Sexual Dysfunction: The Problem

Several years ago, Dr. George Zitnay, then president of the National Head Injury Foundation, testified before congress, and started his prepared remarks with the following statement:

Ladies and gentlemen, I am here today to talk about the largest and most important sex organ in the human body - the brain.

As Dr. Zitnay spoke those words, everyone in the hearing stopped talking and paid strict attention to what he had to say.

Amazingly enough, all of the following have one thing in common:

1. Depression;
2. Brain injury;
3. Post traumatic stress disorder;
4. Amputation;
5. Chronic pain;
6. Disability from work;
7. Sleep difficulties;
8. Frustration;
9. Changed perception of self;
10. Medication;
11. Changed personality;
12. Change in sense of humor;
13. Physical injury;
14. Scarring;
15. Fatigue;
16. Increased stress;
17. Getting behind in bills;
18. Reduced recreational activities;
19. Elimination or reduction of social life;
20. Elimination or reduction of recreational activities;
21. Loss of job.

What all of these have in common is that any or all of these can have an impact upon a person's sexual functioning. For example, many medications have, as a side effect, a potential impact on a person's libido which may not be known to the patient or their family.

Following the injury, it may be weeks or months before the person experiences the romance of a sexual encounter, which may not be the same as it was before the injury. This may lead to embarrassment, and depending upon how the situation is dealt with, may lead to humiliation, particularly on the part of the man. This humiliation may, in and of itself, lead to stress, and in and of itself, lead to an avoidance of the next romantic sexual encounter, which may then engender some feelings of guilt on the part of the uninjured spouse. This may snowball and become a vicious cycle of frustration for both parties.

Where the woman experiences a lack of libido, for any number of reasons related to the injury, the man may feel unloved and unwanted, which leads to stress, arguing, and again, can snowball and become a vicious cycle of frustration for both parties.

The uninjured spouse may then begin to think that the injured spouse no longer cares about them, or no longer has romantic feelings, and is unable to provide an explanation for the cause of the problem. It may very well be that as of that point in time, no one in the health care system has taken the time to explain to either of the parties that any aspect of the injuries may have an impact upon sexual function.

In the book Neuropsychological Assessment, Third Edition, by Dr. Muriel D. Lezak, at page 42, she writes:

One significant personality change that is rarely discussed but is a relatively common concomitant of brain injury is a changed sexual drive level. A married man or woman who has settled into a comfortable sexual activity pattern of intercourse two or three times a week may begin demanding sex two and three times a day from the bewildered spouse. More frequently, the patient loses sexual interest or capability. This leaves the partner feeling unsatisfied and unloved, adding to other tensions and worries associated with cognitive and personality changes in the patient. For example, some brain damaged men are unable to achieve or sustain an erection, or they may have ejaculatory problems secondary to nervous tissue damage. Patients who become crude, boorish, or childlike as a result of brain damage no longer are welcomed bed partners and may be bewildered and upset when rejected by their once affectionate mates. Younger persons brain damaged before experiencing an adult sexual relationship may not be able to acquire acceptable behavior and appropriate attitudes. Adults who were normally functioning when single often have difficulty finding and keeping partners because of cognitive limitations or social incompetence resulting from their neurological impairments. For all of these reasons, the sexual functioning of many brain damaged persons will be thwarted. Although some sexual problems diminish in time, for many patients they seriously complicate the problems of readjusting to new limitations and handicaps, by adding another stage of frustrations, impulses, and reactions.

There may be an escalating cascade of problems which can be, for example:

1. The first problem is that it happens, and then, through embarrassment, reluctance, or other feelings, how is it dealt with? As we all know, while some people may joke and talk about sexuality, when it comes to the individual, there may be reluctance to talk about personal sexual issues, and it may be that this is especially true in term of one's own partner. It may be that the entire relationship has flourished before injury without there having been a discussion about sexual issues, and now, any discussion must revolve around sexual dysfunction about which both may be ignorant.

2. The second problem may be that no one will admit it, not even one partner to another.

3. That where it is the woman who has had a loss or decrease of libido, following injury, the man may assume that her lack of interest means that she no longer cares for him, and this leads to another whole set of problems.

4. People may not even suspect that the injury or medication or consequence of the injury is causing the problem, and they may not have received any such advice or information from the treating health care providers.

5. The relationship begins to deteriorate.

6. The doctor may not know about it because people may not initiate discussion about sexual issues, let alone sexual dysfunction issues, and doctors do not routinely ask about sexual function as part of their history, or as a part of a routine examination.

7. The next problem is that the doctors may not know what to do, or just say something like "it will be all right," and leave the patient without any recommendations.

8. The next problem is that if the person is in a managed care situation, there may be a financial incentive for the primary care physician not to make referrals for an extensive sexual dysfunction work-up that may be appropriate, or, in some cases, the doctor may not care.

9. The next problem is that there are doctors who have the attitude that so long as the person is alive, they should be grateful.

10. Another problem is that if the person initiates discussion, and the doctor does not handle it appropriately, the patient may be embarrassed, humiliated, and the cycle could repeat itself.

One of the concepts in psychology is the concept of what is called a stroke as being a unit of recognition, or a form of stimulation. This is far different from the medical concept of a stroke, and this discussion is related solely to the psychological concept of stroke. In psychology, strokes can be physical, verbal, or non-verbal, and as a person grows older, new ways are discovered to receive and exchange strokes. For example, some may enjoy making presentations at church, or at local groups, because they enjoy the recognition, and the recognition would, in psychology, be called a stroke. The need for stimulation becomes at least, in part, a need for recognition, and this is a very basic human need and, as stated in the book entitled Transactional Analysis by Woollams, Brown & Huige, at page 16:

Since the need for strokes is inherent in each person, exchanging strokes is one of the most important of all human activities.

Further, at page 16:

Since strokes are necessary for survival, a person will do whatever she thinks necessary in order to receive the strokes she needs. A person will develop a style of giving and receiving strokes based on her life position.

Again, remember that the concept of strokes in this context is a psychological term. Now think about the psychological concept of strokes in the context of a relationship between a loving couple, having sexual relations prior to injury. Human sexuality certainly encompasses far more than just the act of sex between two people. When we think of the delicate balance necessary for human sexuality, in terms of mood, physical, mental, emotional, and timing, and then remember that all of this must exist in a multiple of two, the psychological concept of what are called strokes is very applicable.

With the intimacy of the couple's knowledge of each other, they have developed a concept of strokes for each other, and how they receive strokes in the world, through their work, recreational activities, and things. Now, with injury, all of this has changed not only for the injured person, but then in consequence, also for the uninjured person. Just looking at this psychological concept of strokes alone, one could think that there must be a proper balance of strokes, from an emotional point of view, in order for there to be a loving sexual relationship, and if that emotional framework becomes unbalanced and distorted, as it does, that alone can impact on the sexual function.

Consider, for example, a young couple who would typically enjoy going out to dinner, a little dancing, and each other's personality, filled with a sense of humor, as a prelude to sexual relations. Now, following injury, a partner is in pain, has very little sense of humor, does not enjoy eating in the noisy atmosphere of a restaurant, and it is easy to see that the emotional framework of this couple has become unbalanced and distorted, and without help, the relationship may become further unbalanced and distorted through the silence of sexual dysfunction.

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