The following text was copied from a web page that is no longer available, and is meant for educational and personal use only.  Even though it was written in 1993, the information is, for the most part, current.  It's a pretty nice summary of a male quad's sexuality, so it should answer most questions.  If not, feel free to e-mail me, & I'll be happy to try to answer any other questions you have.  Also, please understand that this is a general overview, & does not particularly reflect my sexuality, or that of any other individual who is quadriplegic.  For instance, it covers topics such as jealousy, anger, & depression.  Jealousy just isn't an issue with me; it never has been.  And, while I sometimes still get angry or depressed about my situation, I've never taken it out on a partner, or let it affect my relationships, sexual or otherwise.  Also, it doesn't talk about things such as oral sex as an option.  This can definitely be used to satisfy one's partner.  To get an idea of what it would really be like to make love to a quadriplegic, rent "Coming Home" with Jane Fonda & Jon Voight.  There is a very romantic, tasteful, and accurate love making scene.  Although Jon Voight plays a paraplegic, it's still the closest I've seen to reality.  Besides that, it's a good movie!  If you'd like to read more about sexuality and the disabled, see my Disability Info links.

NOTE:  This was written before the introduction of drugs such as Viagra, Cialis, or Levitra, so it is not included in the Sexual Aids And Options section of the following text.  These products are also a recommended option for males with SCI.

Spinal Cord Injury - InfoSheet #3
"Sexuality in Males with Spinal Cord Injury" Level - Professional

The following is an Information Sheet developed by the Training Office of The RRTC in Secondary Complications in Spinal Cord Injury at UAB Spain Rehabilitation Center. It contains information and resources on issues and concerns dealing with sexuality in males with a spinal cord injury. For permission to reprint for further distribution, contact Linda Lindsey:

via Internet - Lindsey@Sun.rehabm.uab.edu (may not be an active e-mail address)
or write to RRTC Training Office, address and phone listed below.

Published by:
Medical RRTC in Secondary Complications in SCI
Training Office, Room 506, UAB-Spain Rehabilitation Center,
1717 6th Ave. S, Birmingham, AL 35233-7330
(205) 934-3283 or (205) 934-4642 (TTD only)

Date: December, 1993

INTRODUCTION
A spinal cord injury affects a male's sexuality both psychologically and physiologically. The type and level of the spinal cord injury determine the extent that the spinal cord injury affects his sexual functioning. He may face changes in his relationships, his sexual performance, and his ability to biologically father children. He also can expect changes in his feelings and concerns about his own sexuality.

It is important to remember that sexuality includes both emotional and physical aspects, and may or may not involve a partner. The physical aspects of a relationship can involve touching, kissing, or sexual intercourse. All aspects of the male's sexuality need to be addressed and understood.

This information sheet cannot address in detail all the issues related to male sexuality after SCI. For additional information, see the resources listed at the end of this paper.

PHYSIOLOGICAL CHANGES
The level of spinal cord injury affects a male's ability to have an erection. There are two types of erections that a male can have, psychogenic and reflex. A psychogenic erection takes place when a message is sent from the brain, such as, having sexual thoughts or seeing or hearing something stimulating or arousing. A reflex erection occurs when there is direct physical contact to the penis or other erotic areas such as the ears, nipples, or neck. A reflex erection is involuntary and can occur without any sexual or stimulating thoughts.

The nerves that control an erection are located in the sacral segments (S/2-S/4) of the spine. Spinal cord injuries that occur above these segments result in a loss of the ability to have psychogenic erections. The male with spinal cord injury is no longer able to achieve an erection by becoming emotionally or mentally excited; however, these males may be able to have reflex erections with physical stimulation.

It is possible for males with SCI to experience orgasm, especially when concentrating on their partners arousal.

The ability to ejaculate decreases dramatically after a spinal cord injury. The ejaculatory process involves nerves from a number of different levels of the spinal cord; therefore, it is likely to be affected by most spinal cord injuries. Ejaculatory rates vary greatly and are dependent on several factors.

The most important factor affecting the ability to father children is the motility of the sperm. The average motility rates among males with SCI are considerably lower than for the average male without SCI. Because the ability to father children is often a main concern of males with SCI, other options, such as artificial insemination with donor sperm, should be discussed. Medical advice and options for males with SCI, who are interested in fathering children, should be provided by a fertility specialist experienced in spinal cord injury.

