Consortium for Spinal Cord Medicine. Sexuality and reproductive health in adults with spinal cord injury: a clinical practice guideline for health-care professionals

Considerations for Contraception Following Spinal Cord Injury: A Systematic Review

Introduction

Counseling and education on women's health, specifically contraception, following spinal cord injury (SCI) is an important component of care for women with SCI. While a plethora of available contraceptive options exists, research in this area is scarce.

Objectives

This systematic review assesses the quality and quantity of research on contraception for individuals with SCI.

Methods

Literature searches of three medical databases were performed to identify articles that addressed contraception and family planning for women with SCI. Articles were then screened in a two-stage selection process and evaluated for content.

Results

Of 165 articles, 21 were identified that fit the inclusion criteria. The majority (66%) of articles were literature reviews or professional practice guidelines. Fourteen (66%) included information on short-acting hormonal oral contraception, 11 (52%) included information on long-acting reversible contraception, 15 (71%) included information on barrier methods, 6 (29%) included information on fertility awareness, 9 (43%) included information on permanent contraception, and one (5%) included information on emergency contraception.

Discussion

This systematic review demonstrates a paucity of evidence-based information on contraception tailored to women with SCI. It highlights a need for research and comprehensive guidelines on primary and emergency contraception in this population.

Socioeconomic Characteristics, Lifestyle Behaviors, and Health Conditions Among Males of Reproductive Age With and Without Disabilities, NHANES 2013-2018

Health status during the reproductive years influences fecundity, fertility, and the future health of males and their offspring. There remains a dearth of literature examining men's preconception health, especially among high-risk populations, such as those with disabilities. The objective of this study was to examine indicators of preconception health, including chronic medical conditions, lifestyle behaviors, and health care utilization, among males of reproductive age with and without disabilities in the United States. Data were from 3,702 males of reproductive age (18-44 years) who participated in the National Health and Nutrition Examination Surveys, 2013-2018. Approximately 14% of males reported having at least one disability related to vision, hearing, cognition, mobility, self-care, or independent living. Among all men, suboptimal preconception health indicators were prevalent including poor or fair self-rated health; low education and household income status; lack of health insurance and no recent utilization of health care and dental care; cigarette smoking; frequent alcohol consumption and binge drinking; marijuana and illegal drug use; obesity; low fruit and vegetable intake and no multi-vitamin use; low physical activity; short sleep durations; depressive symptoms; and hypertension and asthma. Compared to males with no disabilities, males with any disabilities were more likely to have suboptimal preconception health indicators. Strategies to promote and improve sexual health, preconception care, and family planning services among all men are needed. For males with disabilities, specifically, further investigation of their specific health needs related to sex, reproduction, family planning, and fatherhood, as well as interactions with health care providers, is required.

Sexual activity and function of adult men with spina bifida

OBJECTIVE

Data on sexual function of men with spina bifida (SB) is limited. We aimed to assess sexual activity and erectile dysfunction (ED) in a large international sample of men with SB.

METHODS

Men with SB (≥18yo) were recruited in an international online survey via clinics and social media. We collected data on demographics, ambulation (Hoffer classification), penile rigidity (Erection Hardness Score), sexual activity and ED (International Index of Erectile Function). Non-parametric tests were used.

RESULTS

A total of 162 men (median age 35, 62% shunted, 38% community ambulators) reported sexual desire similar to the general population (p = 0.82), but 55% were dissatisfied with their sex life (Summary Table). Overall, 36% reported full penile rigidity with erections, more commonly with better ambulation (p = 0.01), 69% had ever experienced orgasm and 84% ejaculated. In 44 men (27%) attempting sexual intercourse in the last 4 weeks, 59% had ED (11% severe, 7% moderate, 14% mild-moderate, 27% mild). In this group, 91% of men reporting less than full penile rigidity had ED, compared to 30% with full penile rigidity (p = 0.001). Overall, partnered non-genital contact in the last 3 months was reported by 56%, solo masturbation: 62%, partnered intercourse: 48% (31% vaginal). Of 54 men who used phosphodiesterase type 5 inhibitors (PDE5I), 80% reported improved erections, 56% improved intercourse. Overall, 40% reported non-genital erogenous zones as most pleasurable, especially with poorer ambulation (p = 0.002, chest/nipples: 73%).

COMMENT

Strengths of this study include anonymous, voluntary, online participation maximizing participation of a heterogenous, international population. Whenever available, we compared findings to published values for the general population. Since romantic and sexual activity is a complex intersection of interest, opportunity and ability, a more comprehensive assessment was beyond the study's scope. Future work will focus on the interplay with issues like incontinence.

CONCLUSIONS

ED was frequent among men with SB, especially in men with poorer ambulation. PDE5 inhibitors may be beneficial. Partnered sexual activity was reported by half of the men, although it may not involve penetrative intercourse.

Sexually Transmitted Infections in Women of Reproductive Age by Disability Type

INTRODUCTION

The objectives of this study were to estimate the prevalence of sexually transmitted infections in women of reproductive age by disability type and examine the association between disability types, participant characteristics, and the prevalence of sexually transmitted infections (STIs).

METHODS

Pooled data from 2015 to 2019 National Survey on Drug Use and Health were analyzed in 2022. The analytic sample included 90,233 women of reproductive age (18-49 years). Disability was defined as having any sensory, cognitive, physical, or ≥2 disabilities.. A total of 15% of women reported having a disability. Descriptive analyses were used to estimate the prevalence of STI, and logistic regression analyses were conducted to examine the association of disability type and other participant characteristics with the odds of having STIs.

RESULTS

The prevalence of STIs was more than twice as high for women of reproductive age with cognitive disabilities (6.8%) or ≥2 disabilities (6.7%) as for those without disabilities (2.7%). Women with sensory disabilities (AOR=1.47; 95% CI=1.17, 1.85), cognitive disabilities (AOR=1.89; 95% CI=1.65, 2.17), or ≥2 disabilities (AOR=1.78; 95% CI=1.49, 2.14) had greater odds of STIs than those without disabilities. Bisexual women had higher odds (AOR=1.31; 95% CI=1.14, 1.50) of STIs than straight women, whereas lesbian/gay women had lower odds (AOR=0.41; 95% CI=0.27, 0.63). The odds of STIs were higher among non-Hispanic Blacks (AOR=1.42; 95% CI=1.24, 1.63) and lower among Asian women (AOR=0.62; 95% CI=0.43, 0.90) than among non-Hispanic Whites. The odds of STIs were also greater among participants having any alcohol, cannabis, or illicit drug use.

CONCLUSIONS

Women of reproductive age with disabilities have a higher prevalence of sexually transmitted infections. In addition to disability type, the odds of sexually transmitted infections varied by race/ethnicity, sexual orientation, and substance use.

Sexual dysfunction and sexual concerns among persons with disability due to myelopathy: A cross-sectional study

Objectives

We have very little information about sexual activity and concerns of patients with myelopathy from India. The objectives of this study were to assess the sexual dysfunction and sexual concerns among patients with myelopathy due to spinal cord lesion (SCL).

