about sexuality are to help them to understand what is happening if they should experience sexual problems, increase their openness to discuss problems with medical professionals, and give them information on how to address problems. They should be provided with information on what types of sexual problems may occur and on why these problems happen. This information should be provided in lay language, and any written materials should be at a reading level appropriate for the population. If the person with injury and their partners understand why problems are happening, they are less likely to attribute them to personal or relationship issues. While many persons with TBI will not notice sexual difficulties during rehabilitation, receiving education may increase their openness to seek help if they experience problems later. A rehabilitation professional who discusses sexuality in an open, matter-of-fact way, treating it as simply another potential symptom of the injury and indicating that solutions and treatments exist, can be an important role model for persons with injury and their partners. The message conveyed is that sexuality and sexual problems are solvable and shouldn’t be embarrassing. This is a powerful message for clients and their partners. Education on sexuality should include recommendations for appropriate treatments, presentation of alternative ways to obtain sexual satisfaction, and a list of resources where further information can be obtained. The most important recommendation regarding treatment is to receive a comprehensive medical examination, including blood work and urinalysis. This examination can determine any medical causes of sexual problems. The exam may also indicate the need for referral to a specialist, such as an endocrinologist or gynecologist. Medications should be reviewed for potential side effects on sexual functioning. Referrals for individual psychotherapy, couples counseling, and/or marital or sex therapy may also be warranted. Sexual difficulties, even if directly due to the injury, can have a negative impact on relationships. Furthermore, relationship issues can lead to sexual problems, regardless of injury. Therapy is often a first step toward mending relationships and improving sexual functioning. Often, the solution to improving sexual functioning and satisfaction after injury is to alter the way that people have sex. For example, motor or vestibular impairments may make it difficult to have sex in the traditional missionary position. Educating persons with TBI and their partners about alternative positions may be necessary. For persons who do not have a partner and are feeling sexually frustrated, a discussion of masturbation may be warranted. Motor impairments may impact ability to masturbate. Devices to assist with masturbation are available, and clients should be made aware of these resources. Prosthetic devices are also available for males who have difficulty obtaining or maintaining an erection. The use of Viagra or other drugs to improve sexual potency should only be considered under the supervision of a physician familiar with brain injury and any other medications that the client is taking. Females with decreased vaginal lubrication should be educated regarding the use of lubricants. Sexual dissatisfaction after TBI may be due to social isolation and lack of opportunity to form intimate relationships. People with TBI may need to be guided in how to make social connections. Providing education on community organizations (e.g., churches, Y.M.C.A.s, art groups, social organizations) that can be used as a place to meet new people is often necessary. Social
communication impairments often make it difficult for people with TBI to form new relationships, even when they have opportunity. Social skills training, individually or in groups, can be beneficial. For example, a person with TBI may need to relearn how to make appropriate eye contact, how to initiate conversations, how to be a good listener, and how to respect others’ personal space. Finally, no sexuality education program is complete without information on safe sex, including proper use of birth control and protection against sexually transmitted diseases. Persons with TBI are particularly vulnerable because they may have memory, organization, and behavioral control deficits that make it less likely that they will implement safe sex measures accurately and consistently. Helping them to develop a plan (e.g., carrying contraceptives with them at all times) can be beneficial. Cognitive impairments can also make persons with TBI more vulnerable to sexual abuse or exploitation. They should be educated regarding sexual rights (e.g., right to say no to sex at any time; right to express their needs). Sexual rights also include the right to choose their own sexual partner and to make their own decisions about sexual activity- a right that can sometimes be in conflict with the wishes of caregivers.
Conclusion In conclusion, sexual difficulties are common following TBI. They can be a direct result of injury to the brain and related systems, or can result indirectly from physical, cognitive, emotional, and psychosocial residuals of TBI. All aspects of the sexual experience can be affected, including desire, arousal, sexual performance, and ability to achieve orgasm and satisfaction. Sexual dysfunction can have a negative impact on self-esteem, emotional functioning, and relationships. As rehabilitation professionals, educating persons with TBI and their caregivers about sexuality should be part of the holistic treatment approach. Toward this goal, increasing the knowledge of rehabilitation team members regarding the impact of TBI and sexuality is important. Increasing the comfort level of staff in discussing sexuality is equally important. This requires commitment and coordination among the entire treatment team, and support from management. Hopefully, the information in this article can be used to begin this process within your rehabilitation team. References 1.
2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
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