SEXUAL AIDS AND OPTIONS FOR THE MALE FOLLOWING SCI
Many males have erections; however, these erections may not be hard enough or last long enough for sexual activity. There are several options available for males to use for achieving erections, including penile injections, surgical implants, and the vacuum pump.

Penile injection therapy involves injecting a single drug or a combination of drugs into the side of the penis. This produces a hard erection that can last for one to two hours. These drugs must be used exactly as prescribed by the physician. If not used correctly, the result could be a prolonged erection, called priapism. When priapism occurs, the blood fails to drain from the penis. This can damage the penile tissue and be extremely painful. A person who has a history of substance abuse, therefore, would be a risky candidate for this therapy since its success requires the exact use of the prescribed drug.

Penile injections would be a difficult option for an individual with SCI with limited hand function to use on his own. He must have a partner who is willing to learn to give the injections.

Surgical implantation of a penile prosthesis was the more popular option for individuals with SCI before the discovery of penile injections. The surgical procedure involves inserting an implant directly into the erectile tissues. The three types of implants available are semi-rigid or malleable rods, fully inflatable devices, and self-contained unit implants.

With implants, there is a risk of mechanical breakdown as well as a danger that the implant could push out through the skin. Individuals with SCI usually do not have good sensation in the genital area. They would not experience pain to indicate that the implant has broken through the skin. All surgical implants carry a high risk of infection. If an infection develops, the prosthesis may need to be removed. Penile implants are the most expensive option and some health insurance plans do not cover the costs.

The vacuum pump is the least invasive aid. It is the recommended alternative when penile injection therapy is not an option. It is a mechanical, non-surgical method of producing penile engorgement and rigidity sufficient for intercourse in most individuals.

The penis is placed in a vacuum cylinder. The air is pumped out of the cylinder causing blood to be drawn into the erectile tissues. The erection can be maintained by placing a constriction ring around the base of the penis. This ring also can prevent any urinary leakage that can occur in the individual with SCI who has not emptied his bladder before sexual activity or anyone who has a reflex bladder.

There are several models of vacuum pumps from which to choose. A battery operated model is available for use by those with limited hand function. Other models require good hand function to press the pump against the skin, creating the necessary vacuum. A prescription is required to purchase the medical versions of these devices.

The use of some of the erectile aids may require assistance from one's partner. The male may find it difficult to admit to his partner that he has difficulty having an erection and needs assistance. Sexual counseling can help the individual learn to communicate his needs and feelings concerning sexual issues.

Before using any of the erectile aids discussed above, a thorough physical exam is needed by a urologist familiar with the benefits and side effects of each option as related to SCI. The treatment options available for erectile dysfunction mentioned above WILL NOT affect sexual desire, ejaculation, orgasm or sensation. They WILL NOT solve unrelated marital difficulties.

EMOTIONAL/PSYCHOLOGICAL EFFECTS
Various emotional and psychological issues about one's sexuality need to be examined and understood after a spinal cord injury. Following a spinal cord injury, people are often sensitive about the physical changes which have occurred in their body. This may result in a loss of self-esteem, especially in those who have to depend on others for help. Throughout history, men have equated masculinity with sexual functioning. After a spinal cord injury, it is common for males to have thoughts like, "I can't be a man if I can't have sex with a partner in the same way that I did before my injury." A male's self-esteem may suffer when this realization occurs.

An individual who has a partner at the time of injury may believe the partner is staying in the relationship out of pity. He believes that his partner will eventually leave him for someone who is "normal." Sometimes a male will actually "run off" his partner with the idea that this way he will dissolve the relationship before his partner leaves him. It is a mistake for the male with SCI to assume that his partner will leave. Time and trust are means of testing the permanence of any relationship.

Males who do not have a partner at the time of injury are concerned with how to attract and meet a partner. At first it may be more difficult to get out and go places where he can meet potential partners. He needs to be encouraged to make the effort to continue making social and business contacts, to meet new people, and develop new relationships.

