Review article

Impact of spinal cord injury on sexuality:
Broad-based clinical practice intervention
and practical application
Marika J. Hess1,2,3, Sigmund Hough 1,3,4
1

Spinal Cord Injury Service, VA Boston Healthcare System, West Roxbury, MA, USA, 2Physical Medicine andRehabilitation, Tufts School of Medicine, Boston, MA, USA, 3Harvard Medical School, Boston, MA, USA,
4
Boston University School of Medicine, Boston, MA, USA
Summary: This study focuses on the impact a spinal cord injury may have on achieving physical and emotional
intimacy, and potential to maximize sexual ability and quality of life. Spinal cord injury is a traumatic, life-altering
event that is usually associated with loss of motor and sensory function, as well as sexual impairment. At the timeof injury, the individual is faced with devastating loss and an abundance of new information in a setting of
extreme stress and challenge. In the acute rehabilitation setting, there is often a considerable void inproviding education and resources regarding sexual concerns and needs. There is a positive relationshipbetween sexual education and sexual activity. The impact of inadequate sexual counseling and education asa part of rehabilitation can be deleterious.
Keywords: Sexuality, Spinal cord injuries, Intervention, Best practice, Erectile dysfunction, Rehabilitation, Physical, Patient education, Tetraplegia, Paraplegia,
Autonomic dysreflexia, Assistive devices

Spinal cord injury: a life event
Spinal cord injury is a traumatic, life-altering event for
the injured individual that is usually associated withloss of motor and sensory function, and sexual impairment. The effect on the sexual response depends on thelevel and severity of injury, as well as personal attributes
such as partnership status, pre-morbid sexual experiences
and attitudes, and openness to sexual experimentation.1–3
Sexuality education is often poorly integrated into therehabilitation process4,5 though the change and anticipation of loss may severely threaten a person’s selfesteem and sense of value as a sexual being.6 Together,
these significant losses can lead to physical and emotional
isolation, placing the person at risk for social and psychological withdrawal and depression.

Spinal cord injury and sexuality: who, what, where
The level and completeness of spinal cord injury are
major determinants of sexual functioning7,8 (Table 1).
In the immediate post-injury period, both men andwomen lose ability to have reflexive sexual responses.
Correspondence to: Marika J. Hess, Spinal Cord Injury Service (SCI #128),
VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA
02132, USA. Email: marika.hess@va.go

211© The Academy of Spinal Cord Injury Professionals, Inc. 2012
DOI 10.1179/2045772312Y.0000000025

Once reflexes return, reflexive arousal in men andwomen (erection in men and vaginal lubrication in
women) can be achieved with genital stimulation if thesacral spinal segments and peripheral pathway conveying sensations (cauda equina) are intact.9 However,these reflexive responses are usually short lived, limited
to the duration of stimulation, and often do notachieve a fully satisfactory response.10 If the injury iscaudal to the 12th thoracic cord segment men andwomen can be expected to experience psychogenic
arousal in response to visual, auditory, imaginative,
tactile, and gustatory stimuli.11 Even in the absence ofphysical manifestations of arousal, individuals withspinal cord injury describe subjective arousal similar
to non-injured controls.12,13
For men, the ability to experience erections is preserved more frequently than the ability to experienceejaculation. Whereas up to 95% of men with spinal
cord injury experience ejaculatory problems,14 80%
regain some erectile function by 2 years after spinal
cord injury.15 The ability to achieve erections does
not parallel a man’s ability to become sexually
aroused.12 Therefore, the ability to obtain and maintain erections should not be used to gauge a man’s

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Table 1

Impact of spinal cord injury on sexuality

Potential for sexual response based on spinal cord injury

Complete upper motor neuron
injury cephalad to T11
Complete upper motor neuron
injury caudal to T11–L2 withsparing of sacral spinal
segments

Conus injury/lower motor neuron
injury (loss of sensation/
voluntary control S4–S5, loss of
S4–S5 mediated reflexes)

