Sexuality and a Severely Brain-Injured Spouse

Mrs. Z is a twenty-nine-year-old woman who sustained a severe traumatic brain injury five years ago when she was hit by a car whose driver was drunk. She spent six months recovering, first in the hospital and then in a rehabilitation facility. Since her discharge from the rehabilitation facility, she has been living at home with her husband and her four-year-old twin sons. Mrs. Z is unable to speak, dependent in all mobility and personal care, incontinent, and has a feeding tube. Although alert and able to respond to visual, auditory, and tactile stimuli, Mrs. Z is clearly unable to participate in even basic decisions. She requires twenty-four-hour care.

A few months ago, Mrs. Z suffered abdominal discomfort, and her doctor discovered that she was pregnant. The pregnancy was terminated after physicians consulted on her case and determined that continuing it would compromise her health. Mrs. Z’s parents are deceased, but her two older brothers have accused Mr. Z of rape. They contacted the local police asking that criminal charges be filed and have retained a lawyer to begin guardianship proceedings. Based on their sister’s severe cognitive impairments, they do not believe that Mrs. Z can make any reasonable sense of what is happening to her and think that any sexual contact with a minimally conscious woman is inappropriate. They believe Mr. Z is abusive and his views self-serving.

Mr. Z is adamant that his wife would have wanted to maintain a physical relationship with him and that what takes place in the privacy of their bedroom is not something that should interest the probate courts or the police. As evidence of his fidelity to his marriage vows he argues that he did not divorce his wife when she became disabled and that he still loves her and finds her attractive.

A guardianship agency is reviewing the case for the judge and asks consultants to give their opinions on these questions: Does Mrs. Z’s inability to provide consent to sexual intercourse override Mr. Z’s claims of marital privacy? Does Mrs. Z’s prior sexual relationship with her spouse constitute clear and convincing evidence that she would want her partner to continue this relationship, even if she is only a passive participant? Should Mrs. Z remain with her husband, or should her brothers be given the authority to remove her from her home?

Commentary

by Kristi L. Kirschner
and Rebecca Brashler

While conversations about sexuality after disability are commonplace in rehabilitation, this particular case is unlike any we can recall. It is not like those of patients after spinal cord injuries, where the focus is on changed physiology, fertility, and ways to rediscover intimacy. It is unlike cases involving patients with developmental disabilities that prompt us to assess their understanding of sexuality and the consequences of intercourse and their ability to protect themselves from unwanted sexual advances. It is also unlike cases involving patients with severe cognitive disabilities who live in institutions—such as the young girl in a vegetative state who was raped by a staff member—where we address protection. Discussions about sexuality with the spouse of a person who is unconscious, minimally conscious, or as severely brain injured as Mrs. Z rarely occur.

That doesn’t mean, though, that we don’t discuss physical touch. We encourage family members to help range and massage stiff limbs, for example, and to show their loved ones affection. We teach family caregivers to participate with catheterization and bowel programs. But initiating a frank discussion about sexuality has not felt appropriate with these couples. This case makes us question the wisdom of that practice because of the risks associated with pregnancy and the possibility of rape charges.

In reality, we don’t know much about the normative sexual practices of couples when one member has a severe brain injury. How often does sexual contact occur? Do spouses hope, as popular literature might lead us to believe, that the power of their touch might “awaken” the injured brain? Current research...