Sexual Satisfaction
Discussion
Sexual satisfaction and desire can change after SCI (Acosta-Santillán et al. 2023; Fisher et al. 2002; Kennedy et al. 2006; Lopes et al. 2022; Mendes et al. 2008; Sharma et al. 2006). Many found that sexual desire remained the same (47.2% of people) and some decreased (33.7% of people) (Longoni Di Giusto et al. 2023). Protective factors of sexual satisfaction and reducing sexual dysfunction include fixed partners, masturbation, and sexual intercourse (p<0.05). Physical and emotional changes affected individuals the most (Longoni Di Giusto et al. 2023) but Zanin et al. (2022) found no significant contributions from physical changes to sexual activity. A small study found that exercise intervention increased sexual interest and satisfaction slightly at three timepoints (Pebdani et al. 2020). In a survey study, 77.6% of participants discovered new erogenous zones that can provide sexual and sensual pleasure after SCI (Longoni Di Giusto et al. 2023).
Injury Characteristics
People with lower levels of injury generally experienced less disruption of sexual interest and satisfaction. Acosta-Santillán et al. (2023) found that thoracic patients (27.3) had a lower mean SLQQ score than lumbar patients (63.4) (p<0.001), and that thoracic patients are 8 times more likely to develop sexual dissatisfaction than lumbar patients (p<0.001). Similarly, Scholten et al. (2018) found that individuals with more severe injuries often had lower sexual satisfaction. Clinically, this could mean that higher level of injuries may require different approaches or more customization to achieve sexual satisfaction.
Male Sexual Satisfaction
Men had less satisfaction with their new sexual life after SCI; two studies show that erectile dysfunction was the most impactful factor (p=0.0003) (D’andrea et al. 2020b; Miranda et al. 2016). Interestingly, Miranda et al (2016) also found that men who were more dissatisfied with their sexual life had lower total testosterone (266ng/dL vs 408ng/dL). Not surprisingly, one study found that monthly frequency of sexual intercourse (OR: 11.3), and orgasmic function (OR: 7.1) were positively associated with satisfaction (Ferro et al. 2019). Moreover, men had greater sexual dysfunction in relation to satisfying their partner after SCI such as decrease sexual desire (28.8%), lack of confidence for partner seduction (38.3%), dissatisfaction of foreplay (48.8%), and frustration with partner’s sexual satisfaction (54.6%) (Miranda et al. 2016). One study in India, Sunilkumar et al. (2015) found that strong sexual desire is related to greater depression which is possibly linked to societal expectations and norms for men. These findings suggest that masculinity plays a large role in sexual satisfaction for men following SCI.
Female Sexual Satisfaction
Overall, women were more sexually satisfied than men after SCI (Zanin et al. 2022). Factors that impact sexual satisfaction was lack of genital sensation (p=0.039) and lack of stable partner (p=0.017) (Otero-Villaverde et al. 2015). In their observational study, age, neurological level, time since injury, ASIA score, and spasticity did not show statistically significant differences between women. A comparison study of women with and without SCI, found that married women with SCI are as sexually satisfied as non-SCI controls (Black et al. 1998). There are differences in female and male sexual satisfaction that can be attributed to physical changes following SCI.
Moreno et al. (1995) included sexual parameters in their report of outcome of continent urinary diversion with a catheterized umbilical stoma in women with tetraplegia (n=3). They found that sexual satisfaction improved in the 2 women who were sexually active and body image improved in all 3 women.
Cultural Differences and Sexual Satisfaction
In a study involving South Asian women with SCI, the women reported lack of sexual satisfaction more often than the men (Sharma et al. 2006). Furthermore, women (ASEX Score 21.46) in Turkey reported more sexual problems than men (ASEX Score 15.62) (Ates et al. 2022). Conversely, in two studies of comparing African American and Italian men and women, authors found that the women reported greater satisfaction with their sex lives than the men (Krause et al. 2004; Zanin et al. 2022). Additionally, Sale et al. (2012) found women had significantly more satisfaction than men. It is possible that the variance in sexual satisfaction is affected by cultural differences regarding sex.
Partner Sexual Satisfaction
Following SCI, the changes in sexual function and activity redefine sex for both partners. Barrett et al. (2024) studied partners’ experiences following SCI and three themes emerged: (1) stolen sex through unpreparedness (2) Redefining sex and (3) compromised commitment. One participant highlighted “[Returning] home, finally, after months on the unit. I don’t think we even thought about it before then, there was so much else going on, but then when we realized that this is actually an issue,” the initial shock of feeling unprepared for sexual activity following SCI. Many found compromise or retained initial pre-injury intimacy, others felt stressed regarding sexual performance, worried of hurting their partner, or relearned sex that helps them reconnect their sexual lives.
Conclusion
There are 2 studies with level 5 evidence (Acosta-Santillán et al. 2023; Lopes et al. 2022) that sexual satisfaction decreased after SCI.
There is level 4 evidence (Pebdani et al. 2020) that exercise intervention slightly increased sexual satisfaction and interest.
There is level 5 evidence (Acosta-Santillán et al. 2023) that thoracic patients have lower SLQQ scores than lumbar patients.
There is level 5 evidence (Di Giusto et al. 2023) found that physical and emotional changes affected the participants’ sexual health the most.
There is level 5 evidence (Lopes et al. 2022) that decreased sexual satisfaction was associated with older age, older at injury, and not having sexual counselling.
There is level 5 evidence (D’Andrea et al. 2020b) that men with lower testosterone had lower sexual satisfaction.
There is level 5 evidence (Ferro et al. 2019) that fixed partners, masturbation, and sexual intercourse are protective factors for sexual satisfaction.
There is level 5 evidence (Scholten et al. 2018) that there is at least one person in 81.7% of SCI couples surveyed who felt dissatisfied in their sexual life.
There is level 5 evidence (Smith et al. 2015) that level of sexual function predicted level of sexual satisfaction, that depression was a good predictor of sexual satisfaction in women, and that the lowest sexual satisfaction scores were found in men with SCI.
Discussion
Research shows that sexual function remains important to people after SCI. A systematic review of 24 studies of health and life priorities for persons with SCI determined that motor function, bowel, bladder, and sexual function emerged as the top four functional recovery priorities (Simpson et al. 2012). Two individual studies using community samples showed that the most common significant problem for people with SCI was sexual dysfunction (reported at 41% – New 2016; and 60.8% Park et al. 2016).
Despite the importance of sexual adjustment to overall quality of life, there have been few studies addressing this topic and investigating the effectiveness of interventions on sexual satisfaction and adjustment to SCI. Several studies have reported that the frequency of sexual activity and desire for sexual activity decreases after injury in both men and women (Julia & Othman 2011; Kreuter et al. 2011). The issues that are perceived to affect sexual satisfaction and/or sexual activity are multi-faceted. However, common barriers to sexual satisfaction from the effects of SCI include bladder and bowel problems, as well as other impairments resulting from the severity of injury (e.g., spasticity, lack of mobility) (Biering-Sorensen et al. 2012; Moreno et al. 1995; Anderson et al. 2007). Researchers suggest that improving sexual satisfaction, information, and specific programs during rehabilitation can help women with SCI explore and investigate new erotic possibilities, thereby improving their self-esteem and social relationships (Otero-Villaverde et al. 2015).
