Sex After Brain Injury and Trauma

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Where does our sexuality come from in our Brains?

It is clear that frontal especially prefrontal lobe plays a role in sexual functioning as the cognitive functions are controlled by these areas and are significantly correlated with sexual functioning.  The frontal lobe plays a valuable role in a person’s ability to plan, organize, emotional and behavioural control, personality, problem-solving, attention, social skills, flexible thinking and conscious movement.  Injury to this area can cause problems such as inappropriate sexual behaviour, difficulties with initiating sexual activity or difficulties with motivating oneself to engage in sexual activity.  It can can also cause difficulties with experiencing pleasurable and sexual sensations, spontaneity, and the build-up of arousal.

The temporal lobe plays a role in a person’s memory, recognizing faces, generating emotions, and language. Injury to this area has been linked to an increase in sexual interest and emotions (hyperactive sexuality), although it can also result in a reduced sex drive (hypoactive sexuality). Some people who have had temporal lobe injury have also been found to develop paraphilias (abnormal sexual interests that can sometimes be
dangerous or illegal). Damage to pathways in the frontal and temporal lobes has been linked to difficulties in understanding whether someone else is interested in sexual contact, for example through body language and ‘reading’ emotions.

The parietal lobe plays a role in a person’s perception, spatial awareness, manipulating objects, and spelling; Wernicke’s area – understanding language; Broca’s area – expressing language.  Seizures in this part of the brain can cause some brain injury
survivors to experience sensations in their genitals, including heightened sexual arousal or sensations that are not pleasurable. For some survivors these sensations can even be irritating or painful.

The hypothalamus and pituitary gland parts of the brain are responsible for producing hormones in the body that regulate sex drive. Damage to these parts can therefore result in hormonal problems.

Brain injury is known to cause changes in thinking, behavior and body function which alters the way a person experiences and expresses their sexuality.

Changes to sexual behavior after brain injury could include erectile problems, reduced libido, the inability to orgasm, and the reduction in frequency of sex….or the increase and uncontrolled acting out of sexual behaviors/acts.

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Brain Injury and Consent – Respecting Boundaries

Both cognitive and sexual functioning were found effected post Brain Injury. However less emphasis is given to sexual functioning by the professionals.

It is important for sexual partners, carers and professionals to recognise that brain injury survivors have the same rights as non-disabled people of having their sexual needs met and making their own decisions about their sexuality.

Brain injury is not to blame for a systemic, patriarchal culture of violence against women—one in which more than 30 percent of women murdered every year are killed by their intimate partners (regardless of same sex or opposite sex). But brain injury cannot be removed from that world either, and we should be considering it as an additional risk factor.

That being said, it is important not to engage in sexual activities with someone without their consent, regardless of gender, sexual identity, or disability.  Keep in mind though, they must also be able to legally consent.

If a brain injury survivor lacks capacity and therefore cannot make a safe, informed decision about sex, a best-interests decision should be made with the support of appropriate professionals to ensure that the survivor’s sexual needs are being met in their best interests.

Persons with disabilities are twice more likely to be sexually assaulted than people without a disability according to the 2017 Bureau of Justice’s.

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So what does legal consent mean?

Basically, sexual consent is actively agreeing to participate in a sexual activity before being sexual with someone.  Affirmative consent is when someone agrees, gives permission, or says “yes” to sexual activity with other persons. Consent is always freely given and all people in a sexual situation must feel that they are able to say “yes” or “no” or stop the sexual activity at any point.

Consent can be withdrawn by either party at any point. No means no…. every time. Consent must be voluntarily given and may not be valid if a person is being subjected to actions or behaviors that elicit emotional, psychological, physical, reputational, financial pressure, threat, intimidation, or fear (coercion or force). Consent to engage in one sexual activity, or past agreement to engage in a particular sexual activity, cannot be presumed to constitute consent to engage in a different sexual activity or to engage again in a sexual activity. Consent cannot be validly given by a person who is incapacitated (intoxicated, unconscious or asleep).

A person with a mental disorder, a low mental age, or under the legal age of sexual consent, may willingly engage in a sexual act that still fails to meet the legal threshold for consent as defined by applicable laws.

