Sex Disabil

DOI 10.1007/s11195-017-9493-9

ORIGINAL PAPER

Sexual Function in Men with Traumatic Brain Injury

Jenna Strizzi1 • Laiene Olabarrieta-Landa2 • Silvia Leonor Olivera3 •

Edgar Ricardo Tagarife Valdivia4 • Ivan Andres Rodriguez Soto3 •

Inmaculada Fernández Agis5,6,7 • Juan Carlos Arango-Lasprilla8,9

Ó Springer Science+Business Media, LLC 2017

Abstract Traumatic brain injury has been linked with higher incidence of sexual prob-
lems. As there have been few published reports regarding sexual functioning in men with
traumatic brain injury in Latin America, this study sought to compare sexual measures in
men with traumatic brain injury with healthy controls. The hypotheses that males with TBI
would experience significantly lower indices of sexual functioning compared to unaffected
individuals and that increased age and injury severity would predict lower sexual func-
tioning among participants with TBI were tested. Seventy-one Spanish-speaking Colom-
bian men with a history of moderate to severe TBI who were at least 6 months post-injury,
and 71 healthy controls participated by completing the Sexual Desire Inventory, Interna-
tional Index of Erectile Function, Index of Premature Ejaculation, Sexual Quality of Life
Questionnaire, Index of Sexual Satisfaction. SPSS 22 was used to analyze the results.
When compared to matched controls, males with TBI had significantly lower overall and

& Juan Carlos Arango-Lasprilla

jcalasprilla@gmail.com;
http://www.biocruces.com/web/biocruces/bc5.12
1
Department of Psychology, Roger Williams University, Bristol, RI, USA
2
Psychology and Education Faculty, University of Deusto, Bilbao, Spain
3
Fundación Neuroconnectus, Neiva, Colombia
4
Instituto Vocacional Enrique Diaz de León, Guadalajara, Mexico
5
Autonomous University of Chile, Santiago, Chile
6
Center for Neuropsychological Evaluation and Rehabilitation Research Center of the University of
Almeria, Almeria, Spain
7
Department of Psychology, University of Almeria, Almeria, Spain
8
IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
9
BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain

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dyadic sexual desire, sexual satisfaction and sexual quality of life. Erectile functioning,
ejaculation control, satisfaction with ejaculation control were reported to by lower in the
TBI group than in the control group. Almost 44% of participants with TBI had moderate to
severe erectile dysfunction, whereas nearly 10% of the control group had the same.

Keywords Traumatic brain injury
Sexual functioning
Erectile function
Sexual

satisfaction
Colombia

Introduction

Traumatic brain injury (TBI) is a significant health problem worldwide [1], with leading
causes attributed to consequences of traffic accidents and violence [2]. Regardless of the
cause of brain trauma, the event creates a profound impact on the individual, and often
leaves lasting ramifications which affect their everyday functioning. The wide range of
impairment after TBI has lasting effects on an individual’s sexual functioning [3]. Sexu-
ality encompasses physical, emotional, and psychosocial dimensions of behavior and
personality [4], and is a vital part of the human experience [5]. Some of the most frequently
reported problems after TBI in men are decreased desire [6] and frequency of sexual
activity, difficulty with ejaculation [7], and erectile dysfunction [8, 9]. However, the
percentage of individuals with TBI who report problems with sexual functioning ranges
from 14 to 93% in various published studies, owing primarily to different methodologies
and inherent limitations of research design [10]. Additionally, the vast majority of pub-
lished studies on the topic have been conducted in the developed, Western countries (e.g.,
Australia, the United States, etc.), and very few studies currently in the literature have
explored the issues of sexual functioning after TBI in developing countries, particularly
those in Latin America.
In recent years an increasing number of scientific studies have explored various aspects
of functioning after TBI across countries in Latin America [11, 12], a global region where a
substantial proportion of the population lives below the poverty line [13] and which tends
to have fewer follow-up and rehabilitation services for patients and their families [14]. In
one of the first papers on sexual functioning following TBI in Latin America, Strizzi et al.
[15] reported that a sample of female survivors indicated significantly lower indices of
sexual satisfaction, desire, arousal, and sexual quality of life compared to healthy controls.
However, studies addressing issues of sexuality in male patients with TBI from Latin
America are still lacking.
Therefore, the purpose of the current study was to investigate aspects of sexuality
functioning, including sexual desire, satisfaction, quality of life, as well as erectile and
ejaculatory functioning, in males who experienced a TBI in Colombia. An additional
aim of the study was to compare the indices of functioning on these domains between
the sample of males with TBI and a group of sociodemographically matched healthy
controls. The hypothesis that males with TBI would experience significantly lower
indices of sexual functioning compared to unaffected individuals was tested. Finally, the
study aimed to investigate the relationship between the age and injury severity char-
acteristics of the patients with TBI, and their reported indices of sexual functioning.
Greater age and higher injury severity were hypothesized to significantly predict lower
sexual functioning.