Often the male has thoughts, such as, "I will never find someone to marry." Most males are surprised to find out that this is not a problem. Some males who have a spinal cord injury even report having an easier time meeting females now that they use a wheelchair. When a male is attracted to a female who is not interested in him, he naturally assumes it is because of his spinal cord injury. This is a mistake. During his lifetime, a man may be attracted to a woman who is not attracted to him. Do not assume that lack of attraction has to do with the spinal cord injury. Consider all personal traits when examining one's relationship, such as, grooming, dress, manner of speech, and personal interests.

RELATIONSHIP ISSUES
Partner Perspective
The difference between how the female views sex and how the male views sex plays an important role in any relationship. A female typically places as much, or more, interest in the emotional and romantic aspects of a relationship as she does the physical relationship. After a spinal cord injury, the male needs to consider this in his relationship with his partner. She may not be as concerned as he is about the physical changes resulting from the spinal cord injury and how these changes will affect their sexual relationship. Some women even report relief that sexual intercourse will no longer be the most important part of the relationship.

The male can learn ways to be romantic and intimate with his partner. If the sexual relationship was mutually satisfying before the injury, the readjustment often does not present a problem. A female may first blame herself for not being able to "turn on" or arouse her partner, even though she was told the spinal cord injury was the cause of her partner's lack of erections. The male may need to reassure his partner that the physical aspects of their relationship are satisfying to him.

Both partners need to understand there will be changes in their sexual relationship and there are many considerations to building a strong relationship. The couple can explore and experiment with different ways to be romantic and intimate that are sexually stimulating and fulfilling for both partners.

Jealousy
In any relationship, jealousy can lead to anger and resentment between the partners. Insecurity following a spinal cord injury often leads to the male falsely accusing his partner. An example would be that whenever the partner is away longer than expected, he becomes jealous, assuming infidelity.

Depression
Going home from the rehabilitation center after an SCI often results in a temporary state of depression for both the male and his partner. Withdrawal, crying, anger, and a lack of interest in sex may be signs of depression. The partner may misinterpret these signs. Usually the anger is directed at the partner, creating additional problems in the relationship. The partner may try to ignore these displays of anger because of pity for the male with the spinal cord injury. If the signs of depression continue in either partner, professional counseling should be sought.

Arguments
Money is a primary cause of arguing in most relationships; this may be magnified after an SCI. Hospital bills and the permanent or temporary loss of an income creates financial insecurity. Sometimes there are also role changes in the family. The partner may now have to work to support the family. The male with an SCI may have to take over the parenting and housekeeping roles. If each family member has a rigid view about his or her role, this may become the source of many arguments.

Verbal or physical abuse
Verbal or physical abuse should not be excused. Having an SCI does not give the male permission to be physically or verbally abusive to his partner. If either partner in the relationship feels this is happening, they should be encouraged to contact a professional in the community for help. The psychologist, counselor, or social worker at the rehabilitation center are examples of professionals who could work with the couple on these behaviors. Local community mental health centers and private licensed counselors are also available in most communities.

Bowel/Bladder Accidents
Another physical concern is having a bowel or bladder accident. The fear of an accident may be enough to keep the male from pursuing a physical relationship. He should alert his partner to the possibility of a bowel or bladder accident. Maintaining a regular bowel and bladder program is an important factor that can help prevent accidents. This can eliminate the fear of accidents and relieve anxiety.

PROFESSIONAL COUNSELING
Establishing a healthy sexual relationship may require professional help. Couples or individuals who get sexual counseling can learn effective ways to communicate feelings. Studies show that males with SCI want information about sexual issues. Those who receive the proper information have more positive sexual relationships. It may be difficult to locate a professional trained in sexual counseling who is also knowledgeable about the changes in sexual functioning after SCI. The American Association of Sex Educators, Counselors and Therapists (AASECT) has set standards for certification of professionals working in the field of human sexuality. AASECT can provide a list of qualified professionals in your area. [See: Resources]

SAFE SEX
Today, everyone needs to take precautions to protect himself and his partner from any sexually transmitted diseases (STDs) . STDs include diseases such as gonorrhea, syphilis, herpes, and the HIV virus. These STDs can cause other medical problems, such as, infertility, urinary tract infections, pelvic inflammatory disease (PID), vaginal discharge, genital warts, and AIDS.

