There is no doubt that head injury has lasting effects on a person. In the more severe cases, TBIs, psychosocial aspects of sexual behavior have brought up many questions to my development as well. Laying the groundwork, it is well known, that sexuality is a basic component of human life and disruption of sexual behavior and relationships can have profound effects both on the family and the overall success of a person.
In brain injury individuals, sexual dysfunction is more often a rule then an exception. The disruption in functioning is described as problems with psychological functioning, frequency, libido, and psychosocial adjustment. Boller found that three out of four head injury patients experienced some frequency in sexual relations. Meyer found that 71 out of 100 patients with severe head injury had reduced sexual drive. The incidence of sexual dysfunction increases with the severity of injury. Either way the problems of sexual dysfunction and sexual relationships have largely been ignored in the research literature. Hospitals that I have received treatment from (e.g., St. Vincent and Mayo Clinic) have shed dismal light on the idea of sexual dysfunction. Is this the case because many of the physicians, nurses, psychologists, and social workers lacked training or are uncomfortable discussing sexual issues?
If that is not concerning issue then, facilities are mostly paid by third-parties; sexual dysfunction may not even be important problem for the treatment team. Let us get one thing straight, “SEX,” is a natural part of life and if you are not mature enough talk about this subject then you should not read on but for the ones who are adult enough to talk about sex; let us engage in an open conversation.
The sexual behavior during recovery drastically changes as an individual recovers from head injury. The first is the critical stage of recovery, the patient is awakening from, and it seems like a fog to his or her environment. Often, patients at this stage are only capable of consistently responding to very strong, unpleasant, or aversive stimuli such as pain, loud noise, or strong odors.
Stages of recovery and commonly observed behaviors
|Critical||Public masturbation, sexual delusions, and confabulation|
|Post-critical||Confabulation, inappropriate jokes, physical or verbal approaches, repeated sexual references, sexual identity confusion, depression, and egocentricity|
|Re-entry||Insensitivity to others, impulsivity, social isolation, sexual drive disturbance, or judgment, distractibility, medication effects, emotional lability, disinhibition, responses of partner any emotions in sexual awareness and response. Most importantly; sexual competence does not match the need for sexual attention.|
Post-critical stages of recovery usually involves sexual behaviors that occur as apathy, continuing confusion and disorientation, or disinhibited behavior that occur in an appropriate contexts. The disinhibition sexual behaviors usually associated with frontal lobe injury. The patient lacks awareness of the behavior on other persons. These behaviors are better characterized as sexual misconduct that is inappropriate to the situation rather than sexual dysfunction. Since the patient is usually unaware of both the behavior and its improperty, an effective treatment approach for this type of behavior is a teaching model. The procedure points out the behavior of the patient explains the inappropriateness nature of the behavior, and gives the patient an alternative for said behavior.
This procedure has the advantages of being positive in nature, rather than punishing and giving the patient’s explicit feedback and instruction regarding the target behavior, which is then practiced and reinforced. furthermore, this method is easily learned and applied by families or significant others and has proven to be effective in assisting patients at this stage in acquiring greater awareness and control their behavior (Blackerby, 1986).
It is also at this stage that problems of sex driven changes, depression, cognitive deficits, emotional ability, and self-concept changes become increasingly prominent in the patient’s behavior pattern. If these issues are not addressed during this stage and treatment severe behavior problems and family structure disintegration began to develop. It is also at this point that it becomes important to encourage closeness between the patient and spouse and to begin to restore the balance in the sexual relationship. Sexuality should be acknowledged by all concerned during this stage as a valid rehabilitation issue that affects both the patient and partner! The spouse should be encouraged to touch, talk to, and express affection towards the patient. These early effects are likely to help avoid or minimize even greater problems in the future.
As the individual enters the reentry phase different types of disruption of sexual behavior occur. It can be important if not critical to differentiate these behaviors seen in this they become quite complex and usually involve complicated interactions between the patient, family, or friends, or features of the environment that can reinforce their previous behaviors.
