Next Article in Journal
Comparative Long-Term Cardiovascular Outcomes of Empagliflozin and Dapagliflozin in Heart Failure Patients After Coronary Revascularization: A Retrospective Cohort Study
Previous Article in Journal
Recognizing Catatonia Beyond Hypokinesis: Features Linked to Underdiagnosis and Training Targets
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
JCM
Volume 14
Issue 23
10.3390/jcm14238380
jcm-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

The Hidden Burden of Sexual Dysfunction and Healthcare Service Gaps in Tunisian Spinal Cord Patients: A Cross-Sectional Study

by
Ines Loubiri
1,2,
Ismail Dergaa
3,
Habib Hajji
1,2,
Halil İbrahim Ceylan
4,*,
Mariem Gaddour
1,2,
Nourhene Dridi
1,2,
Hela Ghali
2,5,
Valentina Stefanica
6,* and
Sonia Jemni
1,2
1
Faculty of Medicine of Sousse, University of Sousse, Sousse 4000, Tunisia
2
Physical Medicine and Rehabilitation Department, University Hospital Sahloul, Sousse 4054, Tunisia
3
High Institute of Sport and Physical Education of Ksar Said, University of Manouba, Manouba 2010, Tunisia
4
Department of Physical Education of Sports Teaching, Faculty of Sports Sciences, Atatürk University, 25240 Erzurum, Türkiye
5
Department of Preventive and Community Medicine, University Hospital Sahloul, Sousse 4054, Tunisia
6
Department of Physical Education and Sport, Faculty of Sciences, Physical Education and Informatics, National University of Science and Technology Politehnica Bucharest, Pitesti University Center, 060042 Pitesti, Romania
*
Authors to whom correspondence should be addressed.
J. Clin. Med. 2025, 14(23), 8380; https://doi.org/10.3390/jcm14238380
Submission received: 8 October 2025 / Revised: 4 November 2025 / Accepted: 19 November 2025 / Published: 26 November 2025
(This article belongs to the Section Clinical Rehabilitation)
Browse Figures
Versions Notes

Abstract

Background/Objectives: Spinal cord injury represents a devastating neurological condition affecting approximately 27 million individuals globally, with particularly severe impacts on sexual function. Sexual dysfunction in SCI patients is multifactorial, with prevalence rates reaching 80–90% across different populations. In low- and middle-income countries, sexual health remains critically neglected in rehabilitation settings due to cultural barriers, inadequate healthcare infrastructure, and limited clinician training. Tunisia, with an estimated 31,000 SCI cases, lacks comprehensive data on sexual dysfunction prevalence and healthcare communication patterns in this vulnerable population. Based on identified research gaps, our study aimed to (i) assess the prevalence and severity of sexual dysfunction among Tunisian SCI patients using validated assessment tools, (ii) identify clinical and demographic factors associated with sexual dysfunction, and (iii) evaluate the current state of sexual health communication and rehabilitation services. Methods: A cross-sectional observational study was conducted at Sahloul University Hospital, Sousse, Tunisia, between July and September 2025. Fifty-one adults with chronic SCI (≥12 months post-injury) were recruited through consecutive sampling. Sexual function was assessed using the International Index of Erectile Function (IIEF) for men and the Female Sexual Function Index (FSFI) for women. Additional assessments included demographic data, injury characteristics using the American Spinal Injury Association Impairment Scale, pain evaluation, functional status, psychological well-being, and sleep quality. Statistical analysis included descriptive statistics, Spearman correlations, and significance testing (p < 0.05). Results: Sexual dysfunction affected 84.3% of participants (43/51), with 88.5% of men experiencing moderate-to-severe erectile dysfunction (median IIEF: 12 [7–36.25]) and 80% of women reporting sexual dysfunction (median FSFI: 7.2 [4–24.25]). Severe dysfunction (FSFI ≤ 10) was present in 56% of female participants. Sexual dysfunction correlated significantly with urinary incontinence (p = 0.045) and with measures of functional independence, including SCIM-III (ρ = 0.466, p = 0.016) and FIM (ρ = 0.569, p = 0.002) among men, and SCIM-III (ρ = 0.469, p = 0.018) and FIM (ρ = 0.495, p = 0.012) among women, indicating moderate positive associations between sexual and functional outcomes. Only 11.5% of men achieved normal erectile function (IIEF ≥48). Psychological factors (HAD-S) and pain scores (NRS, DN4) were not significantly associated with sexual function. A total of 92% of patients reported never discussing sexual health with their healthcare providers, and 100% lacked access to dedicated sexual rehabilitation services, underscoring severe care and communication gaps in the Tunisian SCI rehabilitation system. Conclusions: Sexual dysfunction is highly prevalent among Tunisian spinal cord injury patients and is closely associated with reduced functional independence and urinary issues. Despite its significant impact, sexual health remains largely neglected in rehabilitation care. These findings highlight an urgent need to integrate sexual health into national rehabilitation protocols through provider training, multidisciplinary services, and culturally sensitive education. Systematic sexual health assessment and rehabilitation should be considered essential to improving the quality of life and restoring dignity for affected individuals.

1. Introduction

Spinal cord injury represents one of the most significant neurological conditions affecting human health, with a global incidence estimated at 40 to 80 new cases per million people annually, translating to approximately 250,000 to 500,000 new cases worldwide each year [1,2,3,4]. The condition predominantly affects young adults aged 16–40 years, with males constituting approximately 75% of cases and traumatic injuries accounting for 70% of all SCI cases, contributing over 4.5 million years lived with disability annually [1,2].
Regional variations reflect profound differences in healthcare infrastructure, trauma prevention measures, and rehabilitation services, with low and middle-income countries (LMICs) demonstrating concerning patterns of systematic underreporting that likely mask the actual burden due to fragmented healthcare systems [5,6]. The economic impact extends beyond individual suffering, with lifetime costs exceeding $1.5 million per case in developed countries, while LMICs struggle with inadequate resources for comprehensive care delivery [5,7,8].
Sexual dysfunction following SCI represents a multifactorial condition involving complex physiological, psychological, and social factors that profoundly impact quality of life and interpersonal relationships [9,10]. The neurophysiology of sexual function depends on intricate coordination between the autonomic and somatic nervous systems, with specific neural pathways mediating different aspects of sexual response through complex interactions involving sympathetic, parasympathetic, and somatic innervation [10,11]. In men, injuries above T10 typically preserve reflexogenic erections through intact sacral parasympathetic pathways (S2–S4). In contrast, psychogenic erections, mediated by sympathetic thoracolumbar pathways (T11-L2), are commonly compromised, resulting in varied dysfunction patterns depending on the lesion level and completeness [12,13]. Women with SCI frequently experience reduced vaginal lubrication, anorgasmia, and dyspareunia due to disruption of both sympathetic and parasympathetic innervation, with additional complications from autonomic dysfunction affecting cardiovascular responses and genital blood flow [14,15]. The prevalence of sexual dysfunction is consistently high across populations, with studies demonstrating dysfunction rates of 80–95% among men and 70–85% among women, representing one of the most universal consequences of SCI regardless of cultural or geographic context [10].
Despite the overwhelming prevalence and devastating impact on quality of life, sexual health remains critically marginalized within SCI rehabilitation programs worldwide, with particularly severe neglect in LMICs, where cultural stigma, limited healthcare resources, and inadequate provider training compound existing challenges [16,17]. Healthcare communication barriers represent perhaps the most significant obstacle, with studies consistently demonstrating that 70–95% of patients report never discussing sexual concerns with healthcare providers during rehabilitation, stemming from provider discomfort, lack of training, time constraints, cultural taboos, and absence of structured protocols for sexual health screening [18,19]. These communication gaps are exacerbated in traditional societies where sexual topics remain highly stigmatized, creating additional barriers for both patients and healthcare providers who lack culturally appropriate tools and training for addressing sexual health concerns [20,21,22]. The situation in Tunisia and the broader North African region exemplifies these global challenges, compounded by conservative cultural attitudes, healthcare system limitations, and the complete absence of specialized sexual medicine services within public healthcare infrastructure [23,24].
Based on the identified research gaps in sexual dysfunction prevalence, associated factors, and healthcare service delivery patterns in the Tunisian SCI population [25,26,27], our study aimed to (i) assess the prevalence and severity of sexual dysfunction among Tunisian SCI patients using validated assessment tools, (ii) identify clinical and demographic factors associated with sexual dysfunction, and (iii) evaluate the current state of sexual health communication and rehabilitation services in this underserved population.

