How to Address Your Sexuality, Sexual Function, and Fertility
AFter My Injury, the changes to my body image and my sense of sexuality were among the most difficult to accept. I had always taken good care of my body. I had been comfortable with my sexuality, confident in my interactions with the world and with my wife. But after my injury, the changes to my abilities as a sexual partner were emotionally and psychologically devastating. Thankfully, my rehabilitation team began addressing my sexual function on my very first day. I guess that’s a pretty good indication of how important it is in the eyes of medical experts.
Physical intimacy is an essential part of life for most people. Sexual contact nourishes your mental, physical, and emotional health. Intimacy requires mutual vulnerability, which helps you grow as an individual and as a partner. The way I see it, physical intimacy is an emotional nutrient, absolutely essential to the viability of a long-lasting loving partnership. Physical intimacy is also important even if you’re not in a permanent relationship; it can enhance your self-image as well as your physical and emotional well-being. I’m not alone in that perspective; according to many experts, close relationships are essential for our mental and physical health, and sexual satisfaction is key to relationship satisfaction.1
In my years of interacting with other people with ANIs, I’ve consistently found one of their earliest concerns to be the dramatic change to their sexual function. This isn’t surprising, because it’s a natural human desire to bond with others through physical intimacy. Your sexuality includes how you think about yourself, the desires that influence your sexual orientation, and how you express your sexuality—the way you connect emotionally with someone and how you translate that emotion into physical actions.
Sexuality also encompasses your thoughts about your body image, your sense of how attractive you are, your self-esteem, and your ease in social settings. If, after your injury, you view yourself as unattractive, unable to perform intercourse, and unable to make your partner happy, you may feel inadequate, unworthy, and burdensome to your partner. Inevitably, this creates a negative emotional state that can impair your recovery and can damage—perhaps irrevocably—your relationship. If this applies to your state of mind, please know that there are many ways to address these feelings, and knowledgeable clinicians who can help. As someone who was nearly completely paralyzed, I can assure you there is a way back to enjoying physical intimacy and sex.
While there may be obvious visible changes in what you see when you look in the mirror, more important is how you feel about your body. To become a sexual human being again after your injury, think about what you value in yourself and others. Perhaps the most critical step is to take a look at your self-esteem. It’s natural to have low self-esteem when you’re not able to do things for yourself. Becoming comfortable with being dependent on others and learning how to ask for help takes time, openness, and humility. Working on your self-esteem will help you to gain control over your life again and allow you to begin to feel better about who you are—including who you are sexually.
As you recover, you’ll discover your physical abilities to perform in a sexual encounter. The first questions you’ll need to ask are: Can I have an orgasm, and will I be able to go through the physical aspects of arousal (engorgement of the penis or clitoris) and the physical movements required for intercourse and orgasm? You can learn about your sexual ability through masturbation, assuming that your upper extremity function allows for it. You may also find creative ways to stimulate your body, even if your function is compromised. The brain is the largest sex organ; your ability to have an orgasm is determined more by what’s in your head than what’s in your genital area. Though an orgasm is usually associated with a physical sensation, you can experience feelings of intense pleasure without the same physical manifestations. You can develop new pathways to orgasm—by letting yourself be open to them (see page 107). And, of course, there are several drugs and devices that can facilitate the physical components of sex (see pages 112 and 114).
There are ups and downs in every long-term relationship. The state of your partnership at the time of your injury is likely to carry over to your hospitalization and rehabilitation. If your relationship is already struggling, it may not be able to survive your injury. Even if your relationship is strong, it may be rocked to its core. But if you’re able to achieve mutually satisfying physical intimacy, it can be one of the lifelines that pulls you—as individuals and as a couple—through this trauma.
Achieving new ways to find sexual satisfaction together will take work, honesty, a sense of humor, and a willingness to be vulnerable. It’s not easy, but if you try, you may be able to strengthen your relationship and, in turn, your own recovery. I know several couples who have survived the aftermath of one partner’s injury intact and now have wonderful relationships. And many people are able to find partners after their injury as well.
The process of dating can be hard work and may not be much fun. This is especially true if you use a wheelchair, because all of the usual dating routines—going out to dinner, attending concerts or plays, and even visiting your partner’s home—will be changed, especially if these places aren’t wheelchair-accessible. Even if you’re not in a wheelchair, the changes in your behavior, self-esteem, and your physical limitations may make your dating life unusual. For example, I have a good friend who needs someone to drive him around. With some regularity, the driver participates in the conversations between him and his date, which can make things awkward.
