1. Intimate Relationships & Sexuality
After a Stroke
or Brain Injury
West Park Healthcare Centre
Neurological Rehabilitation Service

2. Outline What does intimacy & sexuality mean to you?
Impact of Stroke and Brain Injury on intimate relationships and sexuality
Strategies
Who can help
Helpful resources
To make it more interactive maybe ask participants how they feel about talking about this subject right at the beginning of the presentation

3. What does intimacy & sexuality mean to you?
Attractiveness
Self confidence
Closeness
Compatibility
Pleasure
Passion
Enjoying activities with someone
Intercourse
Love
Marriage
Reproduction
Could use a flip chart or whiteboard to have it more interactive

4. What is sexuality?
Sexuality & intimacy is a central aspect of being human
Different for everyone
Includes sex, gender identity and roles, sexual orientation, pleasure, intimacy and reproduction
Experienced and expressed in our thoughts, behaviours, beliefs, attitudes, values, practices, roles and relationships
Sexuality is not just the act of sexual intercourse. It is about feeling close to someone, feeling loved and special, feeling good about your self as a sexual being etc

5. The location of your injury matters
If your brain injury affected your amygdala which is part of the deep structures of your brain, in the limbic system, you may notice emotional changes.

6. Effects of Brain Injury on Intimate Relationships & Sexuality
Psychological Effects
Relationship Changes
Medical & Physical Issues
Intimate Relationships & Sexuality

7. Medical & Physical Issues
Medications
Physical Limitations
Fatigue
Pain and Sensitivity
Arousal and Erectile Dysfunction
Incontinence
Medical & Physical Issues

8. Medical & Physical Issues
Medications
Some medications can cause decreased sexual desire and interest
It is important to continue to take your medications, please speak with the doctor or pharmacist if you have questions.
Anti-hypertensive (lower your blood pressure): treating hypertension may improve erectile function
Antidepressants
Anti-seizure medications
Opioids: hydromorphone, morphine
NSAIDs – Advil, naproxen
Sleep medication: lorazepam, zopiclone
Medications: Certain medications that controls blood pressure or depression can cause erectile dysfunction, decreased sexual desires and activity as well as impotence. DO NOT stop taking your medications!!!! Consult your family physician regarding alternative medication with fewer side effects.
Sleep medications: can take after sexual activity to prevent drowsiness.
Medical & Physical Issues

9. Medical & Physical Issues
Physical Changes
The following can impact your activity level after a stroke or brain injury:
Muscle stiffness
Muscle weakness
Loss of muscle tone
Spasticity
Decreased endurance
Add info about spasticity…
One side of the body may be weaker than another
endurance
Medical & Physical Issues

10. Medical & Physical Issues
Fatigue
People with stroke and brain injury fatigue more quickly
This fatigue may not be helped by sleep or rest
This type of fatigue can last days to months & can persist for years
Fatigue affects sexual life in people with stroke and brain injury more than those without a brain injury
Can impact daily life, including sexual health
Medical & Physical Issues

11. Medical & Physical Issues
Pain and Sensitivity
You may experience decreased or increased sensation in your body
When you have pain you may be less likely to participate in daily activities
Pain and sensitivity, anywhere in your body, may affect your sexual health
If pain is affecting your sexual health/performance please speak with your physician
Medical & Physical Issues

12. Medical & Physical Issues
Arousal and Erectile Dysfunction
The part of your brain that controls sexual desire and arousal can be impacted after a stroke or brain injury
The most common sexual changes following stroke or brain injury include lower sex drive, changes with arousal and erectile dysfunction
There are medications to combat this, you must speak to your doctor
Changes in arousal/orgasm: premature ejaculation, unable to achieve orgasm, unable to be aroused, erectile dysfunction
Brain function: limbic system and hypothalamus
Medical & Physical Issues

13. Psychological Effects
Change of Emotions
Sense of loss
Decrease in confidence
Depression
Cognitive changes
Psychological Effects

14. Emotional Reactions After Stroke or Brain Injury
Anger
Anxiety
Embarrassment
Guilt
Loneliness
Grief and Loss
Sadness
Don’t feel like themselves
Emotional Anger: You may question why this has happened to you
Anxiety: Anxiety around being able to reconnect with partner, having a relationship, being able to engage in sexual relationship
Embarrassment: The patient may feel ashamed of their loss of ability.
Guilt: The patient may feel sorry for the changes brain injury has caused regarding their family support and or family dynamics.
Loneliness: Feeling of isolation and lack of support from family/ friends.
Grief Loss: Feeling a sense of loss for their ability to function as they did prior to the injury.
Sadness: feeling of sadness regarding the changes one may experience with a stroke or brain injury.
Psychological
Effects
How you feel can impact your relationships with loved ones.

15. Sense of Loss and Changes in Self Confidence
Decrease in confidence level
Isolated or frustrated
Body image changes
Feeling of unattractiveness or not feeling like yourself
Recommendations: Sex does not have to be physical. Touching can be very therapeutic.
Psychological
Effects

16. Depression Depression is common after stroke or brain injury Symptoms:
lack of energy, changes in sleep, decreased appetite, irritability
Depression can also affect your relationship with your partner, including changes in your sexual activity.
Treatment can include talking with your healthcare provider and/or starting medications
Speak with your healthcare team if you have concerns you may be depressed
can decrease your sex drive, arousal and pleasure
Psychological
Effects

17. Cognitive Changes Poor concentration Memory deficits
Difficulty remembering events or details
Difficulty with social skills and communication
Understanding social cues
Planning how to interact with others
Personality changes
Persistent behaviours or thoughts
Psychological
Effects

