1. Sexuality and Spinal Cord Injury
Starting over...

2. Why I am involved…
Part of a poem that explains: I would touch you deep inside And join with you on love’s ride Tumbling through passion’s grace And watch the pleasure on your face

3. Anna Freud said... Sex is something you do.
Sexuality is something you are!

4. Overview of human sexuality...
Human beings are curious creatures with an overwhelming need to learn about the world around them - this includes our bodies and our sexuality.
Sexuality is life-long learning - as I become more informed, I realize just how much I still don’t know!
“I don’t know all about sex, but I am willing to learn.”

5. What really is our “sexuality”
What really is our “sexuality”? There are a number of ways of looking at it. Here goes...
a driving, fundamental and vital life force
our need to express our sexuality is as basic as our need for food, water and rest

6. Sexuality (continued):
central to our identity and self-concept
Sexuality is our personality - it’s what compels us to discover who we are and drives us to express our own uniqueness

7. Sexuality (continued):
Who you are as a total person, your…
abilities
individuality
libido (sex drive)
specific sex acts you enjoy
ability to love and be loved
ability to be loveable and capable

8. Sexuality (continued):
Sexuality is my honest relationship with you -
letting down the walls we hide behind
being “real” - this allows us to love others
no “playing games”
sharing personal experiences is exciting, satisfying and very life-affirming
being honest affirms your right to be you!

9. Sexuality (continued):
Is a celebration of life
our sexuality is an affirmation of life, of being alive
our gift of sexuality is our greatest gift from God
sexuality is love and giving of ourselves

10. Sexuality has two components:
BIOLOGY
libido (hormone levels)
procreation (making babies)
LIFE EXPERIENCE
what sexual acts you enjoy receiving
what sexual acts you enjoy giving
sex is the “glue” in a relationship - it’s helps bond a couple

11. Sexuality…my latest...
Involves the timeless desire for both physical and emotional intimacy
to feel and give affection and pleasure
If you’re healthy, your interest in sex can last your entire life!!

12. Sexual Maturity: A relaxed, natural attitude towards sex: unhurried
unselfish - being able to delay gratification
being aware - “tuned in” to your partner
taking time to pleasure your partner (sensuality)

13. Men’s and women’s views on sex
We approach our sexuality so completely differently -
Men - more visually oriented
Women - more emotionally oriented
Only a generalization - a man uses love to get sex, a woman uses sex to get love
Women are looking for the right mood, men are only looking for the right place

14. Human sexual development over the life-span:
Or- how did we ever get together?

16. Teenage and early 20’s - Males - body centered Intense Physical love
90% + masturbation
orgasm-centered sexuality
“sexual peak”
Females - person centered
Romantic
Sensuous and emotional love
70% masturbation
difficulty transferring masturbation skills to intercourse

17. 30’s and 40’s - Male sexual response slows - peaked at 18
some impotence
frequency of sexual activity decreases
emphasis changes from quantity to quality
sex becomes more than intercourse
Female sexual response quickens
some become multi-orgasmic
sexual peak in late 30’s or early 40’s
increased frequency of masturbation
conception (or not) a major concern

18. 50’s and 60’s - becoming more complete persons!
Males - sex and orgasm of less concern
More emphasis on emotional closeness
Men - more nurturing More complete person
Sexual response slows
Erection difficulties
Females - initiates sex more and more consistent orgasms
Women acknowledge their male aspects and enjoy sex more and initiate sex more often
diminished vaginal lubrication

19. 70’s and 80’s - Male and female - energy level decreases
sexual (physical) response slows further
FANTASY life still active
health and availability of partner a problem
may accept society’s expectations - no sex

20. Sexuality and Spinal Cord Injury
Some specifics -
10% of the population has some form of disability
sexuality and libido not necessarily altered, they’re usually only altered as much as the SCI chooses - and that’s OK!