Dating After an ANI
When I decided to start dating again after my divorce, I asked my married friends to invite a single friend of theirs to join us all for dinner. My hope was that the familiarity of being among friends would lessen the tension of a first date. It did. But it was a painfully slow strategy, because my friends didn’t like being my matchmaker. Even worse, they really didn’t know what kind of person I was looking for—probably because I had no idea myself. After being in one relationship for thirty years, I had no idea how to date, especially not with my new physical limitations. After three such “dates,” I realized I was doomed to another ninety-seven bad experiences (I had promised myself that I would go on a maximum of one hundred dates).
The two other options I had were to ask someone out on a date myself or to try an online dating service. I had accumulated a few names since my divorce, so I called one of them—Dr. Coral Surgeon—to see if she was willing to go on a date, and she said yes. We agreed to double-date with a couple with whom we were both very friendly, but unfortunately, that date never happened, because the other couple had a family emergency. Though we were both nervous to get together alone, we ultimately decided that we had nothing to lose. When we went to dinner, we discovered that we had much in common—to start, we both liked red wine, fish, and rum raisin ice cream. We also found, over time, that we shared similar values, such as love of family, hard work, caring for those in need, participating actively in our community, and a love of the arts (especially dance and painting). Most important, we could talk about any topic, however personal or difficult, with relative ease. This ability to communicate openly, and not avoid issues has paved the way to a successful marriage and has enabled us to enjoy a vibrant and loving relationship for the past eight years.
In speaking with friends since then, I’ve learned that online dating is often a much better option for most people. It will certainly give you a much larger number of people to choose from. There are “general” dating apps and websites, and there are specialized websites for people with particular interests. Several focus on people in wheelchairs and other disabilities. Make sure that your profile mentions that you are disabled and use a wheelchair or a walker; being honest will start the date in the right direction.
Before venturing into the dating world, it may help to reevaluate. Looking good and feeling good about yourself are certainly good places to start. Develop your own style, one that fits your new status in a wheelchair (if you use one), by purchasing new, wheelchair-appropriate attire or altering your existing clothes (more on this on page 214). For example, I stopped wearing regular overcoats and had a tailor modify my overcoats to become capes. At one point, I thought, Just add a cap and you could look like Sherlock Holmes! If you believe in who you are, it’s easy to be attractive to others. And being outgoing and friendly will help you find success dating. Be the person who starts conversations. Get out and do activities that bring you in contact with people who share your interests.
One of the most important components of satisfying physical intimacy is the ability of both partners to engage in open, honest discussions about it. After your injury, that ability becomes even more important, as the physical, emotional, and practical issues of physical intimacy are now different—and, usually, more difficult.
Yet, survey after survey confirms that most sexually active people are uncomfortable talking about sex with their partners (and their doctors).2 Specifically, survey participants said they felt more anxious prior to discussing a sexual conflict than a nonsexual one. After your injury, that kind of attitude won’t help you, which is why I strongly encourage you and your partner to read this chapter together, aloud. This will make having conversations about sex and physical intimacy easier; it doesn’t take long for the uncomfortableness to fade away once you begin.
There are four important points to keep in mind as you begin addressing physical intimacy with your partner. But first, let’s be clear that physical intimacy and sex are not limited to intercourse; that little three-letter word covers a vast expanse of human behaviors.
1. Honest communication is essential. Talking openly with your partner about every aspect of physical intimacy (sexual needs, likes and dislikes, and more) is essential. Good communication is not only expressing your needs but learning how to deliver the message so your partner does not feel burdened, hurt, or misunderstood. This conversation takes two, and needs to be ongoing.
2. Preservation of pre-injury roles matters greatly to your relationship’s viability. As much as possible, your partner should maintain their role in your relationship from before your injury. That’s one of many reasons it’s important to accept offers of help from family, friends, and neighbors to assist with the multitude of mundane activities of daily living (shopping, errands, appointments, and so on) that can overwhelm your partner. It’s difficult to hold on to the romantic and sexual part of your pre-injury life if your partner has become your live-in nurse, therapist, home health aide, and medical liaison.
