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

<b>Background/Objectives</b>: 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. <b>Methods</b>: 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 (<i>p</i> < 0.05). <b>Results</b>: 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 (<i>p</i> = 0.045) and with measures of functional independence, including SCIM-III (ρ = 0.466, <i>p</i> = 0.016) and FIM (ρ = 0.569, <i>p</i> = 0.002) among men, and SCIM-III (ρ = 0.469, <i>p</i> = 0.018) and FIM (ρ = 0.495, <i>p</i> = 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. <b>Conclusions</b>: 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.