Dear Alice,

What can you tell me, a caregiver, about male quadriplegics and sexual intercourse? I take care of a young gunshot victim who is dealing with his sexuality. I would like to better understand what he is dealing with.

Thank you,
A Concerned Caregiver

Dear A Concerned Caregiver,

It is very proactive of you to try to understand your patient, and learning more about what he may be going through may help you care for him better. However, as a care giver, it is important to recognize that this may be something beyond your responsibility or area of expertise. Having a conversation about sex can be uncomfortable and intrusive for many. Therefore, it should not be assumed that your patient is open to talking with you about his sexuality. Still, it is great to be prepared should he ultimately ask for your help and guidance.

Almost everyone can enjoy some form of sexual activity or sensuality, regardless of ability! However, it’s natural for a person to feel anxious, angry, and/or distressed after the loss of his or her normal sexual ability. Discovering sexuality as a person with disabilities often requires the courage to experiment, a degree of imagination to overcome the disability, and the process of coming to terms with her or his new body image. These issues not only hold true for people with new disabilities, but also those with long-standing disabilities. Sexual counseling can be helpful in teaching a patient how to communicate needs and feelings concerning sexual issues.

Getting into the biology, the type and level of the spinal cord injury will determine the effects on his sexual functioning. The nerves that control an erection are located in the sacral segments (S/2-S/4) of the spine. Spinal cord injuries that occur above these segments result in a loss of the ability to have psychogenic erections (brought on by erotic emotional or mental stimulation). However, these males may be able to have reflex erections with physical stimulation. There are several options available for men who would like a little help achieving erections, including penile injections, surgical implants, and the vacuum pump. Speaking with a health care provider may help your patient decide whether or not he would like to use any of these options.

The ability to ejaculate decreases dramatically after a spinal cord injury. The ejaculatory process involves nerves from a number of different levels of the spinal cord; therefore, it is likely to be affected by most spinal cord injuries. Ejaculatory rates vary greatly and are dependent on several factors. However, males with spinal cord injuries may still experience orgasms, especially when concentrating on their partner’s arousal.

Should a discussion about sex come up, it may be helpful to give your patient the following tips:

Explore your body. This can help you figure out what is most pleasing and comfortable. In terms of sex positions, trying a variety of positions may help you expand your sexual repertoire, as well as your pleasure.

When exploring, try to keep a relaxed frame of mind. This will help you laugh off anything that goes wrong, while gaining the maximum benefit from anything that you do discover about the sexual possibilities that are open to you.

Be open to new ideas of sexual expression. While your erections may not be sustainable or strong enough for penetrative sex, don’t fret! There are still plenty of ways to give and receive pleasure, such as oral sex, or the Karezza technique. When both sex partners have high-level spinal cord injuries, an assistant may be employed to assist in wheelchair sex and intercourse.  

Communicate with your partner.This involves speaking up about your concerns and needs, as well as being honest about what is and isn’t working. Taking the time to sort through issues not only helps lovers to feel more successful in their sexual intimacy efforts, but helps them to feel more emotionally intimate as well.

Don’t forget the rubber. Never assume an injury causes infertility or makes a person incapable of catching and spreading Sexually Transmitted Infections (STIs). Using protection, such as a condom, can help protect against unplanned pregnancy and STI transmission.

Some more ideas on being creative can be found in Feeling frustrated about sex and disability.

Being open and honest with your patient can help him have more positive sexual relationships. Various resources may provide you with additional information. These include the film (Sex)abled Disability Uncensored, the Spinal Cord Injury Information Network, the Christopher and Dana Reeve Foundation, and patient forums. Here’s to a healthy and satisfying sexual life for all!


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