Sexual dysfunction is a well-known, yet seldom discussed, complication in individuals who have sustained a traumatic brain injury (TBI). This is likely because it can be uncomfortable for the patient, significant other, and healthcare professional to address these issues. This can cause issues with intimacy, which can lead to relationship problems and emotional distress in both the patient and their partner or spouse.
Common problems documented in men are:
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Decreased desire or drive for sexual activity , , ,
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Difficulty maintaining an erection , ,
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Decreased arousal , ,
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Difficulty achieving orgasm ,
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Ejaculatory dysfunction ,
Similar problems are documented in women, such as:
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Decreased desire for sexual activity , ,
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Difficulty achieving orgasm , ,
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Decreased vaginal lubrication and pain during sex
There are many factors that contribute to sexual dysfunction after a brain injury. Structural damage to the brain is the primary contributor, However, there are social, emotional, physical, and cognitive factors that also play a significant role in sexual dysfunction.
Contributing factors to sexual dysfunction
Anatomical factors
There are many areas in the brain that contribute to sexual function.
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The frontal lobes, limbic, and paralimbic regions are associated with sexual drive, assertiveness, initiation, and sexual preference.
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Injury to the orbitofrontal region can lead to:
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Disinhibition ,
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Hypersexual responses such as inappropriate sexual talk, self-exposure, and genital touching ,
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Injuries involving the dorsolateral frontal injury can lead to:
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Apathy , ,
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Attention deficits
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Initiation impairments ,
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Temporal lobe injuries can also lead to hypersexual behaviors.
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Kluver bucy syndrome is a rare complication caused by damage to the bilateral anterior temporal lobes, and can present with hypersexuality, hyperorality, and exploratory behaviors. , ,
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Seizures in the temporal lobes can manifest with hypersexual or hyposexual behaviors.
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Brainstem lesions:
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Brainstem lesions can affect both sensory input and motor output to the body.
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Damage to areas such as the reticular activating system in the midbrain and pons can affect arousal and alertness.
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The brainstem connects the limbic and paralimbic structures such as the hippocampus, amygdala, hypothalamus, and cingulate gyrus. These areas are involved in producing erections and other sexually related behaviors.
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The neuroendocrine system:
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The hypothalamus and pituitary gland is commonly affected in traumatic brain injuries.
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Can lead to alterations in hormone levels such as testosterone, progesterone, and estrogen, which can then cause changes in menstrual cycle and fertility in women and decreased sperm production and infertility in men. ,
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Subcortical structures such as the thalamus are thought to play a role in penile erection.
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Neurotransmitters:
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Dopamine and serotonin can affect sexual desire.
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Damage to these neurotransmitter pathways can lead to changes in sexual function. ,
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Physical and functional factors
Patients can have physical and functional limitations that can make intimacy with their partners difficult.
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Hemiparesis or spasticity can make positioning and movement difficult and can also cause pain.
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Visuospatial deficits or hemineglect from right hemispheric lesions can also interfere with intimacy.
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Fatigue has also been reported to be a contributing factor in the importance and frequency of sex in brain injury patients. ,
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Oral–motor dysfunction have reported in difficulty kissing and expressing romantic vocalizations. ,
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Headaches, visual impairments, and auditory impairments were also reported to interfere with intimacy.
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Neurogenic bowel and bladder can lead to decreased sexual activity due to fear, anxiety, and embarrassment about having an accident.
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Sensory impairments to certain areas of the body can lead to decreased arousal and difficulty achieving an orgasm. Difficulties with personal hygiene and physical appearance may also affect a patient’s sexual life. ,
Cognitive factors
Individuals with brain injuries will often present with cognitive deficits that will interfere with their independence and activities of daily living, as well as sexual dysfunction.
Common cognitive deficits include:
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Attention and concentration difficulties
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Can lead to difficulties with sexual arousal and ability to focus on sexual activities
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Partners can feel neglected or disinterested due to lack of attention.
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Short-term memory deficits
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May lead to difficulty remembering important events or dates
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Patients may miss opportunities that can lead to intimacy. ,
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Impaired initiation
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Can lead to decreased frequency of sexual encounters ,
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Poor initiation can give the impression of disinterest in their significant other.
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Difficulty with abstract thinking
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Can limit patient’s ability to fantasize, leading to decreased sexual drive and/or arousal ,
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Impaired goal-directed behaviors and planning
Emotional and psychiatric factors
Many emotional and psychiatric factors can contribute to sexual dysfunction , , , :
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Depression
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Adjustment disorder
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Anxiety
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Poor self-esteem and/or body image
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Fear of intimacy
These are common sequalae of TBI caused by sudden changes in function, quality of life, and independence. This can lead to apathy, decreased sexual drive, and arousal. , Patients may distance themselves emotionally from their significant others, which can cause relationship difficulties, avoidance of intimacy, and separation or divorce. ,
Partners and spouses of TBI patients may experience a change in dynamics in their relationship from an intimate partner to one of a caregiver or parent–child. , Some may be unable to overcome the idea of being intimate with a disabled partner. In some cases, the significant other may feel that they are now living with a stranger and feel intimacy is incompatible. ,
Fear itself may lead to an avoidance of intimate activity. Especially in patients who have had a stroke, there can be a fear that sexual activity may lead to another stroke.
Medications
Medications that may contribute to sexual dysfunction may include:
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Antidepressants
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Antiepileptics
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Antipsychotics
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Antihypertensives
TBI patients typically are started on antidepressants due to mood difficulties and to help with neuro-recovery. , Many are also started on antiepileptic and/or antipsychotic medications due to seizures, agitation, and irritability.
