Sexuality, Sex and Rehabilitation after Brain Injury
By Carolyn Rocchio
Brain injury rehabilitation overlooks sexual impact of trauma
One of the common consequences of traumatic brain injury (TBI) is sexual dysfunction. Unfortunately addressing sexual issues as a component of rehabilitation is often overlooked for a variety of reasons.
“Sexuality is an integral part of the human experience” (Sander). We are all sexual beings and sexuality is part of our life experience. Social mores and cultural differences make sexuality a taboo issue in some societies. Many therapists and other direct care providers in hospital and rehabilitation settings are untrained about sexuality and persons with disabilities. Their personal values often interfere with their ability or comfort level discussing the topic. When sexuality is overlooked as part of rehabilitation, sexual dysfunction can become an issue that is very difficult for families to understand. Social isolation, common for persons after TBI, limits opportunities for developing meaningful relationships.
Decreased dollars for rehabilitation services add to the problem. With shorter number of days for care in rehabilitation programs to address the life altering effects of brain injury, such as mobility and cognitive impairments, there may be little time to discuss sexuality. Reimbursement for extended psychological and counseling has been all but eliminated from many insurance policies.
Hyposexuality and hypersexuality after brain injury
Sexual dysfunction after a brain injury may take the form of hyposexuality, as in loss of libido and lack of satisfaction. Hypersexuality can be equally problematic, but far more troubling to manage in rehabilitation and community settings. Hypersexuality manifests as inappropriate behaviors, such as verbal remarks, touching one self or others, exposing genitals, and sexual demands that are considered aberrant. These issues appear equally between men and women.
Cognitive, physical and emotional changes affect sexual functioning
Injury to structures of the brain can result in varying degrees of dysfunction. Systemically a complex set of changes can occur affecting emotions, cognition, behavior, and mobility. Physical changes may alter the ability to enjoy satisfaction, particularly when there are residual physical changes such as:
- movement disorders
- decreased balance
Body positioning, balance, and arousal may require greater patience and guidance from partners. In addition, damage to the frontal or temporal lobes of the brain can affect the endocrine system and neurochemistry, resulting in such emotional responses as apathy, disinhibited behaviors, impulsivity, as well as physical changes in hormone levels.
Even more disabling are the cognitive changes. The frontal and temporal lobes of the brain regulate sexual functioning and are more frequently injured in car crashes and falls causing the brain to bounce around in the skull striking the bony protuberances on the inside of the skull. This often results in the following difficulties in maintaining or initiating satisfying sexual experiences:
- decreased empathy for others
- inability to understand nonverbal cues (feedback)
- impaired social interaction with partners (inappropriate verbal/physical responses)
- difficulty self monitoring (can become aggressive)
Emotional issues, such as depression, can have a negative effect on sexuality. Some persons with brain injury may exhibit a child-like dependency on their partner. Self centeredness in the person after TBI may result in exclusion of the views of others. Any of these can sabotage relationships. Medications commonly prescribed to control seizures and other residual medical and psychological complications of TBI can create additional problems with sexual functioning.
Rehabilitation professionals do not routinely treat or even discuss sexuality with patients for some of the following reasons:
- family members’ discomfort discussing the subject
- therapists’ lack of training about sexuality
- lack of reimbursement for services
- level of cognitive recovery at time of individual’s discharge
How, when and what information on sex and sexuality should be addressed?
There is probably no perfect time that applies to all individuals due to the uniqueness of TBI, the person’s age and life situation, and the individual’s interest in resuming or initiating sexual activity. It is important that rehabilitation programs have printed materials for discussions with the patient, if appropriate during the inpatient stay. They should also be included as part of a discharge plan to help guide discussion once the person is in the community and indicates interest and readiness for sexual activity.
These materials should include:
- general discussion of the many ways brain injury or TBI can affect sexual functioning, i.e., emotionally, physically, cognitively, and psychologically
- safe sex practices, HIV/AIDS, birth control, and sexually transmitted diseases
- methods and devices for self stimulation in the absence of a partner
- community resources should further treatment be required
With proper guidance, family and community support, most survivors of TBI will find ways to express themselves sexually in a responsible manner as part of the experience of their humanness.
Sander, AM. Integrating Sexuality into Traumatic Brain Injury Rehabilitation. Brain Injury/Professional. 7(1) 8-12, 2010
This Fact Sheet is based on an article: Integrating Sexuality into Traumatic Brain Injury Rehabilitation. Brain Injury/Professional. 7(1) 8-12, 2010. Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to order the entire issue or join.