Journal of Sex & Marital Therapy

ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: http://www.tandfonline.com/loi/usmt20

Sexual counseling with spinal cord-injured clients Donald K. Miller M.S.W. To cite this article: Donald K. Miller M.S.W. (1975) Sexual counseling with spinal cord-injured clients, Journal of Sex & Marital Therapy, 1:4, 312-318, DOI: 10.1080/00926237508403705 To link to this article: http://dx.doi.org/10.1080/00926237508403705

Published online: 14 Jan 2008.

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Date: 06 November 2015, At: 07:24

Journal of Sex & Marital Therapy Vol. 1, No. 4, Summer 1975

Sexual Counseling with Spinal Cord-Injured Clients

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Donald K . Miller, M.S.W.

ABSTRACT: Spinal cordinjured clients have many fears and misapprehensions about their sexual functioning. Common beliefs include: (a) disabled men cannot sexually satisfy able-bodied women; and (b) cord-injured persons cannot have sexual intercourse. Such misapprehensions can be helped by the counselor’s willingness to discuss sexual issues openly. Clients need a clear and accurate picture of the facts, as well as encouragement and support to help them rediscover their sexuality. Spinal cord injury does not mean sexual incapacity. Given a knowing and patient partner, most clients can enjoy a satisfying sex life.

Sexual functioning is one of the most sensitive subjects to discuss with clients. Long-standing societal taboos make people reluctant to discuss their sexual problems with social workers. Many feel that it is either socially or legally dangerous to reveal sexual activity to the worker. For the disabled spinal cordinjured client there exists a greater hesitancy to talk about his sexuality. The disabled person’s altered body image makes him feel less sexually attractive and capable than before his injury. The worker doing sexual counseling with disabled clients must make a special effort to put that person at ease, so that the client can feel free t o discuss his sexual concerns openly. At the same time, the worker needs t o be aware of his own sexual values and attitudes t o ensure that they do not interfere in the therapeutic exchange. Finally, the worker must possess an adequate knowledge of the sexual problems facing the disabled client and be able t o discuss these problems comfortably with him. Any expression of disapproval or discomfort on the worker’s part can make the client uneasy and reluctant to talk candidly. Although this paper focuses primarily on the social worker as the sexual counselor, the author feels that any staff member with the proper knowledge and working relationship with the client can help the client deal with his sexual problems. Mr. Miller is Psychiatric Social Worker, Middletown Area Mental Health Clinic, 6 4 South Main Street, Middletown, Ohio 45042. The author wishes to thank Ernie Andrews, M.S.W., Visiting Professor, Ohio State University School of Social Work, for his help and encouragement in writing this article, and Dr. Marvin Spiegel, Department of Physical Medicine, Ohio State University, for his medical consultation.

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AN EXPLANATION OF THE PROBLEM Each year approximately 10,000 people in the United States receive paralyzing spinal cord injuries, and most of them are under 25 years of age.’ Along with loss of mobility and bowel and bladder functioning, spinal cord injuries frequently affect the client’s neurological and physiological sexual capabilities.2 Many spinal cord-injured persons lose the ability t o have psychogenic erections, that is, erections caused by seeing, thinking about, or touching erotic ~ t i m u l i .Fortunately, ~ the majority of cord-injured patients can experience reflexogenic erections, or erections caused by friction or manipulation of the penis. Such an erection can be observed in small infants, who experience erections not from viewing erotic pictures but from rubbing or manipulation. The reflex arc pathway lying below the cord injury itself is most often intact in cord-injured patients, thus allowing a second way of experiencing erections. Bors and Comarr’s3 studies showed that the ability t o experience both reflexogenic and psychogenic erections varies somewhat from patient t o patient, depending upon whether the lesion is complete or incomplete, and whether it occurred in the upper or lower portion of the cord. For example, patients with incomplete upper motor lesions have a statistically higher rate of reflexogenic erections, while those with incomplete lower motor lesions have a higher rate of psychogenic erections. The ability to experience erotic sensation is often impaired. Other effects on patients’ sexual functioning occur in their ability to sire children. Only 5% to 7% of cord-injured persons can expect to produce o f f ~ p r i n g .One ~ of the major reasons for the sterility ~ common in these men is due to their inability to ejaculate p r ~ p e r l y .A occurrence in cord-injured males is retrograde ejaculation, or the retreating of the sperm back t o the bladder instead of out the urethra. Finally, the perception of orgasm as such in spinal cord-injured patients is rare.’ Although some may experience sensation or spasms in the legs or abdomen, there is usually n o feeling of climax from the penis or urethra. Psychologically, both male and female cord-injured patients suffer a loss of self-esteem and experience feelings of anxiety and hopelessness after their injury.6 Sexually, they feel less attractive, and many even feel that their sex lives are over.’ Men perceive a loss of masculinity when they learn of their probable infertility. Women with cord injuries may be less disturbed than men about having sexual relations.8 Although a spinal cord injury may affect a woman’s sensation in her sexual organs, it will not affect her functioning and ability t o experience a relatively normal pregnancy. Since traditionally women are often expected t o play a more passive role sexually, paralysis from a spinal injury may not prevent them from satisfying their partner’s sexual needs. The disabled person’s fears and anxieties about his sexual functioning are compounded by hospital staff’s reluctance t o deal openly with the patient’s

