisfaction with sexual functioning. 62% of spouses/partners reported a decrease in sexual activity during the year post-injury, 34% reported a decrease in sexual drive or desire, and 34% indicated that sexuality was less important in comparison to pre-injury. The sexual functioning of spouses/partners of persons with TBI was highly associated with the sexual functioning of the person with TBI. Age of spouse/partner and sexual functioning in persons with the TBI were significant predictors of spouses/partner’s sexual functioning, even after controlling for gender of partner and the physical, cognitive, participation, and sexual functioning of the person with injury.
Conclusions and Implications
Greater sexual dysfunction in spouses/partners was associated with older age and with poorer sexual functioning in the person with injury. Rehabilitation professionals should provide education on the potential impact of TBI on sexual functioning for both persons with TBI and their spouses/partners and integrate the assessment of sexual functioning into their clinical assessment, making appropriate referrals for therapy.
List of abbreviations:
DISF (Derogatis Interview for Sexual Functioning), DISF-SR (Derogatis Interview for Sexual Functioning Self-Report), DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV), FIMTM (functional independence measure), GCS (Glasgow Coma Scale), GSSI (Global Sexual Satisfaction Index), PART-O (Participation Assessment with Recombined Tools – Objective), TBI (Traumatic Brain Injury), TBIMS(Traumatic Brain Injury Model Systems)
Talking about sex is hard for many people in general. Surviving a stroke and experiencing sexual dysfunction can add to the uneasiness of the subject. Part of getting back into a normal routine and life involves resuming a healthy sex life. The need to love and be loved, and to have the physical and mental release sex provides, is important.
more —> Sex and Sexuality | Stroke.org.