Reader: Family, Professional

Less is known about the effect of spinal cord injury (SCI) on females than on males for several reasons, such as:

1. There are fewer female injuries (one female for every four males) so that no spinal cord program sees very many females per year.
2. The effect of SCI on female sexuality is far less devastating than on males.
3. The physiological sexual responses for women are mostly internal and less conspicuous than in males and, therefore, more difficult to study.

Most of the information that has been reported is subjective (i.e., obtained by history from patients rather than from scientific observation) and is, thus, likely to be less accurate.

Intercourse:

The physiological changes normally associated with sexual response are not essential for a woman to be able to have intercourse. From a practical standpoint the most significant response is lubrication of the vagina and this can easily be substituted (see below). Therefore, sexual counseling needs to be directed at issues such as pregnancy, contraception, pleasure, and practical things like positioning, bowel and bladder management, etc.

Vaginal Lubrication

This is thought to be the physiological equivalent of erection in the male and is probably innervated in the same way. Some SCI women report that they do have reflex lubrication and others do not. This has never been carefully documented and correlated with the level of injury. When substitutes are needed, always use water soluble lubricants, e.g., Today, Astroglide, KY Jelly, etc. Never use Vaseline! (because it is oil based).

Positioning

Spasticity, contractures, areas of hypersensitivity to touch and other problems common to SCI may make it necessary to try a variety of positions for intercourse to find what is the most comfortable.

Orgasm

Orgasm is the intense pleasure that accompanies a climax and is usually associated with other physical events, such as muscle spasms, followed by a feeling of relaxation. Even non-SCI women vary considerably in the type and intensity of orgasm they experience, and some sexually active women are not sure whether or not they have ever had an orgasm. This makes it especially difficult to predict the effect of SCI. However, it has been reported that some women (including those with SCI) experience orgasms following breast and upper body stimulation.

Bladder Management

Women are much more likely to use a Foley catheter for urinary management than men. It is important for women (as well as their partners) to understand that the catheter is NOT in the vagina. Women are much less knowledgeable than men about their genital anatomy because of societal taboos. A mirror can be used to identify the location of the urethra (urine outlet where a catheter is placed) and the vagina (see Fig. 2) in order to emphasize that they are separate openings. For intercourse it is okay to leave a catheter in place. Tape it carefully out of the way (on the lower abdomen or thigh) and lubricate the exposed portion well, so it will not accidentally be pulled out. However, if this is unacceptable to the woman or her partner, the catheter could be removed before intercourse and replaced afterward (if someone knows how).

Fertility

The normal menstrual cycle consists of the growth and maturation each month of one egg (ovum) in the ovary (see Fig. 1) until it bursts out of the ovary (ovulation) and is picked up by the Fallopian tube and transmitted into the uterus to await fertilization by a sperm. If fertilization fails to occur, then menstruation begins 14 days following ovulation and the cycle is repeated. The menstrual cycle is under hormonal (not neurological) control and hormones are distributed via the blood stream. Therefore, a spinal cord injury at any level will NOT affect a woman's ability to get pregnant. However, it is well known that stress of any kind (physical or emotional) can disrupt the menstrual cycle. Certainly a traumatic spinal cord injury is stressful, and on this basis there may be a temporary disruption of the normal cycle. About 50% of newly injured SCI women will not miss any periods and most will resume regular periods within one year. Ovulation may occur prior to the first period, so one should never assume that pregnancy can not result from sexual activity just because periods have not resumed.

A woman whose periods have not resumed after 4-6 months post injury should consult a physician about possible hormone therapy to stimulate ovulation. (See Chapter 14, Reproductive Aspects of Spinal Cord Injury in Females, in Sexual Rehabilitation of the SCI Patient, for further details).

Contraception

Any woman with SCI who is sexually active must use some form of contraception if she does not want to get pregnant. The problems of choosing a method of contraception are much the same as for all women. There is no perfect method that is 100% safe, 100% effective and 100% reversible. Therefore, each woman should discuss with her physician the best method, considering sexual frequency, level of injury, degree of function and various risk factors.