Dopamine has been shown to have an excitatory effect on sexual desire. Serotonin, on the other hand, has been shown to inhibit sexual function. Medications that have antidopaminergic or serotonergic may further alter sexual function.
Antihypertensive can also cause difficulty with erections by lowering the cavernosal artery pressure and can lead to erectile dysfunction.
Treatment
The topic of sexual dysfunction can be uncomfortable to approach by both the patient and their significant other and the healthcare professional. However, it is a common problem that occurs after a brain injury and should be addressed because it can cause negative changes in a patient’s marriage or relationship.
A comprehensive approach should be made to treat sexual dysfunction after a brain injury.
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The PLISSIT model is comprised of four steps: Permission to address sexuality, provide Limited Information about sexual functioning and disability, give Specific Suggestions about particular complaint, and Intensive Therapy. ,
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The BETTER model follows similar principles as the PLISSIT model, but includes a record keeping step. The steps include: Bring up the topic, Explain concerns, Tell about resources, Time the discussion to patient’s preference, Educate patient about disability and treatments, and Record discussion and information shared in patient’s medical record. ,
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The ALLOW model includes these steps: Ask about sexual function, Legitimize concerns, identify Limitations in evaluation of dysfunction, Open up the discussion, and Work together to develop goals and treatment plans.
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Create an open and comfortable environment to discuss and address issues of sexual dysfunction. 3,5,10
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A comprehensive medical examination is important to rule out any underlying medical issues that may contribute to decreased sexual function. , , ,
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Screening for medical comorbidities such as diabetes, heart disease, endocrine function, or hormone levels
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Urological or obstetric/gynecological examination
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Rule out inhibiting factors such as pain or other focal neurological deficits.
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Interdisciplinary approach to address sexual dysfunction , , :
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Physical and occupational therapy can help with education and optimization of comfortable positioning along with adaptive aids and equipment that can assist with intimacy.
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Speech therapy can assist with cognitive and communicative barriers to sexuality.
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Counseling through a sexual health educator, sex therapist, or marital therapist can help with the emotional and social issues that may be present.
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Medications such as performance-enhancing medications and lubrication for women can also help with sexual activity.
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Summary
Sexual dysfunction is a common and multifactorial complication that can occur after TBI. Different components such as structural, functional, social, emotional, and medical factors can contribute significantly to sexual dysfunction. This is a complication that should be addressed by the healthcare professional and the patient and partner. Treatment should be comprehensive and involve an interdisciplinary approach.
Review questions
- 1.
Kluver-Bucy syndrome is a condition caused by damage to the
- a.
Left frontal lobe injury
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Bilateral anterior temporal lobes
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Right parietal lobe
- d.
Brainstem
- a.
- 2.
What cognitive factors can contribute to sexual dysfunction?
- a.
Fatigue
- b.
Attention/concentration deficits
- c.
Spasticity
- d.
Depression
- a.
- 3.
Which area in the brainstem is involved with alertness and can contribute to decreased sexual arousal?
- a.
Reticular activating system
- b.
Hippocampus
- c.
Amygdala
- d.
Hypothalamus
- a.
Answers on page 398.
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- 4.
As a healthcare provider, what is the most appropriate initial step in addressing sexual dysfunction in patients with a brain injury?
- a.
Directly asking if the patient is sexually active with his/her partner
- b.
Creating and open and comfortable environment to discuss and address the issues
- c.
Having a sex therapist in the room during the follow-up visit
- d.
Working up underlying issues for sexual dysfunction such as medical comorbidities, hormone levels, endocrine labs, and performing a gynecological/urological examination
- a.
- 5.
Which of the following medications would have the least impact on sexual dysfunction?
- a.
Amantadine
- b.
Fluoxetine
- c.
Metoprolol
- d.
Keppra
- a.
- 6.
The PLISSIT model was designed as a way to:
- a.
address sexual dysfunction in a stepwise approach.
- b.
investigate the underlying causes of sexual dysfunction.
- c.
create an intimate environment for patients and their partners with cognitive deficits.
- d.
provide medications to help with sexual function.
- a.
- 7.
Damage to the neuroendocrine system can cause which of the following problems?
- a.
Normal sperm count in men
- b.
Increased fertility in men and women
- c.
Alterations in hormone levels
- d.
Unchanged menstrual cycle in women
- a.
- 8.
Damage to which part of the brain can lead to apathy, attention deficits, and poor initiation?
- a.
Dorsolateral frontal lobe
- b.
Brainstem
- c.
Orbitofrontal region
- d.
Hypothalamus
- a.
- 9.
Which statement is true regarding sexual dysfunction?
- a.
The biggest obstacle reported during intimacy is poor body positioning and movement due to spasticity.
- b.
Emotional issues such as depression and adjustment disorder can impact a patient’s sexual drive and arousal and can lead to poor body image and self-esteem.
- c.
Partners of individuals with brain injuries cope well and are not concerned about sexual dysfunction.
- d.
Medications do not usually have an impact on sexual function.
- a.
- 10.
A multidisciplinary approach is important in addressing sexual dysfunction in an individual with a brain injury. Which of the following would be least helpful in treating sexual dysfunction?
- a.
PT/OT can assist with optimization of positioning and recommendations on adaptive aids and equipment
- b.
Speech therapy can address cognitive and/or communicative barriers to sexuality
- c.
Counseling through a sexual health educator, sex therapist, or marital therapist to address emotional and/or social factors that contribute to sexual dysfunction
- d.
Prescribe medications to help with depression and adjustment disorder
- a.
References
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