Sexuality After Traumatic Brain Injury

Angelle M. Sander

GENERAL BACKGROUND

A. A majority (greater than 75%) of persons with complicated mild-to-severe TBI describe themselves as sexually active (including self-stimulation and/or activity with a partner) at 1 or more years postinjury, and 52% to 62% report having a sexual partner [1,2].

B. Sexual dysfunction is frequent after complicated mild-to-severe TBI, occurring in ¼ to over ½ of persons at one or more years postinjury [1–4].

C. Failure to address sexuality can lead to emotional difficulties, low self-esteem, and relationship problems.

COMMON TYPES OF SEXUAL PROBLEMS AFTER TBI

A. Decreased desire or drive [1,2,5–7].

B. Decreased arousal in men [5–9] and women [1,6] (e.g., difficulty obtaining or maintaining an erection in males and decreased vaginal lubrication in females).

C. Decreased ability to achieve orgasm [1,2,6,7,9].

D. Ejaculatory dysfunction in males [10,11].

E. Hypersexuality—drastic increase in sexual drive, accompanied by disinhibition and inappropriate sexual behaviors, or sexual behavior in inappropriate settings; occurs rarely, (less than 10% of persons with TBI receiving rehabilitation services) [12] but results in significant distress for rehabilitation staff and family members [10,13].

F. Qualitative problems with sexual functioning—overall dissatisfaction with sexual activity [1,2,4], decreased frequency of sexual activity relative to preinjury [1,2], fewer opportunities for sexual activity [1,2], and reduced ability to satisfy their partners [2].

CONTRIBUTORS TO SEXUAL DYSFUNCTION AFTER TBI

A. Primary Contributors—direct result of changes to brain structure or function

1. Frontal lobe damage or damage to related subcortical structures [14–17]

a. Dorsolateral frontal damage: apathy and decreased initiation and/or interest in sex

b. Orbitofrontal damage: disinhibited and impulsive sexual behavior

B. Damage to temporal lobe or related limbic structures, including amygdala [14–17]

C. Damage to subcortical structures (thalamus, hypothalamus, hippocampus) [16,17]

D. Damage to afferent (sensory) and efferent (motor) pathways in the brainstem [16]

E. Disruption of neurochemical/neurotransmitter systems (dopamine, serotonin) [14,16]

F. Neuroendocrine dysfunction (hypothalamic–pituitary–gonadal system) [14,16]

1. Damage to hypothalamus and pituitary common with TBI

2. Disruption of hormone levels (testosterone, progesterone, and estrogen)

3. Can lead to disruptions in menstrual cycle and decreased fertility in women

4. Can lead to decreased sperm production and infertility in men

G. Secondary Contributors—due to indirect effects of other changes resulting from TBI

1. Medication side effects [15, 18–19]

a. Anticonvulsants—can result in decreased sex drive and impotence

b. Antidepressants—can result in decreased sex drive, erectile and ejaculatory dysfunction for men, and delayed orgasm for women

c. Anticholinergics—can reduce sex drive and result in erectile and ejaculatory dysfunction

d. Serotonergic agonists—can result in decreased sex drive

2. Physical impairments [15,19]

a. Motor impairments (e.g., spasticity, hemiparesis, decreased balance)—can lead to difficulty with positioning and to pain during sexual activity

b. Sensory impairments—can affect arousal and ability to achieve orgasm

3. Cognitive impairments

a. Impaired attention and concentration can impact sexual arousal and ability to sustain attention during a sexual encounter [19].

b. Impaired memory can impact ability to recall sexual encounters and/or dates that can lead to sexual opportunity [19].

c. Impaired initiation affects frequency of sexual activity and can be interpreted as disinterest by partner [15].

d. Impaired social communication/pragmatics results in decreased awareness of the impact of actions on others; decreased ability to read nonverbal cues and gestures; decreased ability to interpret others’ emotions; decreased empathy; decreased ability to initiate conversation [20].

e. Impaired planning and goal-directed behavior may result in difficulty accomplishing social planning leading to opportunities for sexual relationships (e.g., can’t make a date, plan date activities, set up a romantic environment) [15].

f. Impaired cognitive flexibility and abstract thinking limit the ability to fantasize, which is important for drive and arousal [15].

4. Emotional changes—including depression, low self-esteem, poor body image, childlike and dependent behaviors, self-centeredness, apathy, aggression, impulsivity [19]

5. Relationship issues—reduced relationship quality and quality of overall intimacy among partners [2, 21,22]

TREATMENT

A. The most important thing that you can do for your patients is to create an atmosphere of openness and comfort regarding the discussion of sexuality. Let them know that sexual problems are not infrequent after TBI. Emphasize that problems are treatable.

B. Integrate one or two questions on sexuality into your intake or follow-up interview because many people will not bring up a sexual problem they are having unless directly asked by the physician [1].

1. “Are you sexually active and/or are you satisfied with your sexual functioning?”

2. “Do you have any questions or concerns about the impact of TBI on sex?”

C. Conduct a comprehensive medical examination, referring out and/or treating as appropriate:

1. Screen for other medical illnesses that could contribute to sexual dysfunction (e.g., diabetes, heart disease, kidney disease, thyroid dysfunction).

2. Obtain hormone levels and investigate possibility of pituitary dysfunction.

3. Conduct or refer for urological exam and/or obstetrics/gynecology exam.

4. Review medications for side effects affecting sexual function.

5. Rule out pain as a cause of sexual problems.

6. Rule out motor problems as a contributor to sexual dysfunction.

D. Provide specific suggestions to improve sexual functioning:

1. A change in positioning during sexual activity can reduce impact of motor problems, balance problems, and pain.

2. Assist men with investigating drugs to enhance sexual performance and/or prosthetic devices to compensate for erectile dysfunction.

3. Assist women with investigating lubricants and/or dilators to compensate for lack of vaginal lubrication.

4. Altering the environment during sexual encounters can reduce the impact of distractibility and other cognitive deficits (e.g., arranging a quiet environment, with minimal background noise).

5. Use of erotic movies or books to assist with arousal.

6. Investigation of ways to increase social networks can increase the opportunity to form intimate relationships (e.g., local Y.M.C.A., church groups, and other social organizations). Have a list of these available in your clinic.

7. Provide information on safe sex practices, including birth control and prevention of HIV and other sexually transmitted diseases.

E. Refer for other services as appropriate:

1. Postacute cognitive rehabilitation to address cognitive deficits, such as social communication, that can impact sexual functioning.

2. Individual counseling/psychotherapy to address emotional issues.

3. Marital or couples therapy to address relationship issues.

4. Licensed sex therapy to directly address sexual problems.

5. Bibliotherapy—reading about sexuality and alternative ways for sexual fulfillment—books or Internet, including information on sexual prostheses.

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