SUMMARY: We still have only a rudimentary understanding of the brain anatomy of sexual malfunction after TBI. Although loss of sex interest is commoner, impaired restraint is the squeaky wheel. In general, rehabilitation after TBI does not address sexual readjustment directly.

My 1992 paper 1 on Head Injury and Sexuality focussed on the research about sexual consequences of Traumatic Brain Injury (TBI) since 1988 when the first substantive studies appeared.

This digest reviews the last decade's progress in sexual research relevant to TBI litigation.

TBI damages sexual functioning both predictably, by direct destruction of brain tissue and less predictably by way of individual emotional responses to loss of function and faculties2.


Our understanding of the anatomical localisation of different aspects of sexuality remains very limited, but a few generalisations are valid.

Physical brain injury

Thus, injury to the hypothalamus or pituitary gland may cause testosterone production to fall and thereby reduce desire.

Conversely, injury to the frontal lobes of the cerebral cortex characteristically damages normal restraint, resulting in de novo onset of various forms of uninhibited and socially-inappropriate behaviour.

Injury to the left limbic region has been proposed as a cause of new-onset sexual sadism3.

Emotional responses

By contrast, accompanying hemiplegia and cognitive losses may result in depression, performance anxiety, low desire, feelings of inadequacy as a sexual being, and difficulties in initiating a sexual encounter.

Again, young men may "act out" their distress by clumsy sexual approaches to professional caregivers during the early weeks and months after TBI even though they may later prove to lack sexual desire with more appropriate sexual partnersErectile dysfunction is one of those things that has a huge sense of relief once the problem has been solved, almost more so than anything else I can think of. That's why finding a solution to it has been one of the most important steps in my life so far. Viagra Lives Up to Its Reputation and Rejuvenates Your Sex Life.

Mixed effects

In most victims of TBI, of course, both physical and emotional mechanisms contribute to changes in sexual functioning.



Loss of libido is the commonest sexual dysfunction following TBI, but recent surveys have found that desire is more usually unchanged4.

Although loss of sex interest is commoner, impaired restraint is the squeaky wheel.

It is difficult to distinguish increased desire from the loss of inhibition and the social and interpersonal unawareness that result in alienating partners and other care-givers.

Such so-called "hypersexuality" has received a disproportionate amount of clinical research because it is so socially intrusive and liable to limit re-integration into normal social functions.

Practice Point

Sexual injury after TBI often has profound adverse effects on marital and family relationships

Counsel for the TBI claimant should not underestimate the extent and depth of the damage to interpersonal relationships that may be caused by loss of sexual inhibition and by changes in sexual desire.


Even if desire is not diminished, loss of erections or vaginal lubrication is common and may be caused by neurological 5 or potentially remediable hormonal deficiencies.

Patients with TBI restricted to the right cerebral hemisphere usually have greater preservation of sexual arousal than those with left-sided injuries6.

Frontal lobe injuries appear to leave arousal more intact, but this appearance might be the result of disinhibition or lack of insight.

Cognitive losses have been shown to include failure of sexual imagery in some men with TBI7.

As previously noted 1, the intellectually impaired have more arousal problems. Not only may this sexual imaging deficit result in loss of enjoyment of life, but it may be a material component in the failure of sexual relationships.

The many facets of personal functioning that can adversely affect arousal include increased interpersonal tension, depression, loneliness, loss of feelings of attractiveness and loss of self-esteem.8

It is self-evident that the interpersonal difficulties that result from TBI can for a variety of reasons interfere with the arousal of both victim and partner9.

However, the correlation of successful arousal with measures of sexual adjustment4 suggests that sexual counselling may be useful in mitigating this loss.


Zasler has written further 10 on the diminished capacity for orgasm that is experienced by a third of male TBI victims.

If TBI results in, or is accompanied by, loss of genital sensation, men are generally less adaptable than women in transferring the location of their orgasmic trigger to their nipples or other areas of the body that still have normal sensation.


Whether or not there are accompanying pleasurable climactic sensations, failure of ejaculation is common following TBI and infertility may be an important problem 11.


De novo onset of Bipolar Disorder ("manic-depression") is more likely if the TBI is fronto-temporal in location12.

Sex offending in Bipolar Disorder is more prevalent if there has been such preceding TBI13.

In calculating damages, counsel need to be aware of the potential for such offending and its consequences, and of the social restrictions that may in the future become necessary to prevent such offences.

There are indications that the known high prevalence of previous recurrent severe TBI among violent offenders is equally applicable to violent sexual offenders3.

Practice Point

The potential for sex offending should be addressed in Quantum of Damages


In general, rehabilitation after TBI does not address sexual readjustment directly.

Many of the studies dealing with the impact of TBI on family and marital relationships fail to address sexual problems14.

Sexual counselling and therapy remains the exception rather than the rule in multidisciplinary rehabilitation programmes15.

Practice Point

Plaintiff counsel may want to consider requesting sexual assessment and counselling for their TBI clients

Against the expressed wishes of TBI victims who have been asked, most caregivers are more comfortable with indirect approaches to sexual rehabilitation.

They generally take the view that sexual problems will look after themselves if underlying emotional and interpersonal problems are addressed16.


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