A spinal cord lesion is a catastrophic event. There is an abundance of therapies for this group of mostly young patients: physiotherapy, water therapy, psychotherapy, you name it. But sex therapy is not on the list. Not only many professional helpers, but family members and others believe the patient will never again have a sex life. The unspoken ques­tion they are asking themselves is to what extent someone can love such a badly injured body.

The writer D. H. Lawrence (1885-1930) takes this as his theme in his once shocking but now classic novel Lady Chatterley’s Lover (1928). The main character’s husband is a war invalid, who at the age of 29 suffered a complete spinal cord lesion. His wife is six years younger. It so happens that the husband, Clifford, proved emotionally cold even before his injury. With great artistry Lawrence describes Lady Chatterley’s passionate relationships: first with Michaelis, whose ‘pathetic two-second spasms’ cannot ultimately satisfy her, and later with Mellors, the gamekeeper, the embodiment of the natural male element and the complete antithesis to her wheelchair-bound husband.

Particularly in the initial post-traumatic phase many spinal cord le­sion patients see sex as a closed chapter, something that is no longer compatible with their badly damaged body image. At a later stage spas­ticity or stiff joints may hamper sexual activity, and there may also be involuntary loss of urine during sex, especially if the bladder is not emptied in advance. One positive aspect is that new erogenous zones may develop, such as nipples, neck, earlobes or the skin in the transi­tional area between those parts of the body with and without sensation. Sexual need is particularly great among these patients without a part­ner. That need is catered for, for example, by the TLC Trust (www. tlc- trust. org. uk), which provides counselling and sexual services, and by discussion forums for the disabled like that at www. thesite. org.

A new technique, still in its infancy, is a neurological bypass. This involves an operation to redirect a nerve from the groin to the head of the penis, which requires the damage to the spinal cord to be below the point where the inguinal nerve branches off from the spinal cord, that is, below the first lumbar vertebra. The operation was first per­formed in the Netherlands with spina bifida patients. It often takes at least six months before any kind of sensation returns and it may take two years before it is possible to assess how pleasant that sensation is. The brain has to learn that signals are no longer coming from the groin, since at the beginning a touch to the glans is registered in the groin. The man himself has to begin to (re)associate the sensation in the penis with sex.

If there is a partner and she is responsible for most of the care, that may be to the detriment of the sense of their being lovers. Friction between partners, one of whom is handicapped, often relates to that care. ‘If you have a row with your wife and half an hour later you have to ask her to put you on the toilet, it’s no joke,’ as one spinal cord lesion patient told me. Experts advise that the seriously handicapped are best cared for by a professional rather than by the partner, which is a way of preventing the carer-patient relationship from coming to replace love and friendship.

Partners wanting to end a relationship with a spinal cord lesion patient may feel a certain guilt, which can lead to the postponement of that decision. This may stem from a feeling of responsibility and concern about what will become of the invalid partner. It is important to distin­guish love and pity: in the view of some psychologists staying with some­one out of pity is a mistake. Others believe that love can develop into empathy: the sense of experiencing and sharing the other’s suffering. That does not detract from the fact that it can be a very hard decision, especially if those around one take the side of the person left behind. Lady Chatterley chose to leave after she become pregnant with Mellor’s child and her husband refused a divorce – and who can blame her?