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Sexuality and Spinal Cord Injury. Starting over. Why I am involved… . Part of a poem that explains: I would touch you deep inside And join with you on love’s ride Tumbling through passion’s grace And watch the pleasure on your face. Anna Freud said.

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Sexuality and Spinal Cord Injury

Starting over...

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Why I am involved…

  • Part of a poem that explains:I would touch you deep inside And join with you on love’s ride Tumbling through passion’s grace And watch the pleasure on your face

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Anna Freud said...

  • Sex is something you do.

  • Sexuality is something you are!

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Overview of human sexuality...

  • Human beings are curious creatures with an overwhelming need to learn about the world around them - this includes our bodies and our sexuality.

  • Sexuality is life-long learning - as I become more informed, I realize just how much I still don’t know!

  • “I don’t know all about sex, but I am willing to learn.”

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What really is our “sexuality”?There are a number of ways of looking at it. Here goes...

  • a driving, fundamental and vital life force

  • our need to express our sexuality is as basic as our need for food, water and rest

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Sexuality (continued):

  • central to our identity and self-concept

  • Sexuality is our personality - it’s what compels us to discover who we are and drives us to express our own uniqueness

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Sexuality (continued):

  • Who you are as a total person, your…

  • abilities

  • individuality

  • libido (sex drive)

  • specific sex acts you enjoy

  • ability to love and be loved

  • ability to be loveable and capable

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Sexuality (continued):

  • Sexuality is my honest relationship with you -

  • letting down the walls we hide behind

  • being “real” - this allows us to love others

  • no “playing games”

  • sharing personal experiences is exciting, satisfying and very life-affirming

  • being honest affirms your right to be you!

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Sexuality (continued):

  • Is a celebration of life

  • our sexuality is an affirmation of life, of being alive

  • our gift of sexuality is our greatest gift from God

  • sexuality is love and giving of ourselves

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libido (hormone levels)

procreation (making babies)


what sexual acts you enjoy receiving

what sexual acts you enjoy giving

sex is the “glue” in a relationship - it’s helps bond a couple

Sexuality has two components:

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Sexuality…my latest...

  • Involves the timeless desire for both physical and emotional intimacy

  • to feel and give affection and pleasure

  • If you’re healthy, your interest in sex can last your entire life!!

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Sexual Maturity:

  • A relaxed, natural attitude towards sex:

  • unhurried

  • unselfish - being able to delay gratification

  • being aware - “tuned in” to your partner

  • taking time to pleasure your partner (sensuality)

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Men’s and women’s views on sex

  • We approach our sexuality so completely differently -

  • Men - more visually oriented

  • Women - more emotionally oriented

  • Only a generalization - a man uses love to get sex, a woman uses sex to get love

  • Women are looking for the right mood, men are only looking for the right place

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Human sexual development over the life-span:

Or- how did we ever get together?

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Males - body centered


Physical love

90% + masturbation

orgasm-centered sexuality

“sexual peak”

Females - person centered


Sensuous and emotional love

70% masturbation

difficulty transferring masturbation skills to intercourse

Teenage and early 20’s -

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Male sexual response slows - peaked at 18

some impotence

frequency of sexual activity decreases

emphasis changes from quantity to quality

sex becomes more than intercourse

Female sexual response quickens

some become multi-orgasmic

sexual peak in late 30’s or early 40’s

increased frequency of masturbation

conception (or not) a major concern

30’s and 40’s -

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Males - sex and orgasm of less concern

More emphasis on emotional closeness

Men - more nurturing More complete person

Sexual response slows

Erection difficulties

Females - initiates sex more and more consistent orgasms

Women acknowledge their male aspects and enjoy sex more and initiate sex more often

diminished vaginal lubrication

50’s and 60’s - becoming more complete persons!

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70’s and 80’s -

  • Male and female -

  • energy level decreases

  • sexual (physical) response slows further

  • FANTASY life still active

  • health and availability of partner a problem

  • may accept society’s expectations - no sex

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Sexuality and Spinal Cord Injury

  • Some specifics -

  • 10% of the population has some form of disability

  • sexuality and libido not necessarily altered, they’re usually only altered as much as the SCI chooses - and that’s OK!

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Sexuality Services for Disabled

  • Individual Counselling

  • Group Counselling

  • Couples Counselling

  • Sex therapy

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Sexuality Services for Disabled

  • Sex & disability course

  • Access to reading materials

  • Audio-visual materials

  • Group Discussions

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Sexuality Services for Disabled

  • Contraceptive/Genetic Counselling

  • Obstetrical/ Gynecological/ Urological Care

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SCI sexuality -

  • We are mental, physical, spiritual and emotional people - what affects our physical side may affect all.

