~sexuality

sexuality

• state of mind that represents how individuals feel about themselves, relate to others, establish relationships, and express themselves

• as an occupation, it is highly personal and involves one’s sexual values, beliefs, sexual expression, and how one engages in sex, which varies from person to person 

intimacy

a close, personal, trusting relationship with another person or group of people, which include giving and receiving support and affection

self-intimacy

related to being aware of and connection to one’s authentic, inner self, and may include our self concept, worth, and compassion for others

sexual pleasure

the physical and/or psychological satisfaction and enjoyment derived from shared or solitary behaviors, as well as partnered or multiple partners; consists of solitary behaviors as well as partnered or multiple partners 

• solitary: masturbation and fantasy

• partnered: kissing, touching, oral sex, penetration (vaginal or anal), spicy sex (sex toys, explicit material, group sex, swinging)

sexual self-view

how you see yourself as a sexual being

• sexual preference

• sexual expression

• gender identity

• sexual orientation

• self esteem

• body image

• sexual education

sexual health

• fundamental to the overall health and well-being of individuals, couples, and families, and to the social and economic development of communities and countries; when viewed affirmatively, requires a positive ad respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence

definitions: 

• sexual activity 

• sexual interest

• sexual response

• sexual expression 

• sexual knowledge

• sexual self-view

• intimacy 

• sexual health and family planning 

bias

e.g., ageism, homophobia, transphobia, etc.

• implicit (unconscious bias)

• explicit (conscious bias)

• internalized bias

the truth

• a significant proportion of older adults are sexually active

• wide variety of sexual activities

• this proportion decreases with age

• this decline is more pronounced among women

why do most healthcare practitioners often ignore sexuality in their practice? 

• inadequate knowledge 

• another team member will address it 

• feeling uncomfortable talking about it 

• may think it is expressing interest 

• may be complicated when sexuality differs from own 

• religious

• societal attitudes

• myths of sexuality and people with disabilities 

• limited resources

sexuality and OT

• domain: occupations

Occupational Therapy Practice Framework: Domain and Process 4th Edition (AOTA, 2020)

• activities of daily living (ADL): sexual activity

  • “engaging in broad possibilities for sexual expression and experiences with others (e.g., hugging, kissing, foreplay, masturbation, oral sex, intercourse)

• health management

  • social and emotional health promotion and maintenance

    • “identifying personal strengths and assets, managing emotions, expressing needs effectively, seeking occupations, and social engagement to support health and wellness, developing self-identity, making choices to improve quality of life participation”

  • personal care device management

    • “procuring, using, cleaning and maintaining personal care devices, including…contraception and sexual devices”

• social participation: intimate partner relationships

  • “engaging in activities to initiate and maintain a close relationship, including giving and receiving affection and interacting in desired roles; intimate partners may or may not engage in sexual activity”

• sexuality is considered an activity of daily living and is part of life, and important to most people

• OTP are holistic and consider the person, the activity, and the context

• OTP are experts in adaptive equipment and assistive technology

• OTs are skilled at activity analysis

• therapeutic use of self

• but this is a team approach

lessons from OTs who have been successful in addressing sexuality 

bringing sexuality out of the closet: what can we learn from OTs who successfully address the area of sexuality in everyday practice

• themes & sub-themes

  • sexuality matters

  • know your boundaries

    • person

    • professional

    • organizational

  • just do it

    • tap into existing skill set

    • commitment to self-education and practice

  • seek support and mentoring

PLISSIT model 

4 stage progressive/linear model (kind of a limitation —> EXPLISSIT)

• PLISSIT Model Permission (P): permitting patients to raise sexual issues 

• Limited Information (LI): giving patients limited information about the sexual side effects of treatments 

• Specific Suggestions (SS): making specific suggestions based on a full evaluation of presenting problems 