Materials and Methods

This study was a single-center, cross-sectional, and hospital-based study among male and female patients in the age-group 18-50 years, with disability due to myelopathy due to SCL. The data were collected using a self-designed, pretested, and semi-structured questionnaire by face-to-face interview.

Results

Eighty participants were recruited in the study, of which 62 (77.5%) were men. The mean standard deviation (SD) age of the participants was 33.7 (8.6) years, and mean (SD) age at time of illness was 31.4 (8.6) years with median duration of 17 months. Among 62 males, psychogenic erection was impaired in 77.2%, reflex erection was impaired in 78.9%, and ejaculation was affected in 70.7%. Orgasm was absent or reduced in 66.1% males. Among 18 female participants, psychogenic genital arousal was reduced in 66.5%, reflex genital arousal was impaired in 55.5%, and orgasm was absent in 38.8% subjects. Sexual desire in these patients was unchanged in 41 (51.2%) and decreased or absent in 39 (48.8%). Sexual activity involvement was there in 46 (57.5%) and 34 (42.5%) had not involved in any kind of sexual activity after injury/illness. The main reasons of non-involvement in sexual activity were bladder and bowel accidents, spasticity, and difficulty in positioning.

Conclusion

Comprehensive neurological rehabilitation should address sexual function of affected individual to allow them highest level of function and quality of life.

Sexual Health and Sexual Quality of Life Among Individuals With Spinal Cord Injury in Latin America

Background

Sexual changes are an area of primary concern for individuals with spinal cord injury (SCI) and their partners, but the topic has gone largely unexplored in the research literature.

Objectives

This study examined how individuals with SCI in Latin America experience their sexuality and what issues they and their partners face in this area.

Methods

A total of 248 individuals with SCI from Latin America completed an online 60-item survey regarding sexuality.

Results

The majority of participants (87.7%) reported that they had noticed changes in sexuality after the injury, mainly physical problems (50.7%), emotional problems (38.7%), and changes in relationships with partners (27.5%). Regarding sexual desire, 47.2% indicated that desire remained the same after SCI. The majority of participants (81.9%) indicated not having received any information about sexuality after SCI during their hospital stay but reported that they would have liked to have received information (98.1%). Of all participants, 66.1% reported never having been asked about problems or difficulties in their sexual life after SCI by any health professional.

Conclusion

Interventions designed to educate individuals with SCI regarding the effect of injury on their sexual functioning, responsiveness, and expression, as well as to support them in maintaining and enhancing their sexual well-being, may be extremely beneficial, particularly in Latin America. Findings highlight the distinct need for professionals to introduce the topic of sexuality by discussing it in a straightforward, nonjudgmental manner and to integrate discussions about sex and related issues into assessment, planning, and ongoing treatment.

A Survey of Latin American Rehabilitation Professionals on Addressing Sexuality-Related Concerns After Spinal Cord Injury

To examine rehabilitation professionals' training and education, attitudes, beliefs or misconceptions, and assessment of issues related to sexuality in individuals with Spinal Cord Injury (SCI) and their romantic partners. 318 healthcare professionals from Latin America (LA) who worked with individuals with SCI completed an online survey. 99.0% affirmed that sexuality is an issue that should be addressed during the rehabilitation of people with SCI. 86.0% reported being asked questions about sexuality after SCI by their patients and/or their partners, but only 33.2% of the professionals affirmed that it was very likely for them to initiate a conversation about the topic. Only 35.4% reported discussing sexuality issues with patients and their partners as a regular practice; further, 61.5% of the sample reported not being prepared at a scientific, therapeutic, and/or educational level to be able to advise people with SCI in the area of sexuality. 95.9% indicated they would be interested in attending courses, seminars, or conferences tailored to the topic of sexuality after SCI. Participants agreed nearly unanimously (96.8%) that it would be easier to discuss sexuality with people with SCI and their partners if they had more training on this topic, which they believed should have been received during their undergraduate (63.5%) and advanced (34.9%) studies. Findings provide insight into the way sexuality is addressed and attended to in the field of rehabilitation in LA and inform initiatives to improve the provision of care in the realm of sexuality for individuals after SCI.

The availability and quality of breastfeeding guidelines for women with spinal cord injury: a narrative review

STUDY DESIGN

Narrative review.

OBJECTIVES

To evaluate the availability and quality of breastfeeding guidelines for women with spinal cord injury (SCI).

SETTING

International Collaboration on Repair Discoveries (ICORD), Department of Medicine, Vancouver, BC.

METHODS

An environmental scan restricted to English language literature was performed to identify existing postpartum and breastfeeding guidelines. Guidelines were evaluated using a structured, validated tool (AGREE II) by 13 appraisers [medical/research experts (n = 10) and those with lived experience (n = 3)] from Vancouver and two international sites. Seven guidelines were evaluated across Domain 1 of the AGREE II tool to determine if they were applicable to mothers with SCI/physical disabilities. Domains 2 to 7 were evaluated if the guideline made mention of the SCI population.

RESULTS

Of the seven guidelines evaluated, only one mentioned SCI (Postpartum Care in SCI from BC Women's Hospital). Other guidelines were excluded from further evaluation as they did not address the issue of breastfeeding in women with SCI. The overall scaled score for this guideline was 34.5%. There was significant variability between domains but no AGREE II domain scored greater than 50%, indicating substantial limitations.

CONCLUSIONS

Current breastfeeding guidelines are not targeted to persons with SCI. The one guideline that made mention of women with SCI had significant global deficits. This highlights the importance of developing guidelines for health care providers focused specifically on women with SCI to support and optimize breastfeeding in this unique population for the benefit of mother and infant across the lifespan.

Sexuality Support After Spinal Cord Injury: What is Provided in Australian Practice Settings?: Sexuality Support After Spinal Cord Injury

This study sought to understand what sexuality support Australian health professionals currently provide to people with spinal cord injury (SCI) and their perspectives on what changes may better support the sexuality needs of people with SCI. Australian Health professionals who had worked with people with SCI within the last 10 years were invited to participate in an online survey. Results were analyzed using content analysis and descriptive statistics. The 39 participants were from a range of health professions including medical, allied health, nursing, and peer support. Participants worked in various service settings, with the highest frequency in the community (33%) or inpatient rehabilitation (28%). Analysis indicated 85% of participants had provided sexuality support, however this provision was rarely routine. Discussing sexuality education topics were reported to be routinely provided for less than 16% of participants. Overall, 32% of participants felt sexuality was addressed 'not well at all' in their workplace. Qualitative analysis of open-ended responses produced five themes: barriers to supporting sexuality, health professionals require training, utilizing a team approach, responsibility to initiate conversation, and involving others in support. Barriers to provision included stigma and lack of education. Commonly suggested strategies to improve practice included: increasing sexuality training, utilizing a team approach, initiating the conversation of sexuality early, and consensual inclusion of significant others in sexuality support. The results therefore indicate sexuality support is not routinely provided to people with SCI and findings suggest a need for sexuality training, utilizing a team approach, initiating the conversation, and including significant others.