Incomplete injuries

Likely to experience,reflexive arousal:
erection/vaginal
lubrication

Likely to experience,
psychogenic arousal:
erection/vaginal
lubrication

Orgasm

Yes

No

Yes

Recommendations

1 Genital stimulation
2 Stimulation of sensate
erotic body parts
Yes
Yes
Yes
1 Genital stimulation
2 Stimulation of sensate
erotic body parts
3 Audiovisual, tactile
gustatory and imaginative
stimuli/ fantasy
No
Yes
Yes
1 Assisted lubrication (e.g.
KY jelly)
2 Stimulation of sensate
erotic body parts
3 Audiovisual stimulation/
fantasy• Ability to appreciate pin touch sensation in S2, 3, 4 dermatomes correlates with ability to attain
psychogenic arousal and achieve ejaculation• Ability to perceive T10–L2 dermatomes correlates with the ability to attain psychogenic
erection/lubrication, and the better the response to fantasy• Preservation of sacral sensation or voluntary sacral control of S4–5 correlates with ability toattain reflexogenic erection/vaginal lubrication• Regardless of level or completeness, approximately 50% SCI individuals experience orgasm“Reflexogenic arousal” refers to erection/vaginal lubrication that occur as a result of genital stimulation. “Psychogenic arousal” refers toerection/vaginal lubrication that occur as a result of arousal in the brain (e.g. through hearing, seeing, feeling, or fantasy). “Orgasm”
refers to the perception of a peak feeling of sexual release or climax.

sexual potential.7 Even though orgasm is less common
than in women,16 approximately half of men withspinal cord injury can experience orgasms after
spinal cord injury;16,17 however, the quality of theirorgasm may be different.18 Orgasm can occur in men
who are not capable of ejaculation and is not determined by completeness of the spinal cord injury.18
Similarly, women can experience orgasm after spinal
cord injury, even if their spinal cord injury is complete.
Approximately one-half of women with spinal cord
injury have been found to experience orgasm by selfreport19,20 and in the laboratory setting.13 The
latency to orgasm is increased, but the qualitativedescription of orgasm is indistinguishable from noninjured controls.9 Audiovisual stimulation leads tosimilar subjective and autonomic responses found in
women without injury,21 and can be utilized in conjunction with other methods to facilitate arousal.
Once orgasm is achieved, it is indistinguishable from
non-injured counterparts.9
Vaginal lubrication is more likely to occur when sacral
segments S2–S5 are spared, but can go unnoticed. Women
with sacral preservation can utilize manual and vibratory
self-stimulation to augment their sexual response.9
In general, frequency of sexual activity and intercourse declines after spinal cord injury.3,17,22 Lack ofovert sexual expression can result from the biologicalsequelae of the spinal cord injury or reflect psychological manifestation of emotional loss and detachment.23
However, diminished or absent expression does notequal absent sexuality. The need for sexual expression
and intimacy often remain.24 With time after injury,
sexual activity increases, and its expression oftenchanges.3,20,25 Individuals become more open andlikely to engage in sexual fantasies.26 The frequency of
hugging, kissing, manual stimulation, and use of oralgenital stimulation is not statistically different than incouples without spinal cord injury.3,27
Relationship factors such as partner satisfaction andrelationship quality as well as mood and independence
appear to be more important predictors of sexual satisfaction than genital functioning in both men andwomen.3,6,28 The reasons for pursuing sexual activity
also may change with need for intimacy being the
primary reason followed by sexual need, self-esteem,
and keeping a partner.29,30 Concern over not satisfying
one’s partner consistently ranks similarly to the lack ofpersonal satisfaction. Both men and women reportthat a sense of intimacy and their ability to please
their sexual partner are important determinants of
their own satisfaction.24,31–33 Women and men withspinal cord injury report better sexual satisfaction if

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Impact of spinal cord injury on sexuality

they are in an enduring relationship.31,33–35 Therefore,
rehabilitation team members need to foster open dialogue between the person with spinal cord injury andtheir partners, and support open communication andexperimentation. Involvement of the partner in the
rehabilitation process is critical.25

Spinal cord injury and sexuality in acuterehabilitation
In the acute rehabilitation setting, individuals with spinal
cord injury are taught compensatory techniques to overcome physical limitations in order to maintain or maximize function. However, the person may receive muchless information on the sexual implications of theirinjury and even less on related compensatory strategies.
Studies have shown that there is a large void in
addressing sexual rehabilitation despite continued
acknowledged need for education and counseling.4,5
Furthermore, a positive relationship between sexual education and sexual activity has been shown. Individuals
with spinal cord injury evolve in their readiness to hearand process new information regarding their sexual functioning. Even though sexual education should be available in the acute rehabilitation period, the information
should also be tailored to the individual’s particularneeds as they process the ramifications of their injury.
A longitudinal study assessing the need for sexual education showed that individuals with spinal cord injury
were more realistic about their sexual functioning in
the first 6 months after the spinal cord injury and were
better prepared to assimilate education.36

