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Sexual Function and Reproductive Health after Spinal Cord Injury

Original Editor - Wendy Oelofse

Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson  

Introduction

Sexual function and reproductive health can significantly impact quality of life in people living with spinal cord injury (SCI).[1][2] An individual's sexual and reproductive function post-SCI depends on the level and completeness of the injury.[3] SCI can have a number of direct and indirect effects on sexual functioning, including the ability to engage in sexual activities, intimacy and relationships, sexual self-view, and fertility.[4] Sexual health is, therefore, an important aspect of rehabilitation.[5][6]

It is recommended that people with SCI start talking about their sexual function as early as possible in the rehabilitation process.[7] This might be in the form of formal sex education, informal discussions with a healthcare professional and/or other people with SCI, experimentation and discovery with a partner.[7]

This page acts as the additional notes for Wendy Oelofse's Plus course on Sexual Function and Reproductive Health after Spinal Cord Injury. It provides an overview of the impact of SCI on sexual and reproductive health and explores the role of rehabilitation professionals in preserving or improving sexual function for individuals with spinal cord injury.

Best Practice Guidelines to Promote Sexual Health After Spinal Cord Injury

The following steps have been proposed to help evaluate, provide education and treat sexual concerns after SCI:[8]

  • communicate with the patient
  • ask about any sexual and medical issues that were present pre-injury
  • refer on where appropriate
  • consider if there are any partner, cultural, and psychological issues
  • complete physical and neurological exams, paying close attention to T11-L2 and S2-5
  • provide education to the patient
  • suggest practice
  • follow up by reviewing the basics
  • if problems are ongoing, treat any confounding/iatrogenic issues
  • follow up with the patient again
  • treat the basics (e.g., provide medications to improve desire or arousal)
  • follow up with further communication
  • use more advanced techniques where necessary (e.g., make a referral for invasive techniques or further counselling)

Communication About Sexual Health After Spinal Cord Injury

Clinicians must be comfortable and have sufficient knowledge to communicate with individuals about sexual health after SCI. They must demonstrate respect during these interactions. Strategies to create a respectful environment include ensuring privacy, obtaining consent/permission to ask sensitive questions, being patient, giving the person time to answer questions and tailoring the discussion to match the person's readiness to talk.[8]

The following techniques can be helpful when discussing sexual health with a patient:[8]

  • use a "matter-of-fact" tone of voice and adopt neutral body language
  • use postural echo (i.e., the clinician and patient mirror each other's sitting position)
  • make eye contact with the patient where appropriate
  • make use of written scales or questionnaires
  • ask open-ended questions
  • provide time for the client to tell their story without interrupting them
  • acknowledge any concerns the patient has
  • use reflective listening to show your patient that you understand these issues are important to them
  • normalise the patient's questions and concerns and show that they are legitimate
  • do not make judgmental and/or shaming comments
  • make sure you use conditional phrasing when providing information (e.g., "this is unlikely" or "this may happen")
  • provide reassurance/normalisation

This optional video explains how to start a conversation about sexual health with an individual with an SCI:

[9]

Effects of Spinal Cord Injury on Sexual Function and Reproductive Health

"Patients must be informed that sexual health care is part of their rehabilitation program and that sexual health services will be offered periodically throughout their rehabilitation and can also be requested."[8]

Three spinal segments are of particular importance for sexual function: the T11-L2 sympathetic, the S2–S4 parasympathetic, and the somatic centres.[10]

Direct Effects of Spinal Cord Injury on Sexual Function and Reproductive Health

The direct effects of SCI on sexual response in men and women are different and are discussed in the following sections.

Sexual and Reproductive Responses in Men with a Spinal Cord Injury

"Spinal cord injury frequently occurs in men during the years of their reproductive health peak when they may desire to start a family and have children."[3]

Males with SCI may experience altered or loss of sensation, as well as altered ability to ejaculate.[11] Natural ejaculation is more likely to occur in individuals with incomplete conus or cauda equina lesions and with lesions higher than T6.[12] Note that the conus medullaris is the terminal end of the spinal cord; it is usually located around L1 in adults.[13]

Orgasm and sexual satisfaction may also be altered.[11] Individuals with preserved light touch and pinprick sensation in the T11-L2 dermatomes may be able to achieve psychogenic arousal,[12] and individuals with SCI can develop erogenous zones in new locations at and above their lesion level, including the head or neck, torso, arms, and shoulders.[14][15]

There is a risk of autonomic dysreflexia (AD) on ejaculation in individuals with an SCI above T6. Autonomic dysreflexia can also be an indirect effect of SCI on sexual function.

