By: Stephanie Kokesh, OTD, OTR/L
Addressing sexual health within occupational therapy is vital to providing comprehensive care. It requires skill, tact, and access to appropriate resources. In both clinical practice and the related literature, occupational therapy efforts traditionally focus on restoring independence within productive, self-care and leisure activities (Sakellariou & Algado, 2006). Often overlooked, sexual activity is an activity of daily living that enables well-being through the engagement in “activities that result in sexual satisfaction and/or meet relational or reproductive needs” (American Occupational Therapy Association [AOTA], 2014, p. S19). Although a majority of occupational therapists support holistic, “whole” person care (Jones, Weerakoon, & Pynor, 2005) sexual activity does not receive the same attention as does the more typically addressed activities of daily living (ADL) such as bathing, grooming, and dressing (Hattjar, Parker, & Lappa, 2008). Sexual health – of which includes sexual activity – should be regularly addressed within occupational therapy services for adults with an accepting, problem-solving attitude (Solet, 2007) in order to address the needs of patients from all backgrounds.
Access to and knowledge of related resources have the potential to improve efforts of addressing sexual health from the OT perspective. Oftentimes, one of the most difficult steps is simply opening the door to discussion. Two useful methods, of which can be used partially or in combination, include the PLISSIT Model and the Sexual Assessment Framework (McBride & Rines, 2000).
The PLISSIT model has been a longstanding model for addressing any topic that may be considered “sensitive.” The PLISSIT Model involves: Permission, Limited Information, Specific Suggestions, and Intensive Therapy (see Figure below). The “levels” of information are arranged as such because a majority of clients typically receive the necessary information as related to Permission and Limited Information (and do not require further formal intervention).
Permission may refer to either clinician initiated discussion, or clinician response to a client remark, from which a clinician can normalize the challenges the client is experiencing.
A very simple way to obtain Permission for further discussion is through use of the normalizing “3-Step Method” (McBride & Rines, 2000):
- “Many men/women with (condition) have concerns or questions about the sexual part of their lives.”
- “Have you thought about this at all?”
- “Would you like to talk to someone about it?”
Oftentimes, Permission can easily lead to Limited Information of which involves situating general and basic sexual health related education alongside typically addressed ADL/IADL:
E.g. “We have discussed your sternal precautions as related to your everyday tasks. In addition, a lot of folks have questions about sexual activity after open heart surgery. I want to briefly discuss safety modifications for the next few months.
If further information is desired or required, one is able to provide an individual with Specific Suggestions accordingly. This would involve discussion related to the individual’s unique practices, roles and routines, with subsequent activity analysis and joint problem solving in order to provide the client with relevant individualized education. This is also a point during which the Sexual Assessment Framework can further guide focused discussion (McBride and Rines, 2000).
Intensive Therapy is outside the scope of usual OT practice, and includes referral to or intervention by specialized clinicians including but not limited to the areas of: sexual medicine, gynecology, urology, psychiatry, psychology, etc.
The Sexual Assessment Framework is a road map for addressing the many components that are involved in sexual health. Borrowed from nursing literature (McBride & Rines, 2000), the framework includes: Sexual Knowledge; Sexual Behavior; Sexual Self-View; Sexual Interest; Sexual Response; Fertility and Contraception; and Sexual Activity.
Sexual knowledge involves an individual’s values and beliefs about sex and sexuality. (McBride & Rines, 2000). An OT clinician can provide a client with education regarding anatomy/physiology as impacted by the client’s condition or change in health/functional status. For example, an individual who has sustained a spinal cord injury, will greatly benefit from education regarding changes in neurological function, including impact on sexual function.
Sexual Behavior involves the “ability to initiate or maintain a social/sexual relationship” while Sexual Self-View encompasses one’s self-concept and body image. An OT clinician can explore the client’s former social/relationship roles in order to re-define one’s self as a person, a man or woman, and as a sexual being so as to develop new or modified roles and routines. The Canadian Occupational Performance Measure can be used to identify and prioritize facets related to one’s sexuality and sexual self-view.
Sexual Interest refers to the physical and psychological drive behind sexual activity engagement. Oftentimes, anxiety, fear, depression, and pain often interfere with sexual desire or “libido.” An OT clinician should consider targeting alternative pain management strategies, guided relaxation/meditation, or stress management.
