course material

1. Sexuality and Amputation
Sexuality and AmputationAn approximate number of 160,000 represent the amputations
performed per year in the United States (Bodenheimer et al, 2000). A majority of these
amputations involve lower extremity removal. Common factors or complications that lead
to amputation include cancer, trauma, and congenital limb deficiency. The most common
factor, though is, peripheral vascular disease complications. After these amputations, the
amputees face major adjustments in their emotional, social, and physical aspects. Their
sexuality is also expected to change depending on a couple of factors. Not much research
has been done on changes in sexuality as a result of amputation. Most sexual cultural scripts
prefer to exclude people with physical imperfections. It is sometimes viewed as devaluing
or demoralizing the individual in question. The society also tends to have a general
prejudice towards physically imperfect and disabled persons considering them to be
unworthy of affection especially one that closely relates to sexual activity. In this paper, the
effects of amputation on the sexuality of the amputee will be observed. Related aspects such
as psychological impacts, perception and actual facts on amputees and the availability of
counseling and rehabilitation options for theses individual will be evaluated.Lower-
extremity amputation (LEA) has some outcomes on the functional ability of a person.
Concentrating on the geriatric population it has been observed that the goals and needs
were necessary in measuring the functional outcomes of the patient. Personal care,
recreation, vocational tasks, and household activities are examples of the most appropriate
measures that can be used in geriatric amputees. Although, prosthesis is considered as the
universal measure for functional outcomes, these other measures play an equally important
role in geriatric amputees. The overall functional ability depends on the emotional,
psychological, economic and physical factors therefore each of these components need to be
considered when determining goals for and measuring of a LEA geriatric person (Geertzen
et al, 2009).Abnormality arising in the blood vessels and affecting any part or organ of the
body other than the heart is referred to as a peripheral vascular disease. It can affect blood
supply to and from major organs in the body and peripherally in case of extremities. The
disease causes delayed healing of wounds and also gangrene. Arteriosclerosis (AS) is a PVD
that mostly leads to major LEA. AS is characterized by thickening, narrowing, and loss of
elasticity of the arterial vessels followed by decreased flow of blood to the tissues. 80% to
90% of amputations can be attributed to peripheral vascular disease and of more than half
of all the non-traumatic cases of LEA in the United States arise from individuals with
diabetes (Levin, 2004). There are other PVDs that may lead to LEA such as chronic venous

2. sufficiency (CVI) and Buerger’ s disease. The amputation that results from PVDs is
recommended because of tissue necrosis. Advanced technology has introduced tools such as
arterial reconstruction, peripheral arterial bypass grafting and balloon angioplasty to
prevent lower-extremity amputation. Diabetes individuals, however, do not seem to be
helped by these procedures. The elderly population is especially affected by a series of
impairments that may lead to functional limitations for instance, hypertension, arthritis,
visual impairment, and heart disease.During the rehabilitation process of amputees,
professionals get an opportunity to address the issue of sexuality since in normal
circumstances sexual issues of people with physical disability are avoided. There are two
viewpoint that can be used to analyze the sexuality of LEA individuals namely; sexual
concern and sexual function. Since limb amputates have their sexual function preserved,
their sexual life has not been broadly researched. Compared to studies on persons with
central nervous system impairment, very few published studies can be found on sexuality of
people with LEA.Discussing the sexuality of people with a disability is significant especially
in re-integration. Although the methodologies utilized in the rehabilitation process vary
depending on social backgrounds, cultural backgrounds and generations, the purpose of
rehabilitation remains the same all over. Rehabilitation aims to reduce the barrier between
people with a disability and the social or physical circumstances that surround them (Levin,
2004). The sexual life of these people is one such circumstance that has to be addressed and
barriers to it reduced considerably. An example of how circumstances affect the sexuality of
persons with a disability is the financial strain, lack of physical capability for employment
and lack of satisfaction with working life. These two elements, the psychological and
physical aspects, ultimately influence the sexual performance of the individual. This sexual
part of the person can also be influenced by their partner’ s sexual performance. It is
therefore important to apply the concept of sexual life of the individual during re-
integration.During rehabilitation there are several factors that have hindered discussions
on sexuality. Many cultures view sexuality as a shameful and immoral topic. Also there is a
general view in both persons with or without disability that this topic can only be discussed
between the two sexual partners. The sexual function and sexual concern of a person with
disability remains a delicate topic and one that most professionals are not yet willing to
incorporate into their rehabilitation process. Every individual with a particular disability