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sexual problems. Although staff feel free t o discuss patients’ bowel and bladder problems, traditional cultural taboos make it difficult for them to discuss sexual problems with patients. This is unfortunate, because some patients never discuss their sexual concerns with any staff member during the rehabilitation program. There is some confusion among the staff as to whose responsibility it is to discuss sexual concerns with patients. For example, some staff members won’t discuss sex with patients because they feel that this is the physician’s role. Some physicians, though, won’t broach the subject with their patients until the patient himself brings up the subject. If he is too embarrassed to ask his physican questions about sex, then the patient may never discuss his sexual concerns with anyone while in the hospital. Sometimes the aides or orderlies will talk t o the patient about his sexual problems; however, many of them feel that they d o not have the necessary knowledge or background to help patients deal adequately with this problem. Recent evidence indicates9 that patients are very concerned about their perceived loss of sexuality soon after their injury. The following case from this author’s experience illustrates this point: R is a 19-year-old male paraplegic. This was his second hospital admission. He was injured 8 months previously. During the 1st week after his injury, he related that he was very upset over his loss of sensation in his legs. He was even more upset when he couldn’t feel his penis. He thought that his sex life was now over, and he became even more depressed. Unfortunately, n o one discussed sexual functioning with him until his second hospital admission, 8 months later.

It should be clear t o patients that sex is a problem discussed during their rehabilitation. There should be staff members around with whom they can talk openly about sexual concerns. The social, psychological, and physiological problems involved in sexual functioning for these patients mean that understanding, sensitivity, and an adequate knowledge base are needed by any staff member who does sexual counseling.

THE SOCIAL WORKER AS A SEXUAL COUNSELOR The social worker in a rehabilitation hospital plays a key role in helping the spinal cord-injured person reach his individual potential. The worker’s main function centers on helping patients with their social and emotional problems. When appropriate, the worker does individual counseling, family counseling, and also makes referrals to outside agencies. The worker’s effectiveness in helping the client is enhanced by his ability to form a warm personal relationship with the disabled client. Hohmann” describes the most adequate sexual counselor for these patients as “a person who has an effective, warm, gentle, personal inter-relationship with the patient and who can give accurate neurological, physiological, and psychological information.” While thc physician can offer the

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patient medical explanations, the social worker can help the client deal with the social and emotional aspects of his sexual concerns. The social casework method, which emphasizes the relationship with the client as the key to successful therapy, can be adapted to help workers deal with the disabled client’s sexual problems. Once the worker has established a warm relationship with the client, then he can use casework skills in relating the client’s sexual problems t o the problem-solving process in general. While Pearlman” mentions six of the most common kinds of blocking that occur in a client’s normal problem-solving efforts, the second type seems especially relevant t o sexual counseling with cord-injured patients: “Sometimes people are unable t o solve their problems simply out of ignorance, or misapprehension about the facts of the problems, or the facts of existing ways of meeting it.” Many cord-injured patients are unaware of how other disabled persons deal with their sexual problems. Many are not even aware that they can still engage in some sexual activity after their injury. Some professionals as well may not know that disabled clients can have satisfying sex lives. At the Program in Human Sexuality at the University of Minnesota, Dr. Ted Cole listed the following common “misapprehensions” regarding sex and cord-injured persons: (a) disabled men cannot sexually satisfy able-bodied women; (b) most cord-injured persons cannot have intercourse; and (c) something must be wrong with a woman who marries a disabled man. Helping the patient solve his sexual problems means dispelling some of these misapprehensions. The client needs an accurate picture of the facts t o understand and solve his problems. Cole and his colleagues are trying t o dispel these myths by making professionals aware of techniques cord-injured patients can use to sexually satisfy their partners. The message of his program is that spinal cord injury does not mean sexual incapacity. Given a knowing and patient partner, most patients can have coitus. Before counseling with disabled clients, the worker needs to examine his own sexual attitudes. In his program for professionals, Cole emphasizes that the counselor must have confidence in his own sexuality before he can help other persons deal with their sexual concerns. If the worker has sexual problems himself, then he may allow his own needs t o color his perception of the client’s problems. If the worker feels that cord-injured clients can no longer be sexually attractive, then he may transmit these feelings to the client. The client needs t o know that the worker feels comfortable in talking about sex. The worker should make it clear, though, that frank discussion is simply that and not an overture. If necessary, the counselor may have t o inform the client that the worker is only interested in maintaining a therapeutic relationship, and not a sexual one. The worker should express this view with kindness, being aware that the client’s self-esteem has already been lowered by his disability. Female workers should be aware that male clients

