Beyond Basic ADLs

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April 2002

By Joanne Phillips Estes, MS, OTR/L

Sexual expression is an important but often overlooked activity of daily living.

An activity of daily living (ADL) task that has been overlooked in adult rehabilitation is sexual expression. Healing benefits of sexual expression activity following a life-changing illness, injury, or disease event are documented yet barriers impede intervention in this activity.

Intervention is geared toward patient maximal independence in performing tasks required of their life roles and typically includes retraining in basic activities of daily living (BADL) tasks. This is based on an assumption that people want to take care of their own personal bodily needs as much as possible and also the fact that most insurance reimbursement decisions are based on improvement in BADL task performance.¹ The complexities of adult rehabilitation services obviously extend beyond retraining in self-care abilities.

Sexual Expression Not Addressed

Studies indicate one area of ADL functioning not sufficiently (if at all) addressed in medical model-based intervention and especially in adult rehabilitation programs is that of sexual expression.^2,3 The American Occupational Therapy Association (AOTA) validates sexual expression as a legitimate intervention activity by including it in its ADL list in the Uniform Terminology for Occupational Therapy (3rd ed). AOTA defines sexual expression as "engaging in desired sexual and intimate activities."⁴ Furthermore, evidence supports that participating in sexual expression following a disabling event can aid the healing process by improving patients' physical and psychosocial health.⁵

Participating in sexual expression activities include experiencing benefits of a fulfilling emotional relationship, improving self-esteem, and elevating feelings of self-worth.⁶ Sexual activity may reduce the risk for heart disease in men and increase life satisfaction in the elderly population.⁷ A positive correlation has been shown between dealing with sexual expression and disability adjustment and community reintegration.² Health professionals and patients agree that addressing sexual health should be an integral component of intervention8 but barriers interfering with addressing rehabilitation patients' sexual expression needs are prevalent.

Barriers
Major barriers to sexual expression intervention are reported to be limited occupational therapist knowledge, training, and experience.³ Lack of knowledge leads to therapist embarrassment and discomfort initiating discussion or exploring this ADL function. Therapists may also fear patient misunderstanding of their intentions that could result in accusations of sexual harassment. The need for advanced training and additional knowledge to provide competent intervention is a necessity and includes, but is not limited to, knowledge of sexual anatomy and the body's physiological response during sexual activity; an understanding of relationship dynamics; information regarding effects of the normal aging process on sexual functioning and possibilities for sexual activity within the framework of a particular condition; and a thorough understanding of the influence of the patient's societal and cultural context.⁷

A second barrier is the therapist's assumption that someone else on the treatment team will address the topic.⁷ Unclear role delineation regarding who should provide this intervention causes confusion for patients and therapists alike. Occupational therapy education programs provide minimal training in the area of sexual expression intervention.⁹ OT expertise in promoting functional independence through activity analysis, adaptation of task, environment, or person, and psychosocial impact of physical disability, however, provides beginning level knowledge on which advanced training can be built. There is general agreement in the literature that the team member who has developed the closest rapport with the patient is the one most qualified to assume this role.¹⁰

A third barrier involves therapists' personal values or biases. Therapists may assume that sexual expression is not important to the elderly (ageism) or patients who have a physical disability. It is important for therapists to withhold judgement of patients' lifestyle practices and to treat them with the utmost respect.

Patients may also be uncomfortable discussing their sexual practices with a therapist from a different generation who may also be of the opposite gender. The patient may be of a generation or cultural background that prohibits discussion of these very private matters. Patients may not be ready to address sexuality because they are experiencing depression or needing maximal psychic energy to adjust to new realities such as pain, decreased mobility, compromised social integration, or altered sleep and appetite.¹¹ Patients and their partners may be afraid that sexual activity will be painful or harmful and perhaps avoid resuming sexual activity out of fear of inciting a recurrent heart attack or stroke.² Multiple additional factors can influence a patient's libido including but not limited to: side effects of medication; altered self-image; motor, sensory, or cognitive impairment; change in role status (ie, dependence on partner for completion of self-care activities); incontinence; symptoms of concurrent medical conditions; personal or societal attitudes that sexual activity is only for young and attractive people; lack of partner; and biases about masturbation.²

Effective intervention requires extensive knowledge, strong interpersonal communication skills, maturity, and certain personal characteristics, such as emotional stability, patience, and a sense of humor.⁷ Therapists must have an understanding and acceptance of their values, biases, and limitations in providing intervention in this sensitive area. One framework for sexual expression intervention known as the PLISSIT Model¹² is designed to meet varying levels of patients' individual needs throughout their rehabilitation process.

