Trisha Hicks, LSW, MSW, MEd. Magee Rehabilitation Hospital

Trisha Hicks, LSW, MSW, MEd. Magee Rehabilitation Hospital

Physicians Nurses Therapists Psychologists, Social Workers, Counselors How can I help?

Identified as greatest UNMET need for individuals with spinal cord injuries (Kennedy et al. 2006) Paraplegics rated return of sexual function as their top priority (Anderson, 2004) 40-80% of women and 50-90% of men with multiple sclerosis have sexual complaints or concerns (Foley, 2005)

Circles of Sexuality Sensuality Intimacy Sexual Identity Sexual Health and Reproduction Sexualization Social, cultural contexts

Bancroft s Model (adapted) Direct Indirect Iatrogenic Contextual Sanders/Tepper Model Primary Secondary Tertiary

Males: Erectile dysfunction Ejaculation dysfunction Altered/absent genital sensation Fertility: impaired erectile function, inability to ejaculate, poor semen quality decreased motility, low viability NEW: caused by inflammatory proteins in semen Females: Decreased lubrication Altered/absent genital sensation Fertility intact: special pregnancy concerns

Sensation: altered, heightened- hot spots Movement: positioning, dressing Bowel and bladder function Spasticity: for better or worse Medication side effects Pain Autonomic Dysreflexia Psychological issues

Males: Changes in arousal, orgasm due to nerve damage Erectile dysfunction Reduced penile sensation Difficulty achieving ejaculation Fertility: dry orgasms Females: Changes in arousal, orgasm due to nerve damage Reduced vaginal/clitoral sensation Vaginal dryness

Sensation Mobility Fatigue Changes in muscle tone, weakness Decreased coordination, tremor Spasticity Pain Bowel and bladder incontinence Cognitive changes: attention, memory loss Mood: depression Psychological issues: self-esteem, body image, performance anxiety

Males Decreased or increased desire Difficulty controlling sexual behavior Erectile dysfunction Difficulty reaching orgasm Decreased sperm production Females Decreased or increased desire Difficulty controlling sexual behavior Decreased vaginal lubrication Difficulty reaching orgasm Irregular menstrual cycles

Fatigue: physical and cognitive Spasticity Pain Weakness Coordination deficits, balance Cognitive changes: attention, memory, communication, planning, reasoning, imagining Mood/Emotional changes: labile, sad, nervous, irritability Psychological issues: self-esteem, body image, performance anxiety

No direct sexual dysfunction related to lower limb amputation Some sexual dysfunction reported for individuals with Diabetes Mellitus

Fatigue Mobility Balance Phantom sensations Skin Psychological issues: body image, selfesteem, performance anxiety

Surgery TLSO Cervical collar Colostomy Suprapubic catheter Orthopedic precautions Side effects of medications Antidepressants Heart medications Anti-spasticity meds High blood pressure meds

Relationship status: It s Complicated Home: first floor set-up Beliefs and values Gender roles, relationship roles Stable, chronic condition vs. flare-ups Race, religion, sexual orientation, gender identity

Education, counseling Vacuum pumps Tension rings Oral medications Urethral suppositories Intracavernosal injections Penile prosthesis Assistive devices (e.g. strap on)

Education, counseling Penile Vibratory Stimulation Rectal Probe Electroejaculation Needle Aspiration REMEMBER: Orgasm and ejaculation are not the same thing!

Education, counseling OTC lubricants Recommend avoiding warming, tingling lubricants Water-based or silicone-based work best with condoms (compared to oil-based) Check out Smitten Kitten s blog for more info on lubricants: https://badvibes.org/whats-in-yourlube/ Oestrogen creams for vaginal dryness

Groups of 2-3 Based on your profession, what areas of sexuality might you bring up? How would you introduce the topic of sexuality to this patient? How did it feel to do this? Was there anything that made you feel uncomfortable? What did you feel comfortable discussing?

Ex-PLISSIT (Taylor & Davis, 2006): EX-P: Extended-Permission giving LI: Limited Information SS: Specific Suggestions IT: Intensive Therapy Ways to Give Permission People with [a specific condition] often experience sexual difficulties, such as loss of desire or problems with enjoyment. How have you been affected? Many people are concerned about how this condition and/or treatment might affect their sexuality. What is your experience? What happens when you and your partner try to make love? How has your health affected you as a couple? Has it affected your sexual relationship? Would you like to talk about this?

Education: Group vs. individual vs. couple Primary, secondary, tertiary effects Offers resources (videos, overnight stays) Individual and Couples Counseling: Encourage exploration Follow-up, consult other team members Community Referrals, Outpatient Follow-up System

Anderson KD. Targeting recovery: Priorities of the spinal cord-injured population. J Neurotrauma. 2004;21:1371 1383. Foley, F. Introduction to intimacy and sexuality in MS. MS in Focus. 2005; 6: 4-5. Kennedy, P., Lude, P., & Taylor, N. Quality of life, social participation, appraisals and coping post spinal cord injury: a review of four community samples. Spinal Cord. 2006; 44 (2): 95-105. Taylor B, Davis S. Using the Extended PLISSIT model to address sexual healthcare needs. Nursing Standard. 2006; 21(11): 35-40.

Paralyzed Veterans of America: Sexuality and Reproductive Health in Adults with Spinal Cord Injury: A Clinical Practice Guideline Sexuality and Disability Journal SCIRE Project: https://www.scireproject.com Miami Project to Cure Paralysis: Dr. Nancy Brackett and Dr. Charles Lynne Smitten Kitten blog (lube): www. https://badvibes.org/whats-in-yourlube/ Model Systems Knowledge Translation Center

Videos: Website: Dr. Mitchell Tepper, www.drmitchelltepper.com Mayo Clinic: Feeling Your Way: Relationships and Sexuality after Spinal Cord Injury Kessler Rehab: Sexuality Reborn Facingdisability.com

Written: Paralyzed Veterans of America: Sexuality and Reproductive Health in Adults with Spinal Cord Injury: What you Should Know Magee SCI Manual: Sexuality Chapter (located at: http://www.mageerehab.org/rehabservices/spinal-cord-injury) Male Fertility following SCI: A Guide for Patients (located at: http://www.themiamiproject.org/wpcontent/uploads/2015/07/male-fertilitybooklet-2010-lowres.pdf) PleasureABLE: Sexual Assistive Device Manual Dr. Mitch Tepper: Regain that Feeling Dr. Stan Ducharme: Sexuality after Spinal Cord Injury Robert Baer: Is Fred Dead?

Model Systems Knowledge Translation Center Factsheets: National MS Society: http://www.nationalmssociety.org/ The Ultimate Guide to Sex and Disability Enabling Romance: A Guide to Love, Sex, and Relationships Sexual Function and Satisfaction after TBI: An Educational Manual: http://www.tbicommunity.org/resources/p ublications/sexual_functioning_after_tbi.p df