There are four primary psychological reasons for the emergence of sexual dysfunction.

Chief among them is the fear of re-injury. The patient feels that sexual behavior can put them in harm’s way, that the more vigorous their sexual activity, the more likely they are to exacerbate their problems, sustain increased damage and/or postpone the recovery process. This is similar to that which we see in those patients who have recently had a cardiac event. They believe that the increased heart rate associated with sexual activity will evoke a second myocardial infarction and that this "next one will be" fatal.

A second but obvious cause of sexual dysfunction after back injury is associated with mechanical pain. Simply put, it hurts no matter what position is used during the sexual activity that precedes and includes orgasm, and this pain lingers on after sexual activity. Remember that these patients often describe the simple task of lying in bed, standing by the sink or walking to the mailbox to be exquisitely painful. Avoidance of sexual contact is a means of minimizing pain.

Thirdly, patients also entertain a range of false beliefs regarding their spinal problems. They may hear frightening tales from patients in the waiting room of bladder or bowel incontinence. They may assume that problems with erection, ejaculation and/or orgasm are commonplace, and that concern then becomes an expectancy associated with anxiety; the sexual problems become a self-fulfilling prophecy: "I am afraid this will happen", insuring that it does occur.

A fourth consideration is that sexual problems may have been emerging for a variety of physical and psychological reasons over the months preceding the injury. The injury becomes an additional factor incorporated into the emerging sexual problem. The patient focuses upon the more explicable spinal complaint as a way of accounting for a sexual problem. This overlapping problem is similar to that which occurs in depressed patients who become injured and then attribute their depression solely to the injury.

But I would also like to draw your attention to a fifth possibility which actually may be the most common of all: the spinal complaint that solves a patient’s relationship conflicts.

Sex is not only a means of expressing a relationship; it is a means of rebelling against it. After an injury, a patient who feels unsupported and resentful of their partner now has an effective means of expressing that discontent by sexual incapacity, sexual unavailability, and sexual indifference. An unappreciative, uncaring and perhaps previously sexually unfaithful mate suddenly becomes (through guilt) attentive, concerned, apprehensive and nurturant. They may also become resentful, embittered and demanding. Sexual deprivation of a partner can be an effective, passive-aggressive means of controlling their mate.

Additionally, for a patient with a previously healthy sex life, or a relationship based more upon physical than emotional ties, the compromise necessitated by injury may create fear of abandonment. The injured one often translates this fear into suspicion, questioning fidelity and devotion. Fears of being seen as unattractive and undesirable then contributes to depression and increased marital strife.