Letters

Dear Editor: Sexual dysfunction (SD) after traumatic brain injury (TBI) is an often neglected and underreported issue within the medical field. A recent interesting work by Bivona et al found that TBI survivors and their partners showed a decrease in sexual desire and frequency of sexual intercourse, particularly those who suffered from depression. Of note, this study suggests that SD in patients with TBI is more often the result of relationship dysfunction than a consequence of the brain injury. SD is common among patients with TBI (affecting up to 60% of the patients); many researchers believe that SD among the TBI population is “more often the rule than the exception,” especially when considering the multifactorial etiology of SD, which involves neurological, endocrine, iatrogenic, psychiatric, and psychosocial factors. Indeed, brain trauma could affect all the brain regions involved in sexual response by changing the process of sexual stimuli to preclude arousal, decreasing or increasing desire, and curtailing genital engorgement. In particular, since anterior brain regions are associated with emotional and behavioral impairment, prefrontal and lobar lesions might more frequently generate hyposexuality rather than hypersexuality (e.g., Kluver-Bucy syndrome). SD in patients with TBI seems to be directly affected by both trauma to the complex sexual pathways in the brain and the situational changes in the patient’s mood, the latter contributing to higher SD rates. This supports the idea that depression may play a pivotal role in worsening sexual quality of life for TBI patients and their partners. Patients with TBI may have limited physical ability to communicate, embrace, stimulate, engage in intercourse, and maintain urinary and bowel continence during sexual activity, all of which can further exacerbate SD. And these patients— particularly young, male patients— may regard their sexual loss as the most devastating aspect of their disability. It has been reported that post-TBI SDs do not correlate with cognitive impairment, length of post-traumatic amnesia, or physical neurological disability caused by brain injury; however, independent determinants of sexual outcome include a high sickness-impact profile, low selfesteem, anxiety, and depression. Depression is considered the most sensitive negative predictor of SD in patients with TBI. On the contrary, other authors found significant correlations between post-traumatic endocrine dysfunction and anterior pituitary lesions. Sexuality is one of the most complex aspects of human life. Sexual expression is dependent on functioning anatomical and physiological systems, which are influenced by cognitive and emotional processes. Being knowledgeable of how these systems can influence both the dynamics of an intimate relationship and the physical and psychological aspects of sexual functioning is necessary in order to properly assess and treat sexual problems, including relationship dysfunction. Unfortunately, clinicians may not be comfortable discussing sexual issues with their TBI patients, often because the clinicians lack sufficient knowledge regarding the relationship between sexuality and medical illness. And socio-cultural beliefs may create barriers that prevent patients with TBI from exploring their sexuality and from discussing sexual functioning issues with their clinicians. In conclusion, taking into account the high prevalence of SD in men with TBI and its multifactorial etiology, we believe clinicians who treat patients with TBI should be properly trained in human sexuality in order to better meet the needs of these patients. Clinicians should be prepared to have frank, educated discussions on sexual functioning with all of their TBI patients so that they may provide valuable information to their patients on achieving healthy sexual functioning; this in turn will help their patients and their patients’ partners achieve a higher quality of life.