Vaginal and clitoral function

It is common for people with a vagina to experience changes in sexual function after spinal cord injury (SCI), which can significantly affect emotional wellbeing, body image, relationships, and quality of life. It is important for health professionals to address sexuality proactively, not only fertility, and to create safe, respectful spaces where people feel comfortable discussing their concerns.

Individuals with SCI may experience:

Changes in sexual function

• Reduced genital sensation that can affect sexual arousal and pleasure.
• Reduced vaginal lubrication.
• Reduced clitoral engorgement.
• Pain during sexual activity (dyspareunia).
• Difficulty reaching orgasm or changes in how orgasm is experienced.
• Changes in sexual desire and arousal.
• Risk of autonomic dysreflexia during sexual activity or orgasm, for people with injuries at or above T6.

Genital arousal and vaginal lubrication

SCI can affect how arousal (including vaginal lubrication and clitoral engorgement) occurs in people with a vagina. There are two main types of genital arousal:

Reflex arousal

• Triggered by physical stimulation to genitals (touch)
• More likely in people with injuries at the level of T12 and above (upper motor neuron injuries).

Psychogenic arousal

• Triggered by erotic thoughts or sensory stimuli (such as visual, auditory, or olfactory cues).
• More likely in people with injuries below T12 (lower motor neuron injuries)

Note: The ability to achieve reflex or psychogenic arousal varies depending on individual factors such as the level and completeness of injury, and any other health conditions that affect vascular or neurological function. It is important that individuals discuss their specific circumstances with their healthcare specialist, to explore the most appropriate options for supporting their genital arousal function, vaginal lubrication and overall sexual health.

Health professional role

Here are some practical ways health professionals can support sexual health after SCI:

Encourage self-exploration

• Encourage people with a vagina to self-explore, to identify areas of sensation and pleasure. This builds confidence and supports communication with partners.
• Recommend assessment of light touch and vibration in the perineal area (with consent).
• Encourage experimentation to discover new erogenous zones (e.g. lips, neck, stomach, thighs). Body mapping tools can assist with this.

Provide strategies for increasing lubrication

• Advise that foreplay may help trigger natural lubrication through reflex or psychogenic arousal
• Recommend water-based lubricants, especially if reflex lubrication is impaired or the woman is peri- or post-menopausal.
• Suggest adding water (or saliva) to reduce tackiness.

Offer tools for sexual stimulation

• Vibrators: These tools can assist with clitoral, vaginal, or cervical stimulation.
• Clitoral vacuum pumps: These fit over the clitoris, increasing blood flow to the clitoris, which may improve lubrication and orgasm experience.

While generally considered safe, there are specific precautions that should be taken with use of vibrators or clitoral vacuum pumps due to altered sensation, skin integrity concerns, and potential complications like autonomic dysreflexia.

• Ensure the user can safely position, apply, remove and turn the device on and off. Engage the multi-disciplinary team to assist with adaptations to enable the user to safely hold, position and operate these devices, if required.
• Ideally use devices with adjustable pressure or intensity controls and safety-release mechanisms.
• High-amplitude, high-frequency stimulation should only be trialled in a clinical setting due to its strength and associated risk of autonomic dysreflexia.
• Users should inspect the skin before and after use and avoid use on areas of fragile or broken skin.
• Limit use to short intervals.
• Maintain hygiene, clean the device thoroughly according to manufacture instructions.

Manage pain or spasm during sex

• For painful vaginal spasms that impede the ability to accommodate the penis or other sex aids, suggest non-penetrative sexual activities, anti-spasmodics, or if appropriate, trial vaginal dilators (with relevant precautions).
• Individuals may find that after orgasm, spasms may temporarily subside, making penetrative sex possible.

Adapt positioning and movement

• Individuals may be able to use spasms to assist with positioning.
• Suggest trying different positions to increase comfort and intimacy.
• Provide resources offering suggestions for positioning, such as Sexual Positions for Women with Paralysis: Creativity, Adaptability and Sense of Humour (Regain that feeling) and Sexuality after SCI (SCI BC). Encourage the woman to problem-solve their individual positioning with members of the multi-disciplinary team, where appropriate.
• Provide recommendations for trialling appropriate assistive devices for positioning. Engage the multi-disciplinary team to support goals.

Educate on the risks of autonomic dysreflexia

• Advise individuals at risk of autonomic dysreflexia to stop sexual activity if symptoms arise and seek medical advice if symptoms persist.