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Materials and Methods

Participants

Seventy-one Spanish-speaking Colombian men with a history of moderate to severe TBI

who were at least 6 months post-injury, and 71 healthy controls were recruited for par-
ticipation in the present study. TBI was confirmed through patients’ medical records (loss
of consciousness, positive computed tomography, or magnetic resonance imaging find-
ings). 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 con-
ditions, alcohol or drug abuse, or learning disabilities.
Participants with TBI had an average age of 34.35 (SD = 11.05) and had had a TBI
event on average 21.87 months prior to the study (SD = 16.95, Mdn = 16.00, range
6–96 months). The average Glasgow Coma Scale (GCS) score at the time of hospital-
ization was 9.52 (SD = 3.34, Mdn = 10.00, range 1–14). Motorcycle accidents caused
more than half of the brain injuries; 42% were single and 52% are unemployed at the time
of participation.
The 71 healthy control participants had an average age of 34.87 (SD = 11.35). There
were no statistically significant differences as to socio-demographic variables between the
control group and the TBI group other than employment status (Table 1).

Measures

Sexual Desire Inventory (SDI-2)

The SDI-2 is an 11-item bi-dimensional self-report measure which assesses two types of
sexual desire: dyadic (interest in sexual behavior with a partner; items 1–8) and solitary
(interest in sexual behavior by oneself; items 10–12) [16]. Participants rate how strong
their desire would be in a variety of sexual situations in the last month. The scale is scored
using the sums of item responses, higher scores indicate stronger sexual desire [17, 18].
The SDI-2 has excellent psychometric properties, has been used in both general and
clinical populations, in a wide range of ages and people with diverse relationship statuses
[19]. A previously validated Spanish version of this instrument was utilized [18].

International Index of Erectile Function (IIEF)

An abridged 5-item version of the IIEF was used. This instrument is a widely used scale for
screening and diagnosis of erectile dysfunction (ED) and severity of ED in clinical practice
and research [20]. The score is the sum of the responses to the five items, with overall
scores ranging from 1 to 25. The IIEF classifies ED severity with the following categories:
1–7 Severe ED, 8–11 Moderate ED, 12–16 Mild to Moderate ED, 17–21 Mild ED, and no
ED 22–25 [29].

Index of Premature Ejaculation (IPE)

The Index for Premature Ejaculation (IPE) is a 10-item self-report questionnaire developed
to address three aspects of premature ejaculation (PE): sexual satisfaction, control over
ejaculation, and distress about levels of ejaculatory control. The IPE is a reliable and valid

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Table 1 Participant demographics

Variable TBI group Control group p value
(n = 71) (n = 71)