• Intensive Therapy (IT): referral to intensive therapy (includes psychological interventions, sex therapy, and/or biomedical approaches) 

extended PLISSIT model 

updated more where it’s less linear and more circular

• P: permission giving

• LI: limited information

• SS: specific suggestions

• IT: intensive therapy

recognition model

== specific skills that health practitioners can use to protect and promote sexual health in people with disabilities, thus the HOW this can be achieved

stage 1: recognize the service user as a sexual being

• validation/acknowledgement, normalization and affirmation, importance, relevance

• “you may have sexual concerns (acknowledgment), may clients do (normalization); it is not an area of expertise of mine (limitations), but I appreciate the importance (affirmation); if you wish, I can speak to my colleague about this”

stage 2: provision of sensitive, permission-giving strategies

• invite disclosure, respect privacy 

• “i find some people also want to talk to me about relationships, or have questions about sex; I am happy to discuss this if you have any concerns”

• information leaflets and posters, or pins that would invite questions of sexuality 

stage 3: exploration of the sexual problem/concern

• this can be with the OT or a specific team member 

• permission may lead to a referral for exploration by other team members 

stage 4: address issues that fit within the team’s expertise and boundaries

• analysis of sexual concern, treatment planning, goal setting, and interprofessional work 

• PT (biomechanical issues that cause discomfort), OT (energy conservation, body image, ADLs related to sexuality, positioning, adaptation, if knowledgeable about sexual toys, creams, cock rings, vibrators, penis pumps, etc.), speech (communication), physicians (medications, surgeries) 

stage 5: referral if necessary

• fall outside of the disability team’s role, such as intensive therapy, surgeries, and relationship counseling 

occupational therapy sexual assessment framework (OTSAF)

• person

• performance

• occupation

• context

evaluating sexuality and intimacy

• OT evaluation

  • Occupational Profile (sexual history)

• person

  • client factors

    • values (e.g., sexual self-view, sexual knowledge)

    • beliefs

    • spirituality

  • body functions

  • body structures

• performance

  • performance skills

    • motor skills (e.g., grasp, thrust)

    • socialization (e.g., initiating conversations about sex)

    • sequencing, initiation

• occupation

  • ADL (e.g., sexual activity)

  • IADL (e.g., family planning, sexual expression)

  • social participation (e.g., intimacy)

  • health management (e.g., sexual health)

• context

  • environmental factors

    • e.g., privacy in a nursing home, having a single-bed

  • personal factors

evaluating sexuality and intimacy:

Occupational Performance Inventory of Sexuality and Intimacy (OPSI)

• developed to define the occupational nature of sexuality and intimacy 

• created to be a theoretical occupation-based screen, an in-depth self-assessment, and a performance measure to address sexuality and intimacy

  •  initial screen

  • in-depth self-assessment (covers sexual activity, sexual interest, sexual response, sexual expression, sexual self-review, intimacy, and sexual health and family planning)

  • performance measure

  • scoring form

  • goals

  • referral

OPISI: Initial screen

OPISI: In depth assessment

OPISI: Performance Measure

Prevalence of Sexual Activity

• Decreases with age

• Is lower among women

• Is lower among those with poorer health status

• Remains significant in the elderly

issues and challenges

• stereotypical beliefs and myths 

• demographics

• psychological 

• cognitive changes

• lack of privacy

• physical concerns

age related changes in sexual function

• men vs women

• gradual changes

• changes in hormone levels

• men:

  • testosterone levels decrease very little

  • decreased sperm production and ejaculatory force

  • prostate enlargement

  • decreased desire or arousal

• women:

  • vaginal dryness, reduced lubrication

  • changes in shape and in muscle tone

  • thinning of the vaginal wall

  • reduced size of the clitoris 

  • decreased desire and arousal

age related changes in sexual function vs sexual dysfunction

• DSM-5: sexual dysfunction: 

  • female sexual arousal/interest disorder

    • persistent decrease in sexual interest or arousal that may include reduced desire, fewer sexual thoughts, or decreased physical arousal; in older adults, this can be influenced by hormonal changes (e.g., menopause), chronic illness, medications, fatigue, or emotional factors