18. Communication difficulties
Relationship Changes
Relationship Changes
Relationship Changes
Communication difficulties

19. Relationship changes Altered roles Partner may now be a caregiver
Supporting a person with stroke or brain injury can be positive and rewarding for a partner
Loss of equality in the relationship
May require more help with daily activities
Focus on previously enjoyed activities
Decreased spontaneity
May need to put more planning into intimate activities
Sexual encounters may be “different” now
- Some found it difficult to be attracted to their love ones after caring for them. Some found it difficult to look after their loved ones then have a sexual relationship husband vs caregiver role; wife vs caregiver role
- Focus on what you have and not the deficiencies.
Relationship Changes

20. Communication difficulties
You may have more trouble communicating your needs and wants
Talking about intimacy can be difficult because it is an emotional topic
Plan for the conversation by thinking about what you want to say to your partner
Your speech therapist can help you with expressing your thoughts
Relationship Changes

21. Strategies Connecting your partner/spouse Effective Communication
Finding new relationships
Returning to sexual activity
Energy Conservation

22. Connecting with your partner or spouse
Connect in ways that build intimacy
movie nights, cooking, playing games
rekindle old interests
Laughing, sharing stories
Many people with chronic conditions such as brain injury can and do have fulfilling sex lives with healthy expressions of intimacy, frequency of sex make decrease, but sexual activity and fulfillment is possible.
Sex is a great exercise.
Also remember with aging hormonal changes can affect sexual activity – slower erections and delayed orgasms are common in later life.
The quality not the quantity matters in meaningful relationships

23. Connecting with your partner
Five love languages
Words of affirmation
Giving gifts
Acts of service
Quality time
Physical touch (touching, kissing, hugging)

24. Effective Communication
Talk to your partner
Share your feelings and concerns through writing, speaking and body language
Take time to ask and listen to your partner’s thoughts and feelings
Use ‘I’ statements
reduces blaming the other person
Calm and firm tone of voice
Explain to your partner how brain injury may affect the sexual relationship
Express feelings and fears honestly
Discuss change in roles and responsibilities
Space and time to calm down from anger
Value yourself and opinions – learn to express your needs and wants
Expressing your negative thoughts in a positive manner
Receive feedback positively – accepting compliments, learning from mistakes and asking for help when needed
Learn to say ‘no’ – Understand your limits, don’t allow others to take advantage

25. Finding New Relationships
Plan to meet other people
consider what you like to do
Join an activity or hobby you like
Make yourself available
get out of the house, join a group
Take care of yourself
Dress up, focus on self-care
Develop qualities you admire in others
(humour, caring nature, smile, etc.)
Like many other important tasks in life, meeting someone new can be broken down into smaller chunks.
Find me someone normal? - Define normal? Do you consider yourself normal? Your injury doesn’t define you? There are many people with injuries who live happy, healthy and active lives, brain injury is not different from that and shouldn’t be treated as such, it just requires some adaptation.

26. Returning to sexual activity
Both partners need to consent to any sexual activity Following a stroke or brain injury, a person’s inhibition or judgment can be affected and this needs to be addressed prior to engaging in sexual activity

27. Returning to sexual activity
No one should be forced or pressured to engage in sexual activity Being ready to resume sexual activity will be different for each person in the relationship Having fears and anxiety regarding sexual health after an injury is normal Both partners should feel comfortable and should explore and discuss their concerns
What are your concerns with returning to sexual activity? (ask the group)
Talk to a healthcare provider if you need help discussing these issues with your partner

28. Sexual intimacy Sexuality is more than sex! Talking Touching Kissing
Cuddling
Massages
Masturbation
There are many ways to enhance or engage your sexual life than just intercourse.
It is important that couples/ partners take the time to discuss and creatively come up with new ways to sexually engage with one another.
It is important that partners talk and plan for intimacy at a time that is appropriate and comfortable for each another.
Absence of sensation does not mean absence of feelings.
Inability to move does not mean inability to please.
Inability to perform does not mean inability to enjoy.
Loss of genitals does not mean loss of sexuality.
-Masters, Johnson &Kolodny
Take time to discuss and get creative, and discover new ways to sexually engage with your partner

29. Energy Conservation Planning Time of day
Allow adequate time for intimacy
Prioritizing
Prioritize dedicated time for Intimacy
Limit strenuous activities throughout the day
Pacing
Take things at a slower comfortable pace that is best for you
Rest between activities
Positioning
Try different positions –allow your partner to take on a more active role, positions that reduce stress on the affected side, semi-reclined side lying. Use pillows to support weaker limbs.
Pillows underneath the knees reduces lumbar pressure.
Begin with foreplay as you build up the pleasure

30. General Tips Environment
Relaxing environment – music, dim lighting, candles
Incontinence - use the bathroom prior to sex and empty a catheter bag if applicable
Comfortable room temperature
Medication
Keep up with your medication as per your doctor’s advice
Other Tips
Avoid heavy meals or excessive alcohol
Be aware of signs of distress and take breaks as needed
Stay active to increase overall endurance increased mood

31. Who can help? Doctor Nurse Physiotherapist Occupational Therapist
Pharmacist
Social Worker
Speech Language Pathologist
Psychologist
Speak to anyone on your healthcare team

32. Where else can you find help?
Book: The Ultimate Guide to Sex and Disability.
Barry McCarthy: Rekindling Desire
Barry McCarthy: Sexual Awareness
Pleasure ABLE: Sexual Device Manual for Persons with Disabilities
Sexual Aids:
Heart and Stroke Foundation – sex and intimacy

33. Sexuality and Brain Injury
Any questions???