ABC of sexual health

Almost 4% of the UK population have some form of physical, sensory, or intellectual Impairment--almost 2.5 million people. Many of these disabling conditions can produce sexual problems of desire, arousal, orgasm, or sexual pain in men and women. Sexual difficulties may arise from direct trauma to the genital area (due to either accident or disease), damage to the nervous system (such as spinal cord injury), or as an indirect consequence of a non-sexual illness (cancer of any organ may not directly affect sexual abilities but can cause fatigue and reduce the desire or ability to engage in sexual activity).

The two main points for consideration are how disabling conditions affect sexual function and behaviour and which sexual difficulties most commonly arise.

Effects of Disability on sexual function

Women who undergo radical mastectomy or a disfiguring trauma often report concerns about their femininity and self image such as feelings of lowered self worth or the fear that men will find them less attractive. Similarly, young men with erectile dysfunction often avoid meeting potential partners because of their embarrassment over their inability to perform.

"Sexuality" describes how people express their view of what is sexual. That awareness is the result of all the physical, emotional, intellectual, and social factors that have influenced their development up to that point in their life. Defining sexuality as wider than just physical function is particularly important for people with disabilities. A person who is not able to use part of his or her body still has an equal right to full sexual expression.

Congenital or acquired disability

Congenital or birth impairments often affect all aspects of sexual development, and lack of privacy and independence in daily living means adolescents often miss out on normal sexual experiences. In contrast, an acquired disability may have different implications depending on when it happened. Impairments early in life often produce low social and sexual confidence, whereas patients who become disabled in adulthood are much more aware of what has actually been lost. While the degree of adjustment to either form of impairment may be no different, the process of adjustment is different. How people view their disability and who they see as responsible for managing the effects of the condition greatly influence their ability to cope.

Hidden impairment

Patients with an impairment that is hidden from others but which affects continence or sexual function often find the situation unbearable. People with spina bifida and perineal Paraplegia often walk without apparent difficulty but experience problems with sexual function and with controlling their bladder and bowel. The unpredictability of control often leads them to avoid social mixing, therefore increasing their isolation. People with disabilities often present with low self confidence and a poor body image, and so clinicians should not confuse the severity of a condition with the severity of its impact on the patient.

Key questions in cases of disability

Present condition

* Has the person congenital or acquired disability?

* Is the disability static or deteriorating?

* Is the disability observable by other people?

Effect of condition on sexuality

* Does the disability effect sexual function or sexuality?

* Does the disability impair cognitive or intellectual ability?

* Are there associated iatrogenic factors?

* Is fertility the principal concern?

Men with cardiac difficulties such as angina often present with sexual problems because they are worried about bringing on an attack if they attempt lovemaking. Women with joint difficulties (such as rheumatoid arthritis and Osteoporosis) may find sexual positioning painful and so avoid activity.

Deteriorating conditions

In most cases of trauma patients experience a loss that does not deteriorate, such as spinal cord injury or amputation. However, some conditions like Multiple Sclerosis do deteriorate (in either a stepwise or gradual manner), which requires mental adjustment to the initial diagnosis and to its reappraisal as the condition worsens. Sexual dysfunction may occur in multiple sclerosis initially as a direct result of Demyelination of nerves and may also be the result of indirect effects as the condition deteriorates. There may be problems with other organ systems as well as fatigue, anxiety, Depression, and, indeed, altered desire of the patient's partner. Disability services and general practitioners must address the sexual needs of not only the patients but also their partners at times of need.

Mental impairment

Some conditions such as Huntington's chorea and traumatic brain injury may alter a patient's ability to think in a reasoned way. Injury to the reticular activating system of the pons and midbrain slows arousal, whereas injury to the frontal lobes may result in promiscuity because of reduced inhibition. Indirect effects of brain injury, such as alteration of endocrine function (for example, post-traumatic hypopituitarism), can also affect sexual drive and arousal.

Those with learning difficulties often have problems developing an

understanding of their sexual identity. This may be a direct consequence of their learning impairment or a result of overprotection by families. Parents and curers often feel uncomfortable with a child's developing sexual behaviour, possibly because of fear of exploitation or because of their own lack of understanding or acceptance of the child's sexual needs. The patient's general practitioner is often the person to whom family members first mention their worries or may b4 the first to raise the issue.

Common sexual difficulties

People may have never had a specific sexual experience (primary impairment) or may have become unable to continue with their sex life (secondary impairment). Primary Functional impairments--such as a man's inability to get an erection or to ejaculate or a woman's pain, inability to allow penetration, or anorgasmia--are more common among patients with congenital disabilities or those of early onset and are often hard to resolve. Men are more likely to present than women, possibly reflecting cultural perceptions of the importance of sexual performance and, now, the greater range of treatment options available.

Sexual function and arousal in men and women occur in response to reflexogenic genital stimulation or psychogenic desire in those with intact sexual drive mechanisms. Those with brain or spinal cord injury, or whose injury or disease process affects the spinal cord, experience partial or complete loss of sexual functions. They require comprehensive assessment of the level and degree of damage to the brain and nerve cord and the damage to upper and lower Motor neurones (by testing the bulbocavernosal and anal wink reflexes; see earlier article by Dean). In neurological terms male erection is similar to the female vasocongestive response and lubrication, and male ejaculation is similar to female contraction of the pelvic floor, perineum, and anal sphincter.

Assessing sexual problems in disabled patients. Do I refer for sexual support?