The neurophysiology of sex
Sexuality is part of being human. Our sexuality affects how individuals perceive themselves and how they interact with those around them. Sexuality is a complex area of functioning encompassing sexual development which begins in utero; sexual awareness which develops through childhood and adolescence; sexual responsiveness and awareness (Bancroft J 2009).
It is a key element in the formation of meaningful relationships in adult life. It is an area of strength but also of vulnerability to internal and external factors such as health, self-esteem, societal and family pressures and values.
At the most basic level, sexuality is the means by which a partner is found for reproduction and the passing on of genetic material and this is evident in the animal kingdom as a whole.
However, for humanity, it is about relationships. Neurological trauma or illness can have a major impact on sexual responsiveness and the capacity for relationships. More often than not sexual expression is something that occurs within a relationship.
Part of the normal sexual experience includes masturbation and fantasy but it is in relationships that sexual expression is generally fulfilled.
Why relationships matter
The dynamics of a relationship have a profound effect on sexual functioning. Sexual expression begins with desire which is a function of the brain.
Within the neural pathways there are both inhibitory and excitatory neurotransmitters. Dopamine is excitatory and Serotonin is inhibitory in the pathways linking desire to arousal of the autonomic and peripheral nervous system.
Desire is influenced by a variety of cognitions and emotions such as mood – excited, happy, fearful, oppressed memories of previous good sexual experience or memories of painful abusive relationships.
It will be affected by fatigue which is a very common symptom of neurological disease or trauma. It may be influenced by social context – is this relationship developing in a private setting or is it within a nursing home where privacy is diffcult to establish?
The most recent imaging studies have demonstrated that certain parts of the brain are active in sexual desire, including the anterior cingulate cortex which connects to the amygdala, which in turn has a key role in emotional responsiveness (Zeki A 2007).
The central nervous system, through a complex set of pathways involving the higher levels of cortical functioning, provides a delicately balanced system to allow sexual expression within relationships.
Any part of the system can be affected by physical, psychological, social and emotional factors.
The brain in turn connects through the spinal cord to the periphery. The sacral segment of the spinal cord is a key area from which nerves travel to the genitalia. The parasympathetic output to the genitalia comes from the sacral cord and the sympathetic nerve supply from the thoracic and upper lumbar cord.
In response to sexual arousal the nervous system connects to the genitalia via the spinal cord leading to a neurovascular response with the parasympathetic nerves triggering erection in the male and vasocongestion in the female.
The sympathetic system is involved in ejaculation. Any disease or trauma to the nervous system or medications acting on the nervous system can interrupt the pathways. For example, a thoracic spinal cord injury will separate the sacral spinal cord from control by higher centres so that in the male reflex erections may still occur in response to a variety of stimuli including full bladder or irritation to the skin, but psychogenic erections in response to sexual desire may not occur.
What makes a good couple?
Key factors include mutual attraction, love, having fun together, enjoying sex together, trusting each other, ease of communication and being special to each other.
As relationships move into longer term commitments, there are additional factors, including shared experiences and future plans, hopes and expectations.
Demands are placed on relationships such as financial commitments, bringing up children, looking after elderly relatives.
Meanwhile, each individual brings into that relationship their own health, beliefs, values and approaches to managing stress; their past experiences both good and bad, their need for autonomy and their need for intimacy.
Each person has their own self-image and an image of their partner, which can be quite different to how other people see them. Impacting on the relationship are external pressures which can be social, financial, work and family pressures.
Many factors can challenge the dynamic balance of the relationship and the onset of disease or trauma can have a profound impact.
When everything changes…
The context of most sexual expression is within a relationship. It is also within this context that many people will experience the life-changing impact of chronic disease or acquired disability.
For some couples, problems of adjustment to the changes can be significant and place a strain on the relationship, sometimes leading to separation. For others, the impact of such stress can enhance their closeness.
Different roles tend to be assumed as a relationship progresses. One of the commonest divisions of roles within a long-term relationship is with the arrival of children when, in some cases, one partner assumes the ‘bread-winner’ role and the other home-maker.
Each partner has an image of self and of their partner, and this includes an awareness of their physical and psychological health. The onset of neurological disease and/or disability can present a great challenge to the stable state of a relationship. This may result in a change of physical appearance and cognitive ability.
The couple, having been partners in a familiar relationship, may find now that there is a carer and a partner who requires care. New roles may be taken on by one partner whilst roles must be relinquished by the other.
The shared hopes and expectations for the future may alter. It is important to note that the greatest impact comes from disorders that alter cognitive and emotional responses – rather than just physical functioning.