Interventions: what can be done?
Many persons use pharmacological interventions andadaptive devices to achieve sexual satisfaction. Often,
masturbation can be effective in helping individuals
rediscover what is sexually pleasing and develop confidence. Application of vibrators to erogenous areas canfacilitate achieving sexual arousal and orgasm.21 In
men, vibrators with amplitudes of 2.5 mm and frequencies of 100 Hz are most likely to yield erections.37
Erection may also be achieved with catheter manipulation, application of hot towels to the penile shaft andapplying constrictive band at the root of the penis.11,38
Individuals should explore their bodies and use multiple senses to discover areas that are most sensual andpleasing. After spinal cord injury, different parts of thebody, especially at the level of injury can become sexually pleasurable. For example, stimulation to thenipples, earlobes, or inner thighs may be perceived aserogenous and even evoke genital awareness in theabsence of genital sensation. Genital stimulation itself

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can elicit sexual arousal and even orgasm in some
women with complete spinal cord injuries.39,40 Whenerections are inadequate for sexual intercourse, the“stuffing technique” can be employed to insert theflaccid or semi-erect penis in the partner’s vagina. This
technique may be sexually satisfying for the partner
and also help stimulate and maintain reflexive erectionsin the partially erect penis. Perineal training exercises
can improve penile rigidity and function in men who
have some voluntary control of perineal muscles.41
Decreased lubrication is the female counterpart toerectile dysfunction in men. This decrease is caused byinterruption of sympathetic innervations to the genitalia, and can result in excessive shearing during penetration.13,42 Vaginal stimulation, even in the absenceof sensation, can cause reflexive vaginal lubrication,although this method of lubrication may not be sufficient to allow penetration. Application of lubricant
jelly to the genitalia can facilitate coitus, prevent tissue
injury, and is well tolerated. If an individual does nothave sufficient hand function, the partner can easily
incorporate the application of a lubricant into foreplay.
Water-based lubricants are generally well tolerated anddo not interfere with condoms or silicone-based sex
toys.43

Upper extremity function
A variety of positions for intercourse should be trialed todetermine best comfort and efficacy. If individuals lackstrong upper extremities to support their upper bodies, aside lying or inferior position can be assumed, which
also frees up the upper extremities for touching andfondling. Individuals who do not have hand function
can guide their partner in trialing various positions aswell as stimulation delivery methods. For example,
vibratory stimulation has been reported to be an effective method of enhancing sexual arousal in both men
and women.44 Individuals who lack hand function canbe evaluated for assistive devices. Individuals withlimited grasp may benefit from the addition of straps
to vibrators, while others with minimal or no grasp
can be prescribed custom wrist splints with adaptations
to hold vibrators, dildos, or other appliances. In our
opinion, an ideal candidate is someone who has goodshoulder and elbow strength and range of motion but
lacks intrinsic hand function. In the absence of functional arm capability, vibrators can be attached tovarious body parts such as the thigh or tongue with thehelp of straps. Individuals may choose to use dildos
that can be strapped on to their pelvis with the help of
a harness or can be worn around the thigh with Velcro
straps (Velcro USA Inc., Manchester, NH, USA).45

Hess and Hough

The skin needs to be carefully inspected before and after
use to not reinjure or contribute to skin breakdown.
Another frequently prescribed aid in achieving erections is the vacuum erection device, which causes
penile engorgement by negative pressure.46 Vacuum
erection devices are bulky and require that the penis
be virtually insensate. Even though the battery-operated
devices require less hand dexterity than the manual
option,some
handfunctionisrequired.
Pharmacological agents such as oral phosphodiesterase
inhibitors or intracorporal injections of vasoactive substances are frequently used and very successful.47
Intracorporal injections require intact hand function
and rotation of injection sites. If self-administration is
unrealistic, proper management can be performed bytheir partner or personal care attendant.

