Sexuality: The Most Overlooked ADL
As occupational therapists, addressing activities of daily living, or ADLs, is often our bread and butter. It’s easy to see that things like being able to take a shower, getting dressed in the morning, or even just feeding yourself are integral to living a fulfilling life.
Anyone who has experienced difficulty in these areas knows how important those things become when one can no longer complete them. Our job as therapists is to help our clients do them as independently as possible.
However, many practitioners often overlook one of the most important ADLs of all.
Yes, listed right below grooming, bathing, and dressing in the Occupational Therapy Practice Framework (OTPF) is “Sexual Activity,” defined as such:
Engaging in activities that result in sexual satisfaction and/or meet relational or reproductive needs.
Sexuality and the ability to express it is a foundational characteristic of human beings. In a study of patients undergoing physical rehabilitation, 73% responded that they would be interested in discussing and addressing sexuality as part of their rehabilitation plan.
However, most patients do not bring sexuality up unless specifically probed – citing barriers such as embarrassment, not being sure what to say, and confusion about whether it was even an appropriate topic to bring up.
As occupational therapists, we are uniquely qualified to address this topic – our experience in activity analysis, making adaptations and modifications, and providing education tailored to each individual are all great assets.
Furthermore, acknowledging sexuality fits with the holistic values of occupational therapy – we specialize in treating the whole person, even the parts that may not initially be comfortable to discuss.
So why, by and large, are we not addressing sexuality as an ADL?
Most practitioners I’ve talked to have listed a couple reasons: general discomfort with the subject and lack of knowledge on what to recommend. As crazy as it may sound, all it takes is practice to become comfortable with talking about sexuality with your clients.
Think back to the first time you helped someone with toileting, undressing, or bathing. If you’re anything like I am, you felt a bit awkward and a little intimidated. But after a while, it becomes old hat. Sexuality is the same way. Write down the things you might want to say. Practice starting the conversation with a friend, or even in front of a mirror. It gets easier with time.
One tool that I find very helpful in addressing sexuality is the PLISSIT model. This is a framework designed originally for sexologists, but is useful for other clinical practitioners as well.
PLISSIT is an acronym that stands for the following:
P – Permission:
Give explicit permission to the client to discuss the subject. Try saying something like, “I would like you to know that as part of your rehabilitation, I am here if you have any questions on how this may affect your sexuality. If you’d like more specific information or any handouts on the subject, please don’t hesitate to let me know. Do you have any questions now?”
Don’t be discouraged if your patient declines – it’s a difficult topic to discuss and they may not be ready yet. They may return to you later for a discussion, or they may ask for a written handout.
LI – Limited Information:
Provide general information about client’s condition and the effect it has on sexuality, and ask them if they have specific questions or would like more information. This is a great time to have a short handout available.
SS – Specific Suggestions:
If the client responds well to the limited information you give them, you can give more specific suggestions that are tailored to them. Provide adaptations, modifications, or other education for any concerns they have brought up. If they ask a question you don’t know, don’t be ashamed to admit that with the promise that you will research it for them.
IT – Intensive Therapy:
After discussion, if you feel that your client’s needs are beyond your scope of practice, refer them to another professional, such as sex therapist, psychologist, or talk therapist.
Specific OT Interventions Addressing Sexuality
The best advice I can offer for specific interventions is first doing a little research and becoming familiar with your client’s diagnosis and the effect it has on sexuality. There are often resources that specifically address this, but if not, a little critical thinking goes a long way.
For example, a person with multiple sclerosis is likely going to need energy conservation strategies. A person with cerebral palsy may need alternate positioning suggestions. A person with a spinal cord injury may need to use a vibrator or other tool for masturbation when previously they were able to do so by hand.
Don’t be intimidated if you feel like you don’t know everything – you’re there to problem solve and collaborate with your clients, not be a miracle worker. Ask your clients which parts of sexual activity are important to them and go from there.
This is the first approach to take if possible. It involves a rehabilitative or habilitative approach in which skills are restored or gained. Interventions can be physical in nature: increasing range of motion to make more positions available, increasing endurance for longer sessions of sexual activity, or increasing strength to be able to support a partner are all valid interventions.
Treatment methods can also be cognitive – like providing education on contraceptive use for teenagers with intellectual disability, sexual abuse prevention training for children who have trouble communicating, or working on relationship/social skills for adults with mental illness.
A behavioral approach is also applicable here – many individuals with autism or other social disorders often exhibit challenging behaviors during puberty such as public masturbation, unwanted touching of others, or inappropriate conversations. Social Stories can be a great resource for teaching appropriate behavior, and paired with healthy outlets to explore this part of their lives, these teens may stop maladaptive behaviors entirely.
Adaptive/modifications are any interventions that seek to change or replace instead of improving baseline skills. It could be providing a client with information on what positions they can have sex in while recovering from a total hip replacement, planning out sexual activity for the time of day when a client with chronic fatigue is most energetic, or compensating for decreased sensation with the use of sex toys.
Providing partner education is also valuable here! Any condition that has lasting repercussions is appropriate for this approach.
Remember that this can be a sensitive subject for many people, but it is an important one. Try to think about the effect that a loss of sexuality can have on a person, especially on their roles, routines, and social participation.
Realize that you may be the only healthcare professional assisting your client with this, and be a good advocate for them.
Hopefully some of this information and strategies will help you address your clients’ needs more fully!
How do you address sexuality in your daily OT practice? Do you have any questions or suggestions for other practitioners? Let us know in the comments below.
Further recommended resources:
Addressing Sexuality in Occupational Therapy (AOTA continuing ed article)
This post was originally published on August 22, 2017 and updated on February 1, 2022.