Most often, the problems are multi-factorial in origin. For example, there could be loss of sensation because of MS, which alters the sexual experience, together with fatigue causing a change in overall lifestyle; low mood as a response to loss; medication resulting in specific sexual dysfunction, such as delayed orgasm with the selective serotonin reuptake inhibitors (SSRI anti-depressants); social changes resulting from the loss of income; or practical issues at home, such as no longer managing stairs and therefore, sleeping in a separate room from the partner.
Brain injuries can also lead to impaired self-monitoring, which means the individual may be unable to suppress commenting on things that come to mind no matter how offensive they may be. Self-centredness is also a common trait, as is a lack of empathy.
The ability to take note of how the other person is feeling – whether they’ve had a good or a bad day – without speaking to them, is quite important in relationships.
With acquired brain injury, non-verbal questioning can be lost (Wood R Williams C 2008). Sexual problems are common post brain injury and, in one study, 50% of men identified dysfunction (O’Carroll et al. 1991).
In a minority of patients, increased sexual drive and sexual dis-inhibition can be a problem.
This is more likely to occur with damage to the frontal lobes. Reduced sexual desire and interest are most common and result from the brain damage itself, the effect on the relationship, fatigue, depression, anxiety, low motivation and, sometimes, low testosterone secondary to damage to the hypothalamic pituitary tract.
The partner’s plight
A common observation from partners of people with acquired brain injury is ‘this is not the person I married’. Often in relationships, partners face challenges together. In the event of a trauma, the able-bodied partner may face this new challenge alone.
While this is going on they may also feel a desire to grieve for the old loved one they have lost. But there is no acceptable way for them to do this.
They may feel isolated and in a state of social limbo, in which it feels inappropriate to go out and have fun without their partner. Also, friends may say that the patient looks good, but only the partner sees the major behavioural changes that have occurred. Sometimes we see situations where the relationship had been on the verge of splitting up before the injury or onset of disease.
With the patient, unable to make the decision to end the relationship afterwards, the partner becomes trapped in a loveless or failing relationship out of guilt.
Despite all the pressures trauma and neurological conditions can put on a couple, relationships can be rebuilt. In relationship therapy, we are always honest and explain that things will never get back to how they were.
But, for all the behavioural changes, there may be factors that the partner still finds very attractive. We encourage couples to find new ways to have fun together and to start getting to know one another from scratch.
For men, drugs such as phosphodiesterase inhibitors have proved to be useful treatments for erectile dysfunction. These work on the relaxation of smooth muscle which allows vasocongestion in the genitalia in response to a chemical messenger cyclic GMP.
However, it is always important to approach treatment of sexual disorders in a holistic manner. It is rarely simply a mechanical problem that can be fixed with a pill.
Therefore, taking a full history and if possible seeing the individual with their partner allows the psychosocial aspects of the sexual dysfunction to be explored as well as the physical aspects.
Healthcare professionals need to be alert to the stresses and strains that can be experienced in this area of life which generally people view as very private and personal.
The P-LI-SS-IT model (Annon 1976), which was proposed over 40 years ago, emphasised that the first and most helpful approach to sex and relationship problems was giving people permission (P) to speak about the issues.
People may drop hints that all is not well in a relationship and it is up to the health professional to pick up on that hint.
Even if you are not certain how to help, acknowledge that there is an issue; allow the individual to talk about it and then, if you feel it is beyond your remit or skill, offer to refer to another agency – perhaps to the GP or to a sex and relationships clinic or to an organisation such as Relate.
The most important response is to say, “this is a valid issue to raise and there is help available”. In the PLISSIT model the next three stages are the provision of Limited Information, Specific Suggestions and Intensive Therapy. Most people will be helped in the first one or two steps of this model.
TEN STEPS: How healthcare professionals should approach their patients’ intimate relationship problems.
- Be honest and realistic with patients and partners. They may never recover their old relationship, but could still build a positive new one.
- Consider the difficulties the partner may be going through and how that may be impacting on their health. Do they look exhausted? Have they been crying? A doorstep conversation in private might encourage them to open Perhaps ask them if they have considered visiting their GP about their own concerns.
- Be careful not to overload partners with too many responsibilities, such as helping out with cognitive therapy at home. Although outwardly willing to help, inside they may be feeling drained, isolated and depressed.
- Often patients going through rehab can feel their sexual identity is threatened, leading to low self-esteem. Give them time to do the little things they usually would to look their best. For women, this might include shaving their legs or putting make-up on; for men it might be having a shave or doing their hair.