suffers from particular restrictions in his or her daily life to a certain extent. The functional
limitation of the sexual activity of a disabled person has mostly been addressed in terms of
penile erection or ejaculation and pregnancy and delivery in women. The issue of fertility
and pregnancy in people with disability has been widely researched and technical
advancements made to solve the problems underlying in these aspects of life. The functional
aspect of sexuality is possibly easier to discuss than the concerns that arise regarding the
sexuality of a person with a disability. Of the studies published on sexuality of people with a
physical disability, victims of spinal cord injury comprise the most studies.Studies on
victims of lower limb amputation show that most males suffered some penile erection
trouble. The sexual function may be affected by for instance the psychological trauma.
Although most of the other physical disabilities have been researched regarding the
sexuality of the victims, lower limb amputation has had little studies published regarding it.

3. One reason to this is that the sexual function of these individual is rarely impaired. Also the
fact that prosthesis compensates for the loss of physical function in limb amputees, medical
care is terminated after fitting of another limb hence no more consultations with the
medical professionals. Additionally, the limb amputees enjoy a more independent life
compared to other individuals with physical disabilities. Their physical performance is
better and the only advice they require often is technical advice only from rehabilitation
professionals. A 2000 study by Bedonheimer found that interest in the sexual life in limb
amputees remained high despite the various other problems caused by the loss of a physical
part (Bodenheimer et al, 2000). Also evidence of increased anxiety and depression was
absent. A 1998 study on limb amputees with a majority of elderly individuals found that
43.5% of the participants had talked of their sexual life with someone (Walter and
Williamson, 1998). None of the participants indicated that they had talked to a medical
professional but rather they talked to their spouse or a friend.The study also found that the
number of people with limb amputation who engaged in sexual activities was higher than
those of other physical disabilities. 51 of the 85 respondents engaged in intercourse, 18
kissed and 17 caressed. The quality of sexual life is therefore the concern. 42.4 percent
answered that their sexual life had changed after the amputation. Twenty-six of those who
gave this answer noted that their libido had reduced. These findings are consistent with
those of other studies.On a six point scale, the sexual satisfaction of the respondents was
investigated. Taking 1 to mean ‘ very dissatisfied’ and 6 to mean ‘ very satisfied’ , those
with a partner tended to incline towards 6 while those without a spouse leaned on the side
with 1. The site of amputation (either lower or lower limb) and the cause of amputation
(either non-traumatic or traumatic) did not seem to impact on the sexual satisfaction of the
respondents. The body image of limb amputees is very core in determining their reaction to
sexual and other aspects of their life. How they view themselves and how others view them
in this new body plays a very big role in determining their confidence to engage in sexual
activity or even perform sexually. One reason that illustrates the need for studies on the
body image of limb amputees is the reduced libido experienced after amputation as
reported a number of respondents. Also the loss of a body part makes the limb amputees a
unique body image when compared to the body image of patients who have other types of
physical handicaps. Since a sexual life largely depends on having a partner, a narrow
outlook may strongly impact on the sexuality of a person with limb amputation (Atherton
and Robertson, 2006). The limb amputee might also feel embarrassed to show their
amputated limb to their partner or spouse.The medical professionals should recognize the
needs of the amputee with regards to their sexuality. In the past, amputation surgery and
the rehabilitation process were the key interests that medical professionals focused on. The
quality of life of limb amputees has only recently been embraced and more research has to
be done to determine how issues relating to their quality of life should be addressed such as
their sexuality. Some limb amputees cling to the hope that a newly developed prosthesis
could help improve their sexual life. It is not to be concluded yet as to the particular steps
that could be followed in solving sexuality issues in them but the rehabilitation process
presents a perfect avenue to introduce strategies and counseling sessions addressing the
sexuality of limb amputees.A 1999 study by Bodenheimer includes several other aspects of

4. the sexuality of limb amputees. Sexual fantasy is one of the additional aspects. It was found
that eighty five percent of the participants fantasized at least once per month. On sexual
arousal, only thirty three percent of the subjects reported to have normal arousal whereas
the others had varying problems in the issue of arousal. 67% of the participants stated that
they experienced moderate to high interest in sex and 63% were moderately to highly
satisfied with their relationship with their sexual partner. It is important to note that 90%
percent of the questioned individuals expressed the desire to engage in sexual intercourse
more than one time in a month. The common reasons given for having problems with sexual
activity were lack of interest from the subject, lack of a partner and performance anxiety.
