Introduction

Apart from the disability and the limits it imposes, the problem is of getting through to the minds of the able - bodied that SIP are people with the same kind of human desires and impulses. The disabled are people, and people are sexual. Much of our sense of personhood comes from our ability to play a sexual role. The person with disabilities first obstacle is self de- programming - rejecting the idea that he or she is not a potentially sexual person. The second is effective militancy - doing something about it. The ideal strategy is open discussion with other individuals or couples who share the same problem and counsel each other. In institutions SIP should demand that the matter be talked out . Almost all SIP can be made sexually functional with special counselling and a minimum of physical help. Virtually nobody is too disabled to derive some satisfaction and personal reinforcement from sex.

When a SIP is unable to enjoy sex , the greatest obstacle to enjoyment usually is not the difficulty or impossibility of making particular movements , but the social convention that sex consists of putting the penis in the vagina and that all the rest of the rich range of human sexual responses - oral, manual and skin stimulations are abnormal. That is the reason a SIP begin to think of himself as an invalid and distrust on his own personhood makes him suspect other peoples' affection as pity. Once you overcome that , try and explore your sexuality. Learn the techniques and procedures for sexual exploration and fulfillment. Sexual expression has to be tailor-made for the individual and one has to try hard to achieve it  This is a challenge same as learning other skills of management of spinal cord injury. But sexual challenge is probably the one best worth accepting as one discovers that one is loving, lovable , interacting human being - a participant rather than an onlooker.

The perception of the sexual act in male comprises of erection, orgasm and ejaculation, and in the females the corresponding responses. This is called Penetrative Sex . In sexuality and disability, we redefine it as Participative sex.

The best way to put yourself and people at ease is communication. The partner with a disability needs to educate the other person about the ways in which his or her body is different, both the partners need to communicate about what they like, what they like,what seems to be working for them and any problems they might be having..

For women however the essential sexual functions are unaltered , though there may be a decrease in lubrication of the vagina and they may have little or no sensation on the clitoris.

Erection
The mechanism of erection are complex. When sexually aroused, a man's brain signals the muscles in the penis to relax and the blood vessels to expand. As more blood flows into the penis, the veins that normally allow blood to flow out of the organ become tightly compressed. The result of all this blood trapped blood is an erection. The consistent inability to maintain erection firm enough for satisfactory sexual intercourse is a common feature in case of SCI. This is because for a man to get erection, his brain must send signals along the spinal cord to tell the nerves in his penis that he is sexually aroused so that the mechanism of erection sets in.
There are two types of erections

• Psychogenic - Transmitted by cortical ( brain) stimulation and regulated by sympathetic nerves. It is poorly sustained and lasts briefly in case of SIP.
• Reflexic - It is well sustained and more powerful. Transmitted and integrated - by spinal centres.

Loss of erection may be temporary , often lasting for only first few months after injury,although in men with a lesion below T 12 the ability to achieve even a reflex erection may be permanently abolished

Supra-sacral lesions: Reflex erection is possible .It is activated by stimulation procedure Squeezing of penis, Supra-pubic tapping. Pulling of pubic hair etc.

Sacral lesion : Weak and ill sustained erection . This requires additional maneuvers through the use of:
Vacuum erection aids: A cylinder fits on penis and with a gadget vacuum is created by pumping all the air out of the cylinder. This stimulates blood flow to the area within few minutes and that results in erection. A rubber band is slipped on to the base of penis to maintain erection. After intercourse, the rubber band can be removed and the penis becomes flaccid
Penile Injections : Papaverine or other drugs such as phentolamine are injected into the base of the penis.for getting a good erection. But one has to learn injecting under the guidance of a urologist. One should know the right area ( Corpocavinosum) and be very particular about the dose. A little extra dose can be very dangerous as the erection does not subside for hours and the blood in the penis gets clotted and there would be no more erections in future by any method.In such a situation one must Straight away rush to a doctor specially Urologist.
Energizing Ring : Is made of ebonite and fits behind the man's penis and testicles. The snug fit sets up a tiny charge of static electricity, which cannot be felt ,but has the effect of enlarging the minute blood vessels on which an erection depends. It can nearly always improve an erection which is otherwise incomplete. A cheaper alternative to the energizing ring could be a small loop or tube of latex rubber which fits around the base of the penis. It helps to improve a rather limp erection or helps to maintain an erection which would otherwise be rapidly lost.
VIAGRA :- This drug comes in the form of tablets of 50mg and 100 mg. It can be taken approximately an hour before the love making session. Always wise to start with lower strength.
MUSE :- The drug in the liquid form comes loaded in a special kit. When required the packing can be removed and the drug can be squeezed into the urethera as one puts KY jelly for catheterisation. Penis has to be hold at perpendicular to the body to avoid the back flow of the drug. With a little massage in this position by yourself or by your partner erection is achieved within ten minutes. Drug comes in strengths of 250mg, 500mg, 750mg and 1000mg. SCI people need atlest 500mg strength.

