Before the early 1970s, most people didn't talk about sexuality. Medical professionals didn't think the topic was that important or had a role in the rehabilitation setting. People in rehab tended to regard individuals with disabilities as nonsexual and unable to participate in sexual activities.

During the 1970s and 1980s little was available to assist people with sexuality issues. This was especially true for women. Rehab professionals began to recognize the importance of talking about sexuality but had little to offer in terms of technology, pharmaceuticals, resources, or information.

During the 1980s and early 1990s, new developments and research in the sexuality field remained at a standstill. This situation changed dramatically in the mid-1990s, when the pharmaceutical industry began to take an interest. The field changed beyond anyone's expectations on March 28, 1998—the date Viagra was introduced to the world.

A new sexual revolution began, and things haven't been the same. Many social scientists say the pharmaceutical industry was looking for the "female pill" five minutes after Viagra's introduction. These people strongly believe sexuality has now turned into a medical problem rather than a social/cultural issue. In this regard, psychologists and social workers say relationship issues get lost when we look at sex as a medical issue.

Regardless of its medical or social underpinnings, the search for the "female Viagra" has now become a stampede. With billions of dollars at stake, pharmaceutical giants like Pfizer, Bayer, and Lilly are conducting scientific clinical trials toward the goal of being the first company to obtain FDA approval for the female pill.

Ten years ago, most sexual difficulties were regarded as psychological, with only about 5% considered physical. Today the pendulum has swung completely to the other side. Approximately 90% of sexual dysfunction is now deemed neurological or vascular in origin.

Within the last two years, the National Institutes of Health (NIH) convened a panel of experts to define the term female sexual dysfunction. As a result of this panel, researchers have identified four female sexual problems: low sexual drive, difficulty becoming aroused, inability to reach orgasm, and pain during intercourse.

For women with SCI, sexual dysfunctions are not much different than they are for women who are able-bodied; all the dysfunctions noted above are also observed in women with SCI. The medical issues related to injury and the emotional aspects of adjustment all can contribute to sexual difficulties for women with SCI.

Low sexual desire, a common diagnosis among females, is becoming clearly associated with low testosterone levels in women. The idea of combining testosterone with medications that dilate blood vessels seems to be a direction in which much of the current research is heading. Early study results for postmenopausal women appear especially encouraging.

Good research on testosterone's role in women with SCI doesn't exist. Yet, clinical experience has demonstrated that interest in sex and sexual activity tends to decrease after injury. According to current estimates, 45-52% of women have sexual activity at least once per week postinjury. This compares to other studies showing that 64-76% of these women had sexual activity at least once weekly prior to injury. It is still unclear as to whether this decrease is a result of hormonal changes after SCI.

Psychological issues can also play a major role in decreasing sexual desire following injury. A major psychological contribution is the presence of past physical or sexual abuse. Other emotional issues may include lack of information, adjustment difficulties, depression, feelings of guilt, and conflict in a relationship.

Some women may have had lifelong decreases in sexual desire long before SCI. These patterns continue after injury. One of the best predictors of sexual interest after SCI is the level of interest before it.



Next month, Part 2 explains findings about the remaining three areas of female sexual problems: arousal, orgasm, and pain during intercourse. Dr. Ducharme also discusses treatments for female sexual dysfunction.



Dr. Stanley Ducharme is a clinical psychologist in the Departments of Rehabilitation Medicine and Urology at Boston University Medical Center. For several years, PN/Paraplegia News has included his quarterly column Sexuality & SCI.