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Introduction

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Spinal cord injury (SCI) causes significant disruption to many areas of a person’s life, including sexual health. Sexual health is considered a basic human right, and is a significant component of a person’s overall health and wellbeing (Butler 2003). It has physiological, psychological and social dimensions that cross the lifespan of the human experience. Population-based studies have shown that the prevalence and predictors of sexual difficulties are closely associated with diminished quality of life (QOL) (Laumann et al. 1999). The effects of a SCI on sexual functioning; ability to engage in sexual activites; sexual intimacy and relationships; sexual self-view, and fertility and reproductive health can be categorized in the following way (adapted with permission from Stevenson and Elliott, 2007):

  1. Direct effects of the SCI on motor, sensory and autonomic pathways which alter sexual response specifically: genital sensation; arousal (erection in men and vaginal lubrication and engorgement in women); ejaculation in men, and sensation of orgasm in men and women)
  2. Indirect effects of the SCI such as sensory or motor alterations, bladder and bowel changes, spasticity, fatigue, psychological issues such as anxiety/depression/post traumatic stress disorder, chronic pain, autonomic dysreflexia, and alterations in sexual self-view.
  3. Iatrogenic effects of treatment (e.g. surgery and/or side effects of medications).
  4. Contextual influences, such as the effect of a SCI on relationships, one’s roles and responsibilities in the family unit of culture, and the situational and societal components of the ups and downs of living with a SCI.

 

In 2004, Anderson surveyed 681 participants (approximately 25% were female) asking what “gain of function” was most important to their quality of life. For the majority of individuals with paraplegia, regaining sexual function was rated the highest priority. For those with tetraplegia, sexual function was rated as the second highest priority, after restoration of hand and arm function.

In contrast to the priority given to sexuality by people with SCI, insufficient medical research has been performed in this area to provide a great deal of evidence-based information to guide clinical sexual health practice (Biering-Sorensen & Sonksen 2001; Deforge et al. 2005). Several authors have highlighted the lack of attention given to this area and the resulting dissatisfaction within the SCI community (Tepper 1992; Tepper et al. 2001; Anderson 2004; Kennedy et al. 2006). Current sexual health clinical practice has limitations since it is primarily based on results from case reports and observational studies, with some areas (such as erectile dysfunction in men with SCI) having a larger body of evidence.  Adding to the problem is the fact that rehabilitation professionals may feel uncomfortable discussing sexual issues and are inadequately trained to do so (Herson et al. 1999; Booth et al. 2003; Post et al. 2008). 

This review attempts to summarize the quality of the literature and main research findings to provide some recommendations for sexual and reproductive clinical practice based on evidence existing currently.  In areas where evidence is lacking, recommendations based on case reports, expert opinion and observational studies are also indicated. The clinician can therefore weigh the recommendations separately.