2. Materials and Methods

2.1. Ethical Approval

The study received approval from the Ethical Committee of Sahloul Hospital (approval number: HS41-2025, 12 June 2025) and was conducted in accordance with the principles of the Declaration of Helsinki. Verbal informed consent was obtained from all patients before participation through telephone interviews with particular attention to confidentiality, given the sensitive nature of sexual health assessments.

2.2. Sample Size Calculation

Sample size was determined using the standard formula for cross-sectional prevalence studies: n = Z2 × p(1 − p)/d2, where Z = 1.96 (95% confidence level), p is the expected prevalence, and d is the desired precision. An expected prevalence of p = 0.80 was selected based on international evidence: Cobo-Cuenca et al. (2017) reported 80–95% prevalence in male SCI patients [28], Di Giusto et al. (2023) documented 70–85% in Latin American populations [29], and the Fifth International Consultation on Sexual Medicine (ICSM, 2024) confirmed 80–90% prevalence across diverse SCI populations [10].
The desired precision was set at d = 0.11, reflecting the balance between methodological rigor and recruitment feasibility. While this exceeds conventional thresholds, it aligns with the guidance of Pourhoseingholi et al. [30], who suggest that precision values may reach 0.10 or higher in high-prevalence conditions (p ≥ 0.6). The marginally wider precision was necessitated by limited eligible patients in Tunisia’s two national rehabilitation centers, cultural barriers to discussing sexual health, and the absence of prior national data.
Calculation:                         
n = (1.96)2 × 0.80(1 − 0.80)/(0.11)2 = 3.8416 × 0.16/0.0121 = 50.8 ≈ 51
Post hoc verification: With our achieved sample (n = 51) and observed prevalence of 84.3%, the 95% confidence interval is [71.8%, 92.2%], yielding an achieved precision of ±10.2%, which closely approximates our target and confirms sample adequacy. This sample size is consistent with established SCI studies: Phelps et al. (n = 50) [31], Tzanos et al. (n = 30) [32], and Salmani et al. (n = 28) [33].

2.3. Population

The study included adults aged ≥18 years with chronic SCI, defined as disease duration ≥ 12 months post-injury, who provided verbal consent. Participants were recruited from the Physical Medicine and Rehabilitation inpatient department at Sousse, Tunisia, which admits patients from multiple regions across the central and southern regions. Exclusion criteria comprised concurrent neurological disorders potentially affecting sexual function (Parkinson’s disease, traumatic brain injury, stroke, multiple sclerosis) and current psychiatric disorders such as schizophrenia, delusional states, severe depression, and severe anxiety requiring active treatment, to ensure observed effects could be attributed specifically to SCI.

2.4. Experimental Design

This cross-sectional, observational, analytical study was conducted at the Department of Physical Medicine and Rehabilitation, Sahloul University Hospital (Sousse, Tunisia) between July and September 2025. Admitted Patient records from the 2024 inpatient rehabilitation unit were retrospectively reviewed for eligibility. Eligible patients were consecutively selected and contacted via telephone for a sexual function assessment conducted by two trained operators to ensure consistency and minimize interviewer bias. Standardized interview protocols were implemented to maintain data quality across assessments, with comprehensive training provided to reduce inter-observer variability in discussions of sensitive health topics.

2.5. Assessment Tools

2.5.1. Demographic and Clinical Assessment

A comprehensive standardized form captured demographic variables, including age, gender, marital status, educational level, and employment status. Clinical variables included time since injury, etiology of SCI, neurological level of injury, and American Spinal Injury Association Impairment Scale (AIS) classification [34]. The AIS provides a standardized assessment of motor, sensory, and sacral function with five grades (A–E) and serves as the gold standard for documenting the neurological level and severity of SCI.

2.5.2. Pain Assessment Tools

Pain evaluation utilized two validated instruments: the Numerical Rating Scale (NRS) for nociceptive pain assessment, scored from 0 to 10 with higher scores indicating greater pain intensity, and the Douleur Neuropathique 4 (DN4) questionnaire for neuropathic pain screening [35]. The DN4 consists of 10 items with a cut-off score of 4/10 for neuropathic pain diagnosis, demonstrating sensitivity of 82.9% and specificity of 89.9% in neurological populations.

2.5.3. Functional Independence Assessment

Functional status was assessed using two complementary instruments. The Functional Independence Measure (FIM) evaluates independence in self-care, sphincter control, transfers, locomotion, communication, and social cognition across 18 items [36]. Each item is scored from 1 (total assistance) to 7 (complete independence), yielding total scores ranging from 18 to 126, with higher scores indicating greater independence. The Spinal Cord Independence Measure version III (SCIM-III) assesses explicitly the independence of SCI patients across 19 items in three domains: self-care (0–20 points), respiration and sphincter management (0–40 points), and mobility (0–40 points) [37]. Total scores range from 0 to 100, with higher scores indicating greater functional independence.

2.5.4. Psychological Status Assessment

The Hospital Anxiety and Depression Scale (HAD-S) assessed psychological well-being through 14 self-report items: 7 for anxiety and 7 for depression subscales [38]. Each subscale scores 0–21, with higher scores indicating greater symptom severity. The HAD-S demonstrates excellent internal consistency in SCI populations and has been validated in 963 community-dwelling individuals with SCI [39]. Cut-off scores of 8 or higher provide optimal sensitivity and specificity for screening, while scores of 11 or higher indicate clinically significant symptoms.

2.5.5. Sleep Quality Evaluation

The Pittsburgh Sleep Quality Index (PSQI) assessed sleep quality and disturbances over the past month using 19 questions grouped into seven components [40]. Components include subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. Each component scores from 0 (no difficulty) to 3 (severe difficulty), with total scores ranging from 0 to 21. A global score > 5 indicates poor sleep quality.

2.5.6. Male Sexual Function Assessment Questionnaire

The International Index of Erectile Function (IIEF) assessed male sexual function across five domains: erectile function (6 items, range 1–30), orgasmic function (2 items, range 0–10), sexual desire (2 items, range 2–10), intercourse satisfaction (3 items, range 0–15), and overall satisfaction (2 items, range 2–10). The IIEF exhibits excellent psychometric properties, characterized by high internal consistency, test–retest reliability, and sensitivity to treatment effects across diverse populations [41]. Total scores range from 5 to 75, with established cutoffs: normal function ≥48, mild dysfunction 37–47, and moderate/severe dysfunction ≤36. The French version was translated into Arabic by a qualified physician to ensure linguistic accessibility; however, this translated version has not undergone formal validation.

2.5.7. Female Sexual Function Assessment Questionnaire

The Female Sexual Function Index (FSFI) evaluated female sexual function through 19 items across six domains: desire (2 items), arousal (4 items), lubrication (4 items), orgasm (3 items), satisfaction (3 items), and pain (3 items). Each domain receives a weighted score, with the composite score ranging from 2 to 36; higher scores indicate better sexual function. The FSFI was administered in its validated Arabic version, previously adapted for the Egyptian population [42], demonstrating excellent reliability (Cronbach’s α = 0.97) and construct validity. Established cut-offs classify sexual function as: normal ≥26.55, mild risk 18–26.55, moderate risk 11–17, and severe dysfunction <10.

