The Unspoken ADL
Helping patients regain their sex lives
Monday August 31, 2009
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A surprising number of medical conditions can affect sexuality in some way, reports Cathy Unruh, MS, OTR/L, senior occupational therapist in the occupational therapy department at Central DuPage Hospital, in Winfield, Ill. This is especially true among older patients, who may find sexual function affected by issues ranging from total hip replacement and stroke, to coronary bypass and diabetes-related amputation, among others.
“Many issues can affect a senior’s relationship with sexuality,” confirms Jessica Farman, MS, OTR/L, director of rehabilitation at Belmont (Mass.) Manor Nursing Center. “These include the lack of an available partner, perhaps due to death of a spouse, as well as increased loneliness [and] isolation, mobility issues, pain issues, cognitive changes, medical issues, and effects of medication.”
Among younger patients, sexual function may be affected by such things as spinal cord injury, traumatic brain injury, cancer, multiple sclerosis, and Guillain-Barre syndrome, Farman notes.
Make the Assessment
The role of the OT is multifaceted when it comes to sexuality and sexual function, observes Jody Greenhalgh, OTR/L, MCP, PhD candidate, med/surg/trauma, Stanford (Calif.) Hospital and Clinics. Improving mobility and overall function are the primary objectives, but OTs also provide sexuality education and give patients permission to be loving, sexual beings. “This is something we need to approach early on, because the issue of sexuality is being neglected more and more,” Greenhalgh notes. OTs can help patients adapt in a variety of ways, say those in the field.
“Just as with any other assessment, or ADL, the tasks need to be broken down,” Farman advises. “The clinician should assess the limiting factors that are impacting a patient’s participation in sexual activities. For example, if it’s a sensory deficit, such as following CVA, the OT can instruct the hemiplegic [partner with hemiplegia] to lie on his or her affected side to free the unaffected side for touching or caressing.
“If it is an issue of endurance, then instructing the individual to plan ahead for sexual activity may be indicated. This may include postponing sexual activity until three hours after meals, avoiding sex when fatigued, de-emphasizing sexual intercourse, and suggesting mutual masturbation or oral sex,” Farman says.
Adaptive sexual positions often make sex much easier for individuals with health issues or disabilities, Greenhalgh says. Those who have had a hip replacement, for example, may find sex safer and more pleasurable in the missionary position or by lying on their side with a pillow between their legs.
“For patients who have lost a limb, sitting in a chair can provide necessary support,” Greenhalgh adds. “The missionary position is also good, or reverse missionary with the woman on top. Other options, depending on the disability, include having the woman lie prone over an ottoman, or standing while leaning over a table.”
Maintain Dignity
An equally important issue among many patients is body image. People who have had cancer, had a limb or breast removed, or who must use a catheter or colostomy bag often are troubled by their appearance or disability to the point where it affects their enjoyment of sex. Occupational therapists can assist by providing instruction on proper hygiene, and by offering advice on how to hide or disguise the disfigurement — coping strategies for an individual’s physical concerns.
“It can be as simple as wearing a camisole if a woman has had a mastectomy, or placing a scarf over a scar or wound site,” Greenhalgh reports. “They can still have sex and enjoy sex, but they need help from an OT to adapt to their situation.”
The greatest obstacle for many OTs is simply bringing up the issue of sexuality, especially among older patients who come from a generation in which people simply didn’t talk about such things. Many times, humor, cartoons, and instructional pamphlets are an effective way to open the door, Unruh says.
Most importantly, don’t be afraid to broach the issue, Farman adds. “We ask our patients about many personal and ‘sensitive’ topics, including how they manage toileting themselves, bathing, etc.,” she says. “Sexuality should be treated no differently.
“A person who has suffered a TBI, stroke, broken bone, SCI, and the like, all may have concerns about sexual function. Sexuality needs to be assessed, just like all other ADLs. It may or may not be an issue for that person when the OT first assesses them, but it may come up later in the rehab process, along with other issues.” The OT’s role is to facilitate the discussion of sexuality by giving the patient permission to have a concern, Farman says. “This comes in the form of just asking, ‘Do you have any concerns about sexual function?’ The client may say no, but simply asking opens the door and lets them know that you, as an OT, are available if there are any concerns.” •
Don Vaughan is a medical writer for the Gannett Healthcare Group.
To comment, e-mail oteditor@gannetthg.com.