Impact of spinal cord injury on sexuality

cause or interfere with positioning.50,51 In a survey
studying the impact of spinal cord injury on sexual function 28.7 % of respondents reported their spasticity was
severe enough to require medication.29 When noninvasive strategies are insufficient, pharmacological andneuroablative methods can be considered.52
Taking spasmolytics prior to sexual activity may
reduce the disruptive effects of spasticity.53–56
Although intrathecal baclofen pump delivery is an effective method of achieving spasticity control while minimizing systemic side effects,57 it may have negative
effects on sexual functioning. Reduced libido, difficulty
achieving erections and ejaculations have been reported
and appear to be dose related with reversal of symptoms
with dose reduction.58

Neurogenic bowel and bladder
Spasticity
Spasticity occurs in 65–78% of people with chronic
spinal cord injury.48,49 Spasticity commonly results intypical postures, such as thigh adduction, hip andthigh flexion that can negatively impact positioning conducive to intimacy and sexual functioning. If an individual has significant thigh adduction, determination must
be made as to whether the adduction deformity is fixed
or not. If the muscle is contracted in a shortened position, the limb cannot be stretched passively beyond a
fixed point (fixed deformity). When there is sufficientpelvic access with passive range of motion, the adductor
tone may be amenable to nonsurgical treatment.
Sometimes gentle stretching of the affected muscles
prior to positioning is sufficient and can easily be incorporated into foreplay. Positioning a pillow or wedge
under the individual’s pelvis and legs can minimize thestretch on spastic muscle and allow comfortable positioning. If an individual has severe adductor spasticity
in the thighs, pillows should be placed between theknees to prevent rubbing and skin breakdown. Often,
however, pharmacological treatments need to beconsidered.49–51
The individual and partner may consider carrying out
sexual activities in a wheelchair when hip and knee
flexion spasms are pronounced. This is a viable option
for individuals who have sufficient truncal strengthand balance to maintain a seated position without significant external support and in whom sitting does not
trigger more spasms or spasticity. A seated position
can be more energy consuming and may not be an
option in persons with severe cardiopulmonary compromise. Removable arm rests can facilitate positioning andmovement of both partners. Sexual activities such as
genital penetration can precipitate spasms that either

Spinal cord injury is often associated with decreased
bowel and bladder sensation with poor or no voluntary
control of evacuation that can lead to incontinence.
Urinary and stool leakage can interfere with sexual
activity and can present a major concern for individuals
with spinal cord injury.29,30 Affected individuals should
be on an evacuation program to achieve predictably
timed bowel and bladder activities with minimal accidents. Some individuals empty their bladder andbowel prior to sexual activity and decrease fluid intake
several hours prior to intimacy. Bladder relaxants canbe prescribed to reduce bladder spasms that cause inconvenient urinary leakage.53 If an indwelling catheter isused for bladder management, it can either be
removed before intercourse or taped to the side in aslack position to allow for penile engorgement.
Alternatively, a condom can be slipped over the penis
and catheter, but continued drainage must be ascertained. Suprapubic catheters are preferable to indwelling
catheters because they cause less urethral trauma, areassociated with better self-image and are conducive tosexual activity requiring less preparation.53 Continent
diversion, a technique used to maintain continence by
diverting urine cutaneously via a bowel segment, hasbeen shown to have a positive impact on body image
and sexual frequency in a small sample of women withtetraplegia.54

Autonomic dysreflexia
Autonomic dysreflexia is an abnormal, unabated sympathetic response to noxious or non-noxious stimuli
below the level of injury in individuals with a spinal
cord injury level at T6 and above.55,56,59 It is considered
a medical emergency because it can lead to severe bloodpressure elevations that can be life threatening.

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Ejaculation is a well-known trigger for this condition,60
but erections and sexual stimulation can also precipitate
autonomic dysreflexia.13,61 Usually the rise in bloodpressure and related symptoms are limited to the stimulus exposure, but malaise and blood pressure variability
may sometimes persist after the stimulus is removed,62
and rarely, protracted, persistent, and debilitating autonomic dysreflexia associated with sexual activity has
been described.60 Some individuals do not experience
any symptoms with autonomic dysreflexia while others
develop vasomotor headaches in the absence of significant blood pressure elevations.63 Therefore, it is advisable to check blood pressure during any symptoms andprior to the initiation of pharmacological intervention.
When autonomic dysreflexia develops, the initialmanagement involves placing the patient in an uprightposition to take advantage of an orthostatic reductionin blood pressure and removing the trigger. As recommended in the Guidelines of the Consortium for
Spinal Cord Medicine for the management of autonomic
dysreflexia,64 pharmacological agents should be used if
systolic blood pressure continues to be at or above
150 mmHg in an adult despite nonpharmacologicalinterventions. In individuals who have blood pressure
elevations beyond sexual activity, other sources ofblood pressure elevation need to be investigated, suchas bladder retention and pressure points.

