This paper reviews the literature on female sexuality following spinal cord injury (SCI). Beginning with an overview of spinal cord anatomy and injury classifications, the paper examines how complete and incomplete injuries affect sexual response, vaginal lubrication, orgasm, and erogenous sensitivity in women. It then addresses reproductive concerns including menstruation, fertility, contraception, and pregnancy complications such as autonomic dysreflexia and premature delivery. The review also covers practical considerations for pregnant women with SCI, including mobility, bladder management, and postpartum breastfeeding. The paper concludes by emphasizing that while SCI alters sexual function significantly, meaningful sexual expression and family life remain achievable through informed adaptation and rehabilitation support.
The paper uses a systematic literature synthesis approach, comparing earlier assumptions about female sexual response (modeled on male SCI research) with more recent laboratory-based findings. This comparative technique — showing where prior research was inadequate and where new evidence has corrected it — is a hallmark of an effective literature review in health sciences.
The paper opens with a definition of sexual health and the scope of the review, then provides anatomical background on the spinal cord. It proceeds through injury types and their functional consequences before narrowing to female-specific sexual responses. The second half pivots to reproductive health: menstruation, contraception, pregnancy management, and postpartum concerns. A brief conclusion synthesizes findings and affirms the potential for sexual rehabilitation. This funnel structure — broad physiology to specific clinical guidance — is well suited to a health-science literature review.
Sexual health is not restricted to mere physical or genital function. Sexuality comprises different facets. At the basic, instinctual level, it is the feeling of maleness or femaleness, and how this sexuality and personality impacts — and is impacted by — society (Sipski, Alexander, & Rosen, 1996). It also includes such things as the right to be a sexual person following neurological injury, the opportunity to have knowledge about sexual changes, and to make informed choices about appropriate options. This work involves a review of the literature associated with female sexuality following injury to the spinal cord.
Before delving into the sexual ramifications, it is important to recognize the anatomical and functional features of the spinal cord. The spinal cord enables the brain to communicate with every physical facet of the body — governing independent action and reaction to stimuli. When a spinal cord injury occurs, this communication between the central and afferent nervous system may be severed, resulting in a loss of function. Spinal cord injuries (SCI) occur when a traumatic event damages cells within the spinal cord (Sipski & Alexander, 1997). The trauma may also independently, or as a consequence, sever the neuronal processes that relay signals to and from, and up and down, the spinal cord.
The most common types of SCI include contusions (bruising) and compressions (pressure). Other types of injuries include nerve fiber lacerations and central cord syndrome, which involves damage to the corticospinal tracts of the cervical region of the spinal cord. Severe SCI often causes paralysis — loss of control over voluntary movement and muscles of the body — and loss of sensation and reflex function below the point of injury, including involuntary activities such as breathing and bowel and bladder control. Occasionally, pain or sensitivity to stimuli, muscle spasms, and sexual dysfunction develop over time. SCI patients are also prone to developing secondary medical problems, such as bladder infections, lung infections, and pressure sores.
Damage to the spinal cord due to an injury can be permanent, and currently there is no cure. New research suggests that spinal cord repair and regeneration is possible, and more and more researchers around the world are confident that a cure for paralysis could be as close as ten years away (Ducharme & Gill, 1997).
There are two common manifestations of SCI: paraplegia and quadriplegia. Paraplegia is the loss of sensation and movement in the legs and the trunk (or a part of it), resulting from an injury to the spinal cord below the neck. Quadriplegia (also called tetraplegia) is the paralysis of all four limbs from the neck down, resulting from injury to the neck. Fractures or compression of the vertebrae, which cause permanent damage to the spinal cord, may lead to loss of sensation, movement, pain management, bladder and bowel control, and sexual function. The most common causes of spinal cord injury are car and other motor vehicle collisions (54.7%), falls (17.7%), and other medical conditions and sports injuries (27.6%). SCI is caused by sudden impact that results in crushing the spine and the cord (CureParalysis.org, 1997).
