Factors associated with sexual satisfaction of men with spinal cord injury

Study developed at the Laboratório de Gênero, Sexualidade e Corporeidade (Lagesc) of the Centro de Ciências da Saúde e do Esporte (Cefid) of Universidade do Estado de Santa Catarina (Udesc) – Florianópolis (SC), Brazil. 1Graduate Program in Human Movement Sciences (PPGCMH) of Universidade do Estado de Santa Catarina (Udesc), Florianópolis (SC), Brazil. 2 Graduate Program in Education (PPGE) of Universidade do Estado de Santa Catarina (Udesc), Florianópolis (SC), Brazil. 3 Graduate Program in Physical Education of Universidade Católica de Brasília (UCB), Brasília (DF), Brazil. 4 Capes scholarship student. 35 Factors associated with sexual satisfaction of men with spinal cord injury Fatores associados à satisfação sexual de homens com lesão medular Factores asociados a la satisfacción sexual de hombres con lesión medular Fernando Luiz Cardoso1,2, Isabela Passos Porto1, Helton Pereira De Carvalho1,4, Elisa Pinheiro Ferrari3


INTRODUCTION
Spinal cord injury is responsible for triggering a severe chronic illness and physical disability, implying significant neurological changes [1][2][3] .It is characterized by motor, sensory and neurovegetative disturbances of the body segments located below the injury, compromising superficial and deep sensitivity, motor and autonomic functions [4][5][6] .Its incidence is predominantly in young male adults, and the main etiology is traumatic 69 .
Although some implications of the spinal cord injury, such as physical limitations, are noticeable, their sequelae are not limited to the observable one, which can lead to a decrease in self-esteem, feelings of inadequacy, difficulty in accepting new body image, and sexual alterations, considerable impact in the context of this physical disability [10][11][12][13] .
However, spinal cord injury does not eliminate the sexual context of the affected individual's life and, considering that most of the affected people are young, sexuality has been mentioned as of great importance for the patient, its partner and its relatives, reflecting in an important aspect in the process of physical rehabilitation and social reintegration 14 .
At the same time that Masters and Johnson were researching human sexuality in their functional scope, in an unprecedented way, Bors and Comarr 15 investigated the changes in the sexual function of men with spinal cord injury and, in recent years, the study of sexuality in people with this spinal cord injury has attracted the attention of researchers and health professionals, who have been deprived of the conception of their patients as asexual beings, realizing that sexuality is inherent to the human being and that it is a priority for many of the people affected, attaching importance and studying it with greater determination [16][17][18][19] .
The international literature presents a considerable number of studies emphasizing difficulties and disabilities after spinal cord injury, but the same does not occur with the national literature.Some studies 20,21 began to present possible data on the reality of men and women with spinal cord injury in Brazil, but still without a satisfactory number of participants and also with conclusions that generated more curiosity about the subject.
In addition, studies on the sexuality of people with spinal cord injury focus very much on some aspect of sexuality alone -behavior, desire, response, sexual satisfaction -leaving aside the possibility that these very factors are affecting each other.As well as being affected by social, biological, psychological and physical aspects, such as stability in a relationship, time after injury, frequency with which individuals practice sex, practice of physical activities, age in order to help to understand the factors inherent to sexual satisfaction after spinal cord injury.In this context, the objective of this study was to analyze the factors associated with the level of sexual satisfaction after spinal cord injury.

Participants
This study was conducted based on the database of the research project entitled "Sexuality in Spinal Cord Injury".The study protocol was approved by the Research Ethics Committee (Process No. 023/05).The study population was composed of male spinal cord injured in the city of Florianópolis, SC.
For the selection of the sample, the associations of disabled people were contacted in order to inform them about the subjects' objectives and characteristics for participation in the study.This initial communication with the institutions was necessary for them to assist in the capture process of the subjects, who should present the following inclusion criteria: 1) to have spinal cord injury; 2) to have had any type of sexual activity before spinal cord injury; 3) to have a cognitive preservation; 4) age equal or superior to 18 years.
From this, the coordinator of each institution invited people with spinal cord injury to participate in the study, and sent the contact of the interested ones to the researchers.Recruitment of the sample continued using the "snowball" technique, in which one participant indicated friends and acquaintances to also participate in the study.This technique allowed greater comprehensiveness and increase in the number of subjects.The data collection was developed under three forms of application of the instrument: via e-mail, mail and face-to-face.This technique, also used in different studies 13,22,23,24 , was intended to guarantee that all subjects would receive the same instructions in refers to the completion of the instruments, regardless of the form of application, before each question contained a prior explanation of the concept being investigated and how the respondent should answer the question.