Hormonal changes
Spinal cord injury results in hormonal changes that canaffect sexual behavior and function in both men andwomen. Women with spinal cord injury often experiencetransient amenorrhea after spinal cord injury lasting 6
months in the majority of cases. Elevated prolactin has
been reported in both sexes and should be suspected inwomen with galactorrhea, or prolonged amenorrhea.
These symptoms can be managed with a short courseof bromocriptine. In most women, other sexual hormones remain in normal ranges and do not correlatewith sexual functioning.
A higher incidence of testosterone deficiency exists inmen with spinal cord injury compared with matched
control subjects.65 Low serum testosterone levels correlate with spinal cord injury severity and length of timesince injury.66–68 In a few small studies, hormone-replacement therapy in men with spinal cord injury has
shown modest results on body composition,69,70 but
the effect on sexual function and libido in this population has not been established. Currently, there is insufficient information to make recommendations regarding
routine hormone replacement in men with spinal cord
injury.

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Positioning
Positioning can be greatly affected by a spinal cord injury
due to spasms, spasticity, contractures, and pain.
Limitation in hip extension, abduction, and externalrotation can adversely affect genital stimulation andcoital penetration.71 If spasticity has not led to permanent,
fixed contractures, antispacticity agents such as baclofen,
tizanidine, or benzodiazepines can be helpful whencoupled with a range-of-motion exercise program.48
When counseling a couple following a spinal cord
injury, special consideration should be given to theeffect positioning may have on the respiratory status
and the musculoskeletal and integumentary system of
the individual with spinal cord injury. The weight ofthe partner can impede chest wall excursion causing respiratory distress and cause limb fractures in severely
osteoporotic or osteopenic limbs. Persistent, unrelievedpressure caused by the combined weight of the couple
against bony prominences can lead to skin damage
and breakdown. Couples can adjust positioning suchthat both partners are either side lying (spooning) or
face to face to maximize pressure distribution and minimize balance problems.72 Pillows or similar supports
can be very useful in lifting the pelvis or sustaining contracted or spastic limbs to allow for physical intimacy.
Proper positioning can be performed by the partner if
hand function is limited, but skin integrity needs to beclosely monitored. Slings that wrap around the neckand keep the thighs in a flexed and abducted position
can be applied, but should not cause increased spasticity
or pressure. If an individual with spinal cord injury
lacks pelvic movement, a side lying position can be conducive to thrusting movement and penetration. If an
individual has good upper extremity and truncal
strength a gliding seat that glides back and forth canalso be considered.
Individuals who lack hand function can be evaluatedfor assistive devices. Individuals with limited grasp may
benefit from the addition of straps to vibrators, whereas
others with minimal or no grasp can be prescribedcustom wrist splints with adaptations to hold vibrators,
dildos, or other devices.45 An ideal candidate is someone
who has good shoulder and elbow range of motion but
lacks intrinsic hand function. Individuals who have nohand function can pleasure their partner through creative means. For example, highlighting the areas withsensation such as the back of the ear and using that sensation for excitement and satisfaction. In men whosesacral spinal cord segments and nerve roots are preserved, vibratory stimulation to the penis can greatly
augment reflexive penile erections. This is particularly
true for men with high complete lesions.

Hess and Hough

Skin wounds and pressure sore
Close monitoring of the skin remains very important,especially if one of the partners is completely insensate.
The skin should be checked after intimacy for redness
and induration. If the individual cannot inspect theirskin with a mirror or video technology, a partner orcare attendant should be instructed in visualizationand palpation of the skin. If an individual applies an
aid such as a vacuum device or a dildo, the skin needs
to be carefully inspected after use for redness or induration. Use of satin sheets and pillows may decrease friction and risk for abrasions.
If a person has a pre-existing ulcer, one must be
careful to avoid positions that would further compromise the ulcer by generating pressure or friction. For
example, persons with trochanteric ulcers should avoid
side lying positions, with ischial ulcer avoid seated positions, and with sacral ulcers avoid supine positions.
Superficial ulcers that may come in contact with thepartner can temporarily be covered with a self-adhesivehydrocolloid dressing.