2.5.8. Sexual Health Communication Assessment

Sexual health communication and service access were evaluated through two structured questions: “Has your attending physician ever discussed sexual health with you during your rehabilitation?” and “Have you ever received sexual rehabilitation services or counselling?” Both questions utilized a yes/no response format to assess current gaps in healthcare delivery and communication patterns.

2.6. Statistical Analysis

Statistical analysis was performed using SPSS version 25.0. Normal distribution was assessed using the Kolmogorov–Smirnov test. Parameters with normal distribution were expressed as means and standard deviations (SD), while non-normally distributed parameters were expressed as medians and interquartile ranges [IQR]. Categorical variables were summarized using frequencies and percentages. Univariate comparisons between patients with and without sexual dysfunction were performed using appropriate tests based on variable type and distribution. For categorical variables, the Pearson Chi-Square test or exact Fisher test was used. For continuous variables, the Independent Samples t-test was used if the data met assumptions of normality; otherwise, the Mann–Whitney U test was applied.
In the multivariate analysis, variables with p-values < 0.05 were included in a binary logistic regression model. Variables with p < 0.05 after multivariate analysis were considered independent factors of sexual dysfunction. Adjusted odds ratios (OR) and their 95% confidence intervals (CI) were calculated to estimate the strength of the association. Correlation analyses were conducted using Spearman’s rank correlation coefficients, appropriate for non-normally distributed data, to examine relationships between clinical variables and sexual function scores. The strength of the correlations was categorized as follows: very strong (≥0.70), strong (0.50–0.69), moderate (0.30–0.49), and weak (<0.30). A p-value less than 0.05 was considered statistically significant [43].

2.7. Use of GenAI in Writing

In preparing this paper, the authors utilized the ChatGPT model 4 on 18 September 2025, to revise specific passages of the manuscript, double-check for grammatical errors, and enhance academic English. After using this tool, the authors have reviewed and edited the content as necessary and take full responsibility for the content of the publication.

3. Results

3.1. Demographic and Clinical Characteristics

Fifty-one patients were enrolled in this study, as shown in the flowchart in Figure 1. The study population had a mean age of 43.47 ± 15.43 years and demonstrated a near-equal sex distribution, with a male-to-female ratio of 1.04. The majority of participants were married (64.7%) and had medium socioeconomic status (60.8%). Comorbid conditions were present in 11.8% of participants, with diabetes mellitus being the most prevalent (7.8%), followed by hypertension (5.9%). Table 1 presents the complete sociodemographic characteristics of the study population, including the distribution of educational levels and employment status across the cohort.

3.2. Injury Characteristics and Clinical Profile

Injury characteristics revealed a median time since injury of 22 months [13:36], with traumatic etiology predominating (72.5%). Neurological assessment showed 29.4% with complete injuries (AIS A), 11.8% with sensory incomplete (AIS B), 31.4% with motor incomplete (AIS C), and 27.5% with preserved motor function (AIS D). Cervical injuries accounted for 43.1%, thoracic injuries 37.3%, and lumbar injuries 19.6% of cases. Table 2 presents detailed injury characteristics, including etiological distribution and neurological classification patterns across male and female participants.

3.3. Pain Assessment and Complications

Pain assessment revealed heterogeneous patterns across the cohort. Median NRS score was 4 [2–6], indicating moderate pain levels, while median DN4 score was 3 [2–5]. Nociceptive pain predominantly manifested as shoulder pain affecting 43.1% of participants, while neuropathic pain occurred at the lesion level in 21.5% and below the lesion level in 52.9% of cases. Cutaneous complications were observed in 23.5% of patients, with pressure ulcers distributed across different stages. Neurogenic heterotopic ossifications occurred in 17.6% of cases, primarily affecting the hips (11.8%) and knees (7.8%). Bladder and bowel dysfunction were prevalent, with urinary incontinence reported in 31.4% of cases and constipation in 44% of cases.

3.4. Functional Status Assessment

Functional assessment demonstrated significant variability in independence levels. Mean SCIM-III score was 56.24 ± 21.8, while mean FIM score was 76.18 ± 22.0, indicating moderate functional independence across the cohort. SCIM-III subdomain analysis revealed self-care scores of 12.4 ± 5.8, respiration and sphincter management scores of 23.6 ± 9.4, and mobility scores of 20.2 ± 8.9.

3.5. Psychological and Sleep Quality Assessment

Psychological evaluation using HAD-S revealed a median anxiety subscale score of 6 [5–9] and a median depression subscale score of 7 [4–9]. Only 5.9% of patients exhibited clinically significant anxiety or depression symptoms (HAD-S ≥ 11). Sleep quality assessment showed a median PSQI score of 7 [5–8], with 80.4% of patients reporting poor sleep quality (PSQI > 5).

3.6. Male Sexual Function Assessment

Among male patients (n = 26), the median IIEF total score was 12 [7–36.25], indicating moderate-to-severe sexual dysfunction. Table 3 presents the comprehensive IIEF domain scores and dysfunction severity classifications for the male cohort, along with detailed descriptive statistics for each domain.

3.7. Female Sexual Function Assessment

Among female patients (n = 25), 80% reported sexual dysfunction with a median FSFI total score of 7.2 [4–24.25]. Domain-specific analysis revealed profound impairment across all dimensions. Severe dysfunction (FSFI ≤ 10) affected 56% of women, while moderate dysfunction (FSFI 11–17) affected 24%. Table 4 represents the detailed FSFI domain scores and dysfunction classifications demonstrating the pervasive nature of sexual impairment in this population.

3.8. Associated Factors with Sexual Dysfunction: Univariate and Multivariate Analysis

3.8.1. Univariate Analysis

Table 5 represents univariate analysis of sociodemographic, clinical, complications, functional, psychological, and sleep quality outcomes, showing significant correlations with urinary incontinence (p = 0.045), SCIM-III scores (p = 0.010), and FIM scores (p = 0.011).

3.8.2. Multivariate Analysis

In the multivariate analysis, the independent factor associated with sexual dysfunction was the SCIM-III score, with a p-value of 0.026 and an adjusted odds ratio (ORa) of 0.944 [95% CI: 0.897–0.993].

3.8.3. Correlation Analyses

Table 6 and Table 7 present detailed correlation analyses for IIEF and FSFI scores, respectively, with clinical variables, function scores, and functional independence measures. Spearman’s correlation analysis revealed positive, significant associations between sexual dysfunction, urinary incontinence, and functional outcomes.
Figure 2 represents scatter plots illustrating the relationships between sexual dysfunction and functional outcomes.

3.9. Sexual Health Communication and Service Access

When asked, “Has your attending physician ever discussed sexual health with you?”, 92% of patients (n = 47/51) reported that clinicians never initiated discussions about sexual health during routine follow-ups or rehabilitation encounters. The question “Have you ever received sexual rehabilitation services?” revealed that 100% of participants lacked access to specialized sexual rehabilitation services, counseling, or structured interventions due to the complete absence of such programs within Tunisia’s public healthcare system.