- Consider implementing some training on sex and relationship problems within your ward, unit, service or centre.
- Remember that, ultimately, your primary responsibility is to get the best outcome for the patient – not to influence whether or not their relationship survives.
- Get to know the sources of professional help available in your local area. Relate is a charity offering relationship support across the UK. Some areas are also served by specialist clinical psychology services. Patients should also be encouraged to consider visiting their GP about such matters.
- Remember that sex and relationships are very sensitive topics and most people will not be comfortable talking to strangers about them. Create a safe and secure setting to discuss them. Relationship issues should be presented as a normal and important element of the patient’s overall health and wellbeing.
- Always acknowledge there is a problem if the patient or their partner mentions it or even just hints at it. Never ignore the problem and certainly do not make light of it or embarrass or make fun of the patient.
- If you suspect there are sex and relationship concerns, try asking a non-threatening question. Perhaps as the patient is leaving, ask how things are at home. This gives them an opportunity to get the issue off their chest without bluntly asking them an awkward question.
Barbara Chandler is a consultant in rehabilitation medicine in NHS Highland. Previously she ran a sex and relationships clinic for people with neurological disability in the North of England. She teaches health and social care professionals on sex and relationship issues and has been published extensively on the topic.
Relate: www.relate.org.uk: www.relate.org.uk
The Institute of Psycho-sexual Medicine: www.ipm.org.uk
The College of sex and Relationship Therapists: www.cosrt.org.uk
Taking time to look back – so the way ahead is clearer
Reflective practice within healthcare settings is widely talked about, but not always so easy to implement in the workplace. NR Times speaks to one neurological centre about how it benefits patients and staff there.
Reflective practice and discussion in healthcare settings is a professional requirement for nurses, as laid out by the Royal College of Nursing revalidation requirements as part of their continuous professional development.
It allows professionals to take time to pause and reflect, communicate and plan, which undoubtedly leads to better outcomes for patients and staff.
But in reality, reflective practice can often be left to the bottom of the pile, underneath many of the competing responsibilities facing staff who are often pressed for time.
It could be argued that this is also why reflective practice is so important – healthcare staff are facing so many pressures that it actually makes less sense to neglect the important work of individual and team reflection.
The Royal College of Nursing defines reflective practice as: A conscious effort to think about an activity or incident that allows us to consider what was positive or challenging and if appropriate
plan how it might be enhanced, improved or done differently in the future.
Staff at Elysium St Neots Neurological Centre in Cambridgeshire started doing regular, weekly reflective practices when its new hospital director, Fiona Box, came into the role a few months ago.
The nurses and healthcare assistants from a ward are invited into the meetings and in their absence the therapy staff monitor patients and provide activities.
“We thought it would be helpful for team members to give them the opportunity to think, learn, and to hear their opinions,” says charge nurse Jemima Vincent.
“If we have an incident with a patient, we discuss it in the session” she says.
Sessions are led by the management team, with added input from psychology teams on each ward.
They will talk through any strengths, weaknesses and opportunities, and work through an analysis to learn from the incident and create an action plan.
They talk about the worst-case scenario in relation to an individual situation and discuss how staff would manage that, so they’re better prepared in the event of it happening.
While they focus on one patient at a time, issues arise during conversations that bring in their wider experiences.
In an article* published in the Nursing Times in 2019, Andrea Sutcliffe, chief executive of the Nursing and Midwifery Council said: “In these challenging times for health and social care, it’s so important that collectively we do all we can to support our health and care professionals, and their employers, in devoting time to individual, reflective, personal and honest thinking.”
Fiona has received encouraging feedback from staff, who say the meetings help the staff feel much more involved in a patient’s care and allow the team to increase their knowledge and understanding resulting in a more consistent way of working.
“Healthcare workers often don’t fully understand patients’ diagnoses or why they’re reacting in a certain way, for example,” Jemima says.
“They know a patient presents with certain behaviours and may be taking medicine to help them cope but they’re not aware why the patient is showing signs of aggression and the best response to deescalate the situation,” she says.
“It’s a learning opportunity for staff, because reflective practice means that they can understand a patient’s diagnosis and why they behave how they do,” Jemima says.
“Reflective practice answers their ‘why’ questions, and gives them a more open mind.”
Jemima also benefits from the meetings; it’s a way for her to get to know staff better, especially when it comes to learning opportunities.
“I’m able to understand what level of support each member of the team requires, including training needs and if they need more knowledge on a specific topic.”
In her final year as a mental health nurse student on extended clinical placement at Elysium St. Neots, Jo took part in a reflective practice session.