Sexual Dysfunction and Sexual Concerns among Persons with Disability Due to Myelopathy: A Cross-Sectional Study

Background We have very little information about sexual activity and concerns of patients with myelopathy from India.

Objectives This article assesses the sexual dysfunction and sexual concerns among patients with myelopathy due to spinal cord lesion (SCL).

Materials and Methods Single-center, cross-sectional, hospital-based study among male and female patients in the age group of 18 to 50 years, with disability due to myelopathy due to SCL. The data were collected using a self-designed, pretested, semistructured questionnaire by face-to-face interview.

Results Eighty participants were recruited in the study, of which 62 (77.5%) were men. The mean (standard deviation [SD]) age of the participants was 33.7 (8.6) years, and mean (SD) age at time of illness was 31.4 (8.6) years with median duration of 17 months. Among 62 males, psychogenic erection was impaired in 77.2%, reflex erection was impaired in 78.9%, and ejaculation was affected in 70.7%. Orgasm was absent or reduced in 66.1% males. Among 18 female participants, psychogenic genital arousal was reduced in 66.5%, reflex genital arousal was impaired in 55.5%, and orgasm was absent in 38.8% subjects. Sexual desire in these patients was unchanged in 41 (51.2%), and decreased or absent in 39 (48.8%). Sexual activity involvement was there in 46 (57.5%) and 34 (42.5%) had not involved in any kind of sexual activity after injury/illness. The main reasons of noninvolvement in sexual activity were bladder and bowel accidents, spasticity, and difficulty in positioning.

Conclusion Comprehensive neurological rehabilitation should address sexual function of affected individual to allow them highest level of function and quality of life.

Talking about post-injury sexual functioning: The views of people with spinal cord injuries-A qualitative interview study

AIM

This study aimed to explore perceptions of people with spinal cord injuries regarding the information they received during their rehabilitation programme on post-injury sexual functioning.

BACKGROUND

Spinal cord injury is a traumatic, life-altering event that is associated with loss of motor and sensory function and sexual impairment. Existing evidence suggests that sexual issues are poorly handled during the rehabilitation phase of the patient's journey.

DESIGN

A descriptive qualitative design was utilized in this study.

METHODS

Twenty-nine people with spinal cord injury participated in qualitative in-depth interviews between November 2017 and April 2018, and data were analysed using the Burnard (1991, https://doi.org/10.1016/0260-6917(91)90009-y) thematic analysis framework.

RESULTS

Some participants indicated they were sexually inactive prior to their spinal cord injury. They testified that they had not received information on post-injury sexual functioning. Many participants who received post-injury information on sexual functioning reported dissatisfaction with the content and timing of this information.

CONCLUSION

Personal conversations between spinal cord injured patients and dedicated members of the interdisciplinary health team can enhance the quality of rehabilitation care and patients' satisfaction with rehabilitation care. Nurses are central clinicians in the rehabilitation programme of spinal cord injured patients and should engage in individually designed conversations about post-injury sexual functioning.

Narrative Review of Clinical Practice Guidelines for Rehabilitation of People With Spinal Cord Injury: 2010-2020

ABSTRACT

Clinical practice guidelines provide reliable, vetted, and critical information to bring research to practice. Some medical specialties (e.g., physical medicine and rehabilitation) provide multidomain treatment for various conditions. This presents challenges because physical medicine and rehabilitation is a small specialty, a diverse patient base in terms sociodemographics and diagnosis, treatments are difficult to standardize, and rehabilitation research is underfunded. We wished to identify quality and applicability of clinical practice guidelines and searched "Spinal Cord Injury AND Clinical Practice Guidelines AND Rehabilitation" and vetting process.Three hundred fifty-nine articles were identified of which 58 met all criteria for full-text review of which 13 were included in the final selection. Additional publications were accessed from a nondatabase search. Five articles addressed postacute care, community treatment. Nine articles had no recorded vetting process but addressed rehabilitation as an outcome and were included separately. Many of the clinical practice guidelines were developed without evidence from randomized controlled trials, one had input from stakeholders, and some are out of date and do not address important aspects of changes in demographics of the affected population and the use of newer technologies such as sensors and robotics and devices. Identification of these gaps may help stimulate treatment that is clinically relevant, accessible, and current.

Sexual function and dysfunction in men with spina bifida

Spina bifida is the most common neural tube defect, which can lead to multiple urologic problems stemming from neurogenic bladder including need for lifelong renal monitoring and urinary continence. However, as males with SB age, it is clear that many also start to care about their sexuality, which may also be affected by the disease process. After reviewing the literature, the authors summarize the available information regarding sexual function and sexual dysfunction in adult males with spina bifida, specifically focusing on sexuality education, relationship status/sexual activity, continence, penile rigidity, penile sensation, ability to orgasm, ability to ejaculate, quality of ejaculation and non-genital sexual contact. Finally, the authors conclude that more research is needed in the fields of sexual function and sexual dysfunction in adults with spina bifida. This area of study is in need of objective, standardized research with large cohorts so that we can better study and educate men with SB about the impact of SB on their sexuality.

A Primary Care Provider's Guide to Sexual Health for Individuals With Spinal Cord Injury

The collaboration with individuals regarding their sexual health is an important component of patient-centered health care. However, talking about sexual health in primary care settings is an area not fully addressed as a result of time limitations, medical task prioritization, awareness or knowledge deficit, and discomfort with the topic of sexuality. A critical shift in professional focus from disease and medical illness to the promotion of health and wellness is a prerequisite to address sexual health in the primary care setting. This article provides guidance for practitioners in primary care settings who are caring for persons with spinal cord injury. Clinicians should seize the opportunity during the encounter to reframe the experience of disability as a social construct status, moving away from the narrow view of medical condition and "find it, fix it" to a broader understanding that provides increased access to care for sexual health and sexual pleasure.

Evaluation of the quality of published SCI clinical practice guidelines using the AGREE II instrument: Results from Can-SCIP expert panel

INTRODUCTION

Spinal cord injury (SCI) is a complex condition with substantial adverse personal, social and economic impacts necessitating evidence-based inter-professional care. To date, limited studies have assessed the quality of clinical practice guidelines (CPGs) within SCI. The aim of this study is to evaluate the quality of the development process and methodological rigour of published SCI CPGs across the care continuum from pre-hospital to community-based care.

METHODS

Electronic health databases and indexes were searched to identify English or French language CPGs within SCI published within the last nine years with specific evidence-based recommendations applicable to the Canadian health care setting. Eligible CPGs were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

A total of forty-one CPGs that met the inclusion criteria were appraised by at least four raters. There was high variability in quality. Twenty-seven CPGs achieved a good rigour of development domain score of >70%. Other standardized mean domain scores were scope and purpose (85.32%), stakeholder involvement (65.03%), clarity of presentation (84.81%), applicability (55.55%) and editorial independence (75.83%). The agreement between appraisers (intraclass correlation coefficient) was high (intraclass correlation coefficient > 0.80).

