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by Stanley Ducharme, Ph.D.

For men and women with spinal cord injury, difficulties with sexual functioning are often linked to neurological problems. Erectile problems, difficulty in ejaculation, insufficient lubrication for women and an inability to achieve orgasm often are associated with level and completeness of the spinal cord injury. Although neurological issues may in fact be important factors, these may not always be the only reason for poor sexual functioning. The problem may be far less complicated. All too often, fatigue and depression are common causes of sexual distress for both men and women. Yet, we don’t often associate these conditions with sexual health.

Fatigue is probably epidemic among people with spinal cord injury and their partners. Activities of daily living, longer daily schedules, work/school related pressures and family/home obligations take a tremendous amount of time, energy and effort. In addition, societal expectations to postpone or even skip sleep have increased in recent years. As if this were not sufficient, there is also the erroneous belief that we need less sleep as we grow older. As a result, many of us go through our days feeling tired. We never seem to feel fully rested and refreshed.

Many people, especially men, feel that they should be able to function sexually at any time. Many people feel that sexual functioning has little to do with how they are feeling or how tired they are. Nothing could be further from the truth. As we grow older, fatigue becomes an increasingly important issue in how our bodies will function. Over age 30, physiologic, neurological and hormonal deterioration are facts of life. This deterioration tends to increase more rapidly as the individual becomes older. The sexual responses become slower and often require more stimulation than in early life.

Coupled with fatigue, these gradual physical and hormonal declines can push a man or woman with spinal cord injury over the edge in terms of sexual abilities. Fatigue can intensify sexual dysfunction regardless of other etiology. It can exacerbate both the effects of the aging process and the spinal cord injury. Thus, neurological factors can appear more sexually disabling and more pronounced than they actually are. When fatigued, the man who typically can achieve an erection may not be able to do so. The woman who can have multiple orgasms may find it difficult to become aroused. In many ways when fatigued, our sexual abilities become less predictable.

A man or woman who made love twice or three times on a weekend at age 25, may find themselves in a very different situation at age 50. Sometimes, the mental desire may be there, but the body just won’t cooperate. Having sex following dinner and a video on a Friday night may be problematic after a tiring and busy week. Keeping up with a younger partner, trying to meet unrealistic sexual expectations or trying to prolong youth in an unrealistic manner can produce fatigue and sexual frustration. Fatigue such as this is incompatible with good sexual performance.

Depression can be another factor influencing our sexual performance. Although recent studies have shown that depression is no more prevalent in people with SCI than in the general population (1), it can reduce sexual drive and blunt sexual interest. Depression can reduce energy levels and make it more difficult to achieve optimal physical and sexual functioning. Becoming sexually aroused is difficult if the individual is feeling depressed. Fully enjoying sex may be impossible under these conditions.

Further complicating the effects of depression is the fact that many of the newer anti-depressants also have profound side effects that can negatively impact sexual abilities. Commonly used anti-depressants such as Prozac, Zoloft, Wellbutrin, Pacal and others can influence sexual abilities in a number of ways. This family of medications, known also as SSRI’s, can reduce sexual interest, decrease the ability to achieve erections, reduce vaginal lubrication, prohibit male ejaculation and diminish the capacity for orgasm in both men and women. As with fatigue, depression and anti-depressant medications can intensify the neurological disruptions that affect sexual performance.

When fatigue and depression are present, a number of considerations may be worthwhile. Although it may limit spontaneity, enjoy sexual activities when you are well rested and refreshed. Many doctors, in fact, believe that sexual activities in the morning can be more satisfying. Nighttime oxygenation of the genitals and nocturnal erections often mean better sexual functioning earlier in the day. Later in the day, try a short nap before making love. If making love in the evening, try having sex before eating a heavy meal or before drinking alcohol. Maximize the effects of Viagra by taking on an empty stomach when well rested.

Be realistic about your abilities and communicate these to your partner. Even for men, it’s OK not to be in the mood for sex or to realize that you are too tired at the present time. If you are not in the mood for sex don’t try to fake it. Be sensitive, honest and clear about your needs and desires. Communicating these to your partner can reduce performance anxiety and lessen the chance that your sexual encounter will end in disappointment and frustration.

Often fatigue and depression go hand and hand. There is no reason to feel shame or embarrassment if you find yourself depressed. Such feelings are commonplace in today’s society. Untreated, depression however, can be self-defeating and potentially dangerous. Typically, counseling and medications either alone or in combination with one another are the most common and effective treatments of depression. These treatments can significantly improve appetite and sleep, restore energy and ultimately renew sexual interest.

Although anti-depressants medications can affect sexual performance, your medical doctor can suggest changes in medications or dosages to reduce unwanted side effects. For more information on depression and spinal cord injury, the reader is encouraged to check out “Depression: What You Should Know, A Guide for People with Spinal Cord Injury” available through the PVA Consortium for Spinal Cord Medicine at 1-888-860-7244 or by visiting the PVA website at

(1) Titch, Radnitz and Bauman, Depression and Spinal Cord Injury: A Monozygotic Twin Study, Journal of Spinal Cord Medicine, Vol. 22, No. 4, Winter, 1999, 284-287.

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