Synapse - reconnecting lives

Acquired Brain Injury can have a number of consequences for an individual's sexual functioning. Talking about sex can be embarrassing, but it is important for the person with brain injury and their loved ones to discuss the various issues.

The rehabilitation stage

Impulsivity, disinhibition and lack of awareness may lead to rehabilitation staff getting unwanted sexual attention from the brain injury survivor. The medical team, family and friends need to have a common response to inappropriate sexual behaviour that will assist the person to regain control over very basic impulses when placed in close proximity to a person of the opposite sex. This behaviour can particularly be a problem for males from their late teens to mid-twenties when their sexual urges are strongest. Some of this behaviour may include fantasising, lewd verbal responses, disrobing and/or masturbating in public, impulsiveness, and touching others.

Understanding from the family

Families and partners can have trouble understanding these sexual changes and can react negatively. A good understanding should be gained of how impulsivity, disinhibition and lack of awareness have caused sexual changes.

The brain injury survivor must be encouraged to take control over aspects of their life, when there is a reasonable expectation for responsible behaviour. When sexual behaviour is inappropriate, steps need to be taken to learn better ways for managing or compensating for the lapses in social skills. All members of the family should work to become comfortable in discussing sexual issues, and assist in implementing behavioural modification techniques to manage behaviours.

Common changes

Sexual changes are common after a brain injury. Although we are all sexual in nature, there is a great deal of stigma to sexual behaviour in the wrong place or time. Some of the more common changes include the following:

• Loss of libido or sexual drive
• Inability to achieve or maintain erection
• Inability to orgasm
• Premature ejaculation
• Pain and discomfort during sex
• Hypersexuality (increased desire for sex)
• Sexual disinhibition e.g. talking excessively about sex or inappropriate touching
• Reduced sexual responsiveness or desire for intimacy.

Such changes may be a direct result of damage occurring to particular brain structures underlying sexual functioning. Other biological causes of sexual dysfunction may include damage to genital organs, muscles and bones, spinal cord and peripheral nerve damage, medical conditions, hormonal disturbance and side effects of medication and drugs. In addition to the direct effects of brain injury and other biological causes, changes in sexual functioning may occur more indirectly due to a variety of physical and psychosocial changes.

Psychological changes

• Low motivation
• Medication
• Diabetes or Hypertension (high blood pressure) can reduce libido
• Depression
• Stress and Anxiety
• Emotional reactions e.g. anger, embarrassment, shame and fear of rejection
• Personality changes e.g. aggression
• Cognitive problems e.g. distractibility, perceptual disorders and memory problems
• Communication deficits e.g. Aphasia or missing social cues
• A loss of self-confidence regarding personal attractiveness
• Poor social skills and impaired self-control
• Social avoidance and isolation.
• Relationship breakdown

Assessment

Seeking professional advice can be an embarrassing and sensitive issue for many people as sex is usually a very personal and private aspect of life. People are often more likely to discuss sexual problems with their general practitioner during a visit for other health reasons. Assessment of sexual problems can be a vital first step in learning to manage or discover treatment options. Assessment may involve an interview, questionnaires, physical examination, and neurological and medical tests. In addition to a general practitioner, psychologists and psychiatrists may be involved in the assessment and treatment of sexual problems.

Management of Sexual changes

Partners "and family members" reactions

Partners and family members play a significant role in influencing the person's adjustment to physical and psychosocial changes that affect their sex life. Partners and family members may consider the following forms of coping:

• Developing greater understanding by seeking information on how to support the person
• Learning different techniques and compensatory strategies e.g. different ways of giving and receiving pleasure with the person
• Altering expectations and negotiating about how often, how long and the type of sexual activity the person can achieve
• Being assertive and sensitively communicating personal views
• Making changes to lifestyle and routines that improve quality time together.

Case study

Jill's husband Paul experienced a number of personality changes after his brain injury. In particular Paul's behaviour was childlike and immature and he became overly dependent upon Jill. In many ways Jill felt like she had become Paul's mother rather than his wife, friend and lover. The impact upon their sexual relationship was significant. Jill read some information about the effects of brain injury, organised some regular respite care and learned some behaviour management strategies for encouraging Paul to be more independent. As a result of Jill's increased understanding, some lifestyle changes and new skills, she and Paul now spend more quality time together and their sexual relationship has improved.

Another important issue is the increased vulnerability that people may experience due to cognitive Impairment and emotional distress. In particular, the person may not sense when they are at risk, know how to cope with unwanted sexual advances or understand the consequences of their actions. Family members and friends need to be aware of these issues and discuss any concerns with a professional. Some people may not feel that it is possible to discuss these issues directly with the person with a brain injury. In such cases, a friend or another family member may be a more appropriate person to recommend self-protection strategies or remind the person about general safety issues.

Children's social and sexual functioning

Acquired brain injury can also affect children's social and sexual functioning whereby development may be arrested or they appear to revert to a previous level of development. In less common situations a child may develop physical and behavioural changes earlier than their peers, which are often referred to as 'precocious puberty'. Families and schools may vary greatly in their approaches to educating children about sexual issues and behavioural management. It is recommended that parents and teachers consider resources available in the community e.g. family planning and sexual health clinics and support from professionals specialising in acquired brain injury.

Masturbation

A family member may need to be told that masturbation is an appropriate way to deal with sexual urges, but in the privacy of their own room. It is important to establish ground rules to protect the rights and privacy of others, so when, where and how need to be discussed.

In some cases, a partner or spouse may continue in a caring role but no longer wish to maintain a sexual relationship. In these cases, it needs to be stated clearly and consistently that masturbation will be the only option to sexual urges.

Treatment for sexual problems

Professionals can help individuals cope with a variety of physical and psychosocial changes. Following assessment, specific treatment of sexual problems may involve education, learning new skills and behavioural techniques, physical rehabilitation, aids and medical treatment. Specific forms of treatment may include psychological support, medical and surgical approaches.

Psychological support

A psychologist or social worker can provide sexual and marital counselling to couples to enhance their understanding of sexual changes, communication skills, problem-solving, conflict resolution and caring behaviours. Professionals may also provide literature, audio-visual aids and advice on sexual positions, techniques and aids. A psychiatrist may prescribe medication for either psychological or physical problems.

Medical and surgical approaches

The medical management of sexual problems is usually most applicable for musculoskeletal, neurochemical and vascular disorders. Some examples include hormonal replacement, new medication e.g. anti-spasticity drugs or a change of current medication, neurosurgical and orthopaedic procedures.

Where to get help

• Your doctor
• Neurologist
• Brain Injury Association of Queensland 1800 673 074 or (07) 33671049
• BrainLink Tel. 1800 677 579
• Brain Foundation Tel. 1300 886 660
• Acquired Brain Injury Unit, PA Hospital (07) 3240 2111
• Acquired Brain Injury Outreach Service (07) 5574 4311
• Open Minds (07) 3891 3711

Things to remember

Brain disorders such as traumatic brain injury can alter the way a person experiences and expresses their sexuality. Common problems can include reduced sex drive, difficulties with sexual functioning (such as erectile problems) and behaving sexually at inappropriate times.

Talking about sex can be embarrassing, but it is important for the person with brain injury and their loved ones to discuss the various issues and seek professional advice.

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