  • The desire for love, affection and intimacy usually doesn’t change, but the choice of sexual expression might - depending on the level of paralysis

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SCI sexuality -

  • Sexual intercourse is often understood as the accepted means of sexual expression - but with the level of SCI and the physical condition, the SCI person might want to consider OTHER sexual options

  • Poor self-esteem may affect how SCI person feels sexually

  • Being paralyzed (stress) often causes changes in testosterone and progesterone

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Sexual Options for Paraplegics and Quadriplegics - WHY SEX?

  • Sexual release

  • Emotional fulfillment

  • Couples intimacy and togetherness - especially after orgasm

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Sex -

  • NOT just a source of physical and emotional pleasure, but

  • it bonds and validates a relationship

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Healthy Sexuality and SCI

A work in progress...

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Accept personal responsibility -

  • Be honest - present yourself in a way you feel comfortable

  • You didn’t ask to become disabled - don’t apologize. “I didn’t ask to become disabled, but hey, this is who I am now”.

  • “My disability isn’t me - but I do have a disability that sets certain conditions for my life”.e.g.. Bladder infections

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Be clean, hygienic and presentable -

  • It shows that you care about yourself and others

  • it’s an outward sign to those around you that you feel good about yourself

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Communicate -

  • Be open and honest

  • Often you have to take the lead

  • Use “body language” if possible

  • Use facial expressions

  • Improve ability and style through practice

  • People generally want to know what happened - tell them! It’s a beginning.

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Be assertive -

  • In general - Express what you want

  • In particular - Practice to express desires sensitively

  • Sometimes you think you have communicated and you haven’t at all

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Social Skills training -

  • Initiate interactions or acquire the social skills to do so. Practice!

  • Make the first move - others often initially feel awkward around you.

  • “I often feel that it is my responsibility to help others feel comfortable around me”.

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Accept life now!

  • Learn to like yourself and live.

  • Learn to live in the present moment - it’s all we have to work with.

  • Learn to accept “down” days - everyone has them!

  • Realistic expectations of yourself.

  • Spiritual books and videos helped me.

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A satisfying sex life is possible -

  • Learn the basics - fertility - anatomy - sexual options

  • Get the anger out - “God, I’m mad as hell that this happened to me”

  • “God accepts you where you are at today.”

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A satisfying sex life is possible -

  • Get comfortable with the new you.

  • Don’t deny the anger, fear, depression and anxiety - express them verbally and in writing - thus this talk for me!

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A satisfying sex life is possible -

  • Fantasy and imagery

  • Use all the senses

  • Enjoy partner’s pleasure visually, mentally and emotionally.

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Sexual Needs of any person -

  • Amount

  • Intensity

  • Frequency - differ for ALL people

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Sexual Options -

  • MUTUAL willingness to explore new experiences - reciprocal loving

  • Use ALL the senses

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Sexual Options

  • More sexuality in the brain than in the genitals

  • Especially true of spinal cord injured

  • Communication - of thoughts and feelings - is the key!

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Sexual Options -

  • Fantasy and daydreaming

  • Sensate Focus

  • Intercourse

  • Manual stimulation

  • Oral-Genital sex

  • Vibrators

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Fantasy and Imagination

  • With or without a partner

  • Our brain is the largest sex organ - fantasy

  • Catharsis effect - removing something undesirable - esp. no physical orgasm

  • Aristotelian - purification or relief of the emotions through art - writing, drawing, photography etc.

  • Erotic books and videos (cathartic to me)

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Sensate Focus -

  • Couples exercises developed to reduce performance anxiety, fear of failure

  • focus on touching - enjoyable, affirming, sensual and sexual

  • usually three-stage approach

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Sensate Focus - stage one

  • Unhurried, set aside at least one hour

  • Undress

  • Explore partner’s whole body - do NOT touch each others genitals or female’s breasts

  • Sensual touching - learn to enjoy the process, what is happening NOW

  • Cuddle time

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Sensate Focus - stage two

  • Now add genital touching and female’s breasts

  • Orgasm is not the intent now

  • light, teasing erotic touching - using fingers, tongue, vibrator or other sensual things

  • explore and develop orgasmic potential

  • overcome feelings of inadequacy which might accompany SCI

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Sensate Focus - stage three

  • Partner’s orgasm is the main idea - through intercourse or any other sexual option

  • Watch partner masturbate so you learn what brings them to orgasm - communication and trust

  • Feelings of relaxation and assurance

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Orgasm and SCI

  • Orgasm is more a cerebral event

  • Mingling of sensations and the senses

  • Comfortable resolution

  • Partner’s orgasm assimilated, shared

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Orgasm and SCI

  • “fantasized” orgasms

  • still not the same as before

  • satisfaction doesn’t last as long as before, thus may want to make love more often??

