SCI & Sexuality in Men

Spinal Cord Injury (SCI), Real Men and Sexual Pleasure

When my son started to take his first few daring steps on his own, we rallied around him clapping, coaxing and encouraging him.  He soon realised that there was something special to these small leaps of faith in himself.  As he became more confident he would give a boastful smile in our direction as he took every opportunity that he could to demonstrate his ability to walk on his own.  Learning to walk independently did not only allow him the new found agency to more successfully destroy the living room, but it clearly gave him a sense of personal achievement and independence.  

Anyone who has ever so much as sprained a thumb can testify to the fact that we take our physical abilities for granted on a daily basis. What most of us don’t, however, realise is that not only do we take the practical convenience of our physical abilities for granted, but we underestimate how much our sense of who we are is founded in our physical abilities.  My work with individuals (and their families) following traumatic injuries and illnesses has taught me just how much of ‘who I am’ and ‘what I do’ is bound to my physical abilities.  For a man, the most traumatic experience following a spinal cord injury (SCI) may not be the brutality of the accident that caused his injury but the fact that he can no longer ride a bike with his son, stand at the braai with his “mates”, or be able to achieve an erection out of excitement for his partner.


When you have just come to terms with the realisation that you are, in fact, lying in a rehabilitation hospital and you cant remember the last few weeks of your traumatic recovery, your ability to function sexually might not be the first thing on your mind.  However, following the devastating awareness that much of your physical ability will be lost forever, you do start to slowly consider the implications of this for your intimate life.  As a patient once told me, “I am slowly learning to use this body…I think I’ll start with the basics before I get to sex”.  Although sex might not be the first topic that comes to mind following SCI, at some point you will have many questions that will be made difficult by an ‘unspoken rule’ that our personal concerns about sex are not openly discussed.  The biggest mistake that we can make is to assume that a person with SCI is no longer interested in sex.  Just because the body might no longer function the same sexually does not mean that the mind is no longer interested in sex.  The reality is that other parts of the body might still be capable of experiencing touch and pleasure; the ability to achieve an erection may be possible in some cases and the ability to give someone else pleasure, is certainly still possible.  All it takes is the willingness to experiment.  

A good starting point would be to consider a few frank details:   

Ultimately, damage to the spinal cord disrupts messages between the genitals and the brain.  The nature of this disruption depends on the level and completeness of the injury.  It is only over time that you start to discover the extent of this disruption and it requires a bit of experimentation to get to know what is still working and how.  Unfortunately a complete injury at any level of the spinal cord results in the inability to achieve an erection in response to sexual thoughts and stimulation.  However, this does not necessarily mean that physical stimulation will not cause an erection (even if there is no sensation).  It is sometimes possible to achieve a reflex erection in response to physical stimulation.  Men with injuries to the thoracic or cervical levels often end up getting erections in response to non-sexual stimulation such as movement of the catheter.  With practice, a couple can learn to use this reflex erection to their advantage.  Because these reflex erections rely on nerves in the lower region of the spine, complete lesions in the lumbar and sacral areas normally result in the inability to achieve an erection of any kind.  Nevertheless, medical technology can still help you achieve an erection through oral medications, injection therapy, vacuum pumps and even penile implants.  These solutions, unfortunately, do not improve sensation, ejaculation, orgasm or fertility.


The inability to achieve an erection is not the only difficulty that might interfere with intimacy.  The physical requirements in general of a successful sexual encounter have to be adapted.  You now have to take into consideration: 1) the likelihood of a bowel accident; 2) the type of catheter you are using and how you can keep it out of the way; and 3) what positions are likely to elicit muscle spasms.  Although the initial rehabilitation environment is unlikely to cater for experiments in this area, it might be helpful to at least start to openly discuss sexual intimacy. 


It is important to note at this point that a frank list of the physical sexual implications of SCI does not do any justice to the loss experienced by a patient.  As demonstrated by my son’s learning to walk, our sense of accomplishment is inherently tied to our physical abilities.  As we grow older we learn how what it means to be a ‘good-enough man’ is wrapped up in our physicality.  Soon my son will become aware of his genitals and realise that they are different to girls’ genitals.  He will learn that this difference plays an important role in making him a boy.  He will also start to learn that the rules for how he deals with this bodily part are different to the rules for girls’ and how they deal with theirs.  For example, he might be more likely to stand and “pee” in the garden.  He will also probably be introduced to assumptions that to be a boy means to be stronger and faster than a girl.  He is likely to grow up being quite proudly attached to his genital organ rather than ashamed of it.  Later on in life, the ability of his genitals to respond sexually will become a large part of his repertoire of what it means to be a “good-enough man”. 


The point here is that an injury to the spine can rob you of almost everything that we naively associate with what it means to be a “real man”.  It can rob you of your ability to earn a good living and not only provide for yourself but for others who might depend on you.  A patient once commented: “I never imagined that so many people would have access to my body”.  When your ability to control your own bowels, clean yourself or even take yourself in and out of bed is lost – it is difficult to hold onto your dignity and manhood.  The last blow to these conventional ideas of what it is to be a ‘good-enough man’ is probably the the loss of physical sexual ability.       


So how does the newly injured man make small leaps of faith in himself?  Perhaps he can try and redefine for himself what it means to be a “real man”?  How can you be a “real man” in a wheelchair?  I have have had the privilege of working with many men with spinal cord injuries. All much greater men than I, despite their physical limitations.