She had just finished her dissertation, in which she looked at how settings can increase the opportunities and variety of reflective practices within hospital settings.
The aim of Jo’s session was to reflect on the recent deterioration in a patient’s mental state and the resulting impact on their well-being to ensure staff had a consistent approach to support the patient.
The hospital’s director Fiona asked the team about the patient’s care plan, diagnoses and needs and wishes.
Where staff were unsure of the answers to questions, Jo says Fiona gave them answers and encouraged the team to share their knowledge of the patient, problem solve and come up with an agreed plan to move forward with.
Jo found the session helpful and was impressed with how the healthcare assistants were so involved in the discussions about all aspects of the patient’s care, including the more clinical elements.
Healthcare assistants told her they found the session helpful too and that it made them feel like they had a better understanding of the patient’s changing mental state, behaviours and needs.
Jo says having the opportunity to reflect on practice is a crucial skill for all healthcare workers to help them learn from their experiences and increase self-awareness, which, in turn, can improve individual professional standards, strengthen teams and enhance patient-centred care and clinical outcomes.
For referrals to Elysium St Neots Neurological Centre or other Elysium centres visit: www.elysiumhealthcare.co.uk/neurological
Reference source: https://www.nursingtimes.net/news/ professional-regulation/nmc-highlights-importance-of-nurses- reflection-on-practice-18-06-2019/
Robots and resilience at Askham Rehab
NR Times reports on a new rehabilitation approach taking place in Cambridgeshire.
Despite a year of relentless change and upheaval for all involved in neuro-rehab, one provider in Cambridgeshire has been able to keep its ongoing development on track.
Askham Rehab, part of the Askham Village Community, is a recently-launched specialist rehabilitation service incorporating the latest in rehab robotics and sensor assisted technology.
While the firm has invested in state-of-the-art technology to do the heavy lifting, however, its rehab services remain person-centred, as director Aliyyah-Begum Nasser explains.
“We’re a specialist rehab centre in essence, and so, although the robotic technology helps us to get the most out of our patients and staff, we are very much family-focused.
The equipment is obviously fantastic but we know from experience that a person’s mindset, and their ability to sustain whatever improvements they make, comes down to the people who are supporting them – their family members.
“We’ve been on some real journeys with many of our family members who just didn’t understand the impact of a brain injury in terms of how it can impact behaviour or what it can do for cognition.
“Once they understand that, suddenly they become a lot more compassionate, and a lot more supportive; they become part of the recovery process, rather than being a frustrated observer.”
With recognition of the family’s paramount importance to recovery, Askham Rehab does everything within its power to harness this force – including by enabling families to stay together in specially-designed apartments on site.
Aliyyah-Begum says: “The flats are fully adapted, with cantilever cupboards, height-adjustable sinks in the bathroom and full wet room with turning spaces.
“We have the patients themselves participating in rehab, specifically to their programme, but relatives are also there from the beginning, seeing the improvement and being part of our process from the outset.
“We think of the centre as more of a rehab environment; it’s not a just care home with therapy as an added extra.
“So from the minute our patients wake up to the minute they go to bed, everything is based around their recovery goals, and everyone is working together towards achieving them.”
And robotics are an important tool in pursuing these goals through patient exercise. They help therapists to achieve the repetitions and intensity needed to progress their clients, as Aliyyah-Begum explains.
“The point of the robotics is that they respond to the patient. For example, if you set the machine on a left lower limb, but it senses that there is more pressure being exerted through the right limb than the left, it will automatically respond to make sure the patient is moving the correct part of their body.”
The centre’s head of rehab and nursing, Priscilla Masvipurwa, says: “This is a real a game changer in our approach to rehabilitation.
“Robotics help to bridge the gap, increasing the frequency and repetitiveness of treatment, something that’s an essential part of the process.
“We anticipate that this will enable us to support our patients in reaching their goals in a more efficient and sustainable way.
“The centre has so far invested in four items from robotic rehabilitation firm Tyromotion, but is looking to add more over time, as the benefit to both staff and patients becomes ever more evident.
Aliyyah-Begum says: “It’s really important to the team at the centre that the robotics aren’t just seen as an add on.
“There is a lot of nervousness about robots replacing therapists, but our service is still very much therapy-led.
“What this means in practice is that, where a resident would previously have had maybe an hour of therapy time in an afternoon, now you have an hour of therapy time, and then you can carry on exercising if you want to, or carry on playing games with other residents.
“For example, one of our machines, the Myro, enables patients to play games like bat and ball, or perform virtual tasks like sweeping leaves.