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may be sexually attracted t o them. For a male counselor, relating t o a disabled male homosexual may force the worker t o look at his own attitudes and feelings toward homosexuality. In discussing various sexual practices with the client, the worker should not make any moral judgments. The client should understand from the beginning that he is not there to be judged by the worker. I n his classic work, Sexual Behavior in the Human Male, KinseyI2 pointed out how aware clients are of the interviewer’s feelings and reactions: “A minute change of a facial expression, a slight tensing of a muscle, the flick of an eye, a trace of a change in one’s voice, a slight inflection or change in emphasis, slight changes in one’s rate of speaking . . . or any of a dozen and one other involuntary reactions betray the interviewer’s emotions and most subjects quickly understand them.” Thus, the worker should not underestimate the client’s abilities in perceiving the worker’s true attitudes and feelings. One of the challenges of being a good sexual counselor lies in one’s ability to escape the tendency to counsel o n the basis of one’s own prejudices. l 3 To be effective in helping the client deal with his sexual concerns, the worker must first know what kind of sex life the client had before his injury. It is important to know what was sexually normal or typical for the client previously. Thus, the worker should learn what the client’s primary source of sexual satisfaction was, be it heterosexual, homosexual, bisexual, anal, oral, or other. Also, the worker should know of any sexual problems the client may have had prior t o his injury. In order to learn this information, the worker needs to take a sexual history of the client. I n taking sexual histories, Kinsey12 emphasizes the need for a systematic approach. If possible, a sequence of questions should be planned. Kinsey advises workers to begin the interview with nonsexual subjects, and then gradually build up to more sensitive questions. The worker is less likely t o receive an evasive answer after he has won the client’s confidence. For example, Kinsey recommends that counselors use the following sequence of subjects when interviewing unmarried college males: “nocturnal emissions, masturbation, pre-marital petting, pre-marital intercourse with companions, intercourse with prostitutes, animal contacts and homosexual contacts.” Kinsey also suggests that the interviewer ask all questions directly and without hesitancy or apology. Euphemisms should be avoided in place of franker terms. Often the client can be put more at ease if the worker uses language the client is familiar with. Many clients may not be aware of such technical terms as coitus or ejaculation. The following case from the author’s experience illustrates this point: B is a 29-year-old male paraplegic. During the interview he was asked whether he could have an erection. He replied several times that he could not. The interviewer proceeded for 10 more minutes with the impression that B was unable to have an erection. Shortly thereafter B said: “Oh, do you mean can I get a hard-on? Oh, yea! I can.”

Thus, using the client’s terminology can help the interview.

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After the worker has obtained an adequate picture of the client’s previous sex life, then he can begin discussing various techniques and alternatives open t o the client. In discussing different sexual practices, the client’s physical level of functioning and cultural background should be considered. The worker’s emphasis on sex as a total experience and communication, rather than just penile-vaginal intercourse, may help the client see sex in broader terms. If the male is unable to have an erection, this does not mean that he cannot have sex at that time.14, l 5 Many cord-injured persons receive great pleasure from touching and caressing also. The disabled person especially needs t o explore all possible avenues of sexual satisfactions that fit into his or her values and tastes. During intercourse with a disabled male, the nondisabled female partner usually becomes the more assertive and active partner. The woman frequently will assume the dominant position in order to actively stimulate her partner (some male clients have reported that using a water bed makes them feel more active). This reversal of traditional roles often causes anxiety t o the male. The worker needs t o help the client readjust his view of the male role. If the woman feels comfortable in being active, she can receive great pleasure from her disabled partner: S is a 24-year-old paraplegic, who was married 3 years after his injury. In an interview with a staff physician he reported that he and his wife had achieved satisfying sexual relations. Often, he was able to maintain his erections for an hour or more. If his wife remained active, she was able to have several orgasms in one session.