Fertility challenges and reduced sperm quality are common.[11][16] Priapism—an erection lasting longer than 3 hours—might occur in individuals using certain therapies for erectile dysfunction. Priapism can permanently damage blood vessels in the penis. Males with SCI are also at a higher risk of penile bending (Peyronie’s disease) due to reduced or absent sensation in the penis.

Low levels of testosterone can affect sexual function and libido. Males with SCI can be at risk, and routine screening is recommended.[17] Testosterone replacement therapy should be considered,[17] and testosterone therapy combined with an exercise programme "appears to increase muscle size and strength in men with both complete and incomplete SCI".[18]

Erectile dysfunction is common.[7] Individuals with an SCI at or above T12 may get a reflex erection with stimulation, while those at or below T12 may have a psychogenic erection. Phosphodiesterase type 5 inhibitors (PDE5i) taken orally are recommended as the first choice treatment for erectile dysfunction in SCI, with a 70-80% success rate.[19][20]

Sexual and Reproductive Responses in Women with a Spinal Cord Injury

"Attending to the sexual health and sexual function of women living with SCI supports whole-person care for these women, which will improve clinical outcomes and decrease health care costs."[21]

Menstruation and Menstrual Products

The menstrual cycle may be interrupted in women after SCI, but it usually restarts within 3-6 months.

A woman's level of function and changes in sensation will determine what menstrual products she uses.[22] Tampons can be difficult to manage with changes in sensation, as it can be difficult to ensure proper placement of the tampon and its timely removal.[23] However, tampons typically do not cause skin irritation, and they can usually provide better protection from leakage during transfers.[7] Menstrual pads are a good option for a person with limited hand function,[23] but regular skin checks for signs of irritation and pressure marks between the legs are recommended.[23] Period underwear is another option, but it is important to check for pressure areas where the seams of the underwear touch the skin.[23] Menstrual cups are inserted into the vagina up around the cervix. They are not, however, the best option for people who catheterise from a wheelchair, due to the risk of spillage during removal.[23] Over-the-counter douche products and vaginal hygiene sprays are not recommended.

Sexual Function

Pathways for arousal may be blocked, but using a vibrator can help achieve orgasm. Sensation may be altered or lost, and vaginal lubrication may be affected. A water-based, non-petroleum lubricant, such as KY Jelly, can be used.

Fertility and Contraception

Fertility in females is not affected by SCI, and a normal pregnancy is possible. Birth control options include condoms, birth control pills, NuvaRing (a flexible vaginal ring), intrauterine devices (IUD), implanted hormonal devices, and Depo-Provera injections.

Some considerations apply. Birth control pills have been associated with an increased risk of blood clots, and individuals with a new SCI have a heightened risk of developing blood clots. This trend tends to decrease around 3 months post-injury—combination birth control is often not recommended within the first 3 months of injury, but could be an option after this time. With IUDs, individuals with an SCI may not be able to tell if the IUD is dislodged or if they have signs of infection, such as pelvic pain. Depo-Provera can cause a decrease in bone mineral density, which is significant as osteoporosis is a common comorbidity in SCI.[22][24]

Pregnancy and Delivery

Vaginal delivery is possible, but there is a risk of autonomic dysreflexia during labour.

Gynaecological Health

Women with SCI can experience general and specific gynaecological complications.[7] Some women may not experience symptoms or may not access care due to a lack of information. There is also a general lack of attention to reproductive and gynaecological healthcare for females with SCI, so these women might not receive preventative healthcare services. Physical or environmental barriers (e.g., inaccessible offices/a lack of information about gynaecological issues post-injury) may delay screening or diagnosis of gynaecological cancers or sexually transmitted infections. Routine gynaecological procedures and screening are important, and regular sexual healthcare, including annual pelvic exams, breast cancer screening, and education on menopause, is a priority for women with SCI.[7]

Indirect Effects of Spinal Cord Injury on Sexual Function and Reproductive Health

The indirect effects of SCI on sexual function and reproductive health include sensory and motor alterations, bladder and bowel changes, spasticity, fatigue, psychological difficulties, pain, autonomic dysreflexia, and changes in sexual self-view. Regarding sensory and motor alterations, it is important for individuals with SCI to avoid any forceful pressure when positioning their body for sexual activity; it is worth taking the time to experiment and find the best positioning.[7]

Iatrogenic Effects of Spinal Cord Injury on Sexual Function and Reproductive Health

Iatrogenic effects of treatment may have a significant impact on sexual health after spinal cord injury. Being informed about surgical treatment options and the side effects of medications can positively influence decision-making for sexual health issues, ultimately leading to a better quality of life for individuals with spinal cord injuries.

