Sexual Activity & Participation

• Many conditions may affect sexual activity and participation.
  • Physical, e.g., Cancer
  • Psychological, e.g., Depression
  • Cognitive, e.g., Intellectual Disability
• Occupational therapy practitioners believe that addressing sexual health is a legitimate domain of practice, but they are NOT currently addressing in practice.
• Believed to be due to their lack of knowledge, RATHER THAN their level of comfort that is limited them from addressing these needs in practice.
• Occupational therapists need education and training to improve their practice in addressing clients’ sexual health.
• Current ACOTE standards require education on ADLs from a general perspective and is not specifically outlined.
• Clients with disabilities are less likely to receive adequate education, healthcare, and therapy and more likely to experience sexual stigma and trauma.
• Sexuality has been described is according to the 5 components:
  1. Sensuality
  2. Intimacy
  3. Sexual identity
  4. Reproduction
  5. Sexualization
• Clients may believe myths and this may be a barrier to their sexual participation.
• PLISSIT models describe 4 levels of involvement in the assessment and evaluation of a client’s sexual wellbeing:
  1. Permission
  2. Limited Information
  3. Specific Suggestions
  4. Intensive therapy
• “Extended” PLISSIT model from 2006: addresses the concern of practitioners often bypassing the permission-giving step and going straight ot providing information, IE, a pamphlet, without really giving clients the opportunity to “EX” press their concerns. places permission-giving at the core and places an emphasis on increasing the practitioner’s self-awareness and assumptions about sexuality. 
•  Primary, Secondary, and Tertiary outcomes
  • Primary outcomes address the effectiveness of interventions due to the primary causes of sexual dysfunction, such as erection, vaginal lubrication, and arousal.
  • Secondary outcomes may include things such as pain which co-exists with a condition that may be a barrier to sexuality.
  • Tertiary outcomes include psychosocial ones such as anxiety, depression, self-esteem, satisfaction, and quality of life.
• Sexual response cycle
  • Phase 1 begins with excitement. Keep in mind that this involves the entire body, not just arousal at the sexual organs.
  • Phase 2 is called plateau, which is characterized by increased sensitivity and blood flow to the sexual organs, increased respiration, heart rate, and blood pressure. Muscle tension also increases.
  • Phase 3 is called orgasm, often thought of as climax. The vital signs that increased earlier are at their highest in this phase.
  • Phase 4 is called resolution and the body returns to its normal state of functioning.

Barriers to Sexual Participation

• Tone: hypotonia & hypertonia
• Medications
• Endurance/Fatigue, e.g., cardiac MET levels
• Breathing
• Joint issues
• Muscle contractions
• Pain
• Timing
• Sensation
• Mobility
• Balance
• Weakness
• Comorbid conditions
• Cognition
• Communication
• Psychosocial
• Environmental

Outcome Measures

• Beck Depression Inventory
• Disability Scale
• Fatigue Severity Scale
• Female Sexual Function Index

History

• Client comfort (including environment)
• Confidentiality
• Professionalism
• Topics: Sexual health, Masturbation, Contraception, Aging, Physical Changes, Specific Groups, e.g., LBGTQ, Hygiene, Body image, e.g., scars, Psychosocial, Equipment (Catheters, lines, Adaptive equipment), Perception, Communication with partner, Preferences, Safe sex, Birth control
• Therapeutic communication & use of self

OT Intervention

• Psychoeducation
• Partner Communication
• Modified strategies, e.g., positions
• Assistive devices, e.g., wedges, ramps, mounts, loungers
• Supplies, e.g., lubrication, stimulation devices
• Resources and referral
• Exercises (legal)
• Energy conservation
• Yoga, Mindfulness
• CBT

Positions

“To assess the client’s positioning needs, the therapist must analyze the demands of the particular activity. This analysis entails looking at the physical, psychological, social, cultural, and cognitive aspects of the client’s functioning. Activity analysis should be implemented using an objective and professional perspective.”