CONCLUSION

There is a paucity of CPGs that address community-based specialized rehabilitation and community reintegration. Furthermore, many CPGs only focus on a single impairment at one time point in the care continuum. As SCI is a complex condition that results in multimorbidity and requires health monitoring and intervention across the lifespan, a rigorously developed CPG that addresses high-quality, interprofessional comprehensive care is needed.

Development of the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline: Methods and overview

INTRODUCTION

Spinal cord injury (SCI) is a life-altering injury that leads to a complex constellation of changes in an individual's sensory, motor, and autonomic function which is largely determined by the level and severity of cord impairment. Available SCI-specific clinical practice guidelines (CPG) address specific impairments, health conditions or a segment of the care continuum, however, fail to address all the important clinical questions arising throughout an individual's care journey. To address this gap, an interprofessional panel of experts in SCI convened to develop the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline. This article provides an overview of the methods underpinning the Can-SCIP Guideline process.

METHODS

The Can-SCIP Guideline was developed using the Guidelines Adaptation Cycle. A comprehensive search for existing SCI-specific CPGs was conducted. The quality of eligible CPGs was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. An expert panel (n = 52) convened, and groups of relevant experts met to review and recommend adoption or refinement of existing recommendations or develop new recommendations based on evidence from systematic reviews conducted by the Spinal Cord Injury Research Evidence (SCIRE) team. The expert panel voted to approve selected recommendations using an online survey tool.

RESULTS

The Can-SCIP Guideline includes 585 total recommendations from 41 guidelines, 96 recommendations that pertain to the Components of the Ideal SCI Care System section, and 489 recommendations that pertain to the Management of Secondary Health Conditions section. Most recommendations (n = 281, 48%) were adopted from existing guidelines without revision, 215 (36.8%) recommendations were revised for application in a Canadian context, and 89 recommendations (15.2%) were created de novo.

CONCLUSION

The Can-SCIP Guideline is the first living comprehensive guideline for adults with SCI in Canada across the care continuum.

Metastatic spine oncology: symptom-directed management

Spinal tumors pose significant treatment challenges for the physicians treating them. Understanding the location of the tumor within the intramedullary, intradural extramedullary, or extradural (epidural) space is not only critical in determining a differential diagnosis but may also provide important information about current and future neurologic deficits. Despite significant advances in the treatment of spinal tumors over the past few decades, these patients may still experience significant symptoms related to the tumor or its treatment, such as pain, weakness, impaired sensation, and bowel and bladder dysfunction. Treatment of spinal tumors should involve a multidisciplinary team of neuro-oncologists, spine surgeons, medical and radiation oncologists, physiatrists, and pain specialists to provide comprehensive oncologic management, while optimizing the patient's functional status and quality of life.

Altered sexual function after central neurological system trauma is reflective of region of injury; brain vs spinal cord

OBJECTIVE

To compare and contrast the contributory effects of traumatic brain injury (TBI) and spinal cord injury (SCI) on sexual function and social relationship opportunities, hypothesizing that patterns of change in sexual function would follow etiology.

DESIGN

Cross-sectional, case-matched survey of community living individuals with TBI, SCI or both (termed dual diagnosis).

PARTICIPANTS

Consecutive sample of participants with TBI (n = 25), SCI (n = 24) and dual diagnosis (n = 28), an average 3.6 years post-rehabilitation discharge.

METHODS

Participants were interviewed using a modified version of the 'Sexuality after Spinal Injury Questionnaire.'

RESULTS

Almost all respondents (97%) perceived adverse post-injury change in their experience of neurosexual function and/or social relationships. Physiological aspects of sexual function (e.g., erection, orgasm) were most affected by SCI whereas social relationships appeared more affected by TBI. People with dual diagnoses exhibited a combination of features. Participants with SCI (with or without TBI) were significantly more likely to have their concerns about sexual function discussed during rehabilitation than the TBI group.

CONCLUSION

TBI and SCI produce predictable impacts upon sexual function following injury, the impact of which were less frequently addressed during inpatient rehabilitation for those with TBI.

Exploring Iranian individual's perception toward divorce after disability related to spinal cord injury

STUDY DESIGN

An exploratory qualitative research.

OBJECTIVES

To understand how Iranian individuals with spinal cord injury (SCI) perceive post-SCI divorce.

SETTING

Protection Center of Spinal Cord Disables.

PARTICIPANTS

Post-SCI divorcees who were 18 years and older.

METHODS

The participants were 20 individuals with SCI (9 men and 11 women) who were willing to share their experiences through interviews. They had been referred to the 'Protection Center of Spinal Cord Disables'. The data were collected through ten semi-structured individual in-depth interviews and two focus group discussions. Braun and Clarke's thematic analysis approach was applied to extract the meanings informants used to conceptualize the concept of marriage.

RESULTS

Post-SCI divorce was conceptualized in terms of 'contextual scenarios'. We explored the scenarios related to post-SCI divorce in terms of predisposing scenarios and identified them as ground-breaking stories for constructing a decision process for post-SCI divorce. We also determined efforts that had been made to maintain marital stability.

CONCLUSIONS

Based on our participants' perceptions, post-SCI divorce was affected by their understanding of scenarios resulting in post-SCI divorce and their struggles to stay married.

Supporting sexual adjustment from the perspective of men living with spinal cord injury

STUDY DESIGN

Descriptive phenomenological approach.

OBJECTIVES

This study explored the lived experience of sexuality for men after spinal cord injury (SCI) and described the current state of tools and resources available to assist with sexual adjustment from the perspective of men living with SCI.

SETTING

Men living in the community in Ontario, Canada.

METHODS

Six men (age 24-49 years) with complete or incomplete SCI (C4-T12; <1-29 years post injury) participated in one individual, in-depth, standardized, open-ended interview (68-101 min). Analysis was conducted using Giorgi's method, and involved within case analysis followed by cross-case analysis.

RESULTS

All participants reported that resources available to support sexual adjustment after SCI were inadequate, and the majority of men felt their healthcare providers lacked knowledge regarding, and comfort discussing sexuality after SCI. Men reported sexuality was not a priority of the rehabilitation centers and felt that healthcare providers did not understand the importance of addressing sexuality. Existing resources were described as too clinical and not necessarily relevant given changes in sensation and mobility post injury. Participants provided recommendations for the effective delivery of relevant sexual education information.

CONCLUSIONS

To improve quality of life for men after SCI, suitable resources must be available to support sexual rehabilitation post injury. Future research should focus on developing strategies to facilitate discussions about sexuality between individuals with SCI and healthcare providers, and on developing resources that are effective and relevant for these men.