Examples of iatrogenic effects of treatment on sexual health in individuals with spinal cord injury:

  • failure of intracavernosal injections (ICI) can cause penile bruising, swelling and penile plaque formation at the injection site[25]
  • vacuum erection devices (VEDs) can cause ischaemic injury and subcutaneous haemorrhage due to over-vigorous VED suction[25]
  • baclofen for spasticity treatment can make it more difficult for males with SCI to have an erection[26]
  • antidepressant medications may reduce sexual desire[26]

Contextual Influences of Spinal Cord Injury on Sexual Function and Reproductive Health

SCI can cause changes to relationships and an individual's roles and responsibilities. There are also various everyday challenges associated with living with SCI. These changes can have an impact on an individual's sexual health.

  • Javier et al.[27] found that quality of life improvement in individuals with SCI is associated with improving sexual function
  • Barrett et al.[28] note that "sexual function and satisfaction are highly challenging areas for partners post-spinal cord injury"

Roles of Rehabilitation Professionals in Preserving Sexual Health for Individuals with Spinal Cord Injuries

"It is recommended that all persons working with people with SCIs understand the effects of SCI on sexual function."[7]

Occupational therapists can help to normalise sexual health as part of rehabilitation. They can provide information on adaptive devices for sexual activity, environmental controls, and adapted clothing.[29]

Physiotherapists are often the first rehabilitation professional clients see in the community. They can start the conversation on sexual health, show that sexual health is a normal part of rehabilitation and connect clients to relevant supports where required.[29]

Psychologists and counsellors are trained to address depression, anxiety, loss and grief, role changes, and relationship discord. These are common post-SCI issues, and they can significantly impact sexual health.[29]

Social workers can work with clients to find individual resources and support sources in the community to help clients achieve their sexual health and relationship goals.[29]

Recreational therapists can show individuals with SCI how to express themselves in new ways (e.g., through art, exercise, sports and dance). "This could affect a person’s sense of their sexual self in the world and how they are seen as a sexual person by others."[29]

Vocational rehabilitation therapists support an individual with SCI to return to work, start a new career or become a volunteer. Having a vocation can help a person feel a sense of purpose or wholeness.[29]

Assessment of Sexual Health in People with Spinal Cord Injuries

The assessment of sexual health and satisfaction after SCI must be comprehensive and cover the neurological components of sexual health dysfunction. There is, however, no single measurement tool that can be used to assess all aspects of sexual health and satisfaction after SCI.[30] The following are gold standard resources and assessments that can be used to assess sexual health after spinal cord injury.

International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI):[30]

  • comprehensive motor function and sensation assessment[31]
  • helps to determine the level and completeness of an injury, and these findings can be used to estimate sexual functioning[31]

International Standards to document remaining Autonomic Function after Spinal Cord Injury (ISAFSCI):[30][32]

  • helps describe the specific spinal cord lesion and records the impact of the injury on autonomic responses, including the sexual response
  • an individual is rated on a scale of 0-2 (0 = no function, 1 = impaired function, 2 = normal function) on their experience of the following: arousal, orgasm, and either ejaculation (in men) or sensation of menses (in women)
  • if an individual with SCI does not have the expected sexual function for their level and completeness of injury, any factors that may be interfering with function should be investigated, such as medication, spasticity, etc.

International SCI Data Sets on Male Sexual Function and Female Sexual and Reproductive Function:[33]

Sexual History and Physical Assessment

The sexual history and physical assessment should include the following:[7][34]

  • ask the person with SCI if they are interested in discussing sexual concerns and proceed accordingly
  • ensure that the individual is comfortable with the physical environment and level of privacy
  • ask questions that are direct and open-ended to facilitate discussion
  • obtain information on previous sexual trauma, sexual dysfunction, or sexually transmitted infections that could affect sexual function
  • consider each individual’s life context, including cultural, environmental, spiritual and social factors
  • assessment of the sexual reproductive system, including 1) examination of breasts and genitalia; 2) screening for cervical, ovarian, uterine, breast, prostate, and testicular cancers; 3) screening for sexually transmitted infections, including HIV/AIDS, where necessary and after consulting with the individual; and 4) counselling on the HPV immunisation when relevant
  • physical examination using the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury, checking for 1) preservation of sensation from T11-L2 and S2-5; 2) presence of voluntary anal contraction and reflexes
  • determine the impact of the SCI on an individual's sexual responses, such as genital responses
  • neuromusculoskeletal examination and functional assessment
  • the results of the sexual history and physical assessments can be used to develop a sexual education and treatment plan

Only appropriately trained healthcare professionals should undertake these steps. You must consider your scope of practice before performing any sexual health assessment.