3. Romance sets the stage for sexual intimacy. It’s been said that “foreplay begins at the breakfast table.” How you treat each other from the time the day begins—the respect, affection, and interest you demonstrate—colors the rest of the day, including the possibility of any sexual interlude. Early in a relationship, romance is a given; over time, many couples seem to forget about it. After an ANI, romance is more important than ever to your relationship, which is, in many ways, a brand-new one. It doesn’t take much effort and doesn’t even have to cost money; it just needs to be genuine. Even something small, like leaving a love note on the kitchen table, can be deeply meaningful.
4. Being open to exploring new ways of achieving sexual satisfaction is crucial to your sexual ability and function. After your injury, don’t be reluctant to explore physical intimacy beyond the framework of your pre-injury love life. If none of your doctors or therapists mention it, ask about videos that you and your partner can watch to learn how to be intimate within the restrictions of your injury (these do exist; at my rehab facility, one of my providers gave my wife and me a three-hour-long film to watch. The actors were real couples dealing with ANI limitations). You’ll also learn that you can achieve physical pleasure from sensory inputs and sensations that you would not have thought were part of the sexual experience.
There is a recurring theme in the four points outlined above, and that is the ability to be vulnerable. Please keep that in mind; it’s the cornerstone of long-lasting relationships. Real physical intimacy springs from an emotional connection, not merely a physical attraction, and the foundation of that emotional connection is set in place when you allow your vulnerabilities to be seen. Having a deep sense of trust in your partner will allow you the freedom to be vulnerable, which is essential for mutually satisfying sex.
You may not realize it at first, but maintaining physical intimacy with your partner is a profoundly important aspect of your rehabilitation and recovery. So, while there are challenges to overcome, both physically and emotionally, the good news is that there are many treatments for physical sexual enjoyment, including drugs, devices, and surgical procedures that take advantage of existing healthy nerves to enable arousal and physical intimacy. We’ll explore these more on pages 112 and 114.
Having an ANI does not affect sexual anatomy, but it can cause sexual dysfunction due to problems with motor and sensory function and your body’s arousal responses. Renowned sex therapists Masters and Johnson characterized the sexual response with two physiological responses (a systemic increase in blood flow to certain parts of the body and increases in muscle tension), and four successive stages: excitement, plateau, orgasm, and resolution, as detailed in their 1966 book Human Sexual Response.2 After an ANI, there can be changes in how you experience one or more of the four phases that will prevent the next phase from occurring.3 For some, the phase of excitement (arousal) is markedly decreased due to impaired sensation of the erogenous zones and/or impaired ability of the brain to recognize these sensations due to damage from stroke or TBI.
Sexual arousal includes an increase in heart rate, blood pressure, and breathing, and can include an increase in blood flow to the genitals to prepare your body for sex. For people with vaginas, arousal includes an increase in vaginal lubrication. For people with penises, arousal is signaled by an erection. Arousal happens through two pathways: physical and mental. The reflex pathway (physical) is part of arousal when you are stimulated by sensual touching. Psychogenic arousal (mental) occurs when sensory input alone (seeing, hearing, smelling, or imagining something pleasing to you) turns you on. The brain sends a message via the spinal cord that stimulates vaginal lubrication or develops and maintains an erection.
The brain is the most essential part of sexual arousal. It’s responsible for the coordination of the physical response and is considered the “seat of the orgasm.” Because orgasm is the desired culmination of sexual arousal for many people, it’s the phase that ANI survivors are most concerned about. It’s estimated that 50 to 75 percent of people with penises and 50 percent of people with vaginas recover sufficient function to experience orgasm after injury. The orgasm is usually less intense, however, and takes longer to achieve. Although the exact mechanism is unknown, this is likely due to diminished nerve function secondary to damage to the spinal cord and/or the brain.
Sexual Function in Different ANIs
After your injury, you may experience a change in body image, concern about your attractiveness, fear that you will not be able to have intercourse, and worry about the obstacles imposed by your motor deficits (for example, being unable to support yourself in the “top” position).
After SCI, loss of muscle movement, sense of touch, and sexual reflexes is common. The effects on the four stages of the sexual intimacy cycle depend on your level of injury and whether your injury is complete or incomplete. After stroke, the loss of function is usually on one side of the body, leaving the other side intact and able to sense and move normally; the imbalance created, though, can make many movements difficult, especially if you are elderly or have other musculoskeletal problems. After TBI, loss of sensory sharpness and chronic dizziness can present problems; but perhaps more difficult are the behavioral changes that disrupt your ability to engage in social interactions or that derail the phases of the sexual cycle. After TBI and stroke, the nerves to the penis and clitoris are usually preserved, but the ability of the brain to receive sensory feedback and to respond with arousal may be significantly impaired.