Instruments
Until the development of the research, in the second semester of 2015, standardized and validated questionnaires to evaluate aspects of the sexuality of individuals with spinal cord injury were not evidenced in the national literature.Similarly, studies already performed in Germany 25 and the United States 16 presented the same methodological difficulty regarding standardized and validated questionnaires, and the instruments used were developed by the research institution itself.
Based on these studies, the semi-structured questionnaire used in the present study was composed of three closed and open items that assessed physical activity/sports practice after injury, weekly sexual frequency and sexual satisfaction before and after spinal cord injury.Figure 1 illustrates the instrument used.The practical variable of physical activity was obtained through the question: "Do you practice any sport, do gymnastics or another form of physical exercise?(no, yes occasionally, yes often)".Issues related to sexuality were obtained with reference to two periods, pre and post-injury.
The weekly sexual frequency and sexual satisfaction before and after the spinal cord injury were obtained through the questions, "What is your weekly sexual frequency (≥2 and <2)"; and "How sexually satisfied are you?"Sexual satisfaction was verified by a numerical scale of 11 points (0-10), where zero is "unsatisfied", one to three is "less satisfied," four to six "moderately satisfied" and seven to ten "very satisfied".In order to respond to these types of scales the participants should compare themselves subjectively with the people of their conviviality.For purposes of statistical analysis two categories were considered "unsatisfied" (zero to five points) and "satisfied" (six to ten points).
The sociodemographic variables (age, educational level, biological sex, stable sexual partner, injury characteristics, adapted physical exercise/sport, etc.) were obtained through a self-administered questionnaire.Being categorized as follows: type of injury (quadriplegia and paraplegia); age (≤ 30 years and > 30 years); level of schooling (elementary education, high school and higher education), stable sexual partner (yes and no) and practice of physical exercise/gymnastics/sport (no, yes occasionally, yes often).It was also checked whether or not the participant was a para-athlete.

Statistical analysis
Initially, descriptive analysis was performed using relative and absolute frequencies.Spearman's correlation was used to analyze the magnitude of the association between the independent variables (weekly sexual frequency, age, educational level) and the level of satisfaction after the injury.The Policoric correlation was performed to verify the relationship between the level of satisfaction after the injury and the practice of physical activity, type of injury and stable sexual partner.For the interpretation of the correlation coefficients, the classification was considered as fracture <0.49; moderate 0.50-0.69;strong 0.70-0.89and very strong 0.90-1.00 26.The association between sexual satisfaction and the occurrence of the injury was verified using the Chi-squared test.Statistical analysis was performed using SPSS (Statistical Package for Social Sciences) for Windows version 20.0®, considering a level of significance of 5%.For statistical analysis, statistical software R version 3.3.1 for Windows was used.

RESULTS
80 male medullary injurys, average age 32.2 (± 8.9) years and injury time of 9.2 (± 7.6) years, have participated in this study.Of these, 42.5% had a higher education level, with no stable sexual partner (63.8%), physical activity practitioners (75.0%), spinal cord injured at a time ≤10 years (68.8%) and (56.2%) (Table 1).Graph 1 shows the proportion of satisfied and sexually unsatisfied individuals before and after the occurrence of the spinal cord injury and it is possible to identify that after the injury the prevalence of sexual dissatisfaction (48.8%) was higher than that presented before (15.0%).The data demonstrate a significant difference (p <0.001), in which sexual satisfaction decreases considerably after injury in the participants in this study.The results showed a significant but weak correlation between the level of sexual satisfaction after injury with time of injury, weekly sexual frequency and with stable sexual partners.No significant correlations were found between the level of sexual satisfaction after injury and the level of schooling, age, physical/sports activity and type of injury (Table 2).