Sexual response refers to the physical response and arousal that accompanies sexual activity. We traditionally define this as including: penile erection/vaginal lubrication, nipple erection, ejaculation, and orgasm. Depending on one’s health status, it is important to know how the client’s response has changed. For example, if related to a spinal cord injury, increased physical stimulation may be required to achieve erection, orgasmic threshold may be elevated, and/or increased duration for the refractory period may exist. An OT clinician can empower the client to participate in body/sensory mapping – with self or partner – so as to determine what forms of physical input are pleasurable. In addition, employ the client to consider or explore non-penetrative sexual/intimate activities. Furthermore, an occupational therapist might provide basic education surrounding sexual response in order to assist a patient in identifying challenges and referring patients to the appropriate professionals.
Fertility and Contraception involve family planning, safe sex, and integration of birth control. Depending on the client’s practices, OT may be involved in medication management strategies, or mechanical device management as related to UE function and coordination to manage a male condom; female condom or diaphragm; or feminine hygiene products. In addition, OT can target childcare as related to the necessary motor, process, and social skills (AOTA, 2014; McBride & Rines, 2000).
Lastly, Sexual Activity includes the “motor abilities, hand function, balance, strength, management of bowel and bladder programs…dressing and undressing, transferring, and affectionate activities such as hugging and petting” (McBride & Rines, 2000, p. 10). Patients can be assisted with identifying any challenges related to body functions (e.g. pain, sensation, neuromusculoskeletal and movement-related functions) and performance skills (e.g. motor and praxis skills, sensory-perceptual skills, emotional skills, cognitive skills, and communication/social skills) that may be interfering with the occupational performance of sexual activity. Such information can help the occupational therapist in designing an appropriate plan that meets the patient’s goals while aligning with his/her sexual values and beliefs (AOTA, 2014; McBride & Rines, 2000).
Addressing sexual health within occupational therapy is imperative but infrequently occurs. Often, patients expect clinicians to initiate discussion about sex, whereas clinicians expect the patients to make the first move. Therefore, sometimes a “don’t ask, don’t tell” attitude exists, thus preventing initiation of a sexual health conversation altogether (Forsythe & Horsewell, 2006). Occupational therapists should adopt an active role within sexuality education and support programs (Summerville & McKenna, 1998) for adults receiving occupational therapy services.
The infrequent attention to sexual health related issues could potentially hinder the redefinition of the sexual self or the psychosocial adjustment within a person who has experienced a traumatic event or change in health status (Ide, 2004; Walters & Williamson, 1998). Studies have shown that patients rate sexual fulfillment and sexual reactivation as a high priority during rehabilitation (Northcott & Chard, 2000). In addition, patients who are more knowledgeable regarding sexual health information are more successful in achieving a satisfying sex life following an injury (Forsythe & Horsewell, 2006), thus contributing to increased well-being and quality of life (Jones, Weerakoon, & Pynor, 2005).
The foundation of approaching sexual health consists of maximizing existing or remaining function of both mind and body while adapting to any limitations with an optimistic, positive, and open attitude (Elliott, 2009). An occupational therapy clinician is well suited to encourage a patient to reconceptualize and explore new possibilities of sexual activity (Solet, 2007) through intervention and discussion surrounding sexual health. It is hoped that the suggestions and resources offered can assist occupational therapy clinicians with addressing sexual health and routinely including the discussion of sexual activity into practice.
Special thanks to the clinicians of the Sexual Health Rehabilitation Service of Vancouver Coastal Health, Vancouver, B.C., for sharing your vast amount of skill and knowledge.
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About the Author:
Stephanie Kokesh, OTD, OTR/L, CSRS is the Director of Clinical Education/Academic FW Coordinator for the OTA Program at (Community Based Education and Development d/b/a) CBD College, Los Angeles, CA. She continues to also practice clinically at Cedars-Sinai Medical Center. Stephanie is involved in professional organizations – AOTA, OT Association of CA (OTAC), ACOTE Educational Standards Review Committee, and the Los Angeles OT Leadership Forum (LAOTLF). Stephanie received her entry-level OTD from Creighton University in Omaha, NE. Her “excitement” for sexual health and OT began during her time at Creighton. She was extremely fortunate to have completed her 16-week professional rotation with the Sexual Health Rehabilitation Service at the G.F. Strong Rehab Centre in Vancouver, B.C.
Patient Friendly Resources (not all inclusive):
- PleasureAble Manual: Sexual Device Manual for Persons with Disabilities **FREE!!
- Kaufman, M., Silverberg, C., and Odette, F. (2007). The ultimate guide to sex and disability: For all of us who live with disabilities, chronic pain, and illness. Publisher: Cleis Press Inc.