Patient Sexual Education

When providing sexual education for individuals with SCI, professional boundaries must be maintained at all times. Consider the individual's age at the time of their SCI and their previous sexual experience. Discuss the effects of medication—including prescriptions, over-the-counter drugs, and herbal remedies or supplements—on sexual response and fertility, as well as the effects of alcohol, tobacco, other drugs, diet, and obesity.[34]

Changes in Sexual Function and Other Signs

It is important to note that loss of libido, poor concentration, fatigue, and changes in sleep or appetite can be associated with depression or other psychological conditions in individuals with SCI. In males with SCI, suppressed libido, reduced strength, fatigue, or an inadequate response to phosphodiesterase type 5 inhibitors (PDE5is) for erection enhancement can also indicate testosterone deficiency.[34]

Achieving Sexual Well-Being

To achieve a feeling of sexual well-being, people with SCI need to understand how their bodies function after injury.[35] Healthcare professionals must provide information and education in accordance with the individual’s needs and wishes, and individuals with SCI should be encouraged to explore different methods to enhance their sexual pleasure with appropriately trained health professionals. Information on the following points can help individuals with SCI achieve sexual well-being:[34]

  • methods to enhance sensuality, using all the available senses[36]
  • sexual assistive devices (i.e. sex toys) to improve sexual experience—these devices can be adapted for individuals with reduced mobility, but it is important to discuss cautions and contraindications and information on skin protection, prolonged penile constriction and dysreflexia[37]

Practical Considerations

Carrying out bladder and bowel care before sexual activity should be encouraged, and individuals with SCI should have a plan if incontinence occurs during sexual activity. Having a pressure injury (ulcer) does not prevent an individual with SCI from engaging in sexual activities, but they should be aware of strategies to reduce the risk of skin injury and avoid exacerbating a pressure injury. Individuals with SCI should check areas of skin that lack sensation, including the genitals and buttocks, immediately after sexual activity in case of excessive pressure, tears or friction.

Understanding optimal positioning during sexual activity is important to avoid arm or leg injuries. Sexual activity can change the level of spasticity and can cause autonomic dysreflexia, with or without symptoms—this is particularly common in individuals with injuries at T6 or above, and individuals must be aware that they need to modify sexual activity if they experience autonomic dysreflexia.

It is essential to practise safer sex to reduce the risk of acquiring or transmitting sexually transmitted infections. Individuals with SCI might need assistance from caregivers to prepare for sexual activity, and they should be empowered to ask for and receive this assistance.

Other considerations include specific spine precautions, environmental modifications, and optimal positioning and bed mobility tailored to the individual's injury. Safety considerations for sexual activity while in a wheelchair—each individual must understand the safety limits of their wheelchair. Similarly, safety considerations for sexual activity in the shower or while using shower equipment should be discussed, including care with the temperature of the water to avoid burns, the risk of falling or slipping, and weight limits for shower chairs. Note, there may be options for high-weight-capacity shower chairs.[34]

It is important to note that an individual's need for adaptive equipment might change as they and their partners get older.[34]