Challenges in rehabilitation of patients with nontraumatic spinal cord dysfunction due to tumors : A narrative review

The incidence of cancer-associated non-traumatic spinal cord dysfunction is rising due to population aging and better cancer treatment. The overall benefit of rehabilitation in specialized facilities for traumatic spinal cord dysfunction has been confirmed many times. Because of their fragility and multiple comorbidities cancer patients still face challenges to complete rehabilitation in the spinal rehabilitation facilities. In this narrative review we describe specific aspects, challenges in rehabilitation and opportunities to improve care. A literature search was performed in the PubMed database from 1 January 1978 to 30 November 2018. The focus was to find publications that discuss challenges and opportunities for rehabilitation of patients with non-traumatic spinal cord dysfunction due to a tumor. Most publications described the benefits of rehabilitation in specialized facilities. There were only few publications about survival and functional outcomes after rehabilitation for this patient population. Overall benefits including fewer complications associated with spinal cord dysfunction, less pain and depression, and better quality of life were shown. Within the past decades increasing number of publications revealed a growing interest for this group of patients. Despite major progress in cancer treatment, patients still have a limited vital prognosis and access to specialized rehabilitation units because of the concerns about the medical complexity. Patients with spinal cord tumors can benefit in areas of functionality, mood, quality of life, and survival from inpatient rehabilitation programs, in spite of the increased medical comorbidities.

How Do Iranian People with Spinal Cord Injury Understand Marriage?

Background: Spinal cord injury (SCI) is a life-altering experience. There is little information about the perspectives of people with SCI toward marriage. Purpose: To explore the understandings of Iranian adults with SCI about marriage. Methods: In this qualitative inquiry, using a semi-structured interview guide, we collected data from 53 single adults with SCI (41 men and 12 women) who were referred to the Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences in Tehran. Barun and Clarke's thematic analysis approach was applied for data analysis. Results: "Marriage" was thematized in outer and inner scenarios. The outer scenario was explored in terms of physical disability identified as a seminal determinant in successful marriage. "Attractiveness," "able body for breadwinning," "sexually active," and "reproduction" were dominant concepts extracted from the participants' narratives. The participants' inner scenarios revealed that marriage would be welcomed if a potential partner accepted them as a "whole person" regardless of their SCI condition. Conclusion: The findings suggest that adults with SCI do not ignore or reject marriage, however it was not their life priority due to major concerns that they had internalized. Considering the quality of care, people with SCI must be reassured about their potential to get married. SCI-based sexuality education and premarital counseling support the patients in their postmarital lives. Our findings will provide decision makers and health providers with significant insight for utilizing culturally appropriate services for people with SCI.

Sexual Health in Men With Traumatic Spinal Cord Injuries: A Review and Recommendations for Primary Health-Care Providers

Sexual health has been well established as a salient priority for men following traumatic spinal cord injury; yet, it continues to be under-addressed by health-care providers in both inpatient and community settings. Given that most men with traumatic spinal cord injuries will be followed by community-based primary health-care providers, including family physicians and nurse practitioners, for their long-term health-care needs, these clinicians are well positioned to address ongoing sexual health issues with this population. A scoping review of literature published between 2007 and 2017 inclusive was undertaken to identify what is known about the sexual health of men with spinal cord injuries. Twenty articles met the inclusion criteria. The findings are presented in four themes: (a) patterns and diversity of sexual health concerns; (b) sexual health recovery as an ongoing priority; (c) clinical barriers to addressing sexual health concerns, and (d) recommended interventions and strategies for primary health-care providers. The findings indicate that physiological changes as well as psychological and social factors influence men’s sexual function following spinal cord injury, and that sexual health recovery is an enduring rehabilitation priority. Several barriers including lack of sexual rehabilitation services and consensus around clinician roles, and societal stigmas related to disability and sexuality impede treatment. Attention to sexual health recovery has mainly focused on formal rehabilitation settings; however, many evidence-based clinical strategies and resources are relevant to and adaptable for primary care providers caring for these men in the community.

Sexual behaviours and sexual health outcomes among young adults with limiting disabilities: findings from third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

OBJECTIVE

To explore whether the sexual behaviours and sexual health outcomes of young adults with self-reported disabilities that they perceive limit their activities ('limiting disability') differ from those without disability.

DESIGN

Complex survey analyses of cross-sectional probability sample survey data collected between September 2010 and August 2012 using computer-assisted personal interviewing and computer-assisted self-interview.

SETTING

British general population.

PARTICIPANTS

7435 women and men aged 17-34 years, resident in private households in Britain, interviewed for the third National Survey of Sexual Attitudes and Lifestyles.

MAIN OUTCOME MEASURES

Self-reported sexual behaviour and sexual health outcomes.

RESULTS

Approximately 1 in 10 participants reported having a limiting disability. Sexual behaviours were similar between those with limiting disability and those without, with a few exceptions. Women and men with limiting disability were less likely to report having sexual partner(s) (past year, adjusted ORs (AORs) for age and social class: AORs: 0.71, 0.75, respectively). Women with limiting disability were more likely to report having same-sex partner(s) in the past 5 years (AOR: 2.39). Differences were seen in sexual health outcomes, especially among women; those with limiting disability were more likely to report having experienced non-volitional sex (ever, AOR: 3.08), STI diagnoses (ever, AOR: 1.43) and sought help/advice regarding their sex life (past year, AOR: 1.56). Women with limiting disability were also more likely to feel distressed/worried about their sex life than those without limiting disability (AORs: 1.61). None of these associations were seen in men.

CONCLUSIONS

Young adults with limiting disability, especially women, are more likely to report adverse sexual health outcomes than those without, despite comparatively few behavioural differences. It is important to ensure that people with disabilities are included in sexual health promotion and service planning, and targeted policy and programme interventions are needed to address negative sexual health outcomes disproportionally experienced by people with disabilities.

Fertility and sexuality in the spinal cord injury patient

BACKGROUND

After a spinal cord injury, patients have different perceptions of sexuality, sexual function, and potential for fertility. These changes can greatly impact quality of life over a lifetime.

PURPOSE

The purpose of this workgroup was to identify common evidence based or expert opinion themes and recommendations regarding treatment of sexuality, sexual function and fertility in the spinal cord injury population.

METHODS

As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury (SCI), a workgroup and comprehensive literature search of English language manuscripts regarding fertility and sexuality in the spinal cord injury patient were formed. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs).

RESULTS

Genital arousal, ejaculation, and orgasm are significantly impacted after spinal cord injury in both male and female SCI patients. This may have a more significant impact on potential for fertility in male spinal cord injury patients, particularly regarding ability of generate erection, semen quantity and quality. Female patients should be consulted that pregnancy is still possible after injury and a woman should expect resumption of normal reproductive function. As a result, sexual health teaching should be continued in women despite injury. Pregnancy in a SCI may cause complications such as autonomic dysreflexia, so this group should be carefully followed during pregnancy.

CONCLUSIONS

By understanding physiologic changes after injury, patients and care teams can work together to achieve goals and maximize sexual quality of life after the injury.

Development of a Sexual Needs Rehabilitation Framework in Women Post-Spinal Cord Injury: A Study From Iran

OBJECTIVE

To develop a sexual needs rehabilitation framework in women after spinal cord injury (SCI).

DESIGN

Mixed-methods study. The study consisted of 3 steps: (1) a primary needs assessment with quantitative and qualitative methods; (2) prioritization of identified needs by expert panels; and (3) development of a framework.

SETTING

Multi-dimensional clinical referral center.

PARTICIPANTS

Married women (N=31) with an SCI that occurred at least 1 year ago.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Development of sexual needs rehabilitation framework.