Contraception factors related to SCI to keep in mind:

1. "The Pill:" Inhibition of ovulation using hormones is safer now than in the past, but there is still an increased risk of thrombophlebitis (blood clots). A woman who uses a wheelchair is at further risk for phlebitis because of inactivity. Smoking greatly increases this risk! It is usually recommended that hormone use should not be started until 6-12 months after injury and should be avoided completely in anyone with a history of previous thrombophlebitis.
2. Norplant: This new method of implanting hormones under the skin sounds promising, but there has not yet been enough experience to know what the long term risks might be. There is no reason to think that the risks for SCI are any different from the risks for other women.
3. Barrier Methods: This includes all methods of mechanically preventing sperm from reaching the uterus, such as condom, diaphragm, sponge, etc. The risks are no different from non-SCI women except quadriplegics may need assistance inserting a diaphragm.
4. IUD: There is a high rate of complications in all women and this method is generally discouraged in SCI because the serious complications that can occur will usually be recognized by symptoms of pain. With an inability to feel, these complications might go unnoticed.
5. Rhythm: The rhythm method consists of avoiding intercourse during the peak fertility period (3-4 days around ovulation). The problem is that this time is not easy to predict, especially if menstrual periods are irregular. Therefore, this is one of the least reliable methods of contraception.

Pregnancy

If a woman wants to have children there is no reason why she should not. The most difficult problem is finding an obstetrician who is familiar with SCI or who is willing to learn! Every woman considering pregnancy should have a copy of the American College of Obstetricians and Gynecologists recommendations on "Management of Labor and Delivery for Patients with Spinal Cord Injury" and insist that her physician read it! Copies are available from the Spinal Cord Commission.

Breast Feeding

There is no evidence that women with SCI cannot or should not breast feed if they so desire.

Summary

A spinal cord injury does not prevent a woman from having intercourse or getting pregnant. This paper makes no attempt to address other important issues such as finding a partner, intimacy, sexual satisfaction and self-esteem. These issues are addressed very well in Love: Where to Find It, How to Keep It.

Women who are interested in learning more about female sexuality (not related to spinal cord injury) are encouraged to read The Hite Report. It should be in your local library.

References:

American College of Obstetricians and Gynecologists. (1987). Management of labor and delivery for patients with spinal cord injury. ACOG Committee Opinion. (Number 35 - October 1984, revised 1987). Washington, DC: Author. Available from the Arkansas Spinal Cord Commission.

Becker, E. F. (1991). Love: Where to Find it, How to Keep it. Bloomington, IL: Cheever Publishing.

Berard, E. J. (1989). The sexuality of SCI women: physiology and pathophysiology, a review. Paraplegia, 27, 99-112.

Hite, S. (1976). The Hite Report: A Nationwide Study of Female Sexuality. New York: McMillan Publishing.

Leyson, J. F. J. (Ed.). (1991). Sexual Rehabilitation of the SCI Patient. Clifton, NJ: Humana Press.

McCluer, S. (1985). The Effect of Spinal Cord Injury on Female Sexuality. (Spain Rehabilitation Center videocassette). Birmingham, AL: University Medical Television. Available on loan from the Arkansas Spinal Cord Commission. Also available for purchase from Spain Rehabilitation Center Training Office, 1717 6th Avenue South, Birmingham, AL 35233. Telephone: (205) 934-3283.

Rabin, B. J. (1980). The Sensuous Wheeler: Sexual Adjustment for the Spinal Cord Injured. Long Beach, CA: Author. Available from Barry J. Rabin, Ph.D., Suite 353, 5595 East 7th St., Long Beach, CA 90804.

Sipski, M. L. (1991). The impact of SCI on female sexuality, menstruation and pregnancy: a review of the literature. Journal of America Paraplegia Society, 14, 122-26.