Whatever your injury may be, there are a multitude of psychological and physical treatments that can help you maintain your sexual identity and achieve fulfilling sexual experiences.
After your injury, you may experience loss of sensation in the sexual organs that are most sensitive to stimulation—the penis and the clitoris. Both of these organs send and receive sensory and motor information through the nerve roots at the very end of the spinal cord (sacral levels S2–S4). Therefore, if you have spinal cord dysfunction above S2, you probably won’t have normal sensation and motor sexual function. There is good news for everyone with ANI: Other areas of your body can be stimulated to provide a sensation that the brain can interpret as sexual. To find these areas, you and your partner should explore and locate your erogenous zones. Some of these are likely to be traditionally sensual areas, such as your nipples, lips, ears, neck, and genital area all the way to mid-thigh. But you may discover entirely new areas that you wouldn’t have expected to be pleasurable. People with stroke and TBI are likely to have normal sensation, but the perception by your brain may be decreased, causing difficulty with arousal. Because vision is intact in most people with ANI, watching sexually explicit videos can help to “get going.” In addition, stimulation of the penis and clitoris can be performed with aids such as vibrators and vacuum pumps.
Practice makes perfect. Repetitive stimulation of your newfound sensual areas will increase the sensation that your brain experiences. This phenomenon—when a nonerogenous zone acquires erogenous characteristics if it is repetitively stimulated during physical intimacy—is another example of neuroplasticity (see chapter 3). Your brain adapts to replace sensual feelings from your penis or clitoris to these new areas.
The nerves that exit the spine at S2, S3, and S4, which are necessary for many sexual responses, are also involved in emptying your bowel and bladder. As a result, it’s possible for you to have a bowel or bladder “accident” during sexual intimacy, so it’s important that you maintain a bowel program (more on this on page 148) and empty your bladder before you begin sexual activity.
Because sexual activity involves rubbing, touching, and squeezing, it’s easy to damage skin in areas lacking sensation. As a result, bruising and abrasion of the penis or vulva can occur, especially if lubrication is inadequate. Therefore, lubricants should be used on the genitals prior to sex, if necessary, and both partners should examine their skin after intercourse to be sure that there are no problems. Being aware of potential skin issues is important for a pleasurable and regular sexual experience.
If you have spasticity, you know that certain positions and activities can increase the intensity of the muscle contractions. What you might not know is that the medications that help decrease spasticity may also diminish your sexual drive and your ability to achieve and maintain an erection. This is especially true if you are on multiple medications for spasticity. You may also find that you can actually use spasticity to enhance your sexual experience. While spasticity might give you greater strength and enable you to engage in sexual activity for longer periods of time, it alters everyone’s sexual response differently.
You may have noticed that some of your medicines decrease your sexual desire. This is especially true if you are taking more than one medicine that has side effects. After you get home from the hospital and develop a routine, if you notice that your sex drive is greatly diminished, have a conversation with your doctor about your medications. The medications known to affect sexual interest and function include anti-spasticity drugs, some high blood pressure medications (especially thiazide diuretics), a number of heart medicines, and antidepressants.
Autonomic Dysreflexia in Spinal Cord Injury
If your SCI is at T6 or higher, you are at risk for developing autonomic dysreflexia (AD), a condition in which your “involuntary” autonomic nervous system overreacts to external stimuli. AD is characterized by increased blood pressure, increased heart rate, and blurred vision.4 The nervous system of people with AD overresponds to stimulation that doesn’t bother healthy people. This reaction causes a dangerous spike in blood pressure with any type of stimulation below your level of injury. For example, having your nipples stimulated (nerve roots come from T5 and T6) if your injury is at C6–7 (see Figure 2) may cause you to experience AD.
If you experience symptoms of AD, stop sexual activity immediately and wait until the symptoms go away. You can then resume sexual activity, but try a different position. Should the AD recur, speak with your doctor, who may be able to prescribe a medication to decrease the symptoms.