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  • Usually tried first (cultural expectations)

  • 25% “success” rate, (i.e. Reflex erection and sufficient penetration to please female partner) Reflex erections don’t last long

  • Sexual positions depend upon level of disability

  • Visually and emotionally important to SCI, usually no genital sensations

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Intercourse (continued)

  • Being “connected” through intercourse is more than physical, it’s spiritual to SCI

  • Being together and sharing yourselves - bonding and intimacy

  • Quality of time spent is important

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Intercourse Positions

  • Depends on strength and degree of paralysis

  • woman on top

  • man on top

  • rear entry

  • side-by-side

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Transfer to bed


transfer to w/c

remove catheter or condom

empty bladder

empty bowel

wash genital area

Transfer back to bed

“OK, honey, I’m ready!” “Am I ever horny!”

Partner is already asleep from waiting up for so long

So much for spontaneous sex!

Intercourse is a pain - much preparation work is needed

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  • Sense of Humour

  • Hygiene - especially for partner

  • Time for preparation

  • Reflex erection

  • “Stuffing” technique by women (women must tighten their pubococcygeal (PC) muscles - also helps maintain the erection)

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25% have pleasing intercourse -

  • Reflex erections don’t last long

  • Spontaneity difficult

  • Bladder and bowel trouble even with correct preparation

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Intercourse “tricks”

  • Vibrator to rejuvenate erection

  • Pillow under hips for better penetration

  • self-stimulation by partner - fingers or vibrator

  • vaginal lubricant - KY jelly, astroglide

  • condom over catheter

  • tape catheter to side or hip

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No Erection?

  • Penile suction devices - “Correctaid” and “Erectaid”

  • dildo or other penis stiffener

  • surgical implant of prosthesis - “small carion” and “Scott” prostheses

  • oral medication

  • small needle injections

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Final thoughts on intercourse -

  • “If coitus is desired and erection is of sufficient rigidity and duration to allow penetration to the partner’s satisfaction, the aim of sexual rehab will have been met”

  • Intercourse requires much effort and planning

  • Shere Hite - only 30% of women orgasm through intercourse on a regular basis

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Manual Stimulation

  • more spontaneous

  • orgasm and holding

  • caressing

  • hugging

  • feeling of “oneness” - ESP. with thumb or finger inside (only the first 1/3 of vagina has sensory nerves, so a thumb is enough)

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  • Study his/her masturbation - a real turn-on for most

  • Learned from sensate focus exercises

  • Use any body part to stimulate clitoris and labia, or glans of penis

  • Men - Insert thumb or fingers into vagina

  • Women - Breasts and buttocks can envelop a penis

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Manual stimulation -

  • gives physical pleasure (orgasm) plus emotional warmth (hugs, caresses) and intimacy (placing thumb in vagina) at same time

  • “I want a lover with slow hands…”

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  • Continuous, gentle stimulation

  • More rapid movement as orgasm approaches

  • To improve chances of orgasm - increase body tension

  • Some enjoy anal touching, it’s sexually pleasing - same muscle group surrounds genitals and anus

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Breasts -

  • Not well understood by most men

  • “Direct hot-line” to the clitoris

  • Can be sucked, kissed and touched while touching the genitals. Many women touch their own breasts while masturbating.

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Shere Hite on manual orgasms -

  • “I get very excited when she orgasms. I feel so good. I feel we are flying…During the orgasms she holds me tightly. That was the best.”

  • “…says she loves me and starts grabbing me, and after…very passionate kisses”

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Disabled person and manual stimulation, a summary:

  • Great pleasure as partner goes from arousal to orgasm

  • Partner’s orgasm is assimilated by SCI to help their “orgasm”. A mental, fantasized orgasm, an easing of tension and and a drowsy relaxed feeling. Still NOT the same as a physical orgasm!

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Oral sex...

Or “Oh, yuck! That’s gross!”

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Oral sex definitions -

  • Cunnilingus - stimulation of a female’s genitals with the mouth

  • Fellatio - stimulation of a male’s genitals with the mouth

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Oral sex positions

  • Again depends on level of injury - but almost all SCI can participate

  • “69” position or female on top for mutual oral sex if desired

  • female on top

  • male on top

  • side by side - use your imagination and get real comfortable

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Oral Sex and Spinal Cord Injury

  • Sometimes seems disgusting - at first - to the uninitiated (hygiene and body fluids)

  • highly pleasurable

  • Lonnie Barbach, 1986 - # 1 for AB men (e.g.. Prostitutes) #2 for AB women (most women don’t get oral sex - common among university graduates, but not for high school graduates - U.S. study)

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Oral sex and spinal cord injury

  • Common sexual expression for SCI - because we can and it’s highly pleasurable

  • mouth, lips and tongue are very sensitive (while the rest of your body is paralyzed)

  • touch, taste, temperature, texture and smell of partner are very pleasurable for SCI

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Oral sex and spinal cord injury

  • SCI become more sensitive in areas we can feel - we can receive good feelings

  • partner likes the softness and wetness of the mouth and tongue

  • watching your partner and involving yourself give real pleasure to SCI

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Oral sex

  • Most men enjoy cunnilingus and fellatio

  • Most women enjoy cunnilingus

  • Most women enjoy fellatio - but must talk with the man about his orgasm. Some like the salty ejaculate and some don’t

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What happens with oral sex?