21. Sexuality Services for Disabled
Individual Counselling
Group Counselling
Couples Counselling
Sex therapy

22. Sexuality Services for Disabled
Sex & disability course
Access to reading materials
Audio-visual materials
Group Discussions

23. Sexuality Services for Disabled
Contraceptive/Genetic Counselling
Obstetrical/ Gynecological/ Urological Care

24. SCI sexuality -
We are mental, physical, spiritual and emotional people - what affects our physical side may affect all.
The desire for love, affection and intimacy usually doesn’t change, but the choice of sexual expression might - depending on the level of paralysis

25. SCI sexuality -
Sexual intercourse is often understood as the accepted means of sexual expression - but with the level of SCI and the physical condition, the SCI person might want to consider OTHER sexual options
Poor self-esteem may affect how SCI person feels sexually
Being paralyzed (stress) often causes changes in testosterone and progesterone

26. Sexual Options for Paraplegics and Quadriplegics - WHY SEX?
Sexual release
Emotional fulfillment
Couples intimacy and togetherness - especially after orgasm

27. Sex - NOT just a source of physical and emotional pleasure, but
it bonds and validates a relationship

28. Healthy Sexuality and SCI
A work in progress...

29. Accept personal responsibility -
Be honest - present yourself in a way you feel comfortable
You didn’t ask to become disabled - don’t apologize. “I didn’t ask to become disabled, but hey, this is who I am now”.
“My disability isn’t me - but I do have a disability that sets certain conditions for my life”.e.g.. Bladder infections

30. Be clean, hygienic and presentable -
It shows that you care about yourself and others
it’s an outward sign to those around you that you feel good about yourself

31. Communicate - Be open and honest Often you have to take the lead
Use “body language” if possible
Use facial expressions
Improve ability and style through practice
People generally want to know what happened - tell them! It’s a beginning.

32. Be assertive - In general - Express what you want
In particular - Practice to express desires sensitively
Sometimes you think you have communicated and you haven’t at all

33. Social Skills training -
Initiate interactions or acquire the social skills to do so. Practice!
Make the first move - others often initially feel awkward around you.
“I often feel that it is my responsibility to help others feel comfortable around me”.

34. Accept life now! Learn to like yourself and live.
Learn to live in the present moment - it’s all we have to work with.
Learn to accept “down” days - everyone has them!
Realistic expectations of yourself.
Spiritual books and videos helped me.

35. A satisfying sex life is possible -
Learn the basics - fertility - anatomy - sexual options
Get the anger out - “God, I’m mad as hell that this happened to me”
“God accepts you where you are at today.”

36. A satisfying sex life is possible -
Get comfortable with the new you.
Don’t deny the anger, fear, depression and anxiety - express them verbally and in writing - thus this talk for me!

37. A satisfying sex life is possible -
Fantasy and imagery
Use all the senses
Enjoy partner’s pleasure visually, mentally and emotionally.

38. Sexual Needs of any person -
Amount
Intensity
Frequency - differ for ALL people

39. Sexual Options -
MUTUAL willingness to explore new experiences - reciprocal loving
Use ALL the senses

40. Sexual Options More sexuality in the brain than in the genitals
Especially true of spinal cord injured
Communication - of thoughts and feelings - is the key!

41. Sexual
Options
depend-
Spinal
Cord
Injury
level

42. Sexual Options - Fantasy and daydreaming Sensate Focus Intercourse
Manual stimulation
Oral-Genital sex
Vibrators

43. Fantasy and Imagination
With or without a partner
Our brain is the largest sex organ - fantasy
Catharsis effect - removing something undesirable - esp. no physical orgasm
Aristotelian - purification or relief of the emotions through art - writing, drawing, photography etc.
Erotic books and videos (cathartic to me)

44. Sensate Focus -
Couples exercises developed to reduce performance anxiety, fear of failure
focus on touching - enjoyable, affirming, sensual and sexual
usually three-stage approach

45. Sensate Focus - stage one
Unhurried, set aside at least one hour
Undress
Explore partner’s whole body - do NOT touch each others genitals or female’s breasts
Sensual touching - learn to enjoy the process, what is happening NOW
Cuddle time

46. Sensate Focus - stage two
Now add genital touching and female’s breasts
Orgasm is not the intent now
light, teasing erotic touching - using fingers, tongue, vibrator or other sensual things
explore and develop orgasmic potential
overcome feelings of inadequacy which might accompany SCI

47. Sensate Focus - stage three
Partner’s orgasm is the main idea - through intercourse or any other sexual option
Watch partner masturbate so you learn what brings them to orgasm - communication and trust
Feelings of relaxation and assurance

48. Orgasm and SCI Orgasm is more a cerebral event
Mingling of sensations and the senses
Comfortable resolution
Partner’s orgasm assimilated, shared

49. Orgasm and SCI “fantasized” orgasms still not the same as before
satisfaction doesn’t last as long as before, thus may want to make love more often??