Erectile Dysfunction (ED) is the inability to get and maintain a firm enough erection for intercourse. Erections are caused by the combination of physical stimulation (reflexogenic) and mental imagery (psychogenic). After ANI, the nerve pathways to and from the brain, as well as the brain itself, may be completely or partially damaged. After SCI, when the injury blocks messages in the brain from reaching their intended destination (T10 through L2 nerves), there will be decreased psychogenic stimulation of erections. Loss of nerve function of S2–S4 will prevent reflexogenic erections. If you’ve suffered a stroke, you may experience ED as a result of hypertension. Hypertension limits small blood vessels’ vasodilation (increase in diameter), which is necessary for an erection. Plus, several hypertension medications also cause ED. After TBI, it is difficult to predict how your injury may affect your ability to maintain an erection, since parts of the brain necessary for psychogenic stimulation of erection may be damaged or dysfunctional.
• Treatment: There are many treatments available for ED. Some are as simple as a pill—e.g., Viagra (sildenafil)—that you take prior to intercourse, while others involve devices. You can determine the best treatment options for you by discussing them with your urologist. Insurance usually covers these treatments; your doctor’s office can confirm this for you.
Oral medications for ED include Viagra (sildenafil), Cialis (tadalafil), and Levitra (vardenafil), which are available as pills. Viagra is taken thirty to sixty minutes before engaging in sexual activity, while the others can be taken daily. They all are about 75 percent effective.5 The major side effect is lowered blood pressure, which decreases the engorgement of blood vessels in the penis. The systemic low blood pressure may make you feel dizzy and uncomfortable. If your ED is a result of low libido, your doctor may prescribe testosterone—but the relationship to CVD is complex. Specifically, persons with low testosterone who replace it to normal levels have less CVD. In contrast, people who take it to high levels have an increase in stroke. Therefore, you need an honest conversation with your doctor regarding benefits and risks.6 If an oral medication does not enable you to maintain an erection, you should consult with your urologist regarding the options discussed below.
Urethral suppositories are the next drug of choice after oral medication. Alprostadil, which is identical to prostaglandin E1, a substance that occurs naturally in the penis, increases blood flow into the penis, resulting in an erection. It comes as a suppository that is pushed into the tip of the penis, or as a liquid that is injected into the base of the penis.
Other injectable medications include mixtures of drugs that are more potent than alprostadil alone. When injected into the base of the penis, these medications open blood vessels and cause blood to remain in the penis. The most common drugs are papavarine, phentolamine, and alprostadil. Your urologist will prescribe the proper dose of each and the amount to administer. The goal is to give you an erection that lasts between two and four hours. If the erection is poor or short-lasting, you may need to inject more of the drug. Be aware of a potential complication called priapism, which occurs when the blood does not drain from the penis. This results in an erection that lasts longer than four hours, which can cause permanent damage to the penis. Priapism is considered a medical emergency and requires immediate treatment.
Tension rings are a good choice if you are able to get an erection but unable to maintain it. They’re made of rubber or silicone and are placed around the base of the penis, trapping blood in the penis and allowing it to stay erect. They should only be left in place for 30 minutes, because if they are left on too long, they can cause bruising and skin damage.
Vacuum devices, plastic cylinders that are placed over the penis, can be used if you are unable to get an erection and maintain it. The cylinder is attached to a pump that creates a vacuum, which draws blood into the penis, resulting in an erection. You can then place a tension ring at the base of the penis to maintain the erection.
Surgical implants entail the insertion of either flexible rods or inflatable tubes into the penis. This treatment should be a last resort because it has a 10 percent risk of serious complications, most commonly breaking through the skin. Satisfaction among those who use them is high, but if they ever need to be removed, other methods like injections and vacuum devices can’t be used due to tissue damage.
Decreased libido. Similar to people with penises, people with vaginas may experience decreased libido or a decreased sexual response. Decreased libido can be caused by antidepressants, such as SSRIs. Testosterone has been shown to increase libido at doses that do not cause changes in the body (such as a deeper voice; more hair, especially on your face; and acne). It should be noted that testosterone has not been approved by the FDA for this purpose. Therefore, you will need to discuss this option with your doctor; if you get a prescription, you will have to have it filled at a special pharmacy.