Missionary Position

• Pros:
  • Minimal Energy Requirement: Ideal for partner on bottom with conditions like fatigue or paralysis.
  • Emotional Intimacy: Enhances emotional connection.
  • Accessibility: Suitable for individuals with catheters and stomas, minimizing abdominal pressure.
  • Supportive Position: Pillows under knees or back can reduce strain for those with arthritis or joint pain.
  • Biomechanical Considerations: May reduce pressure on lower back with appropriate support.
• Cons:
  • Hip/Knee Issues: Can exacerbate pain without proper support, particularly for osteoarthritis.
  • Back Strain: May be uncomfortable for those with lumbar spine issues; using pillows can help alleviate this.

Doggy Position (Kneeling)

• Pros:
  • Low Energy Needs: For the partner in front, suitable for hip flexion issues but no abduction.
  • Lower Back Relief: Rear partner may experience less back strain.
  • Adaptations: Pillows under knees can provide support, reducing strain for those with knee osteoarthritis.
  • Biomechanical Considerations: Distributes weight to knees and hips, reducing spinal load.
• Cons:
  • Contraindications: Not suitable for individuals with back pain, arthritis, or joint degeneration.
  • Pressure Points: Can cause discomfort due to weight on knees and hips.
  • Adaptive Tools: Knee pads or cushions can help alleviate pressure.

Doggy Position (Standing)

• Pros:
  • Decreased Back Strain: For the partner in the rear, reducing spinal pressure.
  • Accessibility: Easier for those who have difficulty kneeling or lying down.
  • Biomechanical Considerations: Shifts weight to lower extremities, sparing the spine.
• Cons:
  • Strength and Abduction Required: Partner in front needs good strength and hip abduction, difficult for those with hip arthritis or muscle weakness.
  • Contraindications: Joint degeneration in hips, knees, or ankles can cause pain.
  • Adaptive Tools: Supportive furniture or bars for balance can help.

Cowgirl/Cowboy Position

• Pros:
  • Control and Comfort: Partner on top controls depth and speed, accommodating pain and comfort for conditions like interstitial cystitis.
  • Pressure Relief: Keeps pressure off the bladder and stoma.
  • Flexibility: Partner on the bottom can flex lower extremities and use support for low back pain.
  • Low Energy: Suitable for the partner on the bottom with conditions like chronic fatigue syndrome.
  • Biomechanical Considerations: Allows partner on top to use upper body strength to adjust position.
• Cons:
  • Hip Abduction and Balance: Requires good hip abduction and balance from the partner on top, challenging for those with hip dysplasia or poor balance.
  • Adaptive Tools: Stability aids or a supportive surface can help the partner on top.

Reverse Cowgirl

• Pros:
  • Control: Partner on top can control depth and speed, useful for managing pain.
  • Low Back Pressure: Reduces pressure on the lower back for the partner on bottom.
  • Flexibility: Allows for visual stimulation and variety.
  • Biomechanical Considerations: Partner on top can use arms for support, reducing strain on hips and knees.
• Cons:
  • Hip Abduction and Strength: Requires good hip abduction and strength from the partner on top, challenging for those with hip or knee issues.
  • Balance Required: Can be difficult for those with poor balance or coordination.
  • Adaptive Tools: Use of pillows or supports to maintain stability and reduce strain.

Spooning Position

• Pros:
  • Low Energy: Reduces physical exertion for both partners, beneficial for those with chronic pain or fatigue.
  • Stoma Accommodation: Stoma bag can be positioned out of the way, preventing discomfort.
  • Low Balance Needs: Both partners require minimal balance, suitable for those with balance issues.
  • Swayback Avoidance: No swayback strain for either partner, beneficial for those with spondylolisthesis.
  • Biomechanical Considerations: Supports the spine in a neutral position.
• Cons:
  • Energy Expenditure: Partner in the back will expend more energy, which could be tiring over time.
  • Adaptive Tools: Pillows and cushions can provide additional support and comfort.

Seated Position (e.g., Wheelchair)

• Pros:
  • Accessibility: Ideal for individuals with limited lower body strength or mobility.
  • Control: Allows the receiving partner to control movements, beneficial for conditions like spinal cord injuries.
  • Pressure Relief: Keeps pressure off the lower back and hips.
  • Biomechanical Considerations: Provides stability and reduces the risk of falls.
• Cons:
  • Movement Range: Limited range of movement can reduce variety.
  • Adaptive Tools: May require additional supports or cushions for comfort and stability.