For the disabled female and her male partner, the physical adjustment may be less difficult. The cord-injured female may still comfortably assume a passive position if she wishes. Those patients who have indwelling catheters complain of the inconvenience and unattractiveness of this device. Some physicians advise their male patients t o fold the catheter tube along the penis, place a condom on, and engage in intercourse in this manner. Some men say that this is unaesthetic, and others fear that the enlarged penis will not fit into the vagina. This is not true, though, for the lubricated vagina can accommodate the penis with the catheter tube. For the female patient, the indwelling catheter does not physically interfere in intercourse, but again some clients may find it aesthetically displeasing. Patients with indwelling catheters d o have an alternative: They can remove the catheter or have their partner remove it for them before intercourse. Cord-injured persons who are unable t o have intercourse can engage in other techniques t o achieve sexual pleasure. Cunnilingus, for example, can offer the male an alternative method of pleasing his partner, if he is unable to have an erection. Digital stimulation of the clitoris is another technique males can use. Some clients may want to use sexual aides, such as dildos or vibrators, which are available in local stores. Some of these practices may not be acceptable to all clients, because of conflicting cultural values or personal

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convictions. The worker should emphasize that he is only discussing these techniques as alternatives and that all people may not find them acceptable. Clients should be encouraged t o experiment as much as possible sexually, because, in a sense, they must relearn where the sensitive areas are on their bodies. Many clients report that those areas that were unaffected by the injury actually have increased in sensitivity. F0.r the man, the thigh or abdomen might become a sensitive area that could trigger an erection. Without an understanding partner the disabled person would have even greater difficulties. If a good relationship does not exist between the partners, then techniques alone will not solve their sexual problems. The worker should encourage the client t o express his feelings and fears about sex. If the worker is supportive and encouraging, the client may feel freer to explore the problem openly. Often the psychological feelings of inadequacy can cause more sexual impairment than any actual physical damage. If possible, counseling should be done with both the client and his partner together. By working with both partners, the worker can help t o start a dialogue between the clients to help them discuss openly this sensitive subject. Throughout the sessions the worker should leave room for hope.I6 Current research in this area might help the cord-injured patient t o deal with his sexual problems. Masters and Johnson,” for example, proposed the establishment of a neurophysiology laboratory, with the intention of making findings available for clinical applications among para- and. quadriplegics.

REFERENCES 1. Bucy P: Paraplegia: The neglected problem. Phys Ther 49:260-272, 1969. 2. Fordyce W E: Psychological assessment and management. In F L Krusen et al, Handbook of Physical Medicine and Rehabilitation. Philadelphia, W B Saunders, 1965. 3. Bors E, and Comarr A E: Neurological disturbance of sexual function with special reference to 529 patients with spinal cord injury. Urol Survey 57:191-222. 4. Talbot H S: The sexual function in paraplegia. J Urol 73:91-100, 1955. 5. Friedland F: Rehabilitation in spinal cord injuries. In S Licht (Ed), Rehabilitation and Medicine. Baltimore, Waverley Press, 1968. 6. Jourard S M: Handicap and healthly personality. In Personal Adjustment: An Approach through the Study of Healthly Personality. New York, Macmillan, 1967. 7. Comarr, A E: Psychological aspects of disturbed neuromuscular functioning in the paraplegic. Amer J Surg 91:149-151, 1956. 8. Rusk, H A et al: Comprehensive follow-up study of spinal cord dysfunction and its resultant disabilities. Arch Phys Med 44:208-215, 1963. 9. Cole, T: Sex and the paraplegic. Med World News, January 14, 1972. 10. Hohmann G W: Considerations in management of psychosexual readjustment in cord injured males. Rehabil Psycho 19(2), 1972. 11. Pearlman H H: Social Casework: A Problem Solving Process. Chicago, University of Chicago Press, 1967. 12. Kinsey A C: Sexual Behavior in the Human Male. Philadelphia, W B Saunders, 1948. 13. May R: The Art of Counseling. Nashville, Abingdon Press, 1939. 14. Cole T: Touching. 1971 soundfilm available through Multi Media Resource Center, PO Box 439, San Francisco, California. 15. Cole T: Just What Can You Do? 1971 soundfilm available through Multi Media Resource Center, PO Box 439, San Francisco, California. 16. Branddom R: Sexual function in spinal cord injury. Unpublished manuscript, Ohio State University. 17. Masters W H, Johnson V E: What we still need to learn about sex. Today’s Health, July 1972.

Sexual counseling with spinal cord-injured clients.

Spinal cord-injured clients have many fears and misapprehension about their sexual functioning. Common beliefs include: (a) disabled men cannot sexual...
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