Advising Patients on Sexual Health, Intimacy Issues After TBI

by U.S. Medicine

August 1, 2011

WASHINGTON — Sexual health and intimacy problems are important issues for those who have sustained a brain injury, and providers need to be able to address the topics with TBI patients, researchers said at the Federal Interagency Conference on Traumatic Brain Injury held in Washington.

“There is no doubt that sexuality is an important topic for people after brain injury,” explains Angelle Sander, PhD, co-director of the Brain Injury Research Center at TIRR Memorial Hermann and assistant professor of physical medicine and rehabilitation at Baylor College of Medicine in Houston.

If providers do not bring the subject up of intimacy, Sander says that patients may not realize that sexual intimacy problems they are experiencing are due to their injuries.

“If they have problems with sexual functioning and they have no idea it is related to the TBI, they are going to attribute it to their relationship or to something within themselves and this causes even more difficulties like emotional problems with depression or marital relationship problems,” she says. 

Sander is an investigator for a multi-center longitudinal study that is seeking to determine the frequency, type and severity of changes in sexual functioning associated with TBI. The researchers expect results of that study will create the largest existing prospective database on sexual functioning after TBI. 

Sexual Health in TBI Patients

The areas of the brain most frequently damaged in TBI are areas critical to sexual function, Sander says. In addition, physical impairments that are common after TBI, such as problems with balance and cognitive impairment difficulties with attention, memory and planning also disrupt sexual behavior. In addition, an often overlooked contributor to sexual problems after TBI is medication side-effects, she adds.

Air Force Col. Michael Jaffee, staff neurologist at Wilford Hall Medical Center who serves as a DoD consultant on TBI and is a former national director of the Defense and Veterans Brain Injury Center, told U.S. Medicine that he suspects sexual dysfunction may in fact be “more common” among TBI patients than is currently understood. “When you look at the medical literature where there have been some smaller sample sizes that have been studied, oftentimes you have problems that are reported in approximately 50% of those smaller samples,” he says.

Jaffee says the military is to emphasize a “holistic, multidisciplinary, comprehensive” treatment for TBI patients, focusing on outcomes and enhancing quality of life for the patients and their families. Sexual function can have an impact on quality of life, and providers should look for opportunities to address these types of issues.

Providers could “benefit from more education,” on these issues he acknowledges, which DoD has taken some steps to provide. About a year ago, the Defense and Veterans Brain Injury Center supported a conference on this topic at WRAMC, “with the hopes of being able to increase awareness further for those providers and identify those areas of research that might be best developed to provide better and more targeted treatment,” he says.

Because  patients may not feel comfortable broaching the topic of sexual health with their doctors, injured servicemembers’ spouses may be more likely to bring it up.

“When you are dealing with a problem like this, it may not be reported or documented unless it is really specifically broached in a sensitive way with the patient,” he said. “There are so many different problems being addressed by the provider and the patient that it is important that there is a good therapeutic rapport that the patient feels comfortable discussing these issues.”

Advising Patients on Sexual Health, Intimacy Issues After TBI Cont.

TBI and the Military

The Uniformed Services University of the Health Sciences’ Center for the Study of Traumatic Stress (CSTS) in Bethesda, MD, is working to improve communication around injuries and has released fact sheets for providers and families on intimacy after physical and invisible injuries.

The educational resources are a part of CSTS’s Courage to Care Courage to Talk campaign. This campaign focuses on facilitating and improving communication about injuries, both with the  healthcare providers and within the family of the injured servicemember. Resources to improve communication on various topics are available to both healthcare providers and families and can be found at http://www.couragetotalk.org.

“There are military unique health issues that we address. We then try to promote awareness of these issues,” says Nancy T. Vineburgh, assistant professor in the USUHS Department of Psychiatry and director of the CSTS Office of Public Education and Preparedness.

Fact sheets on intimacy that are tailored to providers treating injured troops recommend that providers educate themselves about sexuality and disability since doctors, nurses, rehab therapists and behavioral health providers can all play a role in helping patients with this topic. In addition, providers are reminded to ask patients if they have sexual intimacy concerns, since the patient is unlikely to bring it up unless asked.

“Even during an acute hospitalization or in an intensive-care unit, people are wondering as to the future of their marriage, the ability to have children or their future attractiveness. Sometimes patients are uncomfortable bringing up the topic, so healthcare providers may need to start the conversation,” the tip sheet, “Physical Injury and Intimacy: Helping Wounded Warriors and their Loved Ones Manage Relationship Challenges and Changes,” stated.

Providers are also encouraged to share with patients the potential impact of prescribed medications. The fact sheets advise clinicians to explain to patients that certain areas of the brain are important for regulating and controlling many aspects of sexuality and that any slight damage to these areas can affect how sexual urges are expressed and how the sexual organs will work.

“Some people with a TBI seem preoccupied with sex, speak about sex at inappropriate times or demonstrate inappropriate sexual behaviors, often without awareness that they are making others uncomfortable. They may appear to have greater sexual drive than before, but it is more likely that the part of the brain that helps us hold back or inhibit impulses and urges has been damaged,” according to the fact sheet.

The fact sheet further states that patients and spouses should know that, in some cases, TBI  “leads to apathy and passivity, resulting in seemingly less interest or motivation to engage in romantic or sexual activities.”

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