Lesions of the spinal cord that result in paralysis of certain areas of the body also produce a corresponding loss of sensation. Complete injuries result in total loss of sensation and function below the injury level, while incomplete injuries result in partial loss. Complete injuries do not necessarily mean the severing of the cord. The cord, a continuation of the brain, is like a coaxial cable measuring about one inch in diameter. From the spinal cord, nerves extend out to the muscles, skin, and bones to control movement, receive sensations, and regulate bodily excretions and secretions (Barker, Barasi, & Neal, 2003).
The ligaments link and support the bones. The spinal cord, like the brain, is surrounded by the meninges — layers of tissue with fluid between them that protect the spine. The main components of the spinal cord are organized as follows. The cervical spine consists of seven vertebrae; joints in this region allow the head to move on the neck and turn sideways, nod, and tilt. The cervical spine is the most mobile region of the spine, which is why the majority of spinal injuries occur in the neck. The thoracic spine has twelve vertebrae, which form the spine for the chest and upper abdomen, each with a pair of ribs attached. Larger and stronger, thoracic vertebrae carry more weight; the rib cage region makes the thoracic spine much less mobile than the cervical spine. Five lumbar vertebrae form the lumbar spine, which takes the most weight — hence these vertebrae are the biggest and strongest bones. The sacrum is a triangular bone formed from five vertebrae fused into a single structure and forms the rear part of the pelvis. The coccyx (tailbone) is also triangular; the final four vertebrae are fused into one.
Fractures can occur to almost any vertebra. Simple fractures are breaks that commonly involve only a chip or a crack in the bone; they are stable, do not usually require treatment, and will not potentially injure the spinal cord. In wedge or compression fractures, the front part of the bone is compressed while the rear part stays intact, forming the wedge shape; these injuries often require pain relief and rest but not necessarily surgery. Burst fractures result from a vertical shearing force, causing one or more vertebral bodies to burst open; these fractures are not stable and require treatment.
The largest problem with cervical spine injury is damage to the spinal cord. The closer the injury to the brain, the greater the consequences. An injury at the top of the cervical spine is likely to be fatal, as those nerves control breathing. Injury at C4 results in breathing difficulties and quadriplegia. If the spinal cord at C5 is injured, the patient has partial shoulder and elbow movement but is otherwise paralyzed. Cord damage at C6 allows use of shoulders and elbows with partial wrist movement but no hand or leg function. Injury at C7 allows shoulder, elbow, wrist, and some hand movement. Damage at T1 (thoracic spine) affects hand movements, while injury lower down results in paraplegia; the lower the injury, the more sensation around the torso is retained.
The spinal cord ends at the level of L1 or L2. Cord injury with paraplegia can still occur at L1 or L2, but below this level there is more room in the spinal canal for the nerves, making isolated nerve injury rare. Injuries to the sacrum and coccyx are rare, as the sacrum is well protected by its position in the pelvis. In pelvic trauma, the sacrum may become dislocated but is rarely broken. Injuries to the coccyx are almost exclusively a result of falling directly onto the buttocks or of giving birth (Vaccaro, 2003).
There are different treatment modalities for suspected spinal injury. X-ray is the most common investigation; while x-rays do not show cord injury directly, they do indicate bony damage. CT (computerized tomography) scans provide further detail to support x-ray findings, assisting diagnosis and treatment planning. Magnetic resonance imaging (MRI) scans provide doctors with additional information about the injury's effects on the spinal cord. Hard collars are used to immobilize a patient's neck as a precaution until exams confirm the absence of spinal injury; softer collars are later used to support the neck during recovery. Surgery is often required to stabilize a fracture, sometimes involving metal plates and screws to support the injured spinal column (Johnston, 2001). Bed rest and traction devices are non-invasive options that allow fractures time to heal.
In the event of a complete spinal cord injury, both men and women experience loss of genital sensation resulting from stimulation. Despite these physical changes, erotic sexual feelings continue to exist. Many people shift their source of eroticism so that the brain receives sexual signals from parts of the body other than the genitals. The brain learns to react sexually to pleasurable touching in other areas; for example, the earlobes and the back of the neck can become erogenous areas. This experience will be different than before but can be equally fulfilling. In others, feelings in these newly discovered erogenous zones may be less intense or more diffuse.
