Enabling sexuality for all: Occupational therapy interventions

Traditionally, occupational therapy sexuality-related interventions have focused on modifications and adaptations to mitigate physical impairment. However, interventions ought to also consider the issues pertaining to consent, ownership, respecting the diversity of sexual and gender-related identities, sexual behaviours and personal responsibility. Interventions might include discussions related to limit-setting, abstaining from sexual activity, risk management, safety planning, relaxation techniques, self-esteem, self-expression, identity and unlearning harmful messages and beliefs. People can present with a variety of abilities, preferences and past experiences, which are important during the intervention process.

To address these topics, it is essential to work closely with and listen to service users, to adopt a non-judgemental attitude and to minimise assumptions. Occupational therapists should conduct a self-reflection of sexual attitudes, values, beliefs and bias and consider sharing these self-reflections with their professional peers. Only by building self-awareness and considering sexuality as part of people’s everyday life can occupational therapists correct misinformation, reconcile implicit or explicit bias, and negotiate differences between themselves and clients. Self-reflection is critical to awareness and understanding of other’s assumptions, beliefs and experiences and this process enhances therapeutic use of self, i.e. an intentional relationship and preparedness to address sexuality and cultural sensitivity (Whitney and Fox 2017).

Occupational therapy and sexuality assessment and interventions

Below, we present evidence of some occupational therapy engagements with sexuality. Peer-reviewed literature is sparse, so this is a limited and not an exhaustive list. Sakellariou (2006) studied men’s perspectives about sexuality post spinal cord injury (SCI) and found that the men were limited by perceived societal opinions that they were asexual, feelings of infantilisation and dependency, social disapproval and anxiety. He argued that it is necessary to develop comprehensive sex education programmes and also to ensure that appropriate personal assistance is available. Similarly, Fritz and Lysack (2015) explored the experiences of 20 women with SCI, focusing on their sexual and reproductive health. These women self-identified reproduction and sexual confidence as important components of their rehabilitation and additionally noted their occupational therapy intervention did not include reproduction or sexuality. The authors recommended that future occupational therapy intervention and education should include a broader concept of sexuality to include sexual intimacy, education on erogenous zones and suggestions to “foster the womans sexual self-esteem”as important for sexual wellness (2015, p. 8).

Adolescents with and without disability are potential clients who may benefit from receiving occupation-focused education about sexuality and dating. In a qualitative study of high school sexual health education for adolescents with disabilities, occupational therapists identified three themes: sexuality is different for each student; parents and teachers “do not know what to do”; and occupational therapy practitioners may be well suited to address these needs (Krantz et al. 2016, p. 4). Gontijo et al. (2016) provided a potential model for adolescent intervention. They implemented an occupational therapy group series for adolescents without disabilities, aged 13—17 in Brazil. The group structure included games to learn about sexual and reproductive health and resulted in a positive correlation between sexuality knowledge and group attendance. Education topics included developmental changes, sexually transmitted diseases and their prevention, reflections about consequences of pregnancy, contraception, how “gender perceptions are constructed and valued during adolescence and how these can influence this publics occupational performance and sexual and reproductive health” (p. 27).This study can be adapted to fit the specific needs of people with specific impairments, as well as be adapted to be inclusive of considerations such as body image, consent, communication of physical assistance needs, boundaries and sexual preferences.

Engel-Yeger et al. (2015) provide evidence for the potential role of occupational therapy practitioners assisting people with post-traumatic stress syndrome (PTSS) to engage in intimate social participation. PTSS is a result of exposure to a traumatic event whereby “the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others” and “the person’s response involved intense fear, helplessness or horror” (American Psychiatric Association 2000). PTSS can result in depression and anxiety diagnoses, which are often referred to as invisible disabilities. Investigating the relationship between the sensory profile of individuals with PTSS and their attitudes towards intimacy, Engel-Yeger et al. (2015) identified correlations between scoring “more/much more than most people” on the Adult Sensory Profile and fear of intimacy on the Fear of Close Personal Relationship Questionnaire, with individuals with PTSS scoring higher on sensory processing tendencies than the control group. The anxiety resulting from the emotional burden from sensory processing disorders can have an impact on the social requirements for intimate relationships and is an area which occupational therapists can help mitigate with sensory processing, emotional regulation and intimacy interventions (Engel-Yeger et al. 2015). Navigating social environments and interactions and engaging in intimate relationships are often required preceding activities to sexual activities. Occupational therapists can enable sexual activity with this population by addressing the noted barriers to social and intimate activities.