If your partner is non - disabled , she can straddle you, open the lips of her vagina and stuff your soft penis in , using her vaginal muscles to hold it in position, this may stimulate erection, but still if it does not, it may still be very pleasurable for both of you.

Beside these devices & methods posture is very important . Male acts as a passive partner and female as an active partner and on top of the male. Legs can be supported by pillows.

If it is not possible to get and maintain an erection there are a range of artificial penises for use when penetration is desired.

This imitation penis , which straps on to the man's body with an elastic harness , may be solid or hollow so that flaccid penis can fit inside. The more sophisticated models can even squirt a warm fluid to stimulate ejaculation . Some even have a built in vibrator.

Those who do not have a partner or for whom sexual intercourse is not possible may need a device to assist masturbation. A vibrator can be used in these instances or to improve love- making.

ORGASM

Many a spinal cord injured people not only enjoy sex , but also experience orgasm. Although the orgasm may be and feel different from those they had before injury , but they are not necessarily less satisfying or intense . Some people say that other parts of their bodies appear to compensate with greater sensitivity for the lack of feelingin their paralyzed parts. It has been found that women with SCI have an alternative sensory path for orgasms coming through the vagus nerve, the 10th cranial nerve and which should not be affected by SCI. It is also likely that hormones released during intercourse play a major role in orgasm.

EJACULATION

The brain plays a large part in the ability to ejaculate, and in the SCI the brain - penis connection is lost. Thus ability to ejaculate returns less frequently, although some men experience a phantom orgasm without ejaculation, when their partner reaches orgasm. However, many do have an orgasm with ejaculation through the use of vibrator. Finally, as everybody knows, ejaculation is only one reflex part of the orgasm and the rest is in the mind.

FERTILITY

In case of women the fertility is not affected by spinal injury, the periods may cease for a while after the injury but they would resume as earlier. They are fertile and thus women should think about contraception if in a sexual relationship.

Infertility in male after spinal cord injury is caused because of

• Failure of ejaculation
• Retrograde ejaculation - the semen instead of being ejaculated in the usual way passes into the bladder. Thus the semen becomes ineffective as fertility is reduced because of acidity of the urine.
• Testicles are affected mainly due to changes in the heat regulatory mechanism. Raised scrotal temperature following sitting on w/chair for long hours has a damaging effect on sperm.
• Chronic infection of the prostrate and seminal vesicles is quite common in men after SCI.

A number of people with spinal cord injury are capable of fathering children . Sperms can be obtained , if ejaculation can't be by

1. Normal masturbation
2. Vibrator : Semen can be obtained in few cases by applying vibrator to the glans ( top part of the penis ). The procedure will not work in men with complete lesion at L1 or lower.
3. Electro-ejaculation : Semen can be obtained from two-thirds of men through electro-ejaculation. The nerve pathways which initiate ejaculation are stimulated electrically by electrodes attached to a probe which is placed in the rectum. This simple procedure can be done either under sedation or general anaesthesia.
4. VAS ASPIRATION :- Sperms can be collected through this method by mico surgical aspiration of sperms from the vas deferens under local anaesthesia. A small incision is made in the skin of the scrotum to expose the vas deferens and then an incision is done in the vas deferens itself to collect the sperm by a fine cannula.

This procedure can be used with people with spinal cord injury showing severe dysreflexia at the time of sperm collection through vibrator or electo-ejaculator.

ARTIFICIAL INSEMINATION
When the male partner is unable to impregnate the female in usual manner because of not getting an erection or ejaculate after SCI. One can think of artificial insemination for fathering a child.There are two types of artificial insemination

1. AIH - artificial insemination by husband
2. AID - artificial insemination by donor

Semen collected is placed high in the woman's vagina, at her most fertile time. The insemination is carried with a special syringe and a cervical cap may be used to keep the sample in place

Autonomic Dysreflexia
If one has a high lesion, sexual activity and especially ejaculation may bring on autonomic dysreflexia . If this happens, one should stop immediately , check all possible causes , sit upright if you have been lying down, and do not hesitate to call the doctor if any symptoms persist. Sublingual Nifadipine in emergency.