Side-by-Side (Face-to-Face)

• Pros:
  • Intimacy: Allows for face-to-face interaction.
  • Equal Participation: Both partners can contribute equally, beneficial for those with joint issues.
  • Biomechanical Considerations: Even weight distribution, reducing strain on specific joints.
• Cons:
  • Coordination Required: Both partners need to move in sync, which can be challenging for those with motor coordination issues.
  • Space Requirement: May require more space and adjustments in bed positioning.
  • Adaptive Tools: Using firm mattresses or supports to maintain alignment.

 

NSFW PRO TIP: Check out websites on sexual activity positions to help visualize this, and learn this for your clients, and yourself. Don’t go down a rabbit hole and get too distracted though. Google: Sex Positions Databases

The NBCOT Exam will probably only test on “popular” and “common” sexual positions mentioned above, if at all. This is for your own education, lol.

Remember: sexual activity and intimacy are not just limited to penetration. There’s oral, foreplay, anal, masturbation, hand stimulation, etc., as seen in this screenshot:

 

Conditions and Contraindications

1. Arthritis: Avoid positions that strain joints (e.g., unsupported missionary, kneeling doggy).
2. Spinal Injuries: Rear-entry and positions requiring flexibility may exacerbate pain; use supportive tools.
3. Pregnancy: Opt for positions that relieve abdominal pressure (e.g., spoon, rear-entry) and use supportive pillows.
4. Fatigue: Side-lying and seated positions are beneficial for reducing physical exertion.
5. Joint Degeneration: Positions that reduce weight-bearing on joints (e.g., standing doggy) should be avoided.

Adaptive Tools and Durable Medical Equipment (DME)

• Pillows and Cushions: Provide support and reduce pressure points.
• Knee Pads: For kneeling positions to reduce joint strain.
• Supportive Furniture: Chairs with armrests or stability bars can aid balance.
• Sex Wedges: Specialized pillows designed to support various positions.
• Grab Bars: Can be installed in the bedroom to assist with balance and positioning.

References

Eglseder, K., Webb, S., & Rennie, M. (2018). Sexual functioning in occupational therapy education: A survey of programs. The Open Journal of Occupational Therapy, 6(3), 13.

McGrath, M., & Lynch, E. (2014). Occupational therapists’ perspectives on addressing sexual concerns of older adults in the context of rehabilitation. Disability and rehabilitation, 36(8), 651-657.

Esteve-Ríos, A., Garcia-Sanjuan, S., Oliver-Roig, A., & Cabañero-Martínez, M. J. (2020). Effectiveness of interventions aimed at improving the sexuality of women with multiple sclerosis: a systematic review. Clinical Rehabilitation, 34(4), 438-449.

Kim, J. H., Yang, Y., & Hwang, E. S. (2015). The effectiveness of psychoeducational interventions focused on sexuality in cancer. Cancer Nursing, 38(5), E32-E42.

Mc Grath, M., & Sakellariou, D. (2016). Why has so little progress been made in the practice of occupational therapy in relation to sexuality?. The American Journal of Occupational Therapy, 70(1), 7001360010p1-7001360010p5.

Pendleton, H. M., & Schultz-Krohn, W. (2017). Pedretti’s Occupational therapy-e-book: Practice skills for physical dysfunction. Elsevier Health Sciences.

​​Taylor S, Harley C, Ziegler L, et al. Interventions for sexual problems following treatment for breast cancer: a systematic review. 2011. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK97245/

Brill, S. (2013). The Ultimate Guide to Sex and Disability. Cleis Press.

Keesling, B. (2006). Sexual Healing: The Compleat Guide to Overcoming Common Sexual Problems. Hunter House.

McBride, K. R., & Renshaw, D. C. (2011). Sexuality and Chronic Illness: A Comprehensive Approach. CRC Press.

Lieberman, J., & Schroeder, E. (2010). The Intimate Couple: How Personal Environment Affects Sexual Health. OT Practice, 15(11), CE1-CE8.

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