Emotional adjustment issues
Depression, anxiety, and overall adjustment to spinal
cord injury within the context of one’s personalized
life experience impacts on one’s sense of sexuality withoneself and with others.73,74 Personality traits, personality disorders, and character developed through life
events impact on expression of sexuality and relationships. Grieving and working toward re-establishing
one’s life and self-meaning take center stage during
recovery efforts. The awareness and perception of sexuality may take a seat near the back of the room, butnever really leaves the room. Sexuality rejoins the recovery efforts to varying degrees based on opportunity,
culture, and environmental climate, and individuality.
The readiness for education, assessment, and intervention relies on the status of the medical condition as
well as the individual’s life situation (e.g. married,
single, divorced, significant partner. or partners/
relationships), persona, emotional state of the individual, and the reality of access and opportunity.
Following the spinal cord injury event, there is a shiftof focus from emergency crisis to living life. Moving
across the continuum of healthcare, the life tasks,
demands, and opportunities for quality living becomesa spotlight on how well and how long one can function
at optimal level. Within the larger picture of healthcare
outcome, it is critical how well health providers address
issues relate to the comfort level, potential bias, and preference, resources available, and environmental support
from the organization and community. The focus of

Impact of spinal cord injury on sexuality

sexuality for some may be one of “if it is not broken,
don’t fix it” and “let sleeping dogs lie.” Others see theissue as one of responsibility to address holistic rehabilitation healthcare.
Cultural values, mores, and personal comfort are ashared dynamic within a relationship, applying the individual with injury and the professional helper.75 In
addition to the heightened imitate exposure on both aphysical and emotional level, professional boundaries
may become blurred at times related to normal humanattraction and life circumstance. In instances of discomfort or concern, awareness, self-monitoring, communication, supervision, or consultation, and adherence toprofessional standards and process are critical toensure quality care and safety for both parties.
The individual may have feelings of sexuality thatare activated and find expression within a necessary
environment related to the level of function and ability
such as in a long-term care or residential setting.
Opportunities for email, visits, internet chat, social gatherings, and privacy occasions are critical resources forthe individual to have access for even the basic aspectsof human relationship. However, such resources may
be encumbered related to medical condition and functioning, settings resources, philosophy, and policy. For
individuals living more independent in the community,
readiness, access, and personal choice join forces as is
the standard in life. Productive and enjoyable relationship building can be a challenge for anyone. Here,
there is the additional burden of injury and related
needs. The most important ingredients are self-esteem,
motivation, confidence in oneself, and support. Dating
and social clubs, internet websites, and making oneself
available in order to have an active outgoing life
promote opportunities for contact.
The age at onset of dysfunction and injury, active
developmental themes, culture, sexual life experience,and personal perspective are important considerations
to guide inquiry and intervention. Following injury,
many medications are used to address the difficulties
stemming from spinal cord injury and other medical
conditions. The medication to assist with erectile dysfunction is generally offered or requested by the individual or couple. However, consideration must be given to
the emotional response to medication such as the potentially perceived shift in locus of control from internal toexternal causality. For example, “I am functioning
because of external aids.” Such a response can impact
on self-esteem and feelings of empowerment where
one’s sense of internal drive is given over to a physiological response and away from the heart. There are also theadvance life-functioning activities following injury that

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includes dating, maintaining relationships, developing
new relationships, communication skills, and application for mutual and open dialogue. Education andinformation, counseling, psychotherapy, peer mentorship, and activities that promote socialization may be
helpful to address such concerns.

Conclusion: best clinical practice
The opportunity to further one’s knowledge about sexuality in general may be obtained in books such as the
Guide to getting it on. 76 Resources specific to maximizing ability after injury can be found in books such aspleasureABLE: Sexual Device Manual for Persons with
Disabilities.45 However, we must go beyond the sole
focus of sexual dysfunction, medications, and devices77
such as vacuum constriction device, penile implants,
or prostheses to “fix it.” Staff and organizational sensitivity training, ethics consultation, and development ofappreciation for diversity within the setting may prove
beneficial to broaden rehabilitation focus and address
the clinical needs and utilize resources available.78,79
There remains a need to increase the comfort level ofstaff and trainees in the provision of education during
screening, assessment, intervention, and discussion oftechniques. Applied education with realistic strategicintervention to address sexuality as a relationship with
one’s self and with others is a direction for best clinicalpractice development, deployment of services, efforts tooptimize utilization, and enhancement of rehabilitation
outcome.

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