4. Discussion

This study reveals a high prevalence of sexual dysfunction among Tunisian patients with spinal cord injury (SCI), affecting 84.3% of participants. The findings confirm our initial hypothesis and highlight more extensive gaps in sexual health services than anticipated, including a complete absence of specialized care and significant communication barriers between patients and providers.
Among male participants, the median International Index of Erectile Function (IIEF) score was 12 [7–36.25], well below the clinical threshold of 48, with 88.5% reporting moderate to severe erectile dysfunction. This prevalence exceeds the 69.2% reported by Migaou et al. in a Tunisian cohort of paraplegic males, likely because we included both paraplegic and tetraplegic patients [23]. Comparable dysfunction rates have been reported internationally, including 89.4% in Spanish SCI males [28], and similar findings have been reported in multicenter European studies [44], supporting the robustness of our results.
The large effect size (Cohen’s d = 1.2) further underscores the clinical significance of these impairments compared to normative populations [45,46]. Female participants also demonstrated severe dysfunction, with a median Female Sexual Function Index (FSFI) score of 7.2 [4–24.25], far below the threshold of 26.55. Notably, 56% scored ≤ 10, indicating profound impairment across all domains, particularly in orgasm (median 2 [0–3.2]) and arousal (median 0.8 [0–4.5]). These results are consistent with international data, including FSFI scores of 14.4 ± 13.7 in Greek women [32] and similar patterns in Iranian SCI patients [47].
The consistency of sexual dysfunction across diverse populations, including comparisons with Tunisian patients with multiple sclerosis [48], suggests that neurophysiological mechanisms underlying sexual impairment in SCI are universal and not confined by cultural or geographic boundaries [49]. These findings reinforce the need to integrate sexual health into rehabilitation protocols as a core component of care. Cultural sensitivity should guide the development of appropriate interventions, but must not justify the exclusion of essential sexual health services. Addressing both medical and psychosocial aspects of sexual dysfunction is critical to improving quality of life and restoring intimate relationships in this population.
This study highlights a critical gap in sexual healthcare among Tunisian patients with spinal cord injury (SCI). Notably, 92% of participants had never discussed sexual health with a healthcare provider, a rate significantly higher than the 65–70% communication gaps reported in other healthcare systems [50]. Furthermore, none of the patients had access to sexual rehabilitation services, reflecting broader systemic challenges in LMICs, where sexual health is often deprioritized due to limited resources, insufficient provider training, and cultural constraints. Compared to high-income countries, where 40–60% of SCI patients receive some form of sexual health counseling, this disparity represents a large effect size (Cohen’s d > 2.0), underscoring inequities in care that cannot be justified solely by cultural norms [51].
Encouragingly, programs such as the sexual and reproductive health initiative supported by the International Development Research Centre (IDRC) in Tunisia demonstrate the feasibility of integrating sexual health into clinical services through multidisciplinary collaboration and culturally sensitive education. These models may inform the development of structured sexual rehabilitation protocols tailored to the Tunisian context [52].
To address these gaps, healthcare providers require formal training, standardized screening tools, and institutional support to deliver evidence-based sexual health interventions. System-level reforms should prioritize integrating sexual health into provider education, policy development, and resource allocation.
Our findings also reveal moderate correlations between sexual dysfunction and functional independence, as measured by SCIM-III (r = 0.34, p = 0.016) and FIM (r = 0.35, p = 0.011). These associations suggest that patients with greater mobility and autonomy may experience better sexual outcomes, potentially due to improved positioning, reduced caregiver dependence, and enhanced self-esteem. However, these correlations explain only 11–12% of the variance in sexual function, indicating that functional status alone is insufficient to predict sexual health [53]. Similar findings have been reported by Di Giusto et al. (r = 0.42) [29] and Harrison et al. (r = 0.38), reinforcing the need for a multidisciplinary approach that combines functional rehabilitation with medical, psychological, and relational support [54].
Sexual dysfunction in SCI is multifactorial, involving both neurophysiological and psychosocial mechanisms. Damage to spinal pathways affecting autonomic regulation and sensory-motor integration can impair arousal, genital response, and orgasm. Studies report that 70–81% of men experience erectile dysfunction, nearly all male patients have ejaculation difficulties, and 50–80% of women report reduced arousal or vaginal dryness. Psychosocial factors such as altered body image, emotional distress, and relationship challenges further exacerbate sexual difficulties and may persist despite physical recovery [10,55].
Urinary incontinence also showed a significant correlation with sexual dysfunction (r = −0.29, p = 0.045), reflecting shared autonomic pathways and psychological impacts. Concerns about hygiene, embarrassment, and spontaneity during intimacy may contribute to reduced sexual confidence [56,57]. Similar associations have been documented by Cramp et al. (r = −0.31) [56] and Sramkova et al. [58]. These findings highlight the importance of integrating urological management into sexual rehabilitation, including catheter education, positioning strategies, and individualized care plans.
Contrary to expectations, pain, depression, and sleep disturbances showed limited associations with sexual dysfunction. Only anxiety scores on the HAD-S scale correlated with specific IIEF domains (orgasmic function: r = −0.31, p = 0.043; intercourse satisfaction: r = −0.29, p = 0.056), representing small effect sizes. This contrasts with stronger correlations reported in other populations, such as those by Pakpour et al. in Iranian SCI patients [59]. The weaker associations in our cohort may reflect cultural differences in symptom reporting, low prevalence of psychological distress (5.9%), or potential resilience factors. Alternatively, the cross-sectional design may not capture evolving psychological adaptation over time.
Future research should explore cultural influences on psychological resilience and their impact on sexual recovery. Despite limited statistical associations, psychological support remains a vital component of comprehensive sexual rehabilitation and should be systematically included in care protocols.

Limitations

This pioneering study provides the first comprehensive evaluation of sexual function among Tunisian SCI patients of both genders, establishing essential baseline data and identifying critical clinical correlates. However, several methodological limitations must be acknowledged. This study’s small sample size (n = 51) limits statistical power and generalizability, although it remains consistent with similar single-center research. The use of telephone-administered sexual health questionnaires, while necessary due to logistical and cultural factors, may have introduced social desirability bias. Additionally, non-response to phone contact excluded several eligible participants, potentially leading to selection bias by over-representing individuals who are more socially engaged or motivated, thereby affecting the representativeness of the findings. However, this sample size aligns with those reported in similar single-center studies conducted in comparable clinical and cultural contexts. For example, Migaou et al. studied 30 Tunisian males [23], Tzanos et al. studied 30 Greek women [32], and Hajiaghababaei et al. examined 105 Iranian women [47]. The cross-sectional design precludes the determination of causal relationships and temporal sequences, limiting understanding of how sexual function evolves during rehabilitation. The absence of control groups prevents comparison with general population sexual function norms, though published normative data provide some reference points. Selection bias may have occurred due to consecutive sampling from a single rehabilitation center, potentially over-representing more severe cases or those with better access to healthcare. The study did not include healthcare provider perspectives, limiting understanding of the systemic factors contributing to communication barriers and service gaps.

5. Conclusions

Sexual dysfunction among Tunisian spinal cord injury patients, affecting over 84% of the sample, represents a critical yet underrecognized healthcare need. Significant associations with functional independence (SCIM-III, FIM scores) and urological complications (urinary incontinence) highlight the multifactorial nature of sexual health challenges and provide specific targets for comprehensive intervention development that must address both neurological and psychosocial factors. Integrating sexual health into rehabilitation policy is essential for improving patient outcomes and promoting equitable care. A strategic model could include routine screening, multidisciplinary collaboration, provider education, and national guidelines supported by institutional frameworks. This approach aligns with international initiatives, such as the WHO Rehabilitation 2030 agenda, which advocates for person-centered, inclusive rehabilitation. Recognizing sexual health as a core component of recovery can enhance quality of life and ensure comprehensive, responsive healthcare delivery.

Author Contributions

I.L. and H.H.: conception and design. H.H. and N.D.: data collection, H.G. and M.G.: analysis and interpretation of the data. I.L., H.H., H.İ.C., V.S. and I.D.: drafting of the paper. I.D., I.L., H.İ.C., V.S. and S.J.: revising it critically for intellectual content. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and received approval from the Ethical Committee of Sahloul Hospital (approval number: HS41-2025, 12 June 2025). Verbal consent was obtained from all participants before initiating the telephone interviews. Each patient agreed orally to respond to the study questions after being informed of the research objectives and confidentiality measures.

Informed Consent Statement

Verbal consent was obtained from all patients involved in the study.

Data Availability Statement

The authors will make the raw data supporting this article’s conclusions available upon request.

