The nature and degree of impairment in sexual functioning after injury to the spinal cord will depend upon the level and the completeness of the lesion. With a complete lesion paraplegic men will rarely experience ejaculation, although orgasm can occur with this. Some have referred to this as a 'phantom orgasm', while others argue that orgasm as such is a central event and does not depend for its occurrence upon peripheral responses (Geiger, 1979). Male paraplegics will generally be able to achieve a reflexogenic erection, but not a psychogenic one and the erection may be difficult to maintain. Less is known about the sexuality of spinal cord injured women than that of men (Thornton, 1979). Vaginal lubrication may still occur as a response to stimulation, and orgasm, as in men. A woman's fertility is not affected, although child-bearing and labour will be more difficult; most men, in contrast, will find that their fertility is severely impaired. The act of intercourse itself is complicated by the spinal cord injury, whichever partner is the injured one. There will be limitations in the positions that can be adopted; involuntary spasms may occur and incontinence, or the management of an indwelling catheter, can be a problem also. Little is known of the psychological impact of sexual dysfunctions. Some commentators have suggested that patients are more concerned about these than about any other aspect of their disability (Bloom, 1974; Breslin, 1971; Cole et al., 1973), but this may overstate the case. In one study paraplegics rated sex the least of the major functional losses resulting from their injury; 52 per cent thought the loss of the use of their legs the most important, 35 per cent the loss of control over bowel or bladder, and only 13 per cent the loss of sexual functioning (Hanson and Franklin, 1976). Furthermore, in long term relationships sexual difficulties may be of secondary importance compared with other problems such as loss of fertility (David et al., 1978).