DISCUSSION
In general, the present study contributes to the literature by adding body of knowledge to the area of spinal cord injury, demonstrating that the level of sexual satisfaction after injury was associated with longer injury time (adaptation), higher weekly sexual frequency and the maintenance of stable sexual partners.In addition, the occurrence of spinal cord injury interfered with the participants' level of sexual satisfaction.
According to the characterization of the subjects of the present study, 56.2% of the interviewees had paraplegia, however, a considerable prevalence of quadriplegics of 43.8% was noted.According to the literature, the relationship between quadriplegia and paraplegia is similar, although the incidence of paraplegics with complete injury and quadriplegic injurys with incomplete injury is higher 2,6,27 .In relation to age, participants in the current study presented an average of 32,2 years, corroborating with the literature that reports the prevalence of spinal cord dales in young male adults, standing out as the main traumatic etiology 2,10 .
Another important aspect found in this study refers to the high prevalence of physical activity among the injured (60.0%).This data demonstrates that a significant portion of individuals with spinal cord injuries perform some type of physical/sports activity.This fact is justified in the literature, since the advances in medicine occurred in the last decades and the consequent increase in survival of people victims of spinal cord injury were accompanied by an evolution in their treatment that began to aim at minimizing the disabilities and complications and the return to society 28 .In this sense, sports and leisure begin to be part of the medical treatment because they are fundamental in the process of coping with the "disadvantage" of the physically disabled.Sport plays a fundamental role in rehabilitation, as it complements and broadens the alternatives; stimulates and develops physical, psychological and social aspects and favors independence 29,30 .Considering that human sexuality is a multidimensional phenomenon and its self-perception is subjective, it is believed that the socialization offered in the environments of physical and sports practices has a great impact on the self-esteem and sexual and affective self-confidence of the spinal cord injured.This hypothesis was recently confirmed by Porto, Cardoso and Sacomori 24 , when they demonstrated quantitatively better data on sexual rehabilitation in men with spinal cord injury in two conditions: para-athletes and sedentary ones.
Regarding the sexual satisfaction before and after the spinal cord injury, we identified that the sexual satisfaction diminished sensibly after the occurrence of the injury.The Study 16 that compared pre and postinjury periods found that before the injury most men were satisfied or very satisfied with their sex life, while a minority showed sexual indifference or dissatisfaction.After the injury, however, the percentage of satisfied has declined to less than half, while most are indifferent, dissatisfied or very dissatisfied with the sexual scope of their lives 16 .This significant change between the pre-and post-trauma periods is independent of the injury level and time, and is reported by both the injured patients with quadriplegia and paraplegia, both by newly injured individuals and with a long period of injury 16 .
Among the factors associated with sexual satisfaction after spinal cord injury, we highlight the frequency of sexual activity, in which the participants with the highest frequency of sexual relations are more satisfied with their sexuality, while the participants who are not sexually active are dissatisfied with the sexual sphere of their lives.This result corroborates, with Cardoso 3 that in carrying out a study with men, affirms that the impairment of spinal cord injury and the consequent decrease in the frequency of sexual activity and difficulty in the practice of sexual intercourse have contributed to a decrease in sexual satisfaction among its participants, which is based on the capacity to provide sexual satisfaction to the partner, showing self-realization of masculinity.
Satisfaction was correlated with having stable sexual partners, which facilitates access to sex.This result corroborates the results found by Phelps et al. 31 when evaluating people with spinal cord injury and by Michael et al. 32 when analyzing the American population in general, who observed that married or stable-union adults showed sexual differences, including more sexual experiences frequent and satisfactory than in single adults, finding satisfaction with marriage, nonsexual aspects of the relationship, and the frequency of the partner's orgasm, were strongly related to sexual satisfaction.
In addition, injury time was also associated with sexual satisfaction, since it is reduced in the newly injured, but tends to increase with the passage of time, although it does not completely recover.Fisher et al. 11 noted in their longitudinal study that sexual satisfaction decreased considerably shortly after the trauma, reflecting what they called the period of asexuality, followed, however, by increasing and maintaining sexual satisfaction, in which the increase and maintenance of sexual activity during the period in which he followed his participants (immediate post-injury to 18 months).
In one of the few Brazilian studies performed, Alves et al. 20 verified the existence of a relationship between the sexual satisfaction of men with spinal cord injury and the time of rehabilitation, noting that more than half of the participants who declared themselves to be sexually satisfied had already obtained discharge of the rehabilitation service.This study demonstrates that the rehabilitation process assists in the readaptation to sexuality and that participants who are at the beginning of the rehabilitation process do not yet have sexuality as a fundamental concern, and may not have survived after the injury, keeping as a reference the sexual practice prior to injury.With these results it is believed that the presence of a longer injury time and a longer rehabilitation time correlates with an increase in sexual satisfaction after spinal cord injury, since it allows more time for sexual readaptation to its new condition.
In this study, no correlation was found between the level of sexual satisfaction after injury with age, physical activity and type of injury.However, the study by McCabe and Teloporos 12 showed that individuals who engage in some physical activity practice have better body and sexual self-esteem, emphasizing an improvement in sexual life.The high prevalence of physical activity presented by the subjects investigated in this study made them a homogeneous group in relation to this variable, a fact that may justify the lack of association between the variables, physical activity and sexual satisfaction found by the present study.
As methodological limitations, the use of a semistructured instrument through self-reports was collected in three different ways: via e-mail, mail and face-to-face.This limitation is typical for the area studies that address invasive issues of private life and the difficulty of accessing these patients spread throughout the general population after a long process of institutionalized rehabilitation.There are practically no studies in this area that evaluate the sexual function of people with spinal cord injury in a probabilistic way and who use primary or direct measures.As a consequence, sexual function after spinal cord injury, despite arousing great interest among researchers and health professionals, still requires studies such as comparative studies that show the similarities and singularities of the preand post-injury periods.Another limitation is the classification of spinal cord injury.Since this study only classified the individuals according to the level of the injury (paraplegia and quadriplegia).For a more concise analysis it is suggested that the studies use the ASIA (American Spinal Injury Association) scale to obtain information on the neurological and functional classification of spinal cord injuries.It is necessary to carry out comparative studies with people of the objective of establishing a parameter to be used in relation to the results obtained.

CONCLUSION
According to the data of the present study it can be concluded that the occurrence of the spinal cord injury interfered with the level of sexual satisfaction.Although the level of sexual satisfaction after injury was associated with the injury time, that is, a longer time adaptation to the new condition; to a higher weekly sexual frequency that implies greater accessibility to sex and; the maintenance of stable sexual partners that provides greater accessibility to sex.The other variables controlled in this study deserve more studies that evaluate its effects on sexual rehabilitation after spinal cord injury in larger groups and from other regions of Brazil.

Table 1 .
Characterization of the sample referring to sociodemographic, sexual and spinal cord injury variables in Florianópolis, Brazil, 2009