Acknowledgments

The authors gratefully acknowledge that preliminary results of this study were accepted for oral presentation at the SOFMER Congress, scheduled to take place on 9 October 2025, in Strasbourg. AI Usage: The authors used the ChatGPT model 4 on 18 September 2025, solely for language polishing, including grammar correction and academic English enhancement, without involvement in the study’s design, analysis, or interpretation. After using this tool, the authors have reviewed and edited the content as necessary and take full responsibility for the publication’s content.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators Global, Regional, and National Burden of Traumatic Brain Injury and Spinal Cord Injury, 1990-2016: A Systematic Analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019, 18, 56–87. [CrossRef]
  2. Ding, W.; Hu, S.; Wang, P.; Kang, H.; Peng, R.; Dong, Y.; Li, F. Spinal Cord Injury: The Global Incidence, Prevalence, and Disability from the Global Burden of Disease Study 2019. Spine 2022, 47, 1532–1540. [Google Scholar] [CrossRef]
  3. Singh, A.; Tetreault, L.; Kalsi-Ryan, S.; Nouri, A.; Fehlings, M.G. Global Prevalence and Incidence of Traumatic Spinal Cord Injury. Clin. Epidemiol. 2014, 6, 309–331. [Google Scholar] [CrossRef] [PubMed]
  4. Nosrati Nejad, F.; Basakha, M.; Charkazi, A.; Esmaeili, A. Exploring Barriers to Rehabilitation for Individuals with Spinal Cord Injury: A Qualitative Study in Iran. BMC Health Serv. Res. 2025, 25, 167. [Google Scholar] [CrossRef]
  5. Kumar, R.; Lim, J.; Mekary, R.A.; Rattani, A.; Dewan, M.C.; Sharif, S.Y.; Osorio-Fonseca, E.; Park, K.B. Traumatic Spinal Injury: Global Epidemiology and Worldwide Volume. World Neurosurg. 2018, 113, e345–e363. [Google Scholar] [CrossRef]
  6. Miyakoshi, N.; Suda, K.; Kudo, D.; Sakai, H.; Nakagawa, Y.; Mikami, Y.; Suzuki, S.; Tokioka, T.; Tokuhiro, A.; Takei, H.; et al. A Nationwide Survey on the Incidence and Characteristics of Traumatic Spinal Cord Injury in Japan in 2018. Spinal Cord. 2021, 59, 626–634. [Google Scholar] [CrossRef]
  7. French, D.D.; Campbell, R.R.; Sabharwal, S.; Nelson, A.L.; Palacios, P.A.; Gavin-Dreschnack, D. Health Care Costs for Patients with Chronic Spinal Cord Injury in the Veterans Health Administration. J. Spinal Cord. Med. 2007, 30, 477–481. [Google Scholar] [CrossRef]
  8. Krueger, H.; Noonan, V.K.; Trenaman, L.M.; Joshi, P.; Rivers, C.S. The Economic Burden of Traumatic Spinal Cord Injury in Canada. Chronic Dis. Inj. Can. 2013, 33, 113–122. [Google Scholar] [CrossRef] [PubMed]
  9. Anderson, K.D.; Borisoff, J.F.; Johnson, R.D.; Stiens, S.A.; Elliott, S.L. The Impact of Spinal Cord Injury on Sexual Function: Concerns of the General Population. Spinal Cord. 2007, 45, 328–337. [Google Scholar] [CrossRef]
  10. Elliott, S.; Birkhäuser, V.; Courtois, F.; Gül, M.; Ibrahim, E.; Kiekens, C.; New, P.W.; Ohl, D.A.; Fode, M. Sexual and Reproductive Health in Neurological Disorders: Recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024). Sex. Med. Rev. 2025, 13, 456–470. [Google Scholar] [CrossRef]
  11. de Groat, W.C.; Yoshimura, N. Anatomy and Physiology of the Lower Urinary Tract. Handb. Clin. Neurol. 2015, 130, 61–108. [Google Scholar] [CrossRef]
  12. Monga, M.; Bernie, J.; Rajasekaran, M. Male Infertility and Erectile Dysfunction in Spinal Cord Injury: A Review. Arch. Phys. Med. Rehabil. 1999, 80, 1331–1339. [Google Scholar] [CrossRef]
  13. Alexander, M.S.; Aisen, C.M.; Alexander, S.M.; Aisen, M.L. Sexual Concerns after Spinal Cord Injury: An Update on Management. NeuroRehabilitation 2017, 41, 343–357. [Google Scholar] [CrossRef]
  14. Lombardi, G.; Del Popolo, G.; Macchiarella, A.; Mencarini, M.; Celso, M. Sexual Rehabilitation in Women with Spinal Cord Injury: A Critical Review of the Literature. Spinal Cord. 2010, 48, 842–849. [Google Scholar] [CrossRef]
  15. Sipski, M.L.; Alexander, C.J.; Rosen, R. Sexual Arousal and Orgasm in Women: Effects of Spinal Cord Injury. Ann. Neurol. 2001, 49, 35–44. [Google Scholar] [CrossRef]
  16. Bryant, C.; Aplin, T.; Setchell, J. Sexuality Support After Spinal Cord Injury: What Is Provided in Australian Practice Settings? Sex. Disabil. 2022, 40, 409–423. [Google Scholar] [CrossRef]
  17. Rassem, M.; Siddiqui, M.; Wunder, S.; Ganshorn, K.; Kraushaar, J. Sexual Health Counselling in Patients with Spinal Cord Injury: Health Care Professionals’ Perspectives. J. Spinal Cord. Med. 2022, 45, 280–286. [Google Scholar] [CrossRef] [PubMed]
  18. Booth, S.; Kendall, M.; Fronek, P.; Miller, D.; Geraghty, T. Training the Interdisciplinary Team in Sexuality Rehabilitation Following Spinal Cord Injury: A Needs Assessment. Sex. Disabil. 2003, 21, 249–261. [Google Scholar] [CrossRef]
  19. Hess, M.J.; Hough, S. Impact of Spinal Cord Injury on Sexuality: Broad-Based Clinical Practice Intervention and Practical Application. J. Spinal Cord. Med. 2012, 35, 211–218. [Google Scholar] [CrossRef] [PubMed]
  20. Sunna, T.; Elias, E.; Summaka, M.; Zein, H.; Elias, C.; Nasser, Z. Quality of Life among Men with Spinal Cord Injury in Lebanon: A Case Control Study. NeuroRehabilitation 2019, 45, 547–553. [Google Scholar] [CrossRef] [PubMed]
  21. Earle, S.; O’Dell, L.; Davies, A.; Rixon, A. Views and Experiences of Sex, Sexuality and Relationships Following Spinal Cord Injury: A Systematic Review and Narrative Synthesis of the Qualitative Literature. Sex. Disabil. 2020, 38, 567–595. [Google Scholar] [CrossRef]
  22. Torriani, S.B.; Britto, F.C.; da Silva, G.A.; de Oliveira, D.C.; de Figueiredo Carvalho, Z.M. Sexuality of People with Spinal Cord Injury: Knowledge, Difficulties and Adaptation. J. Biomed. Sci. Eng. 2014, 7, 380–386. [Google Scholar] [CrossRef]
  23. Migaou, H.; Youssef, I.B.H.; Boudokhane, S.; Kilani, M.; Jellad, A.; Frih, Z.B.S. Sexual disorders among spinal cord injury patients. Prog. Urol. 2018, 28, 980–986. [Google Scholar] [CrossRef] [PubMed]
  24. Khazaeipour, Z.; Taheri-Otaghsara, S.-M.; Naghdi, M. Depression Following Spinal Cord Injury: Its Relationship to Demographic and Socioeconomic Indicators. Top. Spinal Cord. Inj. Rehabil. 2015, 21, 149–155. [Google Scholar] [CrossRef]
  25. Rosen, R.C.; Leiblum, S.R.; Spector, I.P. Psychologically Based Treatment for Male Erectile Disorder: A Cognitive-Interpersonal Model. J. Sex. Marital. Ther. 1994, 20, 67–85. [Google Scholar] [CrossRef]
  26. Wiegel, M.; Meston, C.; Rosen, R. The Female Sexual Function Index (FSFI): Cross-Validation and Development of Clinical Cutoff Scores. J. Sex. Marital. Ther. 2005, 31, 1–20. [Google Scholar] [CrossRef]
  27. Burns, S.M.; Hough, S.; Boyd, B.L.; Hill, J. Men’s Adjustment to Spinal Cord Injury: The Unique Contributions of Conformity to Masculine Gender Norms. Am. J. Mens. Health 2010, 4, 157–166. [Google Scholar] [CrossRef]
  28. Cobo Cuenca, A.I.; Sampietro-Crespo, A.; Virseda-Chamorro, M.; Martín-Espinosa, N. Psychological Impact and Sexual Dysfunction in Men with and without Spinal Cord Injury. J. Sex. Med. 2015, 12, 436–444. [Google Scholar] [CrossRef] [PubMed]
  29. Di Giusto, M.L.; Ertl, M.M.; Ramos-Usuga, D.; Carballea, D.; Degano, M.; Perrin, P.B.; Arango-Lasprilla, J.C. Sexual Health and Sexual Quality of Life Among Individuals With Spinal Cord Injury in Latin America. Top. Spinal Cord. Inj. Rehabil. 2023, 29, 54–69. [Google Scholar] [CrossRef]
  30. Pourhoseingholi, M.A.; Vahedi, M.; Rahimzadeh, M. Sample Size Calculation in Medical Studies. Gastroenterol. Hepatol. Bed Bench 2013, 6, 14–17. [Google Scholar]
