Sex is an “activity of daily living” (ADL) that healthcare professionals may feel uncomfortable or unprepared to address during an assessment.
By acknowledging the important role of sexuality, and learning to facilitate dialogue on this subject, you can help clients develop a positive, pleasurable relationship with their physical self and with their intimate partners.
A useful framework for sexual health conversations is the PLISSIT model (Annon, 1976). Much like a vinyl record, this model is somewhat dated but continues to have value and relevance.
P = Permission
Obtaining a client’s permission to talk about sex is the essential starting point. Listed below is a sample introductory statement, adapted from the CDC’s “A Guide to Taking a Sexual History”:
“I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are personal, but they are important for your overall health.
I ask these questions to all of my adult patients, regardless of age, gender or marital status and this information is kept in strict confidence. Do you have any questions before we get started?”
Another good way to bridge the subject is by inquiring about relationship status and then to ask about sexual health practices. Questions specific to an occupational therapy assessment may include the following:
- Has anyone talked to you about how your injury/illness can affect your ability to have sex (or a sexual relationship)?
- Since your injury/illness, has your relationship with your partner changed? Has there been any change in your physical relationship?
- Has your desire or interest in sex changed?
- Do you have questions or concerns regarding your sexual health that you would like to know?
The clinician will inevitably set the tone with their level of comfort and confidence, or lack thereof. Maintaining eye contact, allowing clients sufficient time to process (hint: count to ten), and not turning fifty shades of red are important factors in establishing rapport and eliciting candid responses. Practice saying the appropriate terms in front of a mirror or with your friends if that helps.
LI = Limited Information
If the client articulates specific concerns then you’ll have an opportunity to provide limited information, meaning that you offer no more than necessary. For example, a client may desire some education on how their condition impacts range of motion during sex; this does not mean they are ready to purchase the Intimate Rider.
Follow your client’s lead and continue to check in for permission before offering additional information. Also, do not feel pressured to generate answers on-demand.
There is nothing wrong with telling a client, “I don’t know but I’ll look into that for you.” Remember that acknowledging and validating your clients’ questions may be as important as the answers you provide.
For educational resources on sex and disability check out the Center for Sexual Pleasure and Health; their website has information on mobility positioning devices, adaptable sex toys, online support forums, and even porn for the blind.
SS = Specific Suggestions
IT = Intensive Treatment
Unless you’ve received advanced training in sexual health, this is likely where your role would end and a referral to a specialist might begin. The American Association for Sexuality Educators, Counselors, and Therapists maintains a hefty referral base of certified sex therapists on their website (http://aasect.org), and these professionals have been trained to address psychological challenges and relationship issues that may accompany loss of sexual functioning.
Likewise, The American Physical Therapy Association has a Section on Women’s Health, which may be a valuable resource if pelvic floor issues (in either gender) contribute to sexual problems.
If you are interested in continuing education on sexual health, there are a number of AASECT-approved training providers, including the South Shore Sexual Health Center in Quincy and the Institute for Sexuality Education and Enlightenment (ISEE) in Northampton. Upcoming courses at South Shore include “Health and Medical Issues,” “Range of Sexual Functioning,” and “Disability and Sexuality.” ISEE offers similar live trainings in addition to pre-recorded webinars.
I would also encourage healthcare professionals to consider becoming certified sexuality counselors through AASECT, as we need more doctors, nurses, and therapists who can talk about sex with comfort and confidence. The University of Michigan offers a sexual health certificate program, part of which can be completed online, that satisfies the core educational requirements.
By addressing sexuality with clients in an empathic, direct manner, we take important steps forward in treating the whole person, normalizing desire for sexual expression, and validating that aspect of their identity and interpersonal relationships.