However, the most common reason was side effects of medication. The subjects in the study
also took part in a sexual position evaluation whereby the sexual position that they used
was indicated. The ‘ subject supine’ was discovered to be the most used position followed
by the missionary position and finally the sidclying position. There was no significant effect
of pain on the various aspects of sexual functions. Depression and anxiety were not noted to
affect the sexual functioning of the subjects. Age is also another factor that was found to
affect sexual functioning. Those above 65 years of age were found to experience more
sexual problems compared to their younger colleagues (Bodeinheimer et al, 2000). The first
few months after amputation were characterized by reduced or no engagement in all the
other sexual domains except sexual fantasy. Some rehabilitation institutions such as
Riverside rehabilitation institution have embarked on a project to offer sexual counseling
and rehabilitation programs aimed at addressing the sexual concerns of amputees. Also
there are several online sites that have embraced the need to provide awareness and
information on ways to deal with the sexual problems arising from amputation one such
site is the sexsupport.org website.Generally when looking at the sexuality of lower limb
amputees as studied in the above two and other studies, it is apparent that the quality of life
is the key issue when the sexuality of limb amputees is raised. Other than the sexual
functioning and sexual concerns of the patients, the psychological element is a matter that
affects the amputees very much. Since they have not lost their sexual function, any problems
arising from the amputation therefore is mostly related to their psychological state
(Geertzen, 2008). The psychological adjustment to lower limb amputation can be addressed
by looking at the depressive and anxious reactions, social discomfort, sense of self and
identity, social functioning and body-image anxiety.Some patients have been known to use
their prosthesis less and to have lower levels of mobility due to depression shortly after
amputation. Poor self related health, more feelings of vulnerability and increased levels of
activity restriction have also been observed from depression in long-term amputations
(Houston, n.d.). Mixed findings have been yielded in a number of researches with some
associating an increase in depression with the amputation and other finding no evidence of
increased levels of depression after amputation. Age has also been pointed as a determiner
as to the adjustment rates and levels after amputation. There is also the factor of time
period after the amputation. The most studies carried out have been on depression 2 to 10
years after amputation. A depression reaction is very common in the initial phase after
amputation. Comparatively higher levels of depression have been found in people who have
lost limbs averaging 2 years. However, there is a decrease in the depression rates in the 2 to

5. year post amputation range. The 10 to 30 years post amputation range has mixed findings.
Some findings indicate elevated rates of depression whereas others show normal levels of
depression. Depression reaction should therefore not be generalized as evidenced rather it
should be understood that different ages, different measurement instruments and different
etiologies give varying results hence specification is necessary.Another measure of
psychosocial adjustment to amputation is anxiety. Findings on anxiety are considered more
straightforward compared to the mixed ones found in evaluating levels of depression
(Lindau et al, 2007). Using the Rorschach tests, a majority of the soldiers subjected to the
study indicated increased levels of anxiety in the period shortly after amputation. Other
studies during year after amputation also gave the same findings of increased anxiety.