Age, years, mean (SD) 34.35 (11.05) 34.87 (11.35) NS

Education, years, mean (SD) 9.08 (3.64) 9.39 (3.39) NS
Cause of TBI, (%)
Motorcycle accident 56.3 –
Car accident 16.9 –
Fall 9.9 –
Pedestrian accident 5.6 –
Firearm 5.6 –
Interpersonal violence 2.8 –
Other 2.8 –
Relationship status, (%) NS
Single 42.3 50.7
Cohabiting 26.8 28.2
Married 25.4 19.7
Separated 2.8 –
Divorced 1.4 1.4
Widowed 1.4 –
Sexual orientation, (%) NS
Heterosexual 97.2 100
Homosexual 1.4 –
Bisexual 1.4 –
Employment status, (%) p \ .001
Employed 38.0 70.4
Unemployed 57.7 22.5
Student 4.2 7.0

questionnaire for the assessment of these areas [21]. Each item has five possible responses;
items 1–8 are reverse scored as 5–1 (in descending order) with the ‘no sexual intercourse,
not applicable’ category set to ‘missing, while items 9 and 10 are scored 1–5 (in ascending
order). Each sub-scale is then standardized onto a 0–100 scale using the following formula:
Control domain: (unstandardized score - 4) 9 100/16; Sexual Satisfaction: (unstandard-
ized score - 4) 9 100/16; Distress (unstandardized score - 2) 9 100/8. Higher scores
indicate more control, more satisfaction, and less distress. The IPE has been developed and
validated in a number of languages, among others, Spanish and United States Spanish [21].

Index of Sexual Satisfaction (ISS)

The ISS is a 25-item self-report instrument used to assess levels of dissatisfaction in the
sexual component of a dyadic relationship [22]. A validated Spanish version was used in
this study [23]. Scores range from 0 to 100 with lower scores representing greater sexual
satisfaction. A clinical cut-off is set at 30; scores above this value indicate a clinically
significant level of sexual dissatisfaction in a relationship. This instrument has been used in
clinical samples [24–27] and has strong psychometric properties [23].

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Sexual Quality of Life Questionnaire (SQoL)

The SQoL comes in male (SQoL-M) and female forms (SQoL-F); the male form was used
in this study. It has been developed to evaluate the impact of sexual dysfunction on quality
of life, specifically to assess sexual confidence, emotional well-being, and relationship
issues. The SQoL-M has 18 items, each with a 6-point response scale (completely agree to
completely disagree). The instrument has good psychometric properties [28–30] and had
been validated in Spanish [31].

Procedure

Participants were recruited by local researchers who reviewed medical records at the
Hospital Universitario Hernando Moncaleano Perdomo de Neiva (Colombia), to identify
individuals with TBI who received treatment between October 2012 and June of 2013.
Possible candidates were screened by telephone for inclusion criteria. Participants with
TBI had not received sexual functioning specific rehabilitation intervention prior to nor
during the study period. The healthy control group was recruited from the general popu-
lation using informational flyers at local establishments as well as through word-of-mouth.
Local researchers explained the procedure of the study to eligible candidates; those who
agreed to proceed signed a form which indicated informed consent in accordance with
regulations of Universidad SurColombiana, Colombia. Socio-demographic information
was obtained, and psychosexual evaluations of both the patient and control group partic-
ipants were carried out in a 1-h interview conducted by a graduate student under the
supervision of a university professor for completion of the instruments described in
‘‘Measures’’. This study was reviewed and approved by the ethics committee of Univer-
sidad Surcolombiana, and is part of a larger study of 100 male and female participants.
Data reflecting the female participants’ experiences have been published [15].

Statistics

Differences on the measures of sexual functioning between the patient and control group
were examined using independent-samples t tests/Kolmorogorov–Smirnov/Shapiro–Wilk
tests after distribution normality was assessed. A chi-square was used to evaluate the
relationship between erectile dysfunction status (mild to no ED vs. severe to moderate ED)
and participant group. Subsequently, in order to explore the relationship between
sociodemographic and TBI variables and indices of sexual functioning, nine multiple
regressions were conducted. In each regression model each of the nine measures of sexual
functioning (overall, dyadic, and individual SDI scores; IIEF score; IPE scores of control,
satisfaction, and distress; ISS score; SQoL score) were entered as a criterion variable, and
patient age, months since the TBI incident, and GSC scores used as independent variables.