3. Tepper, M. (2015). Regain that feeling: Secrets to sexual self-discovery. Publisher: CreateSpace Independent Publishing Platform
Videotape/DVD for Patient/Partner Education (not all inclusive):
Alexander, C. J. & Sipski, M. (Producers). (1993). Sexuality reborn: Sexuality following spinal cord injury. [Videotape]. (Available from the Kessler Medical Rehabilitation Research and Education Corporation, 1199 Pleasant Valley Way, West Orange, NJ 07052).
BC Rehab. (n.d.) Talking about sexual issues and spinal cord injury: A guide for professional caregivers. (Available from The BC Rehab Education Resource Centre, 700 West 57th Avenue, Vancouver, BC, V6P 1S1, (604) 321-3231).
Hebert, L. A. (Producer). (n.d.). Sex and back pain: How to restore comfortable sex lost to back pain. (Available from IMPACC USA, PO Box 1247, 7 Washington Street, Greenville, ME 04441).
Orner, E. (Producer). (n.d.) Untold Desires [Videotape]. (Available from Filmakers Library, 124 East 40th St, NY, NY 10016, (212) 808-4980).
Donnelly, S., Falardeau, K., Falardeau, M., & Gallagher, J. (2012). SexAbility. (Landmark Media, 3450 Slade Run Drive, Falls Church, VA, 22042) Can be purchased at: http://www.landmarkmedia.com/videos_detail.asp?videokey=1713.
Hattjar, B. (Ed). (2012). Sexuality and occupational therapy: Strategies for persons with disabilities. Bethesda, MD: AOTA Press
- Sipski, M. and Alexander, C. (1997). Sexual function in people with disability and chronic illness: A health professional’s guide. Maryland: Aspen Publishers, Inc.
- Sexual Health Rehabilitation Courses (for Allied Health) through British Columbia Institute of Technology
- American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process, 3rd Edition. American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. http:// dx.doi.org/10.5014/ajot.2014.682006
- Anderson, K. D. (2004). Targeting recovery: Priorities of the spinal cord-injured population. Journal of Neurotrauma, 21(10), 1371-1383.
- Elliott, S. (2009). Sexuality after spinal cord injury. In E. C. Field-Fote (Ed.), Spinal cord rehabilitation (pp. 513-529). Philadelphia: F.A. Davis
- Esmail, S., Esmail, Y., & Munro, B. (2001). Sexuality and disability: The role of health care professionals in providing options and alternatives for couples. Sexuality and Disability, 19(4), 267-282.
- Forsythe, E. & Horsewell, J.E. (2006). Sexual rehabilitation of women with a spinal cord injury. Spinal Cord, 44(4), 234-41.
- Greco, S. B. (1996). Sexuality education and counseling. In S. P. Hoeman (Ed.), Rehabilitation nursing: Process and application (pp. 594-623). Louis, MO: Mosby Inc.
- Hattjar, B., Parker, J. A., & Lappa, C. L. (2008). Addressing sexuality with adult clients with chronic disabilities: Occupational therapy’s role. OT Practice, 13(11), CE-1-CE-7.
- Ide, M., Watanabe, T., & Toyonaga, T. (2002). Sexuality in persons with limb amputation. Prosthetics and Orthotics International, 26, 189-194.
- Jones, M. K., Weerakoon, P, & Pynor, R. A. (2005). Survey of occupational therapy students’ attitudes towards sexual issues in clinical practice. Occupational Therapy International, 12(2), 95-106.
- McBride, K. E. & Rines, B. (2000). Sexuality and spinal cord injury: A road map for nurses. SCI Nursing, 17(1), 8-13.
- Northcott, R. & Chard, G. (2000). Sexual aspects of rehabilitation: The client’s perspective. British Journal of Occupational Therapy, 63(9), 412-418.
- Sakellariou, D. & Algado, S. S. (2006). Sexuality and disability: A case of occupational injustice. British Journal of Occupational Therapy, 69(2), 69-76.
- Solet, J. M. (2007). Optimizing personal and social adaptation. In M. Vining Radomski and C. A. Trombly Latham (Eds.), Occupational therapy for physical dysfunction. 6th (pp. 924-950). Philadelphia: Lippincott Williams & Wilkins.
- Summerville, P., & McKenna, K. (1998). Sexual education and counseling for individuals with a spinal cord injury: Implications for occupational Therapy. British Journal of Occupational Therapy, 61, 275-279.
- Townsend, E. A. & Polatajko, H. J. (2007). Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation. Ottawa: CAOT Publications ACE.
- Walters, A. S. & Williamson, G. M. (1998). Sexual satisfaction predicts quality of life: A study of adult amputees. Sexuality and Disability, 16(2), 103-115.