RESULTS

The quantitative phase in the first phase showed that the total mean ± SD score of the Sexual Quality of Life-Female questionnaire was 60.47±1.53, and the total mean ± SD score of the Female Sexual Function Index was 50.54±11.35. Moreover, women's sexual understanding post-SCI in the qualitative assessment revealed the following 3 main themes: (1) "dilemma leading to limited sexual activity"; (2) "seeking positive sexual adjustment"; and (3) "lack of client-based sexual and reproductive education/counseling in the rehabilitation process." Results from prioritizing identified needs in the second step indicated that the most important needs related to sexual aspects of life. In the final step, the framework for Iranian woman with post-SCI sexual rehabilitative needs developed with focus on sexual behavior complication post-SCI as a main need.

CONCLUSIONS

It is important to assess probable unmet needs before designing, planning, and implementing an interventional rehabilitative health care program, especially when focusing on issues of sexuality. A developed framework can be applied by the rehabilitation team during initial caregiving and can be continued as long as needed.

Evaluation of sexual and fertility dysfunction in spinal cord-injured men in Jamaica

INTRODUCTION

Sexual dysfunction and infertility are common in males with traumatic spinal cord injuries (SCIs). The objective of this study was to determine the prevalence of sexual dysfunction and infertility in males with traumatic SCI managed in Jamaica, as well as the therapeutic options offered.

CASE PRESENTATION

A cross-sectional study including males with traumatic SCI managed at the Sir John Golding Rehabilitation Centre, Kingston, Jamaica was carried out between 1 January and 31 December 2015. Sexual function was measured with the International Index of Erectile Function Questionnaire, and further information on social history, fertility desires and treatment options offered were collected. Data were analyzed using Stata 12 for Windows (College Station, TX, USA). The mean age of patients at the time of study was 38.8±15.3 years (range 19-71) with a mean duration of injury of 3.7±2.4 years (range 1.3-15.6). Of 45 patients with traumatic SCI surveyed, 90.7% had erectile dysfunction, with 62.8% being classified as severe and 73.3% of men were unable to ejaculate. Treatment for erectile and ejaculatory dysfunction was offered in only two patients, respectively. Most (71.1%) patients indicated that they wanted to have children in the future, however, no one had been referred for assisted reproductive techniques.

DISCUSSION

Men with traumatic SCI have high rates of severe erectile and ejaculatory dysfunctions, but have preserved interests in maintaining fertility. Adherence to guidelines for sexual education for men with traumatic SCI in Jamaica and the Caribbean is needed.

Utilization and access to healthcare services among community-dwelling people living with spinal cord injury

OBJECTIVE

Describe the utilization, accessibility, and satisfaction of primary and preventative health-care services of community-dwelling individuals with spinal cord injury (SCI).

DESIGN

Cross sectional, in-person or telephonic survey, utilizing a convenience sample.

SETTING

Community.

PARTICIPANTS

Individuals with SCI greater than 12-months post injury.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Demographic, injury related, and 34-item questionnaire of healthcare utilization, accessibility, and satisfaction with services.

RESULTS

The final sample consisted of 142 participants (50 female, 92 male). Ninety-nine percent of respondents had a healthcare visit in the past 12-months with primary care physicians (79%), with SCI physiatrists (77%) and urologists (50%) being the most utilized. 43% of the sample reported an ER visit within the past 12-months, with 21% reporting multiple visits. People who visited the ER had completed significantly less secondary education (P = 0.0386) and had a lower estimate of socioeconomic status (P = 0.017). The majority of individuals (66%) were satisfied with their primary care physician and 100% were satisfied with their SCI physiatrist. Individuals who did not visit an SCI physiatrist were significantly more likely to live in a rural area (P = 0.0075), not have private insurance (P = 0.0001), and experience a greater decrease in income post injury (P = 0.010).

CONCLUSION

The delivery of care for people with SCI with low socioeconomic status may be remodeled to include patient-centered medical homes where care is directed by an SCI physiatrist. Further increased telehealth efforts would allow for SCI physiatrists to monitor health conditions remotely and focus on preventative treatment.

The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome

BACKGROUND

Cauda equina syndrome (CES) is a rare neurologic complication of lumbar herniated disc for which emergency surgical decompression should be undertaken. Despite the common belief that the restoration of functions that are affected by CES can take several years postoperatively, follow up seldom exceeds the first year after surgery. Long term outcome of especially micturition, defecation and sexual function-which are by definition affected in CES-are unknown. The aim of this study is to evaluate 1) postoperative long term outcome of micturition, defecation and sexual function in CES patients 2) attitude of patients towards received hospital care with regard to (recovery of) these functions.

METHODS

CES patients were selected by screening the records of all patients operated on lumbar herniated disc in our university hospital between 1995-2010. A questionnaire was sent to the selected CES patients evaluating current complaints of micturition, defecation and sexual function and attitude towards delivered care with focus on micturition, defecation and sexual function.

RESULTS

Thirty-seven of 66 eligible CES patients were included (response rate 71%, inclusion rate 56%). Median time after surgery was 13.8 years (range 5.8-21.8 years). Dysfunction at follow up was highly prevalent: 38% micturition dysfunction, 43% defecation dysfunction and 54% sexual dysfunction. Younger age at presentation was associated with sexual dysfunction at follow up: for every year younger at presentation, odds ratio for sexual dysfunction at follow up was 1.11 (p = 0.035). Other associations with outcome were not identified. Two-third of the CES patients wished their neurosurgeon had given them more prognostic information about micturition, defecation and sexual function.

CONCLUSION

The presented data demonstrate that dysfunction of micturition, defecation and sexual function are still highly prevalent in a large number of CES patients even years postoperatively. These alarming follow up data probably have a devastating effect on personal perceived quality of life, which should be studied in more detail. CES patients communicate a clear demand for more prognostic information. The presented figures enable clinicians to inform their CES patients more realistically about long term postoperative outcome of micturition, defecation and sexual function after surgical intervention.

Women's Sexual Health and Reproductive Function After SCI

Sexual function and to a lesser extent reproduction are often disrupted in women with spinal cord injuries (SCI), who must be educated to better understand their sexual and reproductive health. Women with SCI are sexually active; they can use psychogenic or reflexogenic stimulation to obtain sexual pleasure and orgasm. Treatment should consider a holistic approach using autonomic standards to describe remaining sexual function and to assess both genital function and psychosocial factors. Assessment of genital function should include thoracolumbar dermatomes, vulvar sensitivity (touch, pressure, vibration), and sacral reflexes. Self-exploration should include not only clitoral stimulation, but also stimulation of the vagina (G spot), cervix, and nipples conveyed by different innervation sources. Treatments may consider PDE5 inhibitors and flibanserin on an individual basis, and secondary consequences of SCI should address concerns with spasticity, pain, incontinence, and side effects of medications. Psychosocial issues must be addressed as possible contributors to sexual dysfunctions (eg, lower self-esteem, past sexual history, depression, dating habits). Pregnancy is possible for women with SCI; younger age at the time of injury and at the time of pregnancy being significant predictors of successful pregnancy, along with marital status, motor score, mobility, and occupational scores. Pregnancy may decrease the level of functioning (eg, self-care, ambulation, upper-extremity tasks), may involve complications (eg, decubitus ulcers, weight gain, urological complications), and must be monitored for postural hypotension and autonomic dysreflexia. Taking into consideration the physical and psychosocial determinants of sexuality and childbearing allows women with SCI to achieve positive sexual and reproductive health.