Classification of Sexual Dysfunction Factors and Causes in the Reentry Stage of Recovery
|Primary||Brain injury/cognition||Poor judgment, egocentricity, insensitivity to partner, poor memory, limited attention span, impulsivity, and apathy.|
|Secondary||Social/environmental||Social isolation and inactivity, depression, anxiety, altered body image, self concept, road changes, and perceptions of TBI patient by others|
|Tertiary||Premorbid||pre-injury social skills, values, and experiences with sexuality, dating, friendship, and marriage.|
Obvious problems can be classified into primary, secondary, or tertiary that reflect the different causative factors as seen from the above graph. the first type of behavior associated with reentry stage is that of injury related cognitive and emotional deficits. In this stage, we have individuals that are alert and interacting actively with the environment, so the cognitive deficits of injury are more prominent. These cognitive schemas have tremendous effects on sexual behavior and socio-sexual interaction. Most importantly the treatment that works the best is cognitive retraining therapy may be helpful in resolving a tension, disinhibition, judgment, and motor and impulsivity deficits.
The next category of sexual dysfunction factors in their re- entry stage is that of social and environmental variables. the individual is beginning to move into the, “normalized,” social environment in which long-term adaption to the injury will occur. Therefore, the social factors that influence sexual adjustment become increasingly salient. factor is way to the spouse, romantic partner, friends, and self-concept have particular impact on the recovering sexuality and adjustment. Treatment is open to discussion of sexuality and should include education, training, and emotional expression in the treatment plan. The final is the tertiary stage. Much of the influence on this stage has a lot to do with the pre-injury values, skills, and experiences. It is at this point where the individual draws on presumed learned behaviors. What are the effects of the head injury on social systems and sexual adjustment?
Following a head injury all social systems in which this individual was involved with before are disrupted and dramatically altered. Sexual dysfunction is just causes as much distress to the families as it does for him or her. The community attitudes toward head injury are subjected to the perceptions of sexuality and handicaps commonly held by the general population. There are three general types of attitudes towards sexuality and disabled individuals (Comfort). The first is that of asexuality in that handicapped individuals do not have sexual feelings or needs because they are disabled. This issue will later be addressed. The second major perception is that of inability. The individual because of his or her handicap are unable to engage in sexual activity. Lastly we have the perception is abnormal. The principal at hand is that satisfy handicap causes the individual to be abnormal in some way; sex with this individual must be abnormal.
The other key components associated with TBI is social isolation. Social isolation is a major problem for sexual adjustment following head injury. Former friends and acquaintances tend to discontinue contact with the patient within six months following discharge from the hospital. In my case after high school. a significant other may even report declining interest in sex with a person. In general, social activities usually declined significantly. Moreover, the physical, cognitive, and behavioral often exclude the person from consideration as a sexual partner by his or her peer group. Another foreseeable issue is causing further injury (e.g., biopsychosocial perspective) during sex.
COMMUNICATION difficulties are often the sole route of problems with the TBI individual and other person. In order to reach peak sexual desire one may achieve through talking. It has been reported that there is a difficulty achieving intimacy with this person when he or she can no longer talk in the same way. A significant other may be just interested in sex due to feeling trapped in a situation with no apparent escape. The person often feels guilty for having these feelings as well as feeling depressed example for being forced into the situation. This cycle up to become increasingly severe over time and may cause profound depression and anger. This in turn leads to further deterioration of the relationship and affect the quality of care given to the TBI individual.
As discussed earlier, brain injured individuals you become either disinhibited or apathetic towards sexual intercourse. In the first instance, a romantic partner may report frustration and dissatisfaction with the relationship and often report apathy as a significant factor in post- injury termination of the relationship. Irregular behaviors from the TBI individual particularly restricts the social mobility of the couple, thus adding; more problems to the relationship. It should also be considered that a person could be overstimulated and unable to maintain behavioral control public or other social situations.
In conclusion, this post was an overview of sexuality disturbances following a head injury; the effects of the head injury on the social and sexual functioning of an individual. Some might suggest treating these problems as part of the rehabilitation process. It should be clear that the problem is a persuasive one, which is generally ignored and rehabilitation literature and applied practice. Yet people, persons with head injuries, are sexual beings. It might be appropriate to close this post with a statement used as a credo,
“I am somebody. I am worthwhile and I am important. I can reasonably expect to love and be loved. Some people will not accept me. Others will recognize, appreciate, and cherish me. I do not only seek and desire love, I am worthy of it and I expect it.”
Blackerby WF: Particle Behavior Management and Head Injury. Texas State Head Injury Foundation. Amarillo, Texas, 1986.
Boller F. Sexual Dysfunction in Neurological Disorders: Diagnosis, Management, and Rehabilitation. New York, Raven Press, 1982, page 141.
Comfort A. Sexual Consequences of Disability. Philadelphia, Massachusetts. 1978, page 205.
Meyer JE: In Dimond SJ: Neuropsychology. Boston, Massachusetts. Butterworth, Inc., 1955.