“However, because it is all sensor-assisted, if it senses that the patient needs to work a certain hand, it will alter what it is asking them to do accordingly, while they won’t even necessarily feel they’re having therapy – it’s all part of the game, and part of their socialising with other residents.”
Askham Rehab forms part of the Askham Village Community, on the edge of Doddington village, in Cambridgeshire.
It provides specialist care for people of all ages, offering day visits, respite care and continuing long-term support, both on-site or at home.
The site consists of five homes, three of which are specialist neurological facilities. In total, the neuro-rehab team can look after up to 52 patients at any one time, with 120 staff made up of rehab professionals and specialists.
The team comprises carers nurses, physiotherapists, occupational therapists, speech and language therapists and psychologists.
Aliyyah- Begum believes that the introduction of the robotic rehab services, combined with the patient-led therapy the group has been offering for 30 years, can only enhance the centre’s outcomes.
She adds: “We know that there is an increasing number of care homes that offer specialist therapy, but the difference with Askham Rehab is that we have embedded it into the whole culture of our setting – and the outcomes really speak for themselves.
“We often discharge people earlier than planned, and that’s a testament to the fact that the patients are really working hard with the team throughout their stay with us to achieve their goals – and that is the key.”
For more information about Askham Rehab, visit www.askhamrehab.com
Astrocytes identified as master ‘conductors’ of the brain
In the orchestra of the brain, the firing of each neuron is controlled by two notes – excitatory and inhibitory – that come from two distinct forms of a cellular structure called synapses.
Synapses are essentially the connections between neurons, transmitting information from one cell to the other. The synaptic harmonies come together to create the most exquisite music–at least most of the time.
When the music becomes discordant and a person is diagnosed with a brain disease, scientists typically look to the synapses between neurons to determine what went wrong. But a new study from Duke University neuroscientists suggests that it would be more useful to look at the white-gloved conductor of the orchestra – the astrocyte.
Astrocytes are star-shaped cells that form the glue-like framework of the brain. They are one kind of cell called glia, which is Greek for “glue.” Previously found to be involved in controlling excitatory synapses, a team of Duke scientists also found that astrocytes are involved in regulating inhibitory synapses by binding to neurons through an adhesion molecule called NrCAM. The astrocytes reach out thin, fine tentacles to the inhibitory synapse, and when they touch, the adhesion is formed by NrCAM. Their findings were published in Nature on November 11.
“We really discovered that the astrocytes are the conductors that orchestrate the notes that make up the music of the brain,” said Scott Soderling, PhD, chair of the Department of Cell Biology in the School of Medicine and senior author on the paper.
Excitatory synapses — the brain’s accelerator — and inhibitory synapses — the brain’s brakes — were previously thought to be the most important instruments in the brain. Too much excitation can lead to epilepsy, too much inhibition can lead to schizophrenia, and an imbalance either way can lead to autism.
However, this study shows that astrocytes are running the show in overall brain function, and could be important targets for brain therapies, said co-senior author Cagla Eroglu, PhD, associate professor of cell biology and neurobiology in the School of Medicine. Eroglu is a world expert in astrocytes and her lab discovered how astrocytes send their tentacles and connect to synapses in 2017.
“A lot of the time, studies that investigate molecular aspects of brain development and disease study gene function or molecular function in neurons, or they only consider neurons to be the primary cells that are affected,” said Eroglu. “However, here we were able to show that by simply changing the interaction between astrocytes and neurons — specifically by manipulating the astrocytes — we were able to dramatically alter the wiring of the neurons as well.”
Soderling and Eroglu collaborate often scientifically, and they hashed out the plan for the project over coffee and pastries. The plan was to apply a proteomic method developed in Soderling’s lab that was further developed by his postdoctoral associate Tetsuya Takano, who is the paper’s lead author.
Takano designed a new method that allowed scientists to use a virus to insert an enzyme into the brain of a mouse that labeled the proteins connecting astrocytes and neurons. Once tagged with this label, the scientists could pluck the tagged proteins from the brain tissue and use Duke’s mass spectrometry facility to identify the adhesion molecule NrCAM.
Then, Takano teamed up with Katie Baldwin, a postdoctoral associate in Eroglu’s lab, to run assays to determine how the adhesion molecule NrCAM plays a role in the connection between astrocyte and inhibitory synapses. Together the labs discovered NrCAM was a missing link that controlled how astrocytes influence inhibitory synapses, demonstrating they influence all of the ‘notes’ of the brain.
“We were very lucky that we had really cooperative team members,” said Eroglu. “They worked very hard and they were open to crazy ideas. I would call this a crazy idea.”
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