Results

Males with TBI reported significantly less overall sexual desire than participants in the
control group; for the dyadic sub-scale these differences were maintained, however, there
were no between-group differences as to desire for individual sexual activity. Significant

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Table 2 Sexuality measure mean scores in the TBI (n = 71) and control (n = 71) groups and between-
group differences
TBI group Control group

Mean (M) Standard deviation (SD) Mean (M) Standard deviation (SD) p value

SDI* 44.06 28.53 59.54 19.64 p \ .001

SDI dyadic* 34.08 21.73 43.97 13.42 p \ .001
SDI individual* 2.06 4.93 4.31 6.21 p = .114
IIEF* 15.67 6.99 21.83 2.94 p \ .001
IPE control* 69.53 28.61 85.90 14.19 p = .017
IPE satisfaction* 70.31 26.56 86.97 12.56 p = .002
IPE distress* 80.47 25.78 82.24 19.02 p = .987
ISS 41.69 16.32 23.37 15.09 p \ .001
SQoL 57.57 26.71 82.63 11.29 p \ .001
SDI Sexual Desire Index; IIEF International Index of Erectile Function; IPE Index of Premature Ejacula-
tion; ISS Index of Sexual Satisfaction; SQoL Sexual Quality of Life Questionnaire
* Kolmogorov–Smirnov and Shapiro–Wilk p \ .05

Table 3 Erectile Function in the TBI (n = 71) and control (n = 71) groups and between-group differences
TBI group (%) Control group (%) p value

Severe to moderate erectile disfunction 43.7 9.9 p \ .001

Mild to no erectile disfunction 56.3 90.1

differences were found for three of four parameters of sexual functioning measured:
erectile function, ejaculation control, and satisfaction with ejaculation control (Table 2).
A higher prevalence of ED as measured by the IIEF was found amongst male survivors
of TBI compared to healthy control individuals (Table 3).
Nine multiple regressions were performed to evaluate the independent relationship
between the variables of age, months since the TBI incident, and GCS scores in the TBI
group and the sexuality constructs measured in the study. These variables were not
associated with sexual satisfaction, overall SDI scores, SDI dyadic or the independent sub-
scale results (p [ .05). In the model for erectile function, age (b = - .313, p = .008),
months since accident (b = .249, p = .034), and GCS score (b = .244, p = .035)
emerged as significant predictors, accounting for 18% of the variability, F (3, 67) = 5.021,
p = .003, R2 = .184. The same model was used to evaluate the three domains of pre-
mature ejaculation, although these were only significant for the distress sub-scale and
accounted for 34% of the variability, F (3, 28) = 4.767, p = .008, R2 = .338, with age as
the only variable which added to the prediction, b = - .591, p = .002 (months since the
accident b = .068, p = .701; GCS b = .043, p = .802). In regard to Sexual Quality of
Life, TBI severity as measured by the GCS score emerged as the only variable which
contributed to the model, F (3, 67) = 4.708, p = .005, R2 = .174. Age (b = - .099,
p = .393), months since accident (b = .191, p = .104), GCS (b = .391, p = .001) were
not significantly associated with the score on the measure of sexual quality of life.

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Discussion

The aims of the current study were to assess sexual functioning, desire and satisfaction in
male survivors with TBI, and to contrast these results with those of a healthy control group.
Significant differences emerged on seven of the nine sexual health constructs measured, in
which members of the patient group reported less sexual desire and sexual satisfaction, and
more sexual problems, including erectile dysfunction, ejaculatory control, and satisfaction
with ejaculatory control.
Similar results regarding higher incidence of sexual problems in individuals with TBI
were reported by other studies [32]. Lower levels of desire and more frequent erectile
dysfunction were found in a survey of 21 men at 16 months post injury [8]. In a study of 64
men with TBI a decrease of erectile function and lower sexual desire was reported [33]. In
another report of 30 men with TBI, 47% were found to have inadequate erectile func-
tioning assessed with the Brief Sexual Function Index [34]. This result is quite similar to
the 43.7% of the participants with TBI reporting moderate to severe ED. The present
results and those found by War et al. [34] are much higher than the 7.7% of the 44
participants reporting sexual dysfunction at the rehabilitation phase found by Aloni et al.
[35]. No between group differences were found regarding SDI Individual scores in this
study, similar results were found in an American study finding no statistically significant
differences between men with TBI and healthy controls with ability to masturbate [36].
The variable of months since the TBI incident was not found to be related with sexual
satisfaction or erectile function in the regression analyses performed. In a longitudinal
study following 129 men with moderate to severe TBI in the first year post injury, sexual
function and satisfaction were found to be stable from 6 to 12 months post injury [37].
Similarly, Sabhesan and Natarajan [38] found that only 38% of participants fully recovered
sexual functioning to pre-injury levels after 1 year of recovery. However, older age and
shorter post-injury time were found to negatively influence sexual functioning in another
study [39].
Male survivors with TBI reported lower sexual quality of life and satisfaction than their
matched control counterparts. These differences could be related to decreased levels of
sexual desire and functioning as the instrument is designed to assess the impact of sexual
problems on sexual confidence, emotional well-being, and relationships. The higher
incidence of sexual problems and lower sexual quality of life have important implications
for clinicians working with males with TBI. Sexuality needs to be addressed as part of an
integral treatment program for males who have suffered a TBI. The results of the present
study serve to inform the development of empirically supported intervention programs.
Currently no such interventions are being systematically carried out in Latin America, and
sexuality rehabilitation is needed to address disparities documented in the scientific lit-
erature. There is a rich area for future research to assess the effectiveness of intervention
programs in improving sexual function in men with TBI.

Limitations

Participants of this study all had moderate to severe TBI as measured by the CGS,
therefore the results may not be applicable to individuals with mild TBI. GCS scores have
been found to not have a high predictive value for outcomes [40]. Through the regression
analyses GCS scores were only predictive with erectile function and were not related to
desire, premature ejaculation, sexual satisfaction or sexual quality of life.

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The study took place in Neiva, Colombia, and the participants had not received general
nor specific rehabilitation interventions. These results permit a better understanding of
sexuality in males with TBI when neither general nor specific rehabilitation programs have
been implemented. Future studies with these participants could deepen the understanding
of sexual functioning, desire, and satisfaction outcomes in men with TBI over time.
This research relied on a cross-sectional design which only informs of a particular
moment. In order to better understand the evolution of sexual functioning after TBI,
longitudinal methods could be used. The control group design only allows for comparison
with people without TBI, comparison cannot be made with pre-injury sexual functioning,
desire or satisfaction. Whether participants had sexual difficulties before the TBI incident
is unknown. Self-report measures were used therefore the results could be subject to social
desirability biases or under reporting due to anosognosia. Future studies could contrast
self-report data with a urologist’s diagnosis of sexual dysfunction and/or participant’s
partner’s accounts of alterations in sexual desire and functioning related to the TBI
incident.

Conclusions

Disparities were found in seven of nine sexuality parameters measured. When compared to
matched controls, males with TBI had significantly lower overall and dyadic sexual desire,
sexual satisfaction and sexual quality of life. Erectile functioning, ejaculation control,
satisfaction with ejaculation control were reported to by lower in the TBI group than in the
control group. Almost 44% of participants with TBI had moderate to severe erectile
dysfunction, whereas nearly 10% of the control group had the same.
Compliance with Ethical Standards

Conflict of interest The authors have no conflicts of interest to report.

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