Vaginal dryness is a problem for many after ANI. During sexual activity, the vagina naturally produces lubrication that helps facilitate sexual activity. For this to happen, both reflexogenic (physical) and psychogenic (mental) stimulation must occur—similar to the process for penile erection. There are a large number of over-the-counter lubricants that can be used prior to and during sexual intercourse; ask your doctor for recommendations. In addition, there are a number of physical stimuli that you and your partner can perform to increase vaginal lubrication, such as oral sex, manual stimulation, and stimulation of other parts of the body such as nipples, ears, and neck. Vaginal dryness can also be treated with a topical or vaginal estrogen cream or patch that stimulates the glands in the vagina to secrete lubricants. Consult with your gynecologist regarding the best approach for you.
The fertility rate after ANI varies significantly depending on your age and the severity of your injury. The two major issues are sperm viability and sperm count. The first step in determining your fertility is to see if you can ejaculate on your own. If you’re unable to ejaculate or do not have enough viable sperm (determined by a sperm test), the usual treatment is penile vibratory stimulation (PVS) and in vitro fertilization (IVF). PVS involves applying a high-speed vibrator to the head of the penis to trigger ejaculation. The efficacy of PVS to obtain sufficient numbers of viable sperm ranges widely, from 15 to 88 percent, depending on age and severity of injury. If having a family is a priority for you, ask your doctor for a referral to a fertility specialist.
Unless you’ve experienced trauma to your reproductive organs, you will typically maintain fertility after your injury. Immediately after injury, you may experience a temporary interruption of your menstrual cycle, which can last up to six months. Once your menstrual cycle resumes, you’ll likely be able to become pregnant. If you have difficulty becoming pregnant, you should see your obstetrician, who may refer you to a fertility expert for evaluation and treatment. Other problems that can affect fertility are autonomic dysreflexia (dangerous spike in blood pressure) in SCI, and pituitary hormone insufficiency after TBI, which can affect sexual function, menstruation, and fertility. Should you decide to have a child, discuss with your doctor how pregnancy may affect your injury and your overall health, and if you have the ability to carry a child for nine months.
Here are some of the major issues to consider:
1. Is it likely that pregnancy will increase your disability?
2. What should you do to prepare for changes like swelling of your feet and legs (edema), morning sickness (which may be worse than usual, because of slow stomach emptying due to autonomic nervous system dysfunction), constipation, and urinary tract infections?
3. Will your medications be harmful to your baby? If, for example, you are taking blood thinners for a history of blood clots or cardiovascular disease, it may be necessary to switch to a safer substitute during your pregnancy.
4. Will you need to take medicine for any other health problems? For example, if you have asthma, depression, diabetes, epilepsy, or high blood pressure, you may need to take medications (or change the dose of current drugs) to stay healthy during pregnancy. Your doctor can help you weigh the risks and benefits of each medicine and determine the safest treatment for you and your baby.
5. What over-the-counter medications are safe to take during pregnancy? Be careful and ask your obstetrician. For example, supplements like feverfew, ginseng, kava, licorice, sage, St. John’s wort, senna, white peony, and large doses of vitamin A may cause harm to the developing baby.
These last four chapters have focused on regaining your health, both mentally and physically. While many of the suggested therapies do not require drugs or devices, an equal number involve medications. Unfortunately, medications come with side effects, and the more you take, the more likely that two or more will interact to cause harmful side effects. Therefore, many people look for ways to heal themselves in other ways. In the next chapter, you’ll learn about some different approaches derived from traditional Eastern medicine.
Physical intimacy is an emotional nutrient, absolutely essential to the viability of a long-term loving partnership. After your injury, your ability for sexual relations with your partner may change a little or a lot. The bedrock of a satisfying, genuine, and long-lasting physically intimate relationship is open, honest, and respectful communication. Here’s what you and your partner need to know:
1. It’s necessary to talk to each other about sex, and to be aware that it is not going to be a one-time conversation.
2. Romance is vital to build and maintain an authentic and satisfying lifelong physical and sexual intimacy with your partner.
3. Your partner should try to maintain their pre-injury role in the relationship as much as possible. Becoming the default full-time caregiver can damage your relationship.
4. Be creative in your exploration of the new boundaries of your sexual abilities and needs.
5. Remember that your biggest, most powerful sexual organ is your brain.
6. Your libido may decrease due to brain damage. Because of decreased sensation in motor innervation, you may experience erectile or clitoral dysfunction. For people with vaginas, decreased vaginal lubrication may require the use of lubricants.
7. Fertility may become a problem because of hormonal, sensory, motor, and autonomic nervous system dysfunction. See a fertility expert if this applies to you.