Contact Resources Consulting Services Home


(Link to this page)

Sexuality And The Rehabilitation Process
Stanley Ducharme, Ph.D.

Next year marks the thirtieth anniversary that I have been involved in the psychological aspects of rehabilitation medicine. Over these years, I have developed a number of interests in my clinical practice. One such area has been the impact of physical disability on sexual functioning. In this regard, I have been involved in providing education and counseling to men and women with spinal cord injury (SCI).


The idea of providing education about sexuality is somewhat unique to the field of rehabilitation medicine. Actually, it has only been since the mid 1970's that people began talking about sexuality as part of the rehabilitation process. Before that, even the doctors didn't think you could have much of a sex life after an injury. They believed that your sex life was virtually over once you became spinal cord injured. As a result, the topic was avoided or ignored.

Not so surprisingly, it was people from the independent living programs and consumers with SCI themselves who began to demand this type of information from their doctors. Consumers challenged the medical establishment. They were going to be sexual. Their marital relationships were important to them. Patients were talking about sex among themselves and they turned to their doctors when they had questions. Back then, medical providers were also embarrassed about sex, but they had no choice but to respond.

Naturally, rehabilitation lasted a lot longer back then and people wanted to know about sex before they went home. In those early days, urologists or gynecologists were rarely involved on the rehabilitation wards and there was very little coordination of services between the rehab doctors and other medical specialists. Eventually, it was Dr. Ted and Sandra Cole at the University of Minnesota who introduced the topic to the field of rehabilitation medicine. They developed educational workshops called Sexual Attitude Reassessment Programs, (SARs).

Hard to believe, but talking about sexual functioning during rehabilitation was controversial and somewhat contentious back in the 1970's. Also, the idea seemed almost academic to many professionals. Even if the doctors agreed that patients should be taught about sex, there was no idea how to do it; who should do it; what information should be conveyed. There were no medications or devices that could be provided. There was no Viagra to give to a patient back in those early days.

The introduction of the penile prosthesis changed all of that. For the first time, the medical establishment felt that they had something to offer. Somehow, talking, understanding and listening just didn't seem to be enough. Men who wanted to be sexually active after SCI were given the option of having a penile implant. And, thousands of men with SCI took up the urologists on their offer.

The Current Situation

Fortunately, today things have changed. Most people receive education and counseling about sex before they leave the rehabilitation hospital. In fact, several studies have looked at people's knowledge about sex at six months and one year after discharge. The results have been surprising!

Studies show that more than 50% of people with SCI are sexually active in the first six months after discharge. Unfortunately, approximately 35% of these people are generally dissatisfied with their first sexual experiences after their injuries. They are unhappy with their physical functioning, ability to satisfy a partner and the lack of pleasure they receive.

What's so shocking is the following conclusion. Once discharged from rehabilitation, at least 95% of people never receive any further education or counseling about how to improve their sexual functioning and satisfaction.

At the one-year mark, most people with SCI still do not feel that they have mastered their sexual adjustment. At least 50% are still dissatisfied with sex and many people decide to put sexual functioning aside. They tend to focus on other aspects of their injuries. They focus on obtaining more physical therapy, gaining more independence and learning their medical care.

Finally, at one year following discharge, about 70% of people aren't sure whom they could talk to and how they could get services related to sexuality even if they wanted them. As a result, they don't ask about sex and many give up on being sexual.

There is a lesson for us rehab people in reviewing these studies. If people with SCI don't get sexual education during their rehabilitation programs, they probably will never get it. There is a limited window of opportunity.

Once discharged, many people with SCI are not comfortable bringing up the topic with their doctors and other health providers. If they do feel comfortable, they don't know with who and how to get the information they need. For the rehabilitation professional, it is a lost opportunity. For the patient, it's a huge loss and directly impacts quality of life.

Nuts and Bolts

The acknowledgement that sexual concerns be integrated into the rehabilitation process is an organizational decision that needs to be supported by departmental managers and administrative staff alike. Without full managerial support, it is difficult for direct care providers to completely incorporate these issues into the structure of team conferences and discharge planning. Consequently, without administrative support, the sexual adjustment becomes secondary to other issues.

Unfortunately, rehabilitation staff members can easily create a negative atmosphere regarding normal sexual exploration and curiosity after injury. It is not uncommon for patients to explore these issues through comments to staff members or occasional sexual advances to staff members. These sexual expressions are naturally difficult and troublesome for staff members.

How we react to sexual comments or sexual advances from the patient, communicates an important message regarding sexuality. At these times, many patients are exploring their sexuality and trying to understand the impact of their injury on sexual attractiveness and functioning. Staff members need to set limits and boundaries in a positive, affirming manner. A punitive, negative and infantalizing response by a staff member can be harmful to the patient's sexual confidence and self-assurance. Ultimately, his self esteem and emotional adjustment to the injury can be compromised.

It is never too early after injury to introduce the topic of sexuality and relationships. Many professionals are concerned that patients have other concerns early in the rehabilitation process. My experience has been the opposite.

Even during an acute hospitalization or in an intensive care unit, people are wondering as to the future of their marriage, the ability to father a child or their future attractiveness to the same or opposite sex. Some people believe that concerns about sex are one of the patient's highest priorities at this time. Often the patient himself is unable to verbalize concerns about sexuality so that staff members need to take the lead in opening these discussions.

Validating these concerns and offering to provide information when appropriate can provide a sense of reassurance and normalization. Often, it's helpful for the person with an SCI to know that such resources are available. All staff members should encourage the individual to ask questions and to verbalize any fears or anxieties associated with their injury or their future.

Although an obviously personal topic, issues of sexuality are best discussed in a natural, comfortable atmosphere. They can be easily integrated into other activities during physical therapy, nursing care or recreation. In fact, these are often the best times to broach the topic and to be available for questions. How the therapist reacts to an erection, a catheter or a personal question during these times, conveys either an encouraging or unacceptable message to the patient. The reaction of the therapist will either promote further questions or discourage a future discussion.

Another issue often debated is who should provide education on sexuality during rehabilitation. Is this the domain of the doctor, the psychologist, nurse or therapist? In general, all team members have a role and a responsibility to address these matters with the patients. Various members of the team should address all issues around sexual positioning, fertility, erections, communication, bladder management during sex and other concerns. If left to one particular discipline, typically these issues don't get talked about and information is not conveyed.

The simple rule of thumb in assuming responsibility for sexual education should depend on what staff member feels most comfortable with the topic and this patient. This is a case-by-case decision. In addition, who does the patient feel the most comfortable with? It is ultimately the comfort level and trust of the patient that should be the deciding factor in making this decision. Patient focused care is always the goal.


In essence, there's no mystery in providing sexual counseling. Early after injury, people with spinal cord injury need to know about what they can expect. People with spinal cord injury, need to know that they have the option as to how sexually active they wish to be. Sex is not lost after injury! It is changed, may not be as spontaneous and may involve the use of medications. Nevertheless, the bottom line remains the same. After injury, you can still be emotionally and physically intimate with another person if you chose to be. The choice is yours.

(Link to this page)

Back to Articles

| Home | Services | Consulting | Resources
| Directions

Web design by flyte new media
email Web Master