  31. Phelps, J.; Albo, M.; Dunn, K.; Joseph, A. Spinal Cord Injury and Sexuality in Married or Partnered Men: Activities, Function, Needs, and Predictors of Sexual Adjustment. Arch. Sex. Behav. 2001, 30, 591–602. [Google Scholar] [CrossRef] [PubMed]
  32. Tzanos, I.-A.; Tzitzika, M.; Nianiarou, M.; Konstantinidis, C. Sexual Dysfunction in Women with Spinal Cord Injury Living in Greece. Spinal Cord. Ser. Cases 2021, 7, 41. [Google Scholar] [CrossRef]
  33. Salmani, Z.; Khoei, E.S.M.; Aghajani, N.; Bayat, A. Sexual Matters of Couples with Spinal Cord Injury Attending a Sexual Health Clinic in Tehran, Iran. Arch. Neurosci. 2018, 6, e83940. [Google Scholar] [CrossRef]
  34. ASIA and ISCoS International Standards Committee The 2019 Revision of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)-What’s New? Spinal Cord. 2019, 57, 815–817. [CrossRef]
  35. Calmels, P.; Mick, G.; Perrouin-Verbe, B.; Ventura, M.; SOFMER (French Society for Physical Medicine and Rehabilitation). Neuropathic Pain in Spinal Cord Injury: Identification, Classification, Evaluation. Ann. Phys. Rehabil. Med. 2009, 52, 83–102. [Google Scholar] [CrossRef] [PubMed]
  36. Heinemann, A.W.; Michael Linacre, J.; Wright, B.D.; Hamilton, B.B.; Granger, C. Measurement Characteristics of the Functional Independence Measure. Top. Stroke Rehabil. 1994, 1, 1–15. [Google Scholar] [CrossRef] [PubMed]
  37. Itzkovich, M.; Gelernter, I.; Biering-Sorensen, F.; Weeks, C.; Laramee, M.T.; Craven, B.C.; Tonack, M.; Hitzig, S.L.; Glaser, E.; Zeilig, G.; et al. The Spinal Cord Independence Measure (SCIM) Version III: Reliability and Validity in a Multi-Center International Study. Disabil. Rehabil. 2007, 29, 1926–1933. [Google Scholar] [CrossRef]
  38. Zigmond, A.S.; Snaith, R.P. The Hospital Anxiety and Depression Scale. Acta Psychiatr. Scand. 1983, 67, 361–370. [Google Scholar] [CrossRef]
  39. Woolrich, R.A.; Kennedy, P.; Tasiemski, T. A Preliminary Psychometric Evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 People Living with a Spinal Cord Injury. Psychol. Health Med. 2006, 11, 80–90. [Google Scholar] [CrossRef]
  40. Buysse, D.J.; Reynolds, C.F.; Monk, T.H.; Berman, S.R.; Kupfer, D.J. The Pittsburgh Sleep Quality Index: A New Instrument for Psychiatric Practice and Research. Psychiatry Res. 1989, 28, 193–213. [Google Scholar] [CrossRef]
  41. Cappelleri, J.C.; Rosen, R.C.; Smith, M.D.; Mishra, A.; Osterloh, I.H. Diagnostic Evaluation of the Erectile Function Domain of the International Index of Erectile Function. Urology 1999, 54, 346–351. [Google Scholar] [CrossRef]
  42. Anis, T.H.; Gheit, S.A.; Saied, H.S.; Al kherbash, S.A. Arabic Translation of Female Sexual Function Index and Validation in an Egyptian Population. J. Sex. Med. 2011, 8, 3370–3378. [Google Scholar] [CrossRef]
  43. Gaddour, M.; Ammar, M.; Fatma, L.B.; Ceylan, H.İ.; Loubiri, I.; El Feni, N.; Jemni, S.; Puce, L.; Bragazzi, N.L.; Dergaa, I. Stifled Motivation, Systemic Neglect: A Cross-Sectional Analysis of Inactivity in Post-Chemotherapy Cancer Survivors in the Middle East and North Africa Region. Cancers 2025, 17, 3375. [Google Scholar] [CrossRef] [PubMed]
  44. Giuliano, F.; Hultling, C.; El Masry, W.S.; Smith, M.D.; Osterloh, I.H.; Orr, M.; Maytom, M. Randomized Trial of Sildenafil for the Treatment of Erectile Dysfunction in Spinal Cord Injury. Sildenafil Study Group. Ann. Neurol. 1999, 46, 15–21. [Google Scholar] [CrossRef] [PubMed]
  45. Sipski, M.L.; Rosen, R.C.; Alexander, C.J.; Gómez-Marín, O. Sexual Responsiveness in Women with Spinal Cord Injuries: Differential Effects of Anxiety-Eliciting Stimulation. Arch. Sex. Behav. 2004, 33, 295–302. [Google Scholar] [CrossRef] [PubMed]
  46. Ramos, A.S.; Samsó, J.V. Specific Aspects of Erectile Dysfunction in Spinal Cord Injury. Int. J. Impot. Res. 2004, 16 (Suppl. S2), S42–S45. [Google Scholar] [CrossRef]
  47. Hajiaghababaei, M.; Javidan, A.N.; Saberi, H.; Khoei, E.M.; Khalifa, D.A.; Koenig, H.G.; Pakpour, A.H. Female Sexual Dysfunction in Patients with Spinal Cord Injury: A Study from Iran. Spinal Cord. 2014, 52, 646–649. [Google Scholar] [CrossRef]
  48. Charfi, A.; Ben Salah, R.; Frikha, O.; Mahfoudh, N.; Kamoun, A.; Bouattour, Y.; Gaddour, L.; Hakim, F.; Bahloul, Z.; Makni, H. HLA Polymorphisms in South Tunisian Systemic Sclerosis Patients: A Case–Control Study. Clin. Rheumatol. 2025, 44, 4053–4059. [Google Scholar] [CrossRef]
  49. Rihab, C.; Sawssan, D.; Najeh, S.; Salma, S.; Nadia, B.; Sonda, M.K.; Nouha, F.; Mariem, D.; Mohamed, M.; Mhiri, C. Sexual Dysfunctions and Self-Esteem in Multiple Sclerosis: A Tunisian Study. Mult. Scler. Relat. Disord. 2023, 71, 104335. [Google Scholar] [CrossRef]
  50. Dahlberg, A.; Alaranta, H.T.; Kautiainen, H.; Kotila, M. Sexual Activity and Satisfaction in Men with Traumatic Spinal Cord Lesion. J. Rehabil. Med. 2007, 39, 152–155. [Google Scholar] [CrossRef]
  51. Kennedy, P.; Lude, P.; Taylor, N. Quality of Life, Social Participation, Appraisals and Coping Post Spinal Cord Injury: A Review of Four Community Samples. Spinal Cord. 2006, 44, 95–105. [Google Scholar] [CrossRef]
  52. Maffi, I.; Affes, M. La santé sexuelle et reproductive en Tunisie. Institutions médicales, lois et itinéraires thérapeutiques des femmes après la révolution. L’Année Maghreb. 2017, 17, 151–168. [Google Scholar] [CrossRef]
  53. Kennedy, P.; Rogers, B.A. Anxiety and Depression after Spinal Cord Injury: A Longitudinal Analysis. Arch. Phys. Med. Rehabil. 2000, 81, 932–937. [Google Scholar] [CrossRef] [PubMed]
  54. Harrison, J.; Glass, C.A.; Owens, R.G.; Soni, B.M. Factors Associated with Sexual Functioning in Women Following Spinal Cord Injury. Paraplegia 1995, 33, 687–692. [Google Scholar] [CrossRef] [PubMed]
  55. Pavese, C.; Kessler, T.M. Prediction of Lower Urinary Tract, Sexual, and Bowel Function, and Autonomic Dysreflexia after Spinal Cord Injury. Biomedicines 2023, 11, 1644. [Google Scholar] [CrossRef] [PubMed]
  56. Cramp, J.D.; Courtois, F.J.; Ditor, D.S. Sexuality for Women with Spinal Cord Injury. J. Sex. Marital. Ther. 2015, 41, 238–253. [Google Scholar] [CrossRef]
  57. DeVivo, M.J.; Fine, P.R. Spinal Cord Injury: Its Short-Term Impact on Marital Status. Arch. Phys. Med. Rehabil. 1985, 66, 501–504. [Google Scholar]
  58. Sramkova, T.; Skrivanova, K.; Dolan, I.; Zamecnik, L.; Sramkova, K.; Kriz, J.; Muzik, V.; Fajtova, R. Women’s Sex Life After Spinal Cord Injury. Sex. Med. 2017, 5, e255–e259. [Google Scholar] [CrossRef]
  59. Pakpour, A.H.; Rahnama, P.; Saberi, H.; Saffari, M.; Rahimi-Movaghar, V.; Burri, A.; Hajiaghababaei, M. The Relationship between Anxiety, Depression and Religious Coping Strategies and Erectile Dysfunction in Iranian Patients with Spinal Cord Injury. Spinal Cord. 2016, 54, 1053–1057. [Google Scholar] [CrossRef]
Jcm 14 08380 g001
Figure 1. Flow chart of the study population.
Figure 1. Flow chart of the study population.
Jcm 14 08380 g001
Jcm 14 08380 g002
Figure 2. Spearman Correlation Scatter Plot Analysis Between Functional and Sexual Health Scores. Scatter plots illustrate the relationships between sexual health scores (FSFI, IIEF) and functional assessment scores (FIM, SCIM). Each plot includes a fitted regression line (black), 95% confidence intervals (red), and Spearman correlation coefficients (r) with associated p-values. (A) FSFI vs. FIM: Moderate positive correlation (r = 0.495, p = 0.012). (B) FSFI vs. SCIM: Moderate positive correlation (r = 0.469, p = 0.018). (C) IIEF vs. FIM: Strong positive correlation (r = 0.569, p = 0.002). (D) IIEF vs. SCIM: Moderate positive correlation (r = 0.466, p = 0.016).