Resources

References

  1. ↑ Anderson KD. Targeting recovery: priorities of the spinal cord-injured population. J Neurotrauma. 2004 Oct;21(10):1371-83.
  2. ↑ Allen A, Heck M, Doig C, Cudmore T, Lawrence K, Mason J. Sexual rehabilitation support experiences of Australian adults living with a spinal cord injury. J Spinal Cord Med. 2025 May 5:1-10.
  3. ↑ 3.0 3.1 Zizzo J, Gater DR, Hough S, Ibrahim E. Sexuality, Intimacy, and Reproductive Health after Spinal Cord Injury. J Pers Med. 2022 Dec 1;12(12):1985.
  4. ↑ Sexual and Reproductive Health Following Spinal Cord Injury. Available from https://scireproject.com/wp-content/uploads/2022/04/Sexual-and-Reproductive-Health-Executive-Summary-Nov.20.18-1.pdf [last access 10.6.2024]
  5. ↑ Goel M, Mazzia C, Kosa SD, Harris A, Berndl A. Sexuality in people assigned female at birth with spinal cord injury: the challenges encountered. J Sex Med. 2025 Apr 15;22(4):562-569.
  6. ↑ Giurleo C, McIntyre A, Kras-Dupuis A, Wolfe DL. Addressing the elephant in the room: integrating sexual health practice in spinal cord injury rehabilitation. Disabil Rehabil. 2022 Jun;44(13):3245-3252.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 Oelofse W. Sexual Function and Reproductive Health after Spinal Cord Injury Course. Plus, 2024.
  8. ↑ 8.0 8.1 8.2 8.3 Alexander M, Courtois F, Elliott S, Tepper M. Improving Sexual Satisfaction in Persons with Spinal Cord Injuries: Collective Wisdom. Top Spinal Cord Inj Rehabil. 2017 Winter;23(1):57-70.
  9. ↑ SCIRE. Sexual Health After Spinal Cord Injury: 5 Guidelines. Available from: https://www.youtube.com/watch?gx4srylNCQU [last accessed 15/6/2024]
  10. ↑ Previnaire JG, Soler JM, Alexander MS, Courtois F, Elliott S, McLain A. Prediction of sexual function following spinal cord injury: a case series. Spinal Cord Ser Cases. 2017 Dec 13;3:17096.
  11. ↑ 11.0 11.1 11.2 Elliott S, Birkhäuser V, Courtois F, Gül M, Ibrahim E, Kiekens C, et al. Sexual and reproductive health in neurological disorders: recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024). Sex Med Rev. 2025 Oct 4;13(4):456-470.
  12. ↑ 12.0 12.1 Sensation, Ejaculation and Orgasm. https://scireproject.com/evidence/sexual-and-reproductive-health/sexual-and-reproductive-health-in-men/sensation-ejaculation-and-orgasm/ [last access 12.06.2024]
  13. ↑ Rider LS, Marra EM. Cauda Equina and Conus Medullaris Syndromes. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537200/
  14. ↑ Alexander CJ, Sipski ML, Findley TW. Sexual activities, desire, and satisfaction in males pre- and post-spinal cord injury. Arch Sex Behav. 1993 Jun;22(3):217-28.
  15. ↑ Anderson KD, Borisoff JF, Johnson RD, Stiens SA, Elliott SL. Long-term effects of spinal cord injury on sexual function in men: implications for neuroplasticity. Spinal Cord. 2007 May;45(5):338-48.
  16. ↑ Cohen N, Shoshany O, Ofran Y, Esh Broder E, Schrier I, Karavani G. Fertility preservation in males with spinal cord, pelvic, and other injuries potentially impacting male fertility. Injury. 2025 Dec;56(12):112819.
  17. ↑ 17.0 17.1 Schopp LH, Clark M, Mazurek MO, Hagglund KJ, Acuff ME, Sherman AK, Childers MK. Testosterone levels among men with spinal cord injury admitted to inpatient rehabilitation. Am J Phys Med Rehabil. 2006 Aug;85(8):678-84; quiz 685-7.
  18. ↑ Gorgey AS, Abilmona SM, Sima A, Khalil RE, Khan R, Adler RA. A secondary analysis of testosterone and electrically evoked resistance training versus testosterone only (TEREX-SCI) on untrained muscles after spinal cord injury: a pilot randomized clinical trial. Spinal Cord. 2020 Mar;58(3):298-308.
  19. ↑ Male Erectile Response and Enhancement. Available from https://scireproject.com/evidence/sexual-and-reproductive-health/sexual-and-reproductive-health-in-men/male-erectile-response-and-enhancement/ [last access 12.06.2024]
  20. ↑ Tienforti D, Felzani G, Di Pasquale AB, Barbonetti A. Which PDE5 inhibitor is the most effective in the treatment of erectile dysfunction in men with spinal cord injury? A systematic review and network meta-analysis. Andrology. 2025 Feb;13(2):314-322.