However, the levels of anxiety of amputees were similar to those of the general population
when they were tested on an average of 2 to 20 years after amputation. Anxiety is therefore
seen to appear in immediate post amputation and up to one year after amputation.Lower
limb amputees also have to cope with the changed body image. In defining body image the
core elements are the psychological experiences, attitudes and feelings relating to the form,
function, desirability, and appearance of the body of an individual influenced by
environmental and individual factors (Ziegler-Graham et al, 2008). Low levels of self
esteem, poor perceived quality of life, depression and elevated levels of general anxiety
have been found to increase body image anxiety in amputees.Another measure of
psychological adjustment is social discomfort and social functioning. More to the physical
limitations, lower limb amputees have to adjust to the idea that they look different from
other people. They shift from the group of normal and physically able to a group of
disability and possible stigmatization. This disability leads them to be treated differently by
the non-disabled. For instance, the non-disabled people often consider the disability of the
disabled individual as the core aspect of their personality and functioning and forget that in
most cases the disability is just one facet of the disabled individual’ s life. The amputee is
bound to have negative experiences that will lead him or her to conclude that the
amputation was a negative occurrence in their life. An example is being avoided by those
without disabilities as they fear saying something that will offend the disabled person or
because they experience unease and general anxiety in the presence of the disabled person.
Social problems such as difficulty in participating in social activities were found in older
individuals and amongst younger amputees, a particular study found that almost half of the
subjects in the study visited relatives and friends less frequently (Reinstein et al, 1978).
Two thirds of the participants in the study were also found to go to the cinema, library,
theater, dances, shows and sports events rarely. There is a direct association between social
discomfort and activity restriction. Public self conscious individuals were found to be often
restricted to engage in household chores, shopping activities and visiting friends in a certain
study. Depression can be a mediator to this relationship between social discomforts and
reduced social functioning.Although not wholly, following an amputation the self identity
and sense of self of an amputee is bound to change. The amputee is forced to adjust to the
new person that he or she has become. In the early phases after the amputation, the
amputee feels vulnerable, empty and mutilated (Stein, 2007). Time helps to open the eyes of
the amputee to the possibility of adjusting to the new limitations and restrictions. The

6. amputee is faced with the requirement to establish a new self based on the new limitations
and restrictions on him or her.There are several factors that are associated with
psychological adjustment in lower limb amputation persons. The cause of amputation is one
such factor which categorizes amputees into trauma amputees and non-trauma amputees.
Denial is the most common emotion displayed by trauma victims after amputation while
anger and hostility are emotions shown by non-trauma amputees after amputation.
However, there are some studies that have found no relation between cause of amputation
and psychological outcomes of the amputation.Level of amputation is another factor in
determining the rate and success of rehabilitation. An example to illustrate this is a study
that found that as the level of amputation increased, use of prosthesis decreased
(Williamson, n.d.). A possible explanation would be that an above the knee prosthesis would
require more energy to operate compared to a below the knee prosthesis. Above the knee
amputations have been found to result to poorer rehabilitation outcomes and increased
levels of activity restrictions.The time since amputation matters a lot when looking at the
psychological outcomes. There are some findings that consider there to be no relationship
between time since amputation and depressive symptoms. In those that a relationship has
been found, a more favorable outcome was observed with the increase in time since
amputation (Ide, 2002). Phantom limb pain, stump pain, prosthesis, age, marital status, and
social support are other factors that are considered to be associated with psychological
adjustment.Although initially the levels of depression and anxiety are higher, they decline
thereafter and conform to the levels of the general population. Social discomfort and body
image anxiety, though, have been found in some amputees possibly due to poorer
adjustment in terms of more activity restriction, anxiety and depression (Ide, 2004). Factors
that have been associated with better coping with psychological adjustment to amputation
include, higher levels of social, partner and family support, higher levels of satisfaction with
