1. “Breaking the ice”: Approaching sexual concerns after stroke Alexandra Richards¹, Rachel Dean², Jerry Burgess¹ and Helen Caird¹
Salomons, Canterbury Christ Church, (2) KMPT NHS Trust
Background Aims
Sexual difficulties after stroke are common
They can include difficulties such as reduced arousal, poor libido, changes in relationship dynamics and fear of engaging in sexual activity (Rosenbaum, Vadas, & Kalichman, 2014).
These difficulties are estimated to effect between 17 and 42% of stroke survivors (Bugnicourt, Hamy, Canaple, Lamy & Legreand, 2014)
Clinical guidelines suggest that patients be asked about sexual concerns
The National Clinical Guidelines for Stroke (2012) recommends regular assessment and reviewing of sexual functioning post-discharge, and that support is provided.
However sexuality is often a neglected topic
Healthcare professionals working in stroke rehabilitation often do not approach the area of sexuality their patients (McLaughlin & Cregan, 2005; Schmitz & Finkelstein, 2010).
It has been suggested that staff behaviour presents a significant obstacle to addressing the sexual concerns of stroke survivors. This study aimed to gain to gain understanding of how staff approach and engage with sexual issues within rehabilitation.
The study aimed to discover:
What is current practice regarding working with sexual concerns?
What is preventing staff from working with sexual concerns?
What might support staff to meet the needs of stroke survivors? ?
Method
Figure 1: Model of Staff engagement with sexual concerns
Personal Level of Comfort
Barriers
Action
Interacts with
Limits
Influences
Participants were 10 healthcare professionals working within stroke rehabilitation, from a range of different disciplines.
Grounded theory methodology was used to analyse data collected from semi-structured interviews. .
Results
The data suggested 3 main categories, made up of 12 sub-categories, and a model was developed of how they related to each other.
Participant’s Personal Level of Comfort with the topic of sexuality interacted with a series of internal and environmental Barriers. Both of these factors influenced the likelihood that a professional took Action to approach the topic of sexuality with a patient and to provide support.
The categories are outlined in Table 1, and the Figure 1 illustrates the model.
Key Findings
Table 1: Categories and Sub-categories of the data
Professionals rarely directly brought up sexuality directly with their patients.
Participants were more likely to take an indirect approach, included coming to discussion of sexuality through another topic (e.g. continence, sleeping arrangements), general open questions and using vague language to allude to sex.
The more comfortable participants did not see themselves as “experts” but used generic communication skills to support their patients. They provided supportive conversation and reassurances, and often nothing further was required.
Sexuality is not included in local policy or procedures (such as assessment forms), which does not serve to legitimise the topic within rehabilitation.
Sexual issues tended to be raised later in rehabilitation, within a longer therapeutic relationship. However, this was when professional input was often reducing.
Participants’ assumptions of how easily distressed patients were by talking about sex did not appear consistent with the reality.
Stereotypes regarding age and gender were evident, and sexuality was often considered to be of lower importance and a low priority to older people and those with significant disabilities.
Category
Sub-category
Personal Level of Comfort
Life Experience
Personality
Work Experience
Barriers
Unsupportive Rehabilitation Environment
Feeling Unknowledgeable
Perceiving patients as uncomfortable talking about sex
Patient's responsibility to initiate
Finding sex entertaining
Action
“Foot in the door” Indirect approaches
Patient bringing up sex directly
Offering an opportunity to discuss sex
Intervention
“Well I’ve seen all that anyway so just talking about sex… it’s not gonna bother me”
“By the time it comes up for most people they’ve actually been discharged “
Clinical Implications
What’s the point of bringing it up if you’re not going to do anything?”
Staff training could incorporate the following:
The relevance of sexuality to stroke rehabilitation
Transferring the clinical skills staff already have to working with sexual concerns
General communication skills for tackling sensitive topics
Reflective practice to consider personal reaction and comfort with these topics
The following could help to legitimise sexuality within stroke rehabilitation:
Developing clear referral pathways
Incorporating sexuality within local policies and procedures
Give patients permission to bring up sexual issues
Use “Sex After Stroke” leaflets and make these visible to patients
“Opens up an avenue for conversation…that almost breaks the ice a little bit for them to ask things”
"I tend to talk them through it erm… they’ve just wanted to say ‘Is it ok?’”