Addressing intimacy and sexuality, as a rehab clinician, might not be the top of your priority list. In actual fact, it might be an area that you struggle with! It is, of course, a sensitive topic, and our discomfort with bringing it up stems from societal issues, pre-existing suppositions about our patients, and even a lack of confidence in our own roles… as healthcare providers.
Let’s have a closer look at the role of the Occupational Therapist, Physical Therapist, and rehab nurse in the discussion of sexuality in rehab- and how we can make this tricky conversation more accessible to everyone.
The Clinician’s Role
“It’s not my role!” This refrain can be heard echoing in the halls of my rehab facilities- but especially when addressing sexuality is on the table. Is it in my scope of practice? Whose role is it, anyway??
Well, when it comes to Occupational Therapists, sex and intimacy falls underneath one of the 9 areas of ADL as outlined in the OT Practice Framework (2014, AOTA). The Framework defines this ADL as: Engaging in activities that result in sexual satisfaction and/or meet relational or reproductive needs. If left unaddressed, it will lead to isolation, poor self esteem, loneliness and decreased self worth. Clients might feel shamed or unworthy of addressing such a sensitive topic with their healthcare provider, which might then lead to unsafe practices, including abuse, dangerous or unhealthy activities, pain, and so on.
Note #1! Sexuality spans a spectrum of activity, including intimacy like flirting, touch, massage, masturbation, and partnered sex. It also influences people’s identity, their connections as a human to the world around them, and their relationships with society at large.
Rehabilitation nurses are also in an excellent position to assure patients that a chronic illness, disability, or change in health status does not signal an end in their sex life. As Gender (1992) noted, many people do not grow up in an environment where sex and sexual preferences are openly discussed, and then when entering nursing school are encouraged to start conversations with their patients wherein they can address these issues. The dissonance is clear! Society sends clear signals that this is a private, intimate situation- and that increases tenfold when there is a problem or perceived issue with ‘normal’ sexual activity.
Note #2! There is no such thing as ‘normal’ sex; and no such thing as ‘doing it wrong’.
Physical Therapists have a unique role to play in sexual health and functioning: combating painful sex through rehabilitation of pelvic floor muscles. Pain can be multi factorial- stemming from nerve injury, scar tissue, musculoskeletal misalignment and injury, and have many other sources. Shame and stigma about pain during sex leads to a lot of silence around this topic.
Men and women can both benefit from the manual therapy techniques, neuromuscular reeducation, behavioral modification, and biofeedback involved with Pelvic Floor PT. Additionally, strengthening of the pelvic floor can help with other barriers to sexuality- such as incontinence, general posture and core strength, and ability to move around and maintain balance.
So with so many clear roles and opportunities for healthcare/therapy clinicians to engage in the topic of sexuality with their patients, why is it so under-addressed?
Well, as we have already noted, societal acceptance of this topic is rooted in young, able-bodied, heterosexual, monogamous persons who are engaging in sexual activity toward the ends of reproduction. This, of course happens to be in the vast minority of representation!
Clinicians widely accept that sexuality is an important area to be addressed with clients, but there are many reasons that there is a gap between ideology and practice. McGrath (2016) sums up some of the reasons as including- lack of knowledge among therapists, client factors including age, marital status, gender; concerns regarding therapist safety; fear of offending client; perceived lack of relevance to client; institutional practices that do not prioritize sexuality; personal attitudes; and lack of clarity regarding role.
You an see that any combination of the above would lead to a complete omission of this subject from practice. Sexuality and the rights of people toward that expression is not addressed in many therapy or nursing curricula, again compounding the factor of clinicians not addressing this area.
How can we get help in addressing this area?
Many patients undergoing rehab have reported that they would appreciate sexuality being brought up as an ADL that would benfit from being addressed, if needed. We can support each other as clinicians in increasing our comfort with addressing these issues by having frank and open conversations about how we feel, peer support in role-playing conversations with patients, and acknowledging the hang-ups that prevent us from effectively addressing this in the first place.
The PLISSIT model is a tool often used clinically to guide practice for clinical professionals in this arena. PLISSIT, standing for Permission-Limited Information- Specific Suggestions-Intensive Therapy can be used to ease us into the discussion, and ascertain how much intervention may be required by the client. An example of how to use this model in practice may look like:
Permission- Creating an environment of permissibility to bring up the topic of intimacy. For example, a clinician may say “We want to address all aspects of your health during your rehabilitation stay, especially areas that you may feel concerned about, like intimacy, sexuality, and so on. I am here to discuss it with you should you have any questions, concerns, or would like more specific information and resources on the topic.” This allows the patient to know that this is a safe environment to bring up the issue, be it in that moment or at a later time.
Limited Information– This stage of the model may guide beginning to include education or intervention with the patient. For example, a clinician may say “Often, (Arthritis/SCI/Joint replacement/etc) can have an effect on sexuality in terms of (pain levels/comfortable or safe positions/sensations/etc). I have some information here about how to discuss and navigate this, if you would like to review ot or discuss with me or anyone from the rest of the team.” Providing limited information requires that the clinician should have baseline knowledge about the condition and its effects on the person, and may be focused on answering some basic questions, resolving concerns or misconceptions, and identifying a need for more resources or help.
Specific Suggestions– Once a client and clinician have established that Limited information is acceptable, and that they would like further information or intervention, the clinician may start giving information more specific to their needs. This could include adaptive positions, tools, alternative means of defining their wants and needs, and further resources and help.
Intensive Therapy– A clinician may feel that a client may require more intervention than they are equipped to speak to- and at this point a more practiced and specialized professional may be required. Depending on the reason that expert intervention is required, the appropriate professional (sex therapist, counselor, pelvic floor physical therapist, etc) can be identified, and your role with the client may revert to being an empowering source, allowing them to feel heard, assuring them of their rights, and so on. There are other guides of addressing this issue with patients, but the PLISSIT model can provide a nice outline to increase a clinician’s confidence.
Of course, we can all accept our own limitations with addressing sexuality in rehab- but at the very least, bringing this topic up will be less isolating for the patient as it will recognize them as a whole, complex, person; taking focus off their perceived ability to engage in relationships or sex. Many times you may be the only professional bringing this topic to light for your client- that is an important role in and of itself!
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References/further reading: https://www.foxrehab.org/video/ageism-sexual-intimacy-conversations/; https://www.aota.org/Education-Careers/Students/Pulse/Archive/career-advice/Sex-intimacy.aspx; https://www.urevolution.com/physical-therapy-for-vaginismus/?fbclid=IwAR0URbBYmWJfac8yJY2MbphMaiD1k6LSgW_VcXgdjYqDmjBcxGHqtQP9UJ4; http://www.terapeutas-ocupacionales.es/assets/files/COPTOA/Bibliotecavirtual/AJOT/Enero-Febrero%202016/7001360010p1.pdf; https://www.tandfonline.com/doi/full/10.3109/09638288.2012.688920;