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10 February 2004

Female sexual response after spinal cord injury

Sexologist Dr Elna McIntosh addresses common concerns about female sexuality after a spinal cord injury.

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Sexologist Dr Elna McIntosh addresses common concerns about female sexuality after a spinal cord injury.

Lubrication:
For women, a main consideration is proper lubrication. If there is lack of sensation and/or inadequate lubrication in the vagina and in all cases of anal intercourse, a water-based lubricant such as Astroglide should be used. Vaseline or other petroleum-based products increase the chance of infection and will deteriorate and reduce the effectiveness of condoms. Use of lubrication applies whether inserting a penis, a vibrator, or any other object into the vagina or rectum.

Physical management for sexual activity:
Physical management for sexual activity might be needed. Proper bowel and bladder management, including management of catheters and ostomies, management of pain and spasticity, and help with positioning and working around ventilators are possible considerations. Avoiding intense genital or anal stimulation when you have a full bowel will help avoid an unscheduled bowel movement during sexual activity. Emptying your bladder before sexual activity will help avoid voiding during sex. It is a good idea to keep some protective sheets (blue pads or chunks), a towel and a urinal nearby if you are concerned about your bowel or bladder.

Women with indwelling catheters can leave the catheter in during intercourse. For women, the condom can be taped to the lower abdomen. Plenty of water-based lubricant should be used when having intercourse and leaving the catheter in place.

Spinal cord injury (SCI) does not protect you from sexually transmitted infections or HIV/Aids. The use of condoms for all types of intercourse is highly recommended to substantially reduce the risk of transmitting infections.

Conception, pregnancy, delivery:
SCI does not physiologically interfere with a woman’s ability to conceive. Although menstruation (periods) may stop for six to eight months after SCI, it is still possible to get pregnant. Regular menstrual cycles will come back in time. Carrying a baby to term involves similar risks to any pregnancy. However, there is increased risk of bladder infection, pressure sores, hypertension and for women with injuries at or above T6, autonomic dysreflexia. All these risks are manageable with a knowledgeable physician. Balancing and transferring may also present an increased challenge. With regard to delivery, women can deliver vaginally despite lack of voluntary muscle control. Breastfeeding is still a viable option although adaptive equipment such as a sling or harness to help hold the baby may be necessary.

Parenting:
Regardless of how you have a baby, if you want to be an active parent, you can. An occupational therapist can help you choose the adaptive equipment (accessible cribs, changing tables, carrying slings, etc) you may need. If you are already a parent of a child who can manage their own personal care, you can still play an active role in parenting your child by giving love, support and direction and finding mutual ways to have fun together.

Contraception:
All options are available to couples interested in contraception. However, a few carry increased risks or may present some physical difficulty using. The intrauterine device or IUD presents increased risks of urinary tract infections and there is decreased ability to self-monitor for perforated uterus or infection for women with loss of sensation. Diaphragms may present a problem with insertion and atrophy in the muscles surrounding the vagina may create a problem with fit and decrease the efficacy of this method. A partner can assist in inserting the diaphragm if you are both comfortable with the situation.

Oral contraceptives (hormonal methods such as the pill) were once believed to present increased risk of deep vein thrombosis (blood clots) for women with SCI. However, this is questionable with newer low-dose oestrogen or progesterone only contraceptives. Depo Provera (three-monthly) and Nur-isterate (two-monthly) contraceptive injections are very convenient as the patient stops menstruating. Women should consult a health care professional familiar with SCI to help them choose the best method. The male condom in conjunction with a contraceptive jelly is still one of the easiest and safer contraceptive methods and it helps prevent the transmission of infections.

Sensation:
Unfortunately, we can’t restore sensation to parts of the body affected by SCI. However, there are commonly used techniques to help increase awareness to areas of our body where sensation is still intact and where we may be open to sexual stimulation. Three options for increasing sexual communication and sexual pleasure are: sensate focus exercises described by Masters and Johnson (1970), pleasure mapping described by Dr Stubbs (1988) and charting your personal extra-genital (areas besides your genitals that may bring sexual pleasure) matrix described by Drs Whipple and Ogden (1989). These are all ways to explore various parts of your body including your head, hair, face, ears and neck; your chest, breasts, nipples, abdomen; your back, buttocks, arms, underarms, hands, fingers, legs, feet and toes.

Exploration can include using different kinds of touch with the hands like stroking, rubbing, squeezing; different kinds of touch with the mouth like kissing, sucking, nipping; incorporating lotions, oils and powders, feathers, silk or even a vibrator. It is best to set time aside to explore a certain portion of your body, say from the shoulders up. During that time just focus on stimulation to the chosen area without any plans of moving to any other areas or of having sexual intercourse. These exercises place the emphasis on intimacy and pleasure versus the goal of performance and orgasm.

These exercises are not specific to people with SCI. Everybody has the potential for sexual growth through these activities. Sexual pleasure adds to quality of life for everybody, including people with SCI.

Sexual pleasure:
It is of importance to note the self-reported incidence of orgasm in people with SCI is consistently around 50%. As mentioned earlier, reports of orgasm have not been strongly associated with level or completeness of the SCI. Many people report an area of hypersensitivity above the level of injury that when stimulated, results in sexual arousal and sometimes orgasm. Other people report having orgasms as the result of stimulation of the ears, neck, breasts or through fantasy. Orgasm in people with SCI usually requires a much longer period of stimulation than before injury. It is also important to note that the majority of people with SCI report sexual satisfaction even if they do not experience orgasm. – (Dr Elna McIntosh, sexologist, Health24)

Adapted from Tepper M.S. (1997) Providing comprehensive sexual health care in spinal cord injury rehabilitation: Continuing education and training for health care professionals. Huntington, CT, Mitchell Tepper

 
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