  • male hypoactive sexual desire disorder

    • long-term reduction in sexual desire that causes distress or concern; in older men, this may be related to normal aging, low testosterone, medical conditions (e.g., heart disease or diabetes), medications, depression, or relationship changes

  • female orgasmic disorder

    • difficulty achieving orgasm, or experiencing significantly reduced intensity of orgasm, despite adequate stimulation; for older women, this may be affected by changes in blood flow, nerve sensitivity, pelvic floor strength, medications, or comfort with sexual activity

  • genito-pelvic pain/penetration disorder

    • ongoing pain, fear, or difficulty with vaginal penetration; in later life, this is often associated with vaginal dryness, thinning of vaginal tissues after menopause, pelvic floor muscle tightness, or past painful experiences

  • erectile disorder

    • difficulty achieving or maintaining an erection sufficient for sexual activity; this becomes more common with age and may be linked to cardiovascular health, diabetes, nerve changes, medications, or stress

  • premature (early) ejaculation

    • ejaculation that occurs sooner than desired, often with minimal stimulation, and causes distress; in older adults, it may be influenced by anxiety, changes in sexual routines, or health conditions, and can often be improved with education and behavioral strategies

  • delayed ejaculation

    • marked delay or inability to ejaculate despite adequate stimulation; in older men, this can be related to medication side effects (e.g., especially antidepressants), nerve changes, chronic illness, or psychological factors

• for each diagnosis, symptoms must…

  • (A) be experienced 75% to 100% of the time,

  • (B) last for at least 6 months, and

  • (C) have caused significant distress; disorder of sexual desire/interest

effects of disease on sexuality 

• arthritic

• chronic pain 

• diabetes

• heart disease

• stroke

• alcohol and drug use

• pulmonary disease

• incontinence

• depression 

• anxiety 

• heath attack 

• medications

• cancer

sexuality and cardiovascular disease

• myths:

  • sex is no longer permissible after a cardiac event

    • just talk to a doctor to make sure you’re being safe

  • person with heart disease will experience chest pain during sexual activity

• risk factors

• MET levels guide for sexual activity

• prior to resuming sexual activities:

  • psychological barriers

  • pain

  • decreased libido

  • erectile dysfunction

older adults and sexually transmitted infections

• older adults may be at an increased risk for STIs

  • lack of screening

  • decline in immune function

  • decreased usage of protection

  • age-related physiologic and anatomic changes

prevalence of HIV in older adults

over half of people with diagnosed HIV were aged 50 and older; compared to all people with HIV, people aged 55 and older have higher viral suppression rates

why is the number of older people with HIV growing?

• treatment of ED

• large population of divorced/widowed and newly dating

• lack of knowledge of HIV

• programs do not target or address risk factors for older adults

• afraid to discuss sex lives

  • may be doing unsafe practices in hiding

• risk factors

sexuality concerns with LGBTQ+ older adults

• under-reporting to health professionals

• often do not disclose their sexual histories or practices

• need for health care professionals to be culturally and clinically sensitive and competent when taking medical, social, and sexual histories

strategies and intervention for older adults

• open communication 

• education and prevention 

• privacy 

• expand the definition of sex

• manage expectation

• stay sexually active

• if you don’t know, just say, and then look for resources and the answers

• direct OT interventions

  • adaptive sexual devices, lubrication, vibrators, masturbation

  • positions, positioning devices, time of day

  • decrease

  • other erroneous zones, body mapping, body awareness

  • ADLs, IADLs to prepare

  • self-image concerns (referral to psych)

  • energy conservation and sex simplification

  • bowel and bladder care

  • fine motor, oral motor interventions

  • pain management (referral to MD)

  • pharmacological intervention (referral to MD)

  • surgical interventions (referral to MD)

  • medication changes for depression/anxiety (referral to psychiatrist)

  • sex therapy (referral to sex therapist)

  • reproductive health access (referral to social work)

  • screening and treatment of STIs, safe sexual practices (refer to nurses or MD)