  • Closeness, bonding, intimacy and love

  • I think because of vulnerability in asking for oral sex

  • Trust, openness and honesty needed

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Shere Hite on male sexuality...

  • “Loved the tenderness and kissing afterwards”

  • For some SCI this is the best time - the emotional closeness

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Shere Hite

  • “Oral sex with a woman is my favorite of all. I feel a great closeness, a deep feeling of intimacy. I feel that she trusts me fully.”

  • “I adore the texture, feel and taste and also the lovely way a woman seems to respond… There seems to be a very open feeling between us.”

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Oral sex summary...

  • Highly pleasurable

  • Trust and openness

  • Love bonds

  • SCI actively involved with all senses

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or “Can’t a real man do a better job?”

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  • Expand the range of sexual expression and sensation

  • Some embarrassment at first sometimes

  • May be only option available to some severely disabled

  • Provide gentle, precise and continuous stimulation to the glans and clitoris

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Who uses them?

  • Enlightened

  • Adventurous

  • Secure

  • Progressive

  • Informed, intelligent and educated (say research studies)

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  • You can’t get “hooked” on a vibrator

  • Using a vibrator does NOT make you a pervert

  • Your relationship isn’t “on the rocks”

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  • Are being talked about more openly - especially female comics

  • Available at specialty sex stores - Cynthia’s

  • Plastic and latex - battery operated

  • “Massagers” - usually more powerful and use electricity

  • Used by men and women for masturbation - sexual feelings are intense and quickly felt

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  • Can make some women orgasmic

  • Why? - steady, concentrated pleasing rhythm

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  • Can become a regular sexual option

  • Used while also kissing the breasts

  • Inserted into vagina

  • Used on anal area at same time as genitals

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Vibrators - conclusion

  • Almost “guaranteed” orgasm because of nature of strong, steady accurate sensory input

  • Great for SCI use, especially if tired or weakness

  • Even quadriplegic hands can hold a vibrator

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Conclusion to “Sexual Options”

  • Making love is a total body, mind and spirit experience

  • Can be enjoyed by all disabled and their partners

  • manual stimulation, oral sex and vibrators - much more spontaneous than intercourse

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Conclusion for “Sexual Options”

  • Pleasurable emotional release of stress and tension

  • Psychologically satisfying and necessary

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Male sexuality -

  • “Men tend to judge the success of their relationship by the quality of their sex life.”

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Male sexuality and SCI

  • 80% of spinal cord injured (SCI) are men

  • Erections are mostly “reflex”

  • “Psychogenic” erections are rare

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Spinal cord injuries -

  • Two types - complete and incomplete

  • Two types - Upper Motor Neuron (UMN) & Lower Motor Neuron (LMN)

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Erections -

  • Complete UMN - more reflexogenic erections of longer duration than LMN injury

  • Incomplete UMN & LMN - more psychogenic erections possible

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Spinal Routes -

  • C1 - T12 intact necessary to achieve a reflexogenic erection - or -

  • If complete above T12 chances of reflex erection good

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Spinal routes -

  • If complete lesion below T12 perhaps no reflex erection, but possible psychogenic erections

  • If complete below S2 - S4 emission and ejaculation possible

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Spinal routes -

  • If incomplete - reflex or psychogenic erections possible

  • Must experiment to see what is possible

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Erection problems -

  • Usually of short duration

  • 25% report satisfactory intercourse

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Erection answers -

  • “Stuffing” technique

  • Kegel exercises

  • Vacuum devices - with band

  • Vacuum devices - “Correctaid”

  • Penile Implants

  • Injections

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Fertility -

  • 0 - 10% SCI able to collect sperm

  • George Szasz (1985) - 10 - 20%

  • UMN less able than LMN

  • WHY? - no emission or retrograde ejaculation

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Sperm -

  • Poor motility

  • poor morphology

  • low sperm count

  • urine spermicidal

  • testicular damage over time

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Ejaculation Aids -

  • Read “Brindley” and “Szasz”

  • Vibrators

  • Electostimulation or electroejaculation

  • Penile injections

  • Intrathecal Neostigmine injections