PLISSIT Model of Intervention
PLISSIT is an acronym for four levels of intervention that were developed by psychologist Dr Jack Anon: permission, limited information, specific suggestions, and intensive therapy.¹²

Permission, the most basic and general level of intervention, allows the patient to express concerns in this area. Patients are reassured that their feelings are normal, acceptable, and a sign of recovery.²

Limited information relates to patient concerns regarding the impact of their specific condition on sexual expression abilities and may consist of dispelling myths.² This level of intervention is often provided in a group setting, includes patients and their sexual partner (if desired), and offers factual information via pamphlets, handouts, and resource lists.²

Specific suggestions are aimed at solving an individual patient's problem and requires advanced knowledge and skill, but may be within the realm of OT service provision. A detailed sexual history is obtained, specific problem(s) identified, and goals collaboratively established that address improved function in the targeted area.² Intervention approaches may include problem solving, education, and compensatory strategies.

The highest level, intensive therapy, requires formal training and documented competence in sex therapy, sexuality counseling, or psychotherapy.² This level of intervention is beyond the scope of typical rehabilitation intervention and indicates the need for referral to a specialist.

References
1. Trombly CA. Conceptual foundations for practice. In: Trombly CA, Radomski MV, eds. Occupational Therapy for Physical Dysfunction. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2002:1-15.
2. Farman J, Friedman JD. Sexual function and intimacy. In: Gillen G, Burkhard A, eds. Stroke Rehabilitation: A Function Based Approach. St Louis: Mosby Yearbook Inc; 1998:423-436.
3. Yallop S, Fitzgerald MH. Exploration of occupational therapists' comfort with client sexuality issues. Aust Occup Ther J. 1997;44:53-60.
4. Uniform Terminology for Occupational Therapy. 3rd ed. Bethesda, Md: American Occupational Therapy Association; 1994.
5. Cole T, Cole S. Rehabilitation of problems of sexuality in physical disability. In: Kotte F, Lehman J, eds. Krusen's Handbook of Physical Medicine and Rehabilitation. 4th ed. Philadelphia: WB Saunders Co; 1990:988-1008.
6. Neistadt ME. Human sexuality and counseling. In: Hopkins H, Smith H, eds. Willard and Spackman's Occupational Therapy. 8th ed. Philadelphia: JB Lippincott; 1993:148-154.
7. Freda M. Addressing the sexual needs of persons with disabilities. In: Christianson C, ed. Ways of Living Self Care Strategies for Special Needs. 2nd ed. Bethesda, Md: American Occupational Therapy Association; 2000:319-332.
8. Butler L, Banfield V, Sveinson T, Allen K. Conceptualizing sexual health in cancer care. West J Nurs Res. 1998;20:683-705.
9. Payne MJ, Greer DL, Corbin DE. Sexual functioning as a topic in occupational therapy training: a survey of programs. Am J Occup Ther. 1988;42:227-230.
10. Couldrick L. Sexual issues: an area of concern for occupational therapists. Br J Occup Ther. 1998;61:538-544.
11. Solet JM. Optimizing personal and social adaptation. In: Trombly CA, Radomski MV, eds. Occupational Therapy for Physical Dysfunction. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2002:761-782.
12. Annon JS. The PLISSIT model: a proposed conceptual scheme for the behavioral treatment of sexual problems. J Sex Educ Ther. 1976;2:1-15.

Joanne Phillips Estes, MS, OTR/L, is assistant professor and department chairperson, Department of Occupational Therapy, Xavier University, Cincinnati. She may be reached via email at estesj@admin.xu.edu.

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April 2002