There are different types of consent to consider and each of them are important to understand and some will overlap with each other during a sexual encounter:

  • Ongoing – anyone can change their mind about what they are interested in doing at any time
  • Informed/Freely/Expressly given – saying “yes” without pressure or manipulation; who has a clear appreciation and understanding of the facts, implications, and future consequences of their action; clearly and unmistakably stated, rather than implied (may be done orally or in writing, or nonverbally)
  • Specific – saying “yes” to one act (such as kissing) doesn’t mean you have said “yes” to others (like oral sex); just because you have participated in an act previously does not grant consent for future acts
  • Informed – not deceiving or lying.  For example, if someone says they will use a condom and they don’t, that is not full consent
  • Implied/Enthusiastic – it’s about wanting to do something, not feeling like you have to or should do something;  inferred from a person’s actions and the facts and circumstances of a particular situation (or in some cases, by a person’s silence or inaction)
  • Unanimous Consent –  general consent, by a group of several parties where everyone in the party consents to a specific act

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How does a brain injury affect sexual functioning?

The following changes in sexual functioning can happen after brain injury in men and women alike:

  • Decreased/Increased Desire: Many people may have less desire or interest in sex. Some people have increased interest in sex after brain injury and may want to have sex more often than usual. Others may have difficulty controlling their sexual behavior. They may make sexual advances in inappropriate situations or make inappropriate sexual comments, or vocal outbursts randomly.
  • Decreased Arousal: Many people have difficulty becoming sexually aroused. This means that they may be interested in sex, but their bodies do not respond to the touch felt that would normally stimulate sexual arousal. Men may have difficulty getting or keeping an erection. Women may have decreased vaginal lubrication (moisture in the vagina), or lack of sensation in the clitoral/vulva areas.
  • Difficulty or Inability to Reach Orgasm/Climax: Both men and women may have difficulty reaching orgasm or climax. They may not feel physically satisfied after sexual activity, or feel guilty for not coming to climax with their partner.
  • Reproductive Changes: Women may experience irregular menstrual cycles or periods. Sometimes, periods may not occur for weeks or months after injury, or may stop altogether. They may also have trouble getting pregnant and develop signs of infertility. Men may have decreased sperm production and may have difficulty getting a woman pregnant.

What causes changes in sexual function after Brain Injury?

There are many reasons sexual problems happen after someone has a brain injury. Some are directly related to the damage to the brain itself. Others are related to physical problems or changes in how the person is thinking about sex or relationships in general.  They may also have had personality changes which causes them to change how they feel about the person(s) they are in relationship(s) with.

Possible causes of changes in sexual functioning after Brain Injury include:

  • Damage to the Brain: Changes in sexual functioning may be caused by damage to the parts of the brain that control sexual functioning.
  • Hormonal Changes: Damage to the brain can affect the production of hormones, like testosterone, progesterone, and estrogen. These changes in hormones affect sexual functioning.
  • Medication Side Effects: Many medications commonly used after brain injury have negative side effects on sexual functioning.
  • Fatigue/Tiredness: Many people with brain injury tire very easily. Feeling tired, physically or mentally, can affect your interest in sex and your sexual activity.
  • Problems with Movement: Spasticity (tightness of muscles), physical pain, weakness, slowed or uncoordinated movements, and balance problems may make it difficult to have sex.
  • Self-Esteem Problems: Some people feel less confident about their attractiveness after Brain Injury. This can affect their comfort with sexual activity, their ability to perform, or their perception of how they may or may not perform.
  • Changes in Thinking Abilities: Difficulty with attention, memory, communication, planning ahead, reasoning, and imagining can also affect sexual functioning.
  • Emotional Changes: Individuals with brain injury often feel sad, nervous, or irritable. These feelings may have a negative effect on their sexual functioning, especially their desire for sex.
  • Changes in Relationships and Social Activities: Some people lose relationships and friendships after brain injury or may have trouble meeting new people. This makes it difficult to date, build meaningful relationships, or find a sexual partner they are confident with, if they find one at all.

What Are Barriers to Sexual Activity?