50. Intercourse Usually tried first (cultural expectations)
25% “success” rate, (i.e. Reflex erection and sufficient penetration to please female partner) Reflex erections don’t last long
Sexual positions depend upon level of disability
Visually and emotionally important to SCI, usually no genital sensations

51. Intercourse (continued)
Being “connected” through intercourse is more than physical, it’s spiritual to SCI
Being together and sharing yourselves - bonding and intimacy
Quality of time spent is important

52. Intercourse Positions
Depends on strength and degree of paralysis
woman on top
man on top
rear entry
side-by-side

53. Intercourse is a pain - much preparation work is needed
Transfer to bed
undress
transfer to w/c
remove catheter or condom
empty bladder
empty bowel
wash genital area
Transfer back to bed
“OK, honey, I’m ready!” “Am I ever horny!”
Partner is already asleep from waiting up for so long
So much for spontaneous sex!

54. Intercourse Sense of Humour Hygiene - especially for partner
Time for preparation
Reflex erection
“Stuffing” technique by women (women must tighten their pubococcygeal (PC) muscles - also helps maintain the erection)

55. 25% have pleasing intercourse -
Reflex erections don’t last long
Spontaneity difficult
Bladder and bowel trouble even with correct preparation

56. Intercourse “tricks” Vibrator to rejuvenate erection
Pillow under hips for better penetration
self-stimulation by partner - fingers or vibrator
vaginal lubricant - KY jelly, astroglide
condom over catheter
tape catheter to side or hip

57. No Erection? Penile suction devices - “Correctaid” and “Erectaid”
dildo or other penis stiffener
surgical implant of prosthesis - “small carion” and “Scott” prostheses
oral medication
small needle injections

58. Final thoughts on intercourse -
“If coitus is desired and erection is of sufficient rigidity and duration to allow penetration to the partner’s satisfaction, the aim of sexual rehab will have been met”
Intercourse requires much effort and planning
Shere Hite - only 30% of women orgasm through intercourse on a regular basis

59. Manual Stimulation more spontaneous orgasm and holding caressing
hugging
feeling of “oneness” - ESP. with thumb or finger inside (only the first 1/3 of vagina has sensory nerves, so a thumb is enough)

60. How? Study his/her masturbation - a real turn-on for most
Learned from sensate focus exercises
Use any body part to stimulate clitoris and labia, or glans of penis
Men - Insert thumb or fingers into vagina
Women - Breasts and buttocks can envelop a penis

61. Manual stimulation -
gives physical pleasure (orgasm) plus emotional warmth (hugs, caresses) and intimacy (placing thumb in vagina) at same time
“I want a lover with slow hands…”

62. How? Continuous, gentle stimulation
More rapid movement as orgasm approaches
To improve chances of orgasm - increase body tension
Some enjoy anal touching, it’s sexually pleasing - same muscle group surrounds genitals and anus

63. Breasts - Not well understood by most men
“Direct hot-line” to the clitoris
Can be sucked, kissed and touched while touching the genitals. Many women touch their own breasts while masturbating.

64. Shere Hite on manual orgasms -
“I get very excited when she orgasms. I feel so good. I feel we are flying…During the orgasms she holds me tightly. That was the best.”
“…says she loves me and starts grabbing me, and after…very passionate kisses”

65. Disabled person and manual stimulation, a summary:
Great pleasure as partner goes from arousal to orgasm
Partner’s orgasm is assimilated by SCI to help their “orgasm”. A mental, fantasized orgasm, an easing of tension and and a drowsy relaxed feeling. Still NOT the same as a physical orgasm!

66. Or “Oh, yuck! That’s gross!”
Oral sex...
Or “Oh, yuck! That’s gross!”

67. Oral sex definitions -
Cunnilingus - stimulation of a female’s genitals with the mouth
Fellatio - stimulation of a male’s genitals with the mouth

68. Oral sex positions
Again depends on level of injury - but almost all SCI can participate
“69” position or female on top for mutual oral sex if desired
female on top
male on top
side by side - use your imagination and get real comfortable

69. Oral Sex and Spinal Cord Injury
Sometimes seems disgusting - at first - to the uninitiated (hygiene and body fluids)
highly pleasurable
Lonnie Barbach, # 1 for AB men (e.g.. Prostitutes) #2 for AB women (most women don’t get oral sex - common among university graduates, but not for high school graduates - U.S. study)