  21. ↑ Piatt JA, Simic Stanojevic I, Stanojevic C, Zahl ML, Richmond MA, Herbenick D. Sexual Health and Women Living With Spinal Cord Injury: The Unheard Voice. Front Rehabil Sci. 2022 May 6;3:853647.
  22. ↑ 22.0 22.1 Craig Hospital. Sexual function for women after spinal cord injury. Available from: https://craighospital.org/wp-content/uploads/sites/Educational-PDFs/786.Sexual-Function-for-Women-After-Spinal-Cord-Injury.pdf (last accessed 24 June 2024).
  23. ↑ 23.0 23.1 23.2 23.3 23.4 Menstruation after Spinal Cord Injury. Available from https://www.uhn.ca/TorontoRehab/Spinal-Cord-Rehab/Spinal-Cord-Essentials/Documents/General-Health/SCE2-Se1-Menstruation-after-SCI.pdf [last access 24.06.2024]
  24. ↑ Varacallo M, Davis DD, Pizzutillo P. Osteoporosis in Spinal Cord Injuries. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526109/
  25. ↑ 25.0 25.1 Afferi L, Pannek J, Louis Burnett A, Razaname C, Tzanoulinou S, Bobela W, da Silva RAF, Sturny M, Stergiopulos N, Cornelius J, Moschini M, Iselin C, Salonia A, Mattei A, Mordasini L. Performance and safety of treatment options for erectile dysfunction in patients with spinal cord injury: A review of the literature. Andrology. 2020 Nov;8(6):1660-1673.
  26. ↑ 26.0 26.1 Sexual Health After Spinal Cord Injury. Available from https://community.scireproject.com/wp-content/uploads/SCIRE-C.-Sexual-Health.-3-Download.pdf [last access 13.6.2024]
  27. ↑ Javier SJ, Perrin PB, Snipes DJ, Olivera SL, Perdomo JL, Arango JA, Arango-Lasprilla JC. The influence of health-related quality of life on sexual desire in individuals with spinal cord injury from Colombia, South America. Sex Disabil. 2013;31(4):325–335.
  28. ↑ Barrett OEC, Ho AK, Finlay KA. Sexual function and sexual satisfaction following spinal cord injury: an interpretative phenomenological analysis of partner experiences. Disability and Rehabilitation 2022; 46(1): 86–95.
  29. ↑ 29.0 29.1 29.2 29.3 29.4 29.5 Spinal Cord Injury Research Evidence (SCIRE) Professional. Clinical focus: multidisciplinary approach to sexual and fertility rehabilitation. Available from: https://scireproject.com/evidence/sexual-and-reproductive-health/sexual-education-and-counselling/clinical-focus-multidisciplinary-approach-to-sexual-and-fertility-rehabilitation/ (last accessed 24 June 2024).
  30. ↑ 30.0 30.1 30.2 Spinal Cord Injury Research Evidence (SCIRE Professional). Data assessment tools for sexual function. Available from: https://scireproject.com/evidence/sexual-and-reproductive-health/sexual-health-assessment/data-assessment-tools-for-sexual-function/ (last accessed 21 June 2024).
  31. ↑ 31.0 31.1 American Spinal Injury Association Impairment Scale (AIS): International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Available from https://scireproject.com/outcome/ais/ [last access 13.06.2024]
  32. ↑ Krassioukov A, Biering-Sørensen F, Donovan W, Kennelly M, Kirshblum S, Krogh K, Alexander MS, Vogel L, Wecht J; Autonomic Standards Committee of the American Spinal Injury Association/International Spinal Cord Society. International standards to document remaining autonomic function after spinal cord injury. J Spinal Cord Med. 2012 Jul;35(4):201-10.
  33. ↑ International SCI Data Sets. Available from https://www.iscos.org.uk/page/Int-SCI-Data-Sets [last access 13.06.2024]
  34. ↑ 34.0 34.1 34.2 34.3 34.4 34.5 Consortium for Spinal Cord Medicine. Sexuality and reproductive health in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med. 2010;33(3):281-336.
  35. ↑ Kreuter M, Siösteen A, Biering-Sørensen F. Sexuality and sexual life in women with spinal cord injury: a controlled study. J Rehabil Med. 2008 Jan;40(1):61-9.
  36. ↑ Hess MJ, Hough S. Impact of spinal cord injury on sexuality: broad-based clinical practice intervention and practical application. J Spinal Cord Med. 2012 Jul;35(4):211-8.
  37. ↑ Sexual Aids. Available from https://askus-resource-center.unitedspinal.org/index.php?pg=kb.page&id=3523 [last access 24.06.2024]
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