If individuals are not sure that either partner is disease free, each should be tested by a health care professional. The safest, most effective routine to follow to prevent sexually transmitted diseases is to use a condom with a spermicidal gel that contains the ingredient Nonoxynol-9. The condom must be used correctly every time partners have sex. The condom is often used as a method for birth control. Even if the female partner is using another form of birth control, a condom still needs to be used to protect against STDs.

STDs can be the cause of many problems if not properly treated. Some STDs can be treated with antibiotics. Others, such as AIDS, have no current cure. The best means to prevent infection is to first be tested. If either party has doubts about being disease free or having any STD, they should use protection in their sexual relationship.

RESOURCES
Books:
Becker, Elle Friedman. (1991). Love, Where to Find It, How to Keep It. Bloomington, IL: Accent Press.

Cole, Sandra S. (1993). Reproductive Issue for Persons with Physical Disabilities. Baltimore: Brooks Publishing Company.

Cole, T., Chilgre, R., and Mooney, T. (1975). Sexual Options for Paraplegics and Quadriplegics. Boston: Little and Brown.

Cornelius, D. (1982). Who Cares: A Handbook on Sex Education and Counseling Services for Disabled People. Baltimore: University Park Press.

Ferguson, Gregory M. (1974). Sexual Adjustment: A Guide for the Spinal Cord Injured. Accent on Living, Inc.

Hammond, M.D., Margaret, C., et al. (Eds.) (1989). Yes, You Can! Chapter 14-Sexuality. Washington, DC: Paralyzed Veterans of America.

Kroll, L. and Klein, E. (1992). Enabling Romance: A guide to love, sex and relationships for disabled people (and the people who care about them). New York: Crown.

Maddox, Sam. (1993). Spinal Network (2nd ed.) . Boulder, CO: Spinal Network, pp.323-347.

Neistadt, M.E. and Freda, M. (1987). Choices: A Guide to Sex Counseling with Physically Disabled Adults. Malabar, FL: Robert E. Krieger.

Rabin, Barry J. (1980). The Sensuous Wheeler. Long Beach, CA.

Sipski, Marca, MD and Glick, Tonnie, (Eds.) (1992) Spinal Cord Injury Manual. Chapter 8-Sex after Spinal Cord Injury. Northern New Jersey Spinal Cord Injury System, Kessler Institute for Rehabilitation.

Sandowski, Carol L. (1989). Sexual Concerns When Illness or Disability Strikes. Springfield, IL: Thomas.

Videos
Evaluation and Management of Sexual Dysfunction in Spinal Cord Injured Males. (1988). Presented by Dr. L. Keith Lloyd, MD and J. Scott Richards, PhD. Birmingham, AL: UAB-Spain Rehabilitation Center.

Sexuality Reborn. (1993). Produced by Dr. Craig Alexander and Dr. Marca Sipski. West Orange, NJ: Kessler Institute for Rehabilitation.

Male Reproductive Function after Spinal Cord Injury: An Overview of Progress in the Field. Fact Sheet No. 10. (1988). National Spinal Cord Injury Association.

Sexuality after Spinal Cord Injury. Fact Sheet No. 3. (1987). National Spinal Cord Injury Association.

Male Spinal Cord Injury and Fertility. (1992). Shirley McCluer, MD. Arkansas Spinal Cord Commission.

Vibrator Technique for Ejaculation. (1992). Shirley McCluer, MD. Arkansas Spinal Cord Commission.

ASECT
The American Association of Sex Educators, Counselors and Therapists.
435 N. Michigan Avenue, Suite 1717
Chicago, IL 60611
(312)644-0828

SIECUS
The Sex Information and Education Council of the U.S.
130 W. 42nd St, Suite 2500,
New York, New York 10036
Information Service available Noon til 5pm (EST)
Mon-Fri. (212)819-9770

Developed by:
Jane Brown, MA, LPC, AASECT
Linda Lindsey, MEd, Media Specialist
© 1993 Board of Trustees of the University of Alabama
The University of Alabama at Birmingham provides equal opportunity in education and employment.

This publication is supported in part by a grant (#H133B80012) from the National Institute on Disability and Rehabilitation Research, Dept of Education, Washington, D.C. 20202. Opinions expressed in this document are not necessarily those of the granting agency.