prosthesis, more time since amputation and an optimistic personality.Psychodynamic
explanations in the past perceived phantom limb pain to be the evidence of
psychopathology in lower limb amputees. It was considered that phantom limb pain
constituted denial through activity in people who have had lower limb amputation. There
are studies that have associated phantom limb pain to body image anxiety citing that more
body anxiety was present in people with phantom limb pain. In addition there has been
established a relationship between phantom limb pain and stress (Hogan and MacLachlan,
2004). However, there is nature of relationship between phantom limb pain and
psychological distress has not been precisely found.Stump pain could be associated with the
well-being of the individual psychologically. It could also be related directly with
depression. The studies carried out on the relationship between stump pain and
psychological outcome have found that stump pain leads to less satisfactory outcome during
rehabilitation. The negative impact of stump on rehabilitation and mobility could cause
depression and anxiety since the activity restrictions have increased.Prosthesis is also a
factor associated with psychological adjustment. Prosthesis can play a major role in helping
individual regain mobility and independent functioning and therefore reducing physical
limitations. As a result of the inter-relation of depression with activity restriction,
prosthesis can therefore impact on the emotional well-being of an amputee (Bodenheimer,

7. 1996). Prosthesis could also reduce body image anxiety as prosthesis reduces the extent of
alteration in body image. In additional to fulfilling certain functional needs, prosthesis plays
a role in concealing the amputation and restoring a normal or former body image in the
individual.The sociademographic factors (age, gender and marital status) also relate with
the psychological adjustment significantly. Psychological well-being following amputation
has been found to not be affected by gender. In the studies that gender has been found to
have an effect on the psychological outcome, the outcomes have been found to be more
positive on men than on women. Depression, low scores on emotional adaptation to role
changes and poor performance on emotional adaptability have been found to be more
prevalent in the studies (Houston, n.d.).Some studies find no relationship between age and
psychological well-being of amputees. In those that have found effects of age on
psychological well-being, older people tend to be favored than young people. Adolescents in
the studies were found to feel self-conscious about their body and to get upset and bothered
due to the stares they get from people and the questions they get asked concerning their
amputation. Education level and income level are other variables that could be associated
with the psychological adjustment in lower limb amputation (Lindau et al, 2007).Looking at
social support requires three theoretical constructs to be created. Support appraisal,
support network resources, and supportive behavior are the three constructs. Supportive
behavior in most studies is viewed to improve adaptability and give positive rehabilitation
outcomes. Support network resources and support appraisal were also found to impact on
the psychological outcomes of the subjects in a similar way as supportive behavior but not
as much.In conclusion, Lower limb amputation is not a new complication in the United
States. Approximately 160, 000 people undergo an amputation every year. Most of these
amputations are lower-extremity amputation. Following the amputation, many things tend
to change in the daily life of the amputee. Sexuality is one among the many life aspects of the
amputee that are bind to change. However, the issue of sexuality has not been addressed by
medical professionals much as in most cultures sexuality is a shameful, immoral, and
personal topic. Most amputees in various studies have been found to prefer to talk to their
friends, or partners about their sexuality and not even one individual reported to have
talked to a medical professional regarding their sexuality. The most common sexuality
aspect that has been addressed in lower limb amputees is fertility and pregnancy. However,
given the sexual problems that arise from amputation it is recommendable that more
studies be carried out on sexuality in lower limb amputees and recommended actions be
applied in the rehabilitation process. Compared to other disabilities, lower limb amputation
preserves the sexual function of the individual. This therefore means that the sexual
problems arising from the amputation are psychological and not health related. It is hence
important to look at the psychological adjustment of lower limb amputation in order to
have a clear picture of the changes expected of the amputee. The common measures of
psychological adjustment include the anxiety reactions, depression reaction, social
functioning, social discomfort, body-image anxiety, sense of self and self identity. There are
also factors associated with psychological adjustment including.References:Atherton, R. and
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