Delivering care under uncertainty: Swiss providers' experiences in caring for women with spinal cord injury during pregnancy and childbirth - an expert interview study

BACKGROUND

When different health problems such as pregnancy and spinal cord injury (SCI) occur together, providing adequate care becomes even more challenging. Women with SCI may encounter a variety of specific problems and symptoms during pregnancy and childbirth, including urinary tract infections, pressure ulcers, constipation, autonomic dysreflexia, and preterm labour. Therefore, expertise from different medical specialties, especially spinal cord medicine and gynaecology are required. What is totally normal for experts of one specialty could cause a problem for experts from another specialty. Therefore, this study aimed to reconstruct the perceptions and experiences of healthcare providers in Switzerland in caring for women with SCI during pregnancy and childbirth.

METHODS

The perception and experience of healthcare professionals toward providing care for women with SCI during pregnancy and labour were elicited using qualitative expert interviews and analysed using grounded theory techniques. Fifteen health professionals were interviewed, including gynaecologists (n = 4), midwives (n = 3), physical medicine and rehabilitation professionals (n = 4), urologists (n = 3), and a peer counselor (n = 1).

RESULTS

Care delivery experiences of health professionals could be described as a forced reaction to decision making under uncertainty. However, health professionals seemed to express three different attitudes while handling the situation: (i) protective concerned attitude, (ii) 'no big deal' attitude, or (iii) precautionary attitude. The applied strategies were influenced by the conditions of the healthcare system, policies in place, and health professionals' behaviours. Consequently, health professionals faced with uncertainty felt like actors in a fragmented treatment process and called for interdisciplinary collaborations.

CONCLUSIONS

Our findings highlight the diversity of perspectives among different healthcare professionals with respect to the approach to care and delivery services for pregnant women with SCI. A need for more specific services, information, guidance, and guidelines for health professionals caring for woman with SCI during pregnancy and childbirth was identified. We strongly recommend further research on the development of integrated care concepts as well as clinical studies for establishing a more profound knowledge base.

Spinal cord injury and women's sexual life: case-control study

Study design :This is a case-control study.

OBJECTIVE

The objective of this study was to estimate the magnitude of association between spinal cord injury (SCI) and women's quality of sexual life and sexual function.

SETTING

This study was conducted in the Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran.

METHODS

From the referral university-based clinics, we used simple random sampling to recruit 62 women: 31 women with SCI and 31 women without SCI. Socio-demographic and reproductive traits questionnaire, Sexual Quality of life-Female (SQOL-F), Female Sexual Function Index (FSFI) and Spinal Cord Independence Measure (SCIM) were completed using telephone and face-to-face interviews in the cases and controls. After univariate analyses, multivariate linear and proportional odds regression models were conducted to investigate the relation between SCI and women's quality of sexual life, as well as sexual function.

RESULTS

The mean age of cases and controls was 35.42±6.51 and 33.77±4.02 years. Most women were high school-educated and housewives. Adjusting for probable confounders, the proportional odds regression model showed a significant relationship between the spinal cord injury (AOR=4.2, 95% CI: 1.8-9.2), non-college-educated (AOR=3.1, 95% CI: 1.2-5.9) and employed (AOR=1.8, 95% CI: 1.1-1.8) variables and being in one of the moderate or poor quality of life classes. Scores of SQOL-F and FSFI domains, except satisfaction, were significantly worse in cases versus controls (P<0.001).

CONCLUSION

Although our participants showed low sexual dysfunction, they tended to report moderate to poor quality of sexual life. Our findings support the implication that sexual rehabilitation must be provided for women with SCI soon after injury.

Discussing reproductive health in spinal care, part II: fertility issues

PURPOSE

Due to advancing insights, discussing fertility in spinal care is an emerging topic. Studies among neurosurgeons to evaluate clinical practice about discussing fertility are non-existent. The aim of this study is to review knowledge, attitude and practice patterns regarding discussing fertility in spinal care.

METHODS

Dutch neurosurgeons and residents were sent a mail-based questionnaire addressing attitude, knowledge and practice patterns regarding discussing fertility.

RESULTS

Response rate was 62 % (compared to mean of 28 % in similar surveys) with 89 questionnaires suitable for analysis. Mean age was 42 years with 83 % of respondents being male. A quarter of respondents stated neurosurgeons are responsible to discuss fertility, with 12 % indicating to actually do this. Fertility is discussed more often with patients with cauda equina syndrome (70 %) and with men (p = 0.006). Merely 8 % of respondents stated to have adequate knowledge on fertility preservation (FP); this percentage was higher for doctors with spinal surgery as specialty (p = 0.015). In case of cauda equina syndrome, doctors with more knowledge discussed fertility more often (p = 0.002). Fifty-three percent of neurosurgeons wished to enhance their knowledge, in order to feel more comfortable to discuss fertility with their patients. Five percent indicated to have ever referred a patient to a fertility specialist.

CONCLUSION

With the exception of cauda equina syndrome, fertility is not routinely discussed in spinal care. Fertility is discussed more often with men. Recent guidelines state that discussing fertility is an essential part of good practice in spinal care. Education on fertility and FP needs to be integrated in the neurosurgical training program to create more awareness, and to enable clinicians to provide adequate information and care to the patient.

Sexual and Reproductive Function in Spinal Cord Injury and Spinal Surgery Patients

Sexual and reproductive health is important quality of life outcomes, which can have a major impact on patient satisfaction. Spinal pathology arising from trauma, deformity, and degenerative disease processes may be detrimental to sexual and reproductive function. Furthermore, spine surgery may impact sexual and reproductive function due to post-surgical mechanical, neurologic, and psychological factors. The aim of this paper is to provide a concise evidence-based review on the impact that spine surgery and pathology can have on sexual and reproductive function. A review of published literature regarding sexual and reproductive function in spinal injury and spinal surgery patients was performed. We have found that sexual and reproductive dysfunction can occur due to numerous etiological factors associated with spinal pathology. Numerous treatment options are available for those patients, depending on the degree of dysfunction. Spine surgeons and non-operative healthcare providers should be aware of the issues surrounding sexual and reproductive function as related to spine pathology and spine surgery. It is important for spine surgeons to educate their patients on the operative risks that spine surgery encompasses with regard to sexual dysfunction, although current data examining these topics largely consists of level IV data.