70. Oral sex and spinal cord injury
Common sexual expression for SCI - because we can and it’s highly pleasurable
mouth, lips and tongue are very sensitive (while the rest of your body is paralyzed)
touch, taste, temperature, texture and smell of partner are very pleasurable for SCI

71. Oral sex and spinal cord injury
SCI become more sensitive in areas we can feel - we can receive good feelings
partner likes the softness and wetness of the mouth and tongue
watching your partner and involving yourself give real pleasure to SCI

72. Oral sex Most men enjoy cunnilingus and fellatio
Most women enjoy cunnilingus
Most women enjoy fellatio - but must talk with the man about his orgasm. Some like the salty ejaculate and some don’t

73. What happens with oral sex?
Closeness, bonding, intimacy and love
I think because of vulnerability in asking for oral sex
Trust, openness and honesty needed

74. Shere Hite on male sexuality...
“Loved the tenderness and kissing afterwards”
For some SCI this is the best time - the emotional closeness

75. Shere Hite
“Oral sex with a woman is my favorite of all. I feel a great closeness, a deep feeling of intimacy. I feel that she trusts me fully.”
“I adore the texture, feel and taste and also the lovely way a woman seems to respond… There seems to be a very open feeling between us.”

76. Oral sex summary... Highly pleasurable Trust and openness Love bonds
SCI actively involved with all senses

77. or “Can’t a real man do a better job?”
Vibrators
or “Can’t a real man do a better job?”

78. Vibrators Expand the range of sexual expression and sensation
Some embarrassment at first sometimes
May be only option available to some severely disabled
Provide gentle, precise and continuous stimulation to the glans and clitoris

79. Who uses them? Enlightened Adventurous Secure Progressive
Informed, intelligent and educated (say research studies)

80. Myths You can’t get “hooked” on a vibrator
Using a vibrator does NOT make you a pervert
Your relationship isn’t “on the rocks”

81. Vibrators
Are being talked about more openly - especially female comics
Available at specialty sex stores - Cynthia’s
Plastic and latex - battery operated
“Massagers” - usually more powerful and use electricity
Used by men and women for masturbation - sexual feelings are intense and quickly felt

82. Vibrators Can make some women orgasmic
Why? - steady, concentrated pleasing rhythm

83. Vibrators Can become a regular sexual option
Used while also kissing the breasts
Inserted into vagina
Used on anal area at same time as genitals

84. Vibrators - conclusion
Almost “guaranteed” orgasm because of nature of strong, steady accurate sensory input
Great for SCI use, especially if tired or weakness
Even quadriplegic hands can hold a vibrator

85. Conclusion to “Sexual Options”
Making love is a total body, mind and spirit experience
Can be enjoyed by all disabled and their partners
manual stimulation, oral sex and vibrators - much more spontaneous than intercourse

86. Conclusion for “Sexual Options”
Pleasurable emotional release of stress and tension
Psychologically satisfying and necessary

87. Male sexuality -
“Men tend to judge the success of their relationship by the quality of their sex life.”

88. Male sexuality and SCI 80% of spinal cord injured (SCI) are men
Erections are mostly “reflex”
“Psychogenic” erections are rare

89. Spinal cord injuries - Two types - complete and incomplete
Two types - Upper Motor Neuron (UMN) & Lower Motor Neuron (LMN)

90. Erections -
Complete UMN - more reflexogenic erections of longer duration than LMN injury
Incomplete UMN & LMN - more psychogenic erections possible

91. Spinal Routes -
C1 - T12 intact necessary to achieve a reflexogenic erection - or -
If complete above T12 chances of reflex erection good

92. Spinal routes -
If complete lesion below T12 perhaps no reflex erection, but possible psychogenic erections
If complete below S2 - S4 emission and ejaculation possible

93. Spinal routes -
If incomplete - reflex or psychogenic erections possible
Must experiment to see what is possible

94. Erection problems - Usually of short duration
25% report satisfactory intercourse

95. Erection answers - “Stuffing” technique Kegel exercises
Vacuum devices - with band
Vacuum devices - “Correctaid”
Penile Implants
Injections

96. Fertility - 0 - 10% SCI able to collect sperm
George Szasz (1985) %
UMN less able than LMN
WHY? - no emission or retrograde ejaculation

97. Sperm - Poor motility poor morphology low sperm count
urine spermicidal
testicular damage over time

98. Ejaculation Aids - Read “Brindley” and “Szasz” Vibrators
Electostimulation or electroejaculation
Penile injections
Intrathecal Neostigmine injections