Traumatic brain injury (TBI) can substantially alter many areas of a person’s life and there has been little research published regarding sexual functioning in women with TBI.
Sexuality and sexual functioning are important aspects of one’s life experience. Greater sexual dysfunction among women (43%) compared to men (31%) has been reported in the general population [
To date, only five studies have conducted a comparative analysis of sexual functioning between persons with TBI and healthy controls [
One study found that women with TBI, having both an endocrine disorder and depression, were the most sensitive predictors of sexual difficulties [
Despite the importance of sexuality after TBI and the unique issues that women with TBI experience in terms of sexual dysfunction, research efforts have utilized nonequivalent control groups, community-based norms, and nonstandardized measures of sexual functioning, which are methodological limitations in the assessment of sexuality after TBI. Several demographic and injury-related characteristics related to sexuality have been identified in the TBI literature, such as age [
Thirty-nine Spanish-speaking Colombian women with a moderate to severe TBI were identified in July of 2013 through a systematic review of all medical records in Hospital Universitario Hernando Moncaleano Perdomo de Neiva from August 2012 to March 2013. All patients had moderate to severe TBI confirmed in these medical records (loss of consciousness, positive computerized tomography, or magnetic resonance imaging). Inclusion criteria required that each participant be between the ages of 18 and 65, and participants were excluded if they had a history of neurological or psychiatric conditions, alcohol or drug abuse, or learning disabilities. All 39 met these inclusion criteria. Between April and December of 2013, these patients were contacted and invited to participate in the study when at least six months had passed since their injury. Ten women could not be contacted and the other 29 consented and completed the study.
The sample of twenty-nine women with TBI had an average age of 36.41 years (SD = 11.87), the average years of education were 9.41 (SD = 3.35), the mean time since injury was 18.03 months (SD = 10.41), and the mean Glasgow Coma Scale score at the time of admission to the hospital was 8.07 (SD = 3.80). The majority (44%) sustained their TBI in a motorcycle accident, 35% were in cohabiting relationships at the time of participation, 35% were employed full-time, and 97% of the TBI sample were self-identified as heterosexual.
For every female patient who completed the study, a healthy female control matched for age was identified and recruited. All controls approached did not have a history of TBI, neurological or psychiatric conditions, alcohol or drug abuse, or learning disabilities. All consented and completed the study. The healthy control group was comprised of 29 women, with an average age of 36.34 years (SD = 11.97). At the time of study participation, 31% were single and employed full-time, and the majority of controls (97%) were self-identified as heterosexual. There were no statistically significant differences based on age, education, marital status, or employment status between the control group and the TBI group (see Table
Participant demographics.
Variable | TBI group | Control group |
|
---|---|---|---|
( |
( |
||
Age, years, mean (SD) | 36.41 (11.87) | 36.34 (11.97) | NS |
Education, years, mean (SD) |
9.41 (3.35) | 9.45 (3.33) | NS |
Cause of TBI, % | |||
Motorcycle accident | 44.8 | — | |
Interpersonal violence | 13.8 | — | |
Fall | 13.8 | — | |
Sports accident | 10.3 | — | |
Pedestrian accident | 6.9 | — | |
Car accident | 6.9 | — | |
Other | 3.4 | — | |
Relationship status, % | NS | ||
Married | 31.0 | 31.0 | |
Cohabiting | 34.5 | 31.0 | |
Single | 24.1 | 31.0 | |
Separated | 6.9 | 6.9 | |
Widowed | 3.4 | — | |
Sexual orientation, % | NS | ||
Heterosexual | 96.6 | 96.6 | |
Homosexual | 3.4 | 3.4 | |
Employment status, % | NS | ||
Full-time employment | 34.5 | 31.0 | |
Unemployed | 34.5 | 37.9 | |
Student | 6.9 | 10.3 | |
Part-time employment | 6.9 | 6.9 | |
Stay at home parent | 6.9 | 3.4 | |
Other | 10.3 | 6.9 |
The FSFI is a self-report measure of female sexual function, which contains 19 items. It has 6 domains: desire (2 questions), arousal (4 questions), lubrication (4 questions), orgasm (3 questions), satisfaction (3 questions), and pain (3 questions) [
The ISS is a self-report scale that measures the degree of dissatisfaction in the sexual component of a dyadic relationship [
The SQoL has male (SQoL-M) and female (SQoL-F) forms. It evaluates the impact of sexual dysfunction on quality of life, including sexual confidence, emotional well-being, and relationship issues. The SQoL-M has 18 items and the SQoL-F has 18 items, each with a 6-point response scale (“completely agree” to “completely disagree”), and standardized total scores range from 0 to 100. Higher scores indicate better sexual quality of life. It has good psychometric properties [
The SDI-2 is an 11-item self-report measure of sexual desire that assesses dyadic and solitary sexual desire as two subscales [
Local researchers reviewed medical records to identify individuals with TBI who were treated at the Hospital Universitario Hernando Moncaleano Perdomo de Neiva, between October 2012 and June 2013 in Neiva. Each candidate was screened by telephone to determine whether he or she met inclusion or exclusion criteria. The healthy control group was recruited from the general population through flyers at neighborhood churches, stores, and restaurants and by general word of mouth. After the details of the study were explained to each eligible candidate, individuals who expressed interest were invited to participate. Once the individuals with TBI and healthy controls agreed to participate in the study, they were asked to sign a form that indicated their informed consent in accordance with regulations approved by Universidad Surcolombiana, Colombia. All of the participants completed an interview with a graduate student under the supervision of a university professor. The student collected demographic information and conducted a psychosexual evaluation with TBI survivors and the healthy controls. The interviews lasted for approximately 1 hour. This study was reviewed and approved by the ethics committee of Universidad Surcolombiana.