Figure 2. Spearman Correlation Scatter Plot Analysis Between Functional and Sexual Health Scores. Scatter plots illustrate the relationships between sexual health scores (FSFI, IIEF) and functional assessment scores (FIM, SCIM). Each plot includes a fitted regression line (black), 95% confidence intervals (red), and Spearman correlation coefficients (r) with associated p-values. (A) FSFI vs. FIM: Moderate positive correlation (r = 0.495, p = 0.012). (B) FSFI vs. SCIM: Moderate positive correlation (r = 0.469, p = 0.018). (C) IIEF vs. FIM: Strong positive correlation (r = 0.569, p = 0.002). (D) IIEF vs. SCIM: Moderate positive correlation (r = 0.466, p = 0.016).
Jcm 14 08380 g002
Table 1. Sociodemographic characteristics of the population.
Table 1. Sociodemographic characteristics of the population.
CharacteristicsTotal PopulationMale Patients (n = 26)Female Patients (n = 25)
Age, years, Mean ± SD43.47 ± 15.4342.04 ± 15.0844.16 ± 15.86
Marital status, N (%)
 Married33 (64.7)15 (57.7)18 (72)
 Single18 (35.3)11 (42.3)7 (28)
Residence, N (%)
 Urban34 (66.7)16 (61.5)18 (72)
 Rural17 (33.3)10 (38.5)7 (28)
Socioeconomic level, N (%)
 Low15 (29.4)8 (30.8)7 (28)
 Medium31 (60.8)14 (53.8)17 (68)
 Good5 (9.8)4 (15.4)1 (4)
Comorbid conditions, N (%)
 Yes6 (11.8)4 (15.4)2(8)
 No45 (88.2)22 (84.6)23 (92)
Smoking, N (%)19 (37.3)18 (69.2)1 (4)
Table 2. Clinical characteristics of injury.
Table 2. Clinical characteristics of injury.
CharacteristicsPopulation (n = 51)Male Patients (n = 26)Female Patients (n = 25)
Time since injury, months, median, [IQR]22 [13–36]16 [13–29.25]29 [18–37]
Etiology, N (%)
 Traumatic37 (72.5)18 (69.2)19(76)
 Non-traumatic14 (27.5)8 (30.8)6 (24)
NLI, N (%)
 Cervical22 (43.1)11 (42.3)11 (44)
 Dorsal19 (37.3)9 (34.6)10 (40)
 Above T1031 (60.8)16 (61.5)15 (60)
 Lumbar10 (19.6)6 (23.1)4 (16)
AIS, N (%)
 A15 (29.4)8 (30.8)7 (28)
 B6 (11.8)4 (15.4)2 (8)
 C16 (31.4)8 (30.8)8 (32)
 D14 (27.5)6 (23.1)8 (32)
NLI: neurological level of injury; AIS: ASIA Impairment Scale; IQR: Interquartile range.
Table 3. IIEF subscale results.
Table 3. IIEF subscale results.
NMedianIQR
Erectile function261[1–12.25]
Orgasmic function261[1–6.5]
Sexual desire263.5[3–5.25]
Intercourse satisfaction263[0–4.75]
Overall satisfaction262.5[2–6]
IIEF2612[7–36.25]
IIEF: International Index of Erectile Function, IQR: Interquartile ranges.
Table 4. FSFI subscale results.
Table 4. FSFI subscale results.
MedianIQR
FSFI7.2[4–24.25]
FSFI desire1.2[1.2–4.5]
FSFI arousal0.8[0–4.5]
FSFI lubrication1.5[0–4.05]
FSFI orgasm2[0–3.2]
FSFI satisfaction3.6[1–4.8]
FSFI pain0[0–3.6]
FSFI: Female Sexual Function Index; IQR: Interquartile range.
Table 5. Univariate analysis of sociodemographic, clinical variables, complications, functional, psychological, and sleep quality outcomes.
Table 5. Univariate analysis of sociodemographic, clinical variables, complications, functional, psychological, and sleep quality outcomes.
VariableValueSexual
Dysfunction No (n = 8)		Sexual
Dysfunction Yes (n = 43)		p-Value
Age Median, SD 40.7 ± 14.843.5 ± 15.50.645
Marital Status N (%)Married6 (18.2)27 (81.8)0.696
Single2 (11.1)16 (88.9)
Residence N (%)Urban5 (14.7)29 (85.3)1.000
Rural3 (17.6)14 (82.4)
Socioeconomic level N (%)Low4 (26.7)11 (73.3)0.213
Medium,4 (11.1)32 (88.9)
Good
Comorbidities N (%)Yes-6 (14)0.572
Smoking N (%)yes2(25)17(39.5)0.694
EtiologyTraumatic5 (13.5)32 (86.5)0.668
Non traumatic3 (21.4)11 (78.6)
Time since injury Median [IQR] 33.5 [13–70.5]20 [13–36]0.491
AIS N (%)complete-15 (34.9)0.087
incomplete8 (100)28 (65.1)
Level D10Above D104 (50)27 (62.8)0.696
Below D104 (50)16 (37.2)
Urinary Incontinence N (%) -16 (37.2)0.045
Pressure ulcers N (%) 1 (12.5)11 (25.6)0.662
NHO N (%) -9 (20.9)0.322
NRS [IQR] 4.5 [0.75–5.75]4 [2–6]0.895
DN4 [IQR] 3 [1–6.5]3 [2–5]0.979
HAD-S A [IQR] 7.5 [6–9]6 [5–9]0.183
HAD-S D [IQR] 6.5 [4.5–9.75]7 [4–9]0.794
SCIM-III [IQR] 69 [62–89.75]52 [38–69]0.010
FIM Mean, SD 94.38 ± 17.7772.79 ± 21.800.011
PSQI Mean, SD 8.12 ± 5.416.79 ± 2.660.855
NHO: Neurogenic Heterotopic Ossifications; NRS: Numerical Rating Scale; DN4: Douleur Neuropathique 4; HAD-S: Hospital Anxiety and Depression Scale; A: Anxiety; D: Depression; SCIM-III: Spinal Cord Independence Measure version III; FIM: Functional Independence Measure; PSQI: Pittsburgh Sleep Quality Index; AIS: ASIA Impairment Scale; IQR: Interquartile Ranges.
Table 6. Correlation of the International Index of Erectile Function with clinical variables.
Table 6. Correlation of the International Index of Erectile Function with clinical variables.
Erectile
Function		Orgasmic
Function		Sexual
Desire		Intercourse
Satisfaction		Overall
Satisfaction		IIEF
Total
Ager−0.118−0.21−0.2230.012−0.085−0.064
p-value0.5650.3040.2730.9550.6810.756
Time since injuryr−0.371−0.432−0.312−0.17−0.151−0.192
p-value0.0620.0270.1210.4050.4610.346
NRSr−0.263−0.376−0.297−0.274−0.186−0.287
p-value0.1940.0590.1410.1760.3640.155
DN4r−0.245−0.326−0.264−0.355−0.228−0.225
p-value0.2280.1040.1920.0750.2620.27
HAD-S Ar0.350.4230.3330.4070.0530.303
p-value0.080.0310.0970.0390.7970.133
HAD-S Dr−0.038−0.093−0.0160.1010.0880.134
p-value0.8550.6520.9380.6230.6680.515
SCIM-IIIr0.5290.4570.3770.1290.550.466
p-value0.0050.0190.0580.5310.0040.016
FIMr0.6090.5520.5010.290.5650.569
p-value0.0010.0030.0090.1510.0030.002
PSQIr0.0280.019−0.2670.183−0.083−0.073
p-value0.8920.9270.1880.370.6850.724
NRS: numerical rating Scale; DN4: Douleur Neuropathique 4; HAD-S: Hospital Anxiety and Depression Scale; SCIM-III: Spinal Cord Independence Measure Version III; FIM: Functional Independence Measure; PSQI: Pittsburgh Sleep Quality Index; r: Spearman’s rho.
Table 7. Correlation between the Female Sexual Function Index and clinical variables.
Table 7. Correlation between the Female Sexual Function Index and clinical variables.
DesireArousalLubricationOrgasmSatisfactionPainTotal
Ager0.0710.0850.1440.2440.0450.0760.191
p-value0.7380.6870.4910.240.8330.7160.36
Time since injuryr0.450.3690.3620.320.310.2870.39
p-value0.0240.0690.0750.1190.1310.1650.054
NRSr0.0020.017−0.0150.099−0.049−0.1160.1
p-value0.9930.9360.9450.6380.8170.5820.635
DN4r0.1620.2580.2260.2740.060.2120.183
p-value0.440.2140.2780.1860.7740.3090.381
HAD-S anxietyr0.2560.2610.2290.3160.210.1370.284
p-value0.2170.2070.270.1240.3140.5130.169
HAD-S depressionr−0.0270.1630.0790.227−0.003−0.0530.184
p-value0.8990.4380.7060.2750.9880.8020.379
SCIM-IIIr0.6640.5360.5640.4920.5080.6830.469
p-value<0.0010.0060.0030.0130.01<0.0010.018
FIMr0.6660.5570.5890.5090.4820.6480.495
p-value<0.0010.0040.0020.0090.015<0.0010.012
PSQIr−0.164−0.092−0.173−0.022−0.188−0.142−0.097
p-value0.4330.6620.4070.9170.3690.4980.646
NRS: numerical rating scale; DN4—Douleur Neuropathique 4 Questionnaire; HAD-S—Hospital Anxiety and Depression Scale; SCIM-III—Spinal Cord Independence Measure, version III; FIM—Functional Independence Measure; PSQI—Pittsburgh Sleep Quality Index; FSFI—Female Sexual Function Index; r: Spearman’s rho.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Loubiri, I.; Dergaa, I.; Hajji, H.; Ceylan, H.İ.; Gaddour, M.; Dridi, N.; Ghali, H.; Stefanica, V.; Jemni, S. The Hidden Burden of Sexual Dysfunction and Healthcare Service Gaps in Tunisian Spinal Cord Patients: A Cross-Sectional Study. J. Clin. Med. 2025, 14, 8380. https://doi.org/10.3390/jcm14238380

