R - SEXUAL HEALTH & RELATIONSHIPS
R.1.1
Clinicians should ensure that discussions regarding sexuality and reproductive health occur with individuals with SCI in acute, rehabilitation, and community settings as sexuality and reproductive health is one of the highest priorities for individuals with SCI. (Adapted from CSCM 2010, p.304; Level C)
R.1.2
Clinicians should use the Permission, Limited Information, Specific Suggestions, and Intensive Therapy (PLISSIT) as a model for framing sexual health discussions. (Adapted from CSCM 2010, p.305; Level C)
R.1.3
Clinicians should engage in open, non-judgmental conversations about sexuality based on an individual’s readiness/interest early on in care and throughout their lifespan. Maintaining privacy, respect and professional boundaries while taking into consideration the individual's life context and sexual expression regardless of gender preference and orientation is recommended. (Adapted from CSCM 2010, p.305; Level C)
R.1.4
All health professionals interacting with individuals with SCI should have access to resources/education, a basic knowledge of sexual health issues after SCI, and specialists knowledgeable on sexual health. (Adapted from CSCM 2010, p.305; Level C)
R.1.5
SCI rehabilitation centres should support the education and training for a local sexual health mentor who can support their colleagues to allow for the development of a sexual health support network throughout the country. (Adapted from CSCM 2010, p.305; Level C)
R.2.1
Clinicians should develop a sexual health education and treatment plan with the individual based on their sexual history, physical exam findings and preferences. (Adapted from CSCM 2010, p.309; Level C)
R.2.2
Clinicians should educate individuals with SCI about the effects of prescription medication (over-the-counter and herbal remedies) on sexual response and fertility. (Adapted from CSCM 2010, p.309; Level C)
R.2.3
Clinicians should educate individuals with SCI about the effects of alcohol, tobacco, and other drugs, as well as unhealthy eating habits and obesity, on sexual response and fertility. (Adapted from CSCM 2010, p.309; Level C)
R.2.4
When counselling on the sexual health of an individual, clinicians should consider socio-cultural and religious influences and do not make assumptions about sexuality based on age. (Adapted from CSCM 2010, p.313; Level C)
R.2.5
Use professionally approved educational videos and vetted websites when providing sexual health education using media. Institutions should provide sexual health educators institutional access to these resources. (Adapted from CSCM 2010, p.313; Level C)
R.2.6
Clinicians should ensure premenopausal women with SCI have proper information regarding the effect of injury on menstruation and discuss contraception options. If menses have not resumed one year after injury, an endocrinology referral should be sought by the primary care provider. (CAN-SCIP 2020; Level C)
R.2.7
Education should be provided to men with SCI that reflex erections could occur with either sexual stimulation or nonsexual stimuli. (Adapted from CSCM 2010, p.320; Level B)
R.3.1
Individuals with SCI and their partners should be provided opportunities to discuss and ask questions regarding intimacy, sexuality, and fertility during all phases of care (acute, rehab and community). Providers must protect the confidentiality of both partners. (Adapted from CSCM 2010, p.329; Level C)
R.3.2
Discuss and offer guidance on maintaining or developing interpersonal and sexual relationships. Discuss the added cautions of using the Internet to meet new partners, particularly relating to how to discuss or present disability online. (CSCM 2010, p.330; Level C)
R.3.3
Encourage romantic partners to seek caregiving services in order to provide care for activities of daily living that may affect the sexual relationship. (Adapted from CSCM 2010, p.331; Level C)
R.4.1
Clinicians should ensure that a comprehensive medical assessment of the genital and reproductive systems is conducted after SCI. This assessment should include screening for cancers and sexually transmitted diseases per non-SCI guidelines. Additional considerations exist for prostate screening in men with SCI, as many factors may affect PSA levels. (Adapted from CSCM 2010, p.308; Level A)
R.4.2
The primary care provider should refer the individual with SCI to an accessible office or specialist to ensure screening is completed. If the primary care provider's office is not accessible, or they are not personally able to perform comprehensive sexual reproductive care. (CAN-SCIP 2020; Level C)
R.4.3
Perform a physical examination using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), with special attention to the preservation of sensation from T11–L2 and S2–5, along with a determination of the presence of voluntary anal contraction and reflexes to assess sexual function. Assess the impact of the individual's injury on sexual responses (i.e., genital responses, based on a neurologic examination). Full physical examinations and neurological assessments should be conducted regularly in order to detect changes over time that may affect sexual function. (Adapted from CSCM 2010, p.308; Level B)
R.4.4
Clinicians should routinely assess sexual and medical history (pre- and post-injury), desire, erection, ejaculation, lubrication, and pain with sexual acts. (CAN-SCIP 2020; Level C)
R.4.5
Clinicians should consider evaluating men with SCI for testosterone deficiency, particularly in those with a concomitant head injury, untreated sleep apnea, or in cases of chronic opioid use. (Adapted from CSCM 2010, p.311; Level C)
R.4.6
Clinicians should consider conducting a urethral trauma assessment in individuals with SCI who use intermittent or an indwelling catheter to empty the bladder as this may affect sexual activity. (CAN-SCIP 2020; Level C)
R.5.1
SCI clinicians should discuss and consider the following principles to ensure sexual well-being:
- Maximize inherent sexual potential prior to using medical interventions
- Adapt to limitations with the use of medical therapies or sexual aids and
- Remain open-minded during sexual adaptation.
R.5.2
Clinicians should routinely provide information on methods to enhance sensuality by using all available senses. Encourage individuals with SCI to consider expanding their sexual repertoire to enhance sexual pleasure following injury. The emphasis of the discussion should be pleasure and not just function. (Adapted from CSCM 2010, p.313; Level C)
R.5.3
Ensure that individuals with SCI receive counselling that promotes a positive body image and encourages respect for one’s body after SCI. (CSCM 2010, p.331; Level C)
R.5.4
Discuss fluctuations and potential changes that may occur with sexual desire, interest, arousal and orgasm following SCI. (Adapted from CSCM 2010, p.319/320; Level B)
R.5.5
Self and/or partner exploration is encouraged. Strategies and aids can be recommended based on their limitations, interests, and needs (i.e., hand function, difficulty holding on to devices, leg floppiness, finding straps). (Adapted from CSCM 2010, p.320,321; Level A)
R.6.1
Performing bladder emptying prior to sexual activity is strongly recommended, and individuals with SCI should be encouraged to explore contingency plans if incontinence is to occur. (Adapted from CSCM 2010, p.315; Level B)
R.6.2
Discuss any bladder dysfunction with their partner, as optimization of bladder management will improve socialization and relationships. (Adapted from CSCM 2010, p.315; Level B)
R.6.3
Proper securing of catheters during sexual activity to maintain urethral integrity should be discussed. (Adapted from CSCM 2010, p.315; Level B)
R.6.4
Indwelling urinary catheters should be secured for sexual activity to limit friction in both men and women. We recommend that condoms are placed over the penile shaft and catheter in men. (Adapted from CSCM 2010, p.315; Level B)
R.7.1
Optimize bowel routine as part of participating in sexual activity to avoid incontinence. (Adapted from CSCM 2010, p.315; Level C)
R.7.2
Educate individuals with SCI that penetrative anal sexual activity may have increased risk of complications such as issues with skin integrity due to decreased sensation in this area, provocation of anal contraction or relaxation and unwanted incontinence. (Adapted from CSCM 2010, p.315; Level C)
R.8.1
Educate individuals with SCI on changes to sensitivity following SCI, including potential hypersensitivity, hyposensitivity, allodyna or lack of sensation. Individuals with SCI may find it most beneficial to focus on pleasurable areas and work on desensitizing areas of hypersensitivity. (CAN-SCIP 2020; Level C)
R.8.2
Discuss the potential for discovering and developing new areas of the body that may stimulate sexual arousal (i.e., erogenous zones, areas with intact sensation) and lead to enhanced sexual pleasure. (CAN-SCIP 2020; Level C)
R.9.1
Inform individuals with SCI that it is common for the degree of spasticity to change as a result of sexual activity. (Adapted from CSCM 2010, p.316; Level C).
R.9.2
Discuss safety issues with individuals with SCI and their partners when engaging in sexual activity. Positioning options should be discussed as related to their level of mobility, and positioning aids can be recommended as needed. Sexual activities involving the use of a wheelchair, hot water shower or shower equipment should be discussed, and factors relating to balance and trunk stability should also be considered on an individual basis. (Adapted from CSCM 2010, p.318; Level C)
R.10.1
Individuals with SCI should be encouraged to perform skin checks regularly after sexual activity. Positioning aids (such as support pillows) to limit pressure points and friction can be recommended if issues with skin breakdown occur. (Adapted from CSCM 2010, p.315; Level C)
R.11.1
Autonomic dysreflexia can be triggered with sexual stimulation in individuals with injury levels T6 and above. Individuals with SCI are encouraged to have a blood pressure cuff at home and following autonomic dysreflexia protocols. If autonomic dysreflexia becomes problematic in sexual activity, individuals with SCI are encouraged to speak to their health care providers to look at ways to modify stimulation or medications. (Adapted from CSCM 2010, p.316; Level A)
R.12.1
Ensure that individuals with SCI are aware of the risks related to sexual services or products available without a prescription. (Adapted from CSCM 2010, p.322; Level C)
R.12.2
Assess the current level of erectile function in men with SCI and suggest interventions taking into consideration the level of invasiveness, cost, and side effects. (Adapted from CSCM 2010, p.322; Level C)
R.12.3
In men, if testosterone deficiency is determined to be a contributing factor in his lack of libido or sexual dysfunction (including lack of PDE5i response for erections), consider testosterone replacement therapy. For men wishing to be biological fathers, alternative medications can be prescribed to raise serum testosterone without interfering with sperm production. (Adapted from CSCM 2010, p.322; Level C)
R.12.4
Inform men with SCI about the full range of options for treating erectile dysfunction and develop an individualized treatment plan as needed. Educate men with SCI about:
- oral medications, such as PDE5i, to treat erectile dysfunction
- risks and benefits of vacuum devices for the treatment of erectile dysfunction
- intracavernosal injections for the treatment of erectile dysfunction
- Permanent penile prosthesis (also known as implantable penile protheses) for the treatment of erectile dysfunction when nonsurgical treatments are ineffective or unsatisfactory.
R.12.5
Clinicians should provide individuals with SCI with education and training on vibrators that are available to enhance genital arousal orgasmic potential. (Adapted from CSCM 2010, p.325; Level C)
R.12.6
Clinicians should discuss the benefits and risks of the use of medications such as sildenafil and flibanserin for sexual arousal disorder in women with SCI. (CAN-SCIP 2020; Level C)
R.12.7
Educate women with SCI about the effects of perimenopausal and menopausal changes on sexual function, bone health, accelerated metabolic aging, and metabolic syndrome after SCI. (Adapted from CSCM 2010, p.328; Level C)
R.13.1
Perform semen analysis for men interested in biological fatherhood in order to provide information and make recommendations for achieving pregnancy. (CSCM 2010, p.328; Level A)
R.13.2
Provide women with SCI information about fertility, birth control and pregnancy. (Adapted from CSCM 2010, p.326; Level B)
R.13.3
Inform women that fertility is often preserved following an SCI and encourage pre-conception counselling on the effects of SCI on pregnancy labour and delivery. (Adapted from CSCM 2010, p.326; Level B)
R.13.4
Men and women with SCI should be individually informed of the possibility of biological parenthood, adoption and donor insemination. (Adapted from CSCM 2010, p.328; Level B)
R.14.1
Inform women on the safest birth control options available on an individualized basis. If there are concerns related to contraindications, referral to a specialist to determine an appropriate method is necessary. (Adapted from CSCM 2010, p.326; Level C)
R.15.1
Outline the steps that can be taken to ensure the best medical outcomes for the pregnant woman with SCI. Recommend that a multi-disciplinary team (including general practioner, physiatrist, OB-GYN, physiotherapist, occupational therapist, nurse) with SCI expertise be involved throughout the pregnancy. (Adapted from CSCM, p.326; Level B)
R.15.2
Provide advance training (i.e., shoulder exercise program to support transfers during pregnancy), frequent monitoring of wheelchair seating, transfer technique and status of daily activities to ensure safety during pregnancy. (Adapted from CSCM 2010, p.326; Level C)
R.15.3
Closely monitor autonomic dysreflexia and its complications during pregnancy, labour, delivery, and breastfeeding. (Adapted from CSCM 2010, p.327; Level C)