Women with TBI reported significantly lower mean scores than the control group on the FSFI subscales of desire, arousal, lubrication, orgasm, and sexual satisfaction (see Figure
Female Sexual Function Index mean subscale scores.
Participants in the TBI group scored significantly lower on the SQoL and the SDI Dyadic subscale and notably higher than the women in the control group on the ISS. There were no statistically significant between-group differences with Overall SDI and the SDI Individual subscale scores. See Table
Sexuality measure mean scores in the TBI (
TBI group | Control group |
|
|||
---|---|---|---|---|---|
Mean (M) | Standard deviation (SD) | Mean (M) | Standard deviation (SD) | ||
SQoL | 56.54 | 16.56 | 84.64 | 13.00 |
|
SDI |
38.21 | 23.58 | 49.59 | 21.09 |
|
SDI Dyadic |
26.38 | 18.67 | 37.38 | 15.76 |
|
SDI Individual |
4.62 | 7.23 | 2.72 | 5.31 |
|
ISS | 47.44 | 14.75 | 22.61 | 8.96 |
|
Notes:
SQoL: Sexual Quality of Life Questionnaire; SDI: Sexual Desire Index; ISS: Index of Sexual Satisfaction.
Although the sample size for these regressions was limited to the 29 women with TBI in the current sample, multiple regressions with three predictors using this sample approximately meet the conventional guidelines of having 10 participants per predictor variable. Additionally, a power analysis was conducted for a multiple regression with three predictors. With an
The model for the FSFI lubrication subscale was statistically significant (
The third model with the orgasm subscale as the independent variable was statistically significant (
The final model for sexual satisfaction was significant (
Also for the TBI group only, a series of simultaneous multiple regressions were performed in order to investigate the connections from age, months since injury, and TBI severity with sexual desire. The model with Overall SDI score as the dependent variable was statistically significant (
Five multiple regressions were also conducted to assess whether the independent variables of age, months since injury, and initial GCS were associated with the dependent variables of SQOL, FSFI Pain, FSFI Desire, ISS, and SDI Individual scores. None of these models were statistically significant.
The principal objectives of this research were to evaluate the sexual functioning, desire, and satisfaction in women with TBI, as well as compare these areas with a control group. Women with TBI reported sexual difficulties in the six areas of sexual functioning evaluated and fared worse than the control group in eight of eleven sexuality constructs measured.
The mean FSFI score for women with TBI was 15.12, well below the 26.55 cutoff for sexual dysfunction [
The multiple regressions found that age has a negative relationship with both arousal and lubrication in women with TBI; similar results have been found by other authors in population-based studies [
Two measures for sexual satisfaction were utilized, the Female Sexual Functioning Index Satisfaction subscale and the Index of Sexual Satisfaction. For both measures, women with TBI reported significantly lower sexual satisfaction than their counterparts in the control group. This disparity could be related to the difficulties reported with desire, arousal, lubrication, and orgasm. Consistency in orgasm frequency has been found to influence sexual satisfaction in Spanish women without TBI [
Of the two measures used to assess sexual desire, differences between the study groups were found with the FSFI Desire subscale and the Sexual Desire Inventory Dyadic subscale; women with TBI endorsed less desire than participants without. Similar differences were not found in a comparable control group method study [
A limitation of this study is the relatively small sample size; therefore these results should be interpreted with caution. In fact, various effects should be interpreted with caution, due to the fact that familywise error corrections were not used because of the study’s limited sample size. The cross-sectional design of this study is a potential limitation, because the results speak to a specific moment in time. Longitudinal methods would be required to verify whether the sexual difficulties and disparities in sexuality measures between women with TBI and control groups found are maintained over time. Preinjury sexual functioning, desire, and satisfaction were not assessed in this study; therefore, no comparison of the results can occur regarding pre- and postinjury sexuality. The participants of this study were recruited in a specific region of Colombia, where they did not have access to rehabilitation programs, as compared to many other studies [
Sexuality was assessed through self-report measures, and social desirability may play a role in such a sensitive and often stigmatized construct. Similarly, individuals with TBI frequently do not accurately perceive changes in their functioning levels [
The participants with TBI all had moderate to severe TBI according to the GCS. These results cannot be extrapolated to people with mild TBI. GCS scores did not correlate with or predict any other variables. As indicated by Balestreri et al. [
This cross-sectional self-report control group design study gives insight into sexual functioning, desire, and satisfaction in women with TBI. Compared to the control group, women with TBI had reduced sexual desire, arousal, orgasm function, sexual satisfaction, and lubrication. No between-group differences were found with pain during sexual activity or overall sexual desire scores. TBI severity as evaluated by the GCS did not predict any of the variables, while age was negatively associated with arousal, lubrication, orgasm, and sexual satisfaction and months since injury positively influenced the same areas of sexuality. These findings suggest the critical need for sexual rehabilitation interventions for women with TBI.
The authors declare that there is no conflict of interests regarding the publication of this paper.