There are some intervention strategies that can be very useful for sexuality-focused interventions. Positive visualisation of sexual activity, establishing a sexual role model to emulate, positive refraining, positive body image awareness, masturbation, practicing assertive communication and grading activities required to meet a potential partner are suggestions by which occupational therapy practitioners can assist their clients with improving their sexual self-esteem. Additionally, intervention can explicitly allow the individual to explore their sexual self-view and concept and recognise the often-damaging effect of societal norms. For example, people with disabilities may be viewed as asexual or oversexualised, possibly leading to a dislike of their bodies or the attention they receive. Such external stigma can skew internal sexual self-view development or feelings of attractiveness. Occupational therapy focuses on guiding individuals to take ownership over intentionally shaping and embracing their sexual self-view unapologetically by utilising non-judgemental and empowering attitudes towards their clients. The process can look like this: collaborate with service users so they can (1) identify their core values, (2) build self-awareness of harmful messaging and replace that messaging with positive cognitive refraining, (3) consider lifestyles and outward image that affirms and/or excites them, (4) establish steps to asserting the image and engaging in sexual activity, (5) conduct safety planning for asserting that image or engaging in sexual activity, if needed, and (6) assert the chosen image and engage in or pursue chosen sexual activities.

There are a few examples of occupational therapists who have specifically explored sexuality for people with disabilities. Ellis and Dennison (2015) published a guide which follows an activity analysis format for veterans engaging in sexual activity and intimacy They highlight common combat-related injuries, including PTSS and urogenital injuries, and offer holistic suggestions to enhance performance and satisfaction with sexual activity. Naphtali et al. (2009) provide a resource for people who are interested in learning about specific assistive devices to enhance sexual performance. Both resources offer suggestions for sexual activity and sexual relationships with self and/or others, such as communication scripts, strategies to enhance sexual desire and modifications, adaptations and accommodations for sexual positioning.

Occupational empowerment framework and rights-based approach

The concept of empowerment, as presented by Hammell (2016), and a rights-based approach could be used by occupational therapists to conceptualise the broad possibilities of sexuality interventions and advocacy relevant for people with disabilities. Hammell uses the World Bank Empowerment Framework, which defines empowerment as “the process of increasing the assets and capabilities of individuals or groups to make purposive choices and to transform those choices into desired actions and outcomes” (World Bank 2014).The Empowerment Framework includes four components, which can be used as guides for client intervention and a call to action for a practice change in occupational therapy.

Increasing assets

First, occupational therapists should consider how they can encourage utilisation and strengthening of the assets already possessed. For the client, this might be increasing the range of motion in order to attain a certain sexual position or guiding improved self-awareness to promote stress management skills for an individual who identifies with a sexual minority group and experiences discrimination and bullying. Occupational therapy practitioners can acknowledge inherent assets of the profession, including activity analysis, holistic understanding of human occupation and client-centred care as assets enabling therapists to address sexuality topics with people with disabilities.

Increasing capabilities

Increasing capabilities relates to how people are enabled within their communities to potentialise themselves with the available assets they have. Occupational therapists promote and advocate for safe and inclusive environments for their clients, as well as working with clients to mitigate the challenges of the environment. For example, an occupational therapist can work with a person who identifies as transgender on a safety plan for accessing unfriendly environments. Furthermore, occupational therapists should reflect on their unique understanding of how environment impacts occupation and influence policy to enable safe community access for sexual and gender minorities. Similarly, it is important to develop opportunities for occupational therapists to learn and practice their skills related to sexuality intervention for people with disabilities.

Transforming choices into action

“Transforming choices into action” refers to understanding what the goal of the client is and the specific barriers to bridging the goal with attainment. It is important for the occupational therapist to understand the social structures that limit sexual fulfilment and expression for clients and allow the reluctance of the profession to address this aspect of the human experience. For example, an occupational therapist who is unfamiliar with sexual bondage may become uncomfortable or judgemental if the client’s goal is to reengage in that activity. The occupational therapist can uphold this component by researching the activity components of sexual bondage, respecting the clients choices and collaborating with the client on this engagement goal.Transforming choices into action highlights the importance of humans’ freedom to choose and do.

Accomplishing desired actions and outcomes

Client-centred care places the client at the centre of the therapeutic decision-making process and is paramount to successful intervention. Bright et al. encourage occupational therapy professionals to ask themselves, regarding their clients, “who are they and what do they need?” versus “what’s wrong with them and how do 1 help them?” (Bright et al. 2012, p. 1002, cited in Hammell 2016). Asking this question helps to prevent the clinician’s personal biases and experiences from limiting the therapeutic relationship. These questions are particularly important for sexuality interventions. Considering the minimal social discussion related to the wide variety of preferences and activities that are experienced by humans, individuals can often think, “normal is what I do, abnormal is what I don’t do,” as it relates to sexual expression and engagement. For this reason, self-reflection of values, attitudes, beliefs, and biases is important to maintain focus on the client’s goals and how they wish to achieve them.

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