Introduction

Spinal cord injury (SCI) causes significant disruption to many areas of a person’s life, including sexual health. Sexual function for both men and women following SCI varies significantly depending on their level and the severity of injury (Ekland et al. 2008; Krassioukov et al. 2017; Sipski et al. 2006; Taylan et al. 2019; Krassioukov & Elliott 2017). Sexual health has physiological, psychological, and social dimensions that can change throughout the lifespan; it is considered a basic human right by the World Health Organization and it is a significant component of a person’s overall health and wellbeing (Butler 2003). Population-based studies have shown that the prevalence and predictors of sexual difficulties are closely associated with diminished quality of life (QOL) (D’Andrea et al. 2020b; New 2018). The effects of a SCI on sexual functioning (e.g., ability to engage in sexual activities, sexual intimacy and relationships; sexual self-view, and fertility and reproductive health) can be categorized in the following way:

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) Typically, people with SCI below L2 are capable of psychogenic arousal (sensory stimulation including dreams or fantasies), whereas those with lesions above T11 are capable of reflexogenic arousal (direct touch or stimulation – e.g., urinary care in a man with tetraplegia may cause an erection) (Biering-Sorensen et al. 2015).
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 (PTSD), 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.

(adapted with permission from Stevenson and Elliott, 2007).

Anderson (2004) surveyed 681 people with SCI (approximately 25% were female) asking what “gain of function” was most important to their quality of life. For most people 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. Yet, insufficient medical research has been performed in SCI to provide a great deal of evidence-based information to guide clinical sexual health practice (Biering-Sorensen & Sønksen 2001; Deforge et al. 2005; Longoni Di Giusto et al. 2022). Several authors have highlighted the lack of attention given to this area and the resulting dissatisfaction within the SCI community (Anderson 2004; Kennedy 2006; Tepper 1992; Tepper et al. 2001). Thus, current sexual health clinical practice has limitations as it is primarily based on results from case reports and observational studies (with some areas like erectile dysfunction in men with SCI having a larger body of evidence). Possibly due to this general lack of evidence, many rehabilitation professionals may feel uncomfortable discussing sexual issues, not confident enough to deliver the best care to their patients, and are not adequately trained to do so (Herson et al. 1999; Booth et al. 2003; Longoni Di Giusto et al. 2022; Post et al. 2008).

This review summarizes the 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, observational studies, and expert opinion have also been included. Within this module, ‘women’ refers to persons assigned female at birth whereas ‘men’ refers to individuals who are assigned male at birth. We acknowledge that gender and sex extend beyond the binary, however, in this module we will use ‘men’ and ‘women’ as this is how original studies reported their findings.