Sexual Health of Polish Athletes with Disabilities

The purpose of this study was to determine sexual functioning of Polish athletes with disabilities (including paralympians). The study encompassed 218 people with physical disabilities, aged between 18 and 45 (149 men and 69 women). The entire research population was divided into three groups: Polish paralympians (n = 45), athletes with disabilities (n = 126) and non-athletes with disabilities (n = 47). The quality of sexual life of Polish paralympians was measured by using the Polish version of Female Sexual Function Index and International Index of Erectile Function. Clinically significant erectile dysfunctions were most often diagnosed in non-athletes (83.33%) with 50% result of severe erectile dysfunctions, followed by athletes and paralympians with comparable results of 56.98% and 54.17% respectively (p = 0.00388). Statistically significant clinical sexual dysfunctions concerned lubrication, orgasm as well as pain domains, and prevailed among female non-athletes (68.42%, 68.42% and 57.89%). Practising sports at the highest level has a favourable effect on the sexuality of men and women with physical disabilities. Men with physical disabilities manifest more sexual disorders than women, an aspect which should be considered by health-care professionals working with people with disabilities.

Perceived needs and experiences with healthcare services of women with spinal cord injury during pregnancy and childbirth - a qualitative content analysis of focus groups and individual interviews

BACKGROUND

Women after a spinal cord injury (SCI), who decide to get pregnant and to become mothers, have special health care service needs. This study aims to identify the perceived service needs of woman with SCI during pregnancy and childbirth in Switzerland and to reconstruct their experiences of healthcare service utilization based on their accounts.

METHODS

A qualitative content analysis based on focus groups and individual interviews was conducted. 17 mothers with SCI who had given birth following SCI within the past 15 years participated. The data were transcribed verbatim before content analyses were carried out. Primary data was collected from August 2012 to September 2013 at the Swiss Paraplegic Research Centre, Nottwil; the University of Lausanne and at the homes of the participants.

RESULTS

Mothers reported a broad spectrum of medical needs, including the need for access to improved integrated care. They also reported difficulties finding providers with knowledge of both paraplegiology (i.e. spinal cord medicine) and gynaecology. Mothers preferred using local health care services and regular birth hospitals, and reported receiving no additional benefit from the services of specialised SCI centres during pregnancy. A pre-existing provider-patient relationship was helpful for optimizing care processes.

CONCLUSION

This study showed that pregnant women with SCI have various perceived healthcare needs and health care service use. Effective programs to improve these women's access to integrated care during pregnancy and childbirth and policies requiring the provision of specific pregnancy information and pre-birth services are necessary.

Psychometric properties of the Sexual Adjustment Questionnaire (SAQ) in the Iranian population with spinal cord injury

STUDY DESIGN

This is a cross-sectional study.

OBJECTIVES

The objective of this study was to examine the psychometric properties of the Sexual Adjustment Questionnaire (SAQ) for Iranian people with spinal cord injury.

SETTING

This study was conducted in the brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran.

METHODS

We assessed the psychometric properties of the SAQ, with 200 participants (men=146, women=54) completing the scale. An evaluation of its test-retest reliability was performed over a 2-weeks period, on a subsample of 30 patients recruited from the overall group. Cronbach's α-coefficient was computed for assessment of internal consistency reliability. In addition, content and face validity were examined by an expert committee. Construct validity was assessed by examining convergent and discriminant validity. Finally, exploratory factor analysis was used to extract the factor structure of the questionnaire.

RESULTS

The Cronbach's α and intraclass correlation coefficient were 0.77 and 0.72 retrospectively. With regard to construct validity, there was a significant (P=0.009) negative correlation (r=-0.28) between the SAQ score and age. Those with lower levels of educations scored significantly lower on the SAQ (P=0.04). The exploratory factor analysis indicated a four-factor structure for the questionnaire, accounting for 68.9% of the observed variance. The expert committee approved the face and content validity of the developed measure.

CONCLUSION

The SAQ is a valid measure for assessing sexual adjustment in people with spinal cord injury. The evaluation of sexual well-being may be useful in clinical trials and practical settings.

"Don't Think Paralysis Takes Away Your Womanhood": Sexual Intimacy After Spinal Cord Injury

Sexuality and intimacy are important components of health and well-being. Issues surrounding sexuality and intimacy are equally important for men and women living with physical disabilities, including spinal cord injury (SCI). Yet, women's sexuality after SCI remains largely unexamined. This article presents the findings from an in-depth qualitative investigation of the sexual and reproductive health experiences of 20 women with SCI in or around Detroit, MI. Findings echo existing literature documenting the sexual consequences of life after SCI and suggest new areas of inquiry important for better addressing sexual concerns across the lifespan. Specifically, findings suggest a need to consider the variable effects of SCI on sexual intimacy in relation to a person's developmental trajectory, the appropriate timing of sexual education, the need to expand conceptualizations of sexual intimacy, and the ways SCI may affect sexuality in later life.

Sexuality of Disabled Athletes Depending on the Form of Locomotion

The main purpose of this study was to determine sexuality of disabled athletes depending on the form of locomotion. The study included 170 disabled athletes, aged between 18 and 45. The entire population was divided into 3 research groups depending on the form of locomotion: moving on wheelchairs (n=52), on crutches (n=29) and unaided (n=89). The research tool was a questionnaire voluntarily and anonymously completed by the respondents of the research groups. The questionnaire was composed of a general part concerning the socio-demographic conditions, medical history, health problems, a part dedicated to physical disability as well as the Polish version of the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI) evaluating sexual life. STATISTICA 10.0 for Windows was used in the statistical analysis. Subjects moving on crutches were significantly older than ones moving on wheelchairs and unaided (34.41 ±11.00 vs. 30.49 ±10.44 and 27.99 ±10.51 years, respectively) (p=0.018). Clinically significant erectile dysfunctions were most often diagnosed in athletes moving on wheelchairs (70.27%), followed by athletes moving on crutches and moving unaided (60% and 35.42%, respectively; p=0.048). Clinical sexual dysfunctions were diagnosed on a similar level among all female athletes. It was concluded that the form of locomotion may determine sexuality of disabled men. Males on wheelchair revealed the worst sexual functioning. Female athletes moving on wheelchairs, on crutches and moving unaided were comparable in the aspect of their sexual life.

Sexual dysfunction in patients with spinal cord lesions

Many aspects of sexuality can be disrupted following a spinal cord lesion (SCL). It can alter an individual's self-esteem and body image, interfere with positioning and mobility, introduce unexpected problems with incontinence and spasticity, decrease pleasure, and delay orgasm. Sexual concerns in men can involve erectile function, essential for intercourse, ejaculation function, necessary for fertility, and the ability to reach orgasm. In women they can involve concerns with vaginal lubrication, genital congestion, and vaginal infections, which can all go unnoticed, and orgasm, which may be lost. All of these concerns must be addressed during rehabilitation as individuals with SCL continue to live an active sexual life, and consider sexuality among their top priority for quality of life. This chapter describes the impact of SCL on various phases of men's and women's sexual responses and on various aspects of sexuality. Treatments are described in terms of what is currently available and what is specific to the SCL population. New approaches in particular for women are described, along with tips from sexual counseling which consider an overall approach, taking into account the primary, secondary, and tertiary consequences of the SCL on the individual's sexuality. Throughout the chapter, attempts are made to integrate neurophysiologic knowledge, findings from the literature on SCL, and clinical experience in sexual rehabilitation.