These can include:

  • physical and sensory issues such as medical complications, orthopedic injuries, equipment, medication and side effects (causing drowsiness, headaches, or loss of libido), fatigue (lack of stamina or interest), motor function (paralysis, spasticity, coordination), various levels of pain or spasms, sensory tolerance and changes, hormone level and their effects, endocrine abnormalities, fluctuating hormone levels, incontinence, seizures, dizziness, weakness, limited mobility, or problems with balance
  • cognitive issues such as attention, memory problems (not remembering partner or not remembering previous intimate moments), awareness, language and communication, decreased initiation/motivation, impulsivity, difficulty making decisions, regulation of behaviors/emotions, planning and time management
  • behavioral, emotional, and social issues such as personality changes, adjustment and loss, depression, anxiety, perception and expression of emotions, anger, temper, aggressive sexual activity, apathy, disinhibition, lability, diminished self-esteem, lack of self-confidence, distractibility, acting out inappropriately, decreased social contact, relationship changes, role status, socioeconomic status, transportation obstacles, residential obstacles, stigma about having a disability and being sexually active.

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What can be done to improve sexual functioning after TBI?

  • Talk with your doctor, nurse practitioner, or other health or rehabilitation professional about the problem, so they can help you find solutions. Some people may feel embarrassed talking openly about sexual issues. It may help to keep in mind that sexuality is a normal part of human functioning, and problems with sexuality can be addressed just like any other medical problem. If you are not comfortable discussing sexual problems with your doctor, it is important to find a health professional who you do feel comfortable talking with.
  • Get a comprehensive medical exam/screening. This should include blood work that checks a variety of labs (perhaps thyroid panel, adrenals and cortisone levels, hormones, inflammation markers, nutrition levels, etc) and maybe a urine screen. Make sure you discuss with your provider any role your medications may play. Women should get a gynecology exam and men may need a urology exam. Ask your doctor to check your hormone levels at the very least.
  • Consider psychotherapy or counseling to help with emotional issues that can affect sexual functioning. Adjusting to life after a brain injury often puts stress on your intimate relationship. If you and your partner are having problems with your relationship, consider marital or couples therapy.
  • Consider starting sex therapy. A sex therapist is an expert who helps people to overcome sexual problems and improve sexual functioning. You can search for a certified sex therapist in your geographic area on the following
  • Accept being celibate.  It’s absolutely okay if you have no interest in sex or sexual activity whatsoever.  This can be a complicated topic if in a marriage or committed relationship.  This is where communication and understanding are really a necessary aspect of the relationship.
  • Talk with your partner and plan sexual activities during the time of day when you are less tired.
  • If you decide to have sex, once ready to take the plunge, position yourself so that you can move without being in pain or becoming off balance. This may mean having sex in a different way or unfamiliar position. Discuss this with your partner.
  • Arrange things so that you will be less distracted during sex. For example, be in a quiet nurturing, safe environment without background noise, such as television.
  • If you have trouble becoming sexually aroused, it may help to watch movies or read books/ magazines with erotic images and other sexual content.  On the other side of this….too much artificial stimulation can also hamper the triggering of natural stimulation in some people and can also give a false sense of reality of what healthy relationships are supposed to look like, or how an average person is able to perform.
  • There are sexual aids developed to help people with disabilities.  Sensual touch and sensual massage may assist in relaxing the body for the sexual experience.
  • Increasing your social network can increase the opportunity to form intimate relationships. You may consider joining a club or becoming involved in other social organizations.

Who should be dealing with your sexuality?  Who can you talk to about it?

  • Physiatrists
  • Primary Care Physicians
  • Urologists, Gynecologists
  • Endocrinologists
  • Behavioral Health (Psychologist /Psychiatrists)
  • OT / PT / Speech Language Pathology
  • Nurses
  • Social Workers/Medical Case Managers
  • Fertility Specialists
  • Certified Sex Counselors or Therapists
  • You and Partner
  • Other Survivors

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Compiled from Model Systems, After Trauma, Sex and Sexuality After Brain Injury BookletBIAMI, VICE, Cognitive and Sexual Functions in Patients with TBI and personal experience.