Clinical review

Sexual problems of disabled patients

Clive Glass,  Bakulesh Soni. 

Almost 4% of the UK population have some form of physical, sensory, or intellectual impairmentalmost 2.5 million people. Many of these disabling conditions can produce sexual problems of desire, arousal, orgasm, or sexual pain in men and women. Sexual difficulties may arise from direct trauma to the genital area (due to either accident or disease), damage to the nervous system (such as spinal cord injury), or as an indirect consequence of a non-sexual illness (cancer of any organ may not directly affect sexual abilities but can cause fatigue and reduce the desire or ability to engage in sexual activity).

The two main points for consideration are how disabling conditions affect sexual function and behaviour and which sexual difficulties most commonly arise.

	Effects of disability on sexual function

Top Effects of disability on... Common sexual difficulties

Women who undergo radical mastectomy or a disfiguring trauma often report concerns about their femininity and self image such as feelings of lowered self worth or the fear that men will find them less attractive. Similarly, young men with erectile dysfunction often avoid meeting potential partners because of their embarrassment over their inability to perform.

"Sexuality" describes how people express their view of what is sexual. That awareness is the result of all the physical, emotional, intellectual, and social factors that have influenced their development up to that point in their life. Defining sexuality as wider than just physical function is particularly important for people with disabilities. A person who is not able to use part of his or her body still has an equal right to full sexual expression.

Patients with an impairment that is hidden from others but which affects continence or sexual function often find the situation unbearable (Detail from Boors Carousing (1644) by David Teniers the Younger)

Congenital or acquired disability
Congenital or birth impairments often affect all aspects of sexual development, and lack of privacy and independence in daily living means adolescents often miss out on normal sexual experiences. In contrast, an acquired disability may have different implications depending on when it happened. Impairments early in life often produce low social and sexual confidence, whereas patients who become disabled in adulthood are much more aware of what has actually been lost. While the degree of adjustment to either form of impairment may be no different, the process of adjustment is different. How people view their disability and who they see as responsible for managing the effects of the condition greatly influences their ability to cope.

Hidden impairment
Patients with an impairment that is hidden from others but which affects continence or sexual function often find the situation unbearable. People with spina bifida and perineal paraplegia often walk without apparent difficulty but experience problems with sexual function and with controlling their bladder and bowel. The unpredictability of control often leads them to avoid social mixing, therefore increasing their isolation. People with disabilities often present with low self confidence and a poor body image, and so clinicians should not confuse the severity of a condition with the severity of its impact on the patient.

Deteriorating conditions
In most cases of trauma patients experience a loss that does not deteriorate, such as spinal cord injury or amputation. However, some conditions like multiple sclerosis do deteriorate (in either a stepwise or gradual manner), which requires mental adjustment to the initial diagnosis and to its reappraisal as the condition worsens. Sexual dysfunction may occur in multiple sclerosis initially as a direct result of demyelination of the nerve and may also be the result of indirect effects as the condition deteriorates. There may be problems with other organ systems as well as fatigue, anxiety, depression, and, indeed, altered desire of the patient's partner. Disability services and general practitioners must address the sexual needs of not only the patients but also their partners at times of need.

Mental impairment
Some conditions such as Huntington's chorea and traumatic brain injury may alter a patient's ability to think in a reasoned way. Injury to the reticular activating system of the pons and midbrain slows arousal, whereas injury to the frontal lobes may result in promiscuity because of reduced inhibition. Indirect effects of brain injury, such as alteration of endocrine function (for example, post-traumatic hypopituitarism), can also affect sexual drive and arousal.

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	Common sexual difficulties

Top Effects of disability on... Common sexual difficulties

People may have never had a specific sexual experience (primary impairment) or may have become unable to continue with their sex life (secondary impairment). Primary functional impairmentssuch as a man's inability to get an erection or to ejaculate or a woman's pain, inability to allow penetration, or anorgasmiaare more common among patients with congenital disabilities or those of early onset and are often hard to resolve. Men are more likely to present than women, possibly reflecting cultural perceptions of the importance of sexual performance and, now, the greater range of treatment options available.

Sexual function and arousal in men and women occur in response to reflexogenic genital stimulation or psychogenic desire in those with intact sexual drive mechanisms. Those with brain or spinal cord injury, or whose injury or disease process affects the spinal cord, experience partial or complete loss of sexual functions. They require comprehensive assessment of the level and degree of damage to the brain and nerve cord and the damage to upper and lower motor neurones (by testing the bulbocavernosal and anal wink reflexes; see earlier article by Dean). In neurological terms male erection is similar to the female vasocongestive response and lubrication, and male ejaculation is similar to female contraction of the pelvic floor, perineum, and anal sphincter.

Effects of drugs
Many disabled people take drugs to control conditions associated with their disability or for pre-existing conditions. Drugs prescribed for medical conditions account for about 25% of cases of erectile dysfunction, and 10% of commonly prescribed drugs produce erectile dysfunction. Overuse of other addictive drugs such as alcohol, tobacco, and cannabis can also disrupt sexual functioning.

Erectile dysfunction
Loss of erectile function is the commonest sexual problem among disabled patients. Even in cases of a clear physical cause, psychological factors are often also important. Physical loss of erection is most often treated by injection of drugs directly into the penis or, recently, with the oral drug sildenafil (Viagra), which has been shown to enhance erectile ability in 70-90% of patients. Vacuum devices can be used by men who do not want to inject themselves, and there are topical preparations, but these are used less often because of their relative lack of success. Patients with erectile dysfunction of primarily psychological origin may benefit from a wide range of specialist psychological therapies, which usually include their partner.

Difficulties with ejaculation
Ejaculatory dysfunction among disabled people is most common in men with spinal cord injury, multiple sclerosis, spina bifida, and transverse myelitis. Ejaculation involves closure of the bladder neck (through sympathetic stimulation) and relaxation of the external sphincter.

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Fertility problems
For men with neurological impairment, obtaining semen with a reasonable sperm count and motility is a problem. The same difficulty occurs with many other injuries and as a side effects of drugs used to treat various conditions.

Assisted conception
Technology exists to obtain ejaculate from most men, but the problem of semen quality, particular sperm motility, remains. The reason for this is unclear, although scrotal hyperthermia, long term use of certain drugs, prolonged sitting in a wheelchair, and repeated urinary tract infections have all been suggested.

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	Acknowledgments

The posters for the Spinal Injuries Association were reproduced with permission of the SIA, and the photographs were by Jim Kelly.

Clive Glass is consultant clinical psychologist and Bakulesh Soni is consultant at the North West Regional Spinal Injuries Unit, Southport District General Hospital.

The ABC of sexual health is edited by John Tomlinson, physician at the Men's Health Clinic, Winchester, and London Bridge Hospital, and formerly general practitioner in Alton and honorary senior lecturer in primary care at the University of Southampton.