AMA Style

Loubiri I, Dergaa I, Hajji H, Ceylan Hİ, Gaddour M, Dridi N, Ghali H, Stefanica V, Jemni S. The Hidden Burden of Sexual Dysfunction and Healthcare Service Gaps in Tunisian Spinal Cord Patients: A Cross-Sectional Study. Journal of Clinical Medicine. 2025; 14(23):8380. https://doi.org/10.3390/jcm14238380

Chicago/Turabian Style

Loubiri, Ines, Ismail Dergaa, Habib Hajji, Halil İbrahim Ceylan, Mariem Gaddour, Nourhene Dridi, Hela Ghali, Valentina Stefanica, and Sonia Jemni. 2025. "The Hidden Burden of Sexual Dysfunction and Healthcare Service Gaps in Tunisian Spinal Cord Patients: A Cross-Sectional Study" Journal of Clinical Medicine 14, no. 23: 8380. https://doi.org/10.3390/jcm14238380

APA Style

Loubiri, I., Dergaa, I., Hajji, H., Ceylan, H. İ., Gaddour, M., Dridi, N., Ghali, H., Stefanica, V., & Jemni, S. (2025). The Hidden Burden of Sexual Dysfunction and Healthcare Service Gaps in Tunisian Spinal Cord Patients: A Cross-Sectional Study. Journal of Clinical Medicine, 14(23), 8380. https://doi.org/10.3390/jcm14238380

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop