Sexual changes

Families and partners can have trouble understanding these sexual changes and can react negatively. A good understanding should be gained of how impulsivity, disinhibition and lack of awareness have caused sexual changes.  

The brain injury survivor must be encouraged to take control over aspects of their life, when there is a reasonable expectation for responsible behaviour. When sexual behaviour is inappropriate, steps need to be taken to learn better ways for managing or compensating for the lapses in social skills. All members of the family should work to become comfortable in discussing sexual issues, and assist in implementing behavioural modification techniques to manage behaviours. 

Impulsivity, disinhibition and lack of awareness may lead to rehabilitation staff receiving unwanted sexual attention from the brain injury survivor. The medical team, family and friends need to have a common response to inappropriate sexual behaviour that will assist the person to regain control over sexual impulses. This behaviour can particularly be a problem for males from their late teens to mid-twenties when their sexual urges are strongest. Some of this behaviour may include fantasising, lewd verbal responses, disrobing and/or masturbating in public, impulsiveness and touching others. 

Sexual changes are common after a brain injury. Although we are all sexual in nature, there is a great deal of stigma to sexual behaviour in the wrong place or time.  

Some of the more common changes include:  

• loss of libido or sexual drive 
• hyper-sexuality (increased desire for sex) 
• inability to achieve or maintain erection 
• inability to orgasm 
• premature ejaculation 
• pain and discomfort during sex 
• sexual disinhibition, e.g. talking excessively about sex or inappropriate touching 
• reduced sexual responsiveness or desire for intimacy.  

These changes may be a direct result of damage which occurred to particular brain structures underlying sexual functioning. Other biological causes of sexual dysfunction may include damage to genital organs, muscles and bones, spinal cord and peripheral nerve damage, medical conditions, hormonal disturbance and side effects of medication and drugs. Psychological and psychosocial changes can also have an impact on sexual function.  

Some of the reasons for changes in sexual function include:   

• low motivation 
• medication 
• diabetes or hypertension (high blood pressure) can reduce libido  
• depression  
• stress and anxiety  
• emotional reactions, e.g. anger, embarrassment, shame and fear of rejection  
• personality changes  
• cognitive problems, e.g. distractibility, perceptual disorders and memory problems  
• problems with communication e.g. aphasia or missing social cues  
• a loss of self-confidence regarding personal attractiveness  
• poor social skills and impaired self- control  
• social avoidance and isolation  
• relationship breakdown. 

Seeking professional advice can be an embarrassing and sensitive issue for many people as sex is usually a very personal and private aspect of life. People are often more likely to discuss sexual problems with their doctor during a visit for other health reasons. Assessment of sexual problems can be a vital first step in learning to manage or discover treatment options. Assessment may involve an interview, questionnaires, physical examination, and neurological and medical tests. In addition to a doctor, psychologists and psychiatrists may be involved in the assessment and treatment of sexual problems. 

Jill’s husband, Paul, experienced a number of personality changes after his brain injury. In particular, Paul’s behaviour was childlike and immature, and he became overly dependent upon Jill. 

In many ways Jill felt like she had become Paul’s mother rather than his wife, friend and lover. The impact upon their sexual relationship was significant. Jill read some information about the effects of brain injury. She then organised regular respite care and learned some behaviour management strategies for encouraging Paul to be more independent. As a result of Jill’s increased understanding, some lifestyle changes and new skills, she and Paul now spend more quality time together and their sexual relationship has improved. 

Another important issue is the increased vulnerability that people may experience due to cognitive impairment and emotional distress. In particular, the person may not sense when they are at risk, know how to cope with unwanted sexual advances or understand the consequences of their actions. 

Family members and friends need to be aware of these issues and discuss any concerns with a professional. Some people may not feel that it is possible to discuss these issues directly with the person with a brain injury. In such cases, a friend or another family member may be a more appropriate person to recommend self-protection strategies or remind the person about general safety issues.