For women, spinal cord injuries can affect vaginal lubrication. Women lubricate variably — from physical stimulation or sexual thoughts. If vaginal lubrication is unsatisfactory, a water-soluble lubricant can be recommended. Sildenafil may also be of value in women with SCI by increasing blood flow to the perineum and increasing vaginal lubrication (Crenshaw & Goldberg, 1996).
In the case of incomplete injuries, a clear picture is more difficult to form. Factors such as the location of the injury and the degree of sensation and motor functioning can be important in predicting changes to sexual response. A general indicator of possible normal sexual function is the ability to control bladder and bowel movement.
Among males, erectile and ejaculatory functions require the interaction between the vascular, nervous, and endocrine systems. An erection is controlled by a reflex arc mediated in the sacral spinal cord, while ejaculation is primarily controlled by the sympathetic nervous system. These fibers originate in the thoracolumbar spinal cord and travel through the sympathetic chain and splanchnic nerves into the hypogastric plexus, ultimately supplying the vas deferens, seminal vesicles, and ejaculatory ducts in the prostate (Bancroft, 1989).
Adaptation to an SCI is a gradual process that extends over a prolonged period of time. Successful sexual adjustment is influenced by many factors, such as age at the time of injury, quality of social supports, physical health, gender, and severity of the injury. Patients are counseled to achieve as rapid a sense of closure as possible so that quality of life can be nurtured and developed. Attempts to recapture previous sexual habits are generally detrimental; instead, patients are encouraged to learn new sexual abilities.
The effect of spinal cord injury on sexual response depends on the degree of completeness or incompleteness of the injury and whether the neurological damage affecting the sacral spinal segments involves an upper or lower motor neuron injury. Whether an SCI is considered complete or incomplete is determined by the presence of voluntary rectal contraction and the ability to perceive sensation around the rectum.
Previous research suggested that female sexual function would be affected similarly to male sexual function, with psychogenic and reflex lubrication maintained in a comparable fashion depending on the level and degree of injury. More recent laboratory-based research supports the hypothesis that women with complete SCI and upper motor neuron injuries affecting the sacral spinal segments will maintain the capacity for reflex lubrication while losing the capacity for psychogenic lubrication (Sipski, Rosen, & Alexander, 1995).
In women with incomplete injuries and upper motor neuron injuries, research indicates that the preservation of the ability to perceive pinprick sensation in the T11–L2 dermatomes may serve as a predictor of the capacity for psychogenic lubrication. Similar to male sexual function, females with spinal cord injury have been shown to have the capacity to achieve orgasm approximately 50% of the time, and this capacity has not been found to be related to the degree of injury (Cooper, 1995). Lesions of the orbital parts of the frontal lobes may remove moral-ethical restraints and lead to indiscriminate sexual behavior, while superior frontal lesions may be associated with a general loss of initiative that reduces all impulsivity, including sexual.
During the acute rehabilitation phase, a sensitive discussion regarding sexuality is appropriate. The person with SCI may inquire about issues such as dating, attractiveness, relationships, parenthood, and physical appearance. Other topics of interest may include erections, lubrication, sensation, orgasm, ejaculation, and fertility. Many individuals will inquire about sexuality as it relates to bladder and bowel function. Even if the patient does not initiate such discussions, it is important for members of the rehabilitation team to provide basic information.
Women with spinal cord injuries suffer a temporary loss of their menstrual periods after injury, typically lasting about four to six months. Resumption of periods occurs in a pattern similar to the individual's pre-injury cycle. Menstrual pain is still present after spinal cord injury, and there is generally no decrease in the ability of a woman with SCI to conceive. For this reason, the importance of using birth control must be emphasized with women who have spinal cord injuries.
Every spinal cord injury is different, and the impact that a particular SCI has on sexual functioning varies. It depends on the type and level of injury and the treatment and medication used. There are no definitive rules about how a person's sexual response changes after a spinal cord injury. Functions controlled by the nerves below the level of injury are lost, and the higher the location of the lesion, the greater the loss of function. Traffic accidents, diving accidents, and falls are the most common causes of SCI, with the most adverse physical effects being paraplegia and quadriplegia.
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