1. Sex and Sexuality Discussion in Physical Therapy Practice Biomedical Ethics Fall 2007 Ilene Rosenthal-Schulman

2. Human Beings are Sexual Beings

3. Beyond The Biology and Reproduction Sex has an important place in a person’s life beyond reproduction – To experience pleasure, desire and intimacy Pleasure – Is an affirmation of life – Adds meaning to life Sexual Pleasure is particularly powerful in making one feel alive.

4. Agenda 1. Definitions 2. Patient Practitioner Communication 3. Why don’t we talk about? 4. Treating the whole person 5. Initiating the sexual health conversation

5. Definitions Sex Sexuality Sex Acts Sexual Maturity

6. Sex One of the four primary drives The others being Hunger Thirst Avoidance of Pain Our Femaleness or Maleness

7. Sex Acts Any behavior involving the secondary erogenous zones and genitalia. Examples: – Kissing – Hugging – Caressing – Fondling – Sexual Intercourse

8. Sexuality The combination of sex drive, sex acts and along with learned behaviors around communication and relationship patterns. Levels of sexuality: – Conversation – Shared activities and interests – Various expressions of affection and intimacy – Sexual intercourse

9. Sexual Maturity People are considered sexually mature when they have a positive and healthy integration of the primary sex drive.

10. Patient-Practitioner Communication There is Lack of Communication between patients and health care providers about sexual health Even though patients may want to or need to talk about how their complaint or disability may effect their sexual health

11. “Lack of communication between healthcare professionals and women with ovarian cancer about sexual issues” Ml Stead, JM Brown British Journal of Cancer (2003) 88, 666-671 Investigation of the attitudes and behaviors of the doctors and nurses treating women with ovarian cancer towards the discussion of sexual issues Interviews with doctors (11 male ; 5 female) and nurses (2 males; 25 females) Interviews with patients (15 women) Behaviors of healthcare professionals – 98% thought sexual issues should be discussed – Only 21% actually discussed the matters Experience of Communication from interviews with women – No woman had received written information – Only two had bried discussions

12. Patients may want to talk to us about Sex A study of 31 senior citizens (15 men, 16 women) mostly in their 80’s – Cognitively intact and living independently at a nursing home Survey of hierarchy of needs rated on a Likert-Like Scale – Mood (4.4; 4.3) – Memory (4.2; 4.2) – Sleep (3.8; 3.9) – Sex (3.5; 2.8) – Appetite (2.8; 2.6) Sex was moderately important and more important than appetite 23/31 of residents expressed belief that sexuality should be discussed openly with their health care professionals

13. Why Don’t We Talk About Sex? Reasons cited by medical practitioners in Stead study “it is not my responsibility” “it is inappropriate for me to talk to patients” Embarrassment Lack of privacy Limited time Should wait until the patient asked about sex Lack of knowledge/experience/skills Lack of resources to provide support if a problem was identified Low priority at diagnosis and during treatment

14. In the Scope of our Practice We are members of medical teams that revolve around total rehabilitation To ignore the subject of sexual health, or downplay it, may only further handicap the patient

15. Rehabilitative Medicine and Therapy The Whole Person Frequently Addresses Physical Cognitive Emotional status Vocation Leisure Self Care Functioning Not Frequently Addressed Sex Love Intimacy Relationships Esmail, Esmail, 270

16. PLISSIT model of sexual counseling

17. Initiating the sexual health conversation Include questions on sexual functioning in patient questionnaires or intake forms Have a list of printed resources available During initial Evaluation – “Ask how does this physical impairment affect your sex life?” The question is as important as asking “How does this impairment effect your sleep?” If the patient shows obvious physical cues of discomfort discontinue discussion At least they know you care about this aspect of their lift They may tell you next time

18. A Fine Balance Both patient and professional are caught in a dilemma of who will initiate the topic of sex Keep the conversation professional, confidential without being perverted, tawdry or otherwise inappropriate.

19. Be Aware of Cultural Differences We must be aware of the fact that many cultures have different rules and customs with regard to their sexuality and sexual practices Having same sex chaperones available to allay anxiety about sensitive topic discussions

20. Basic Rules for Effective Communication About Sexuality within a Rehabilitation Setting 1. Prevent Shaming Experiences 2. Maintaining Privacy 3. Do Not Make Judgments

21. Preventing Shameful Experiences Shame implies admitting to oneself that part or all of the self is unacceptable Shaming experiences can be avoided by providing – Physical privacy – Psychological privacy – Carefully reading body language – Explaining that the given topic of discussion is not intended to embarrass, but to help provide effective care

22. Maintaining Privacy Acknowledge and emphasize confidentiality – Sometimes in a hospital or sub-acute care setting personal autonomy is limited and some privacy protection may be jeopardized Make use of curtains Close doors when possible

23. Listening without passing Judgment Patients may not have the same – Sexual functioning – Relationship pattern Every person is free to choose their style of sexuality All personal attitudes, ideologies or religious beliefs on the part of the medical team need to be identifies and avoided at all costs Be aware of facial expressions and your body language – Can be an nonverbal form of passing judgment

24. Sexual Misconduct Biggest Ethical Issue Patients confide in us and may misconstrue our interest in their sexual health as being more than a professional interest It is important not to TOUCH a patient, even a pat on the shoulder, when having an open and candid discussion about sex and sexual health

25. References Tepper MS. Sexuality and Disability: The Missing Discourse of Pleasure. Sexuality and Disability. Vol. 18, No. 4. 2000 Tan G., Waldman K, Bostick R. Psychosocial Issues, Sexuality and Cancer. Sexuality and Disability. Vol. 20, No. 4. Winter 2002 Boyer F. Ethical Considerations when Providing Information on Genital and Sexual Consequences of Spinal Cord Injury. Sexuality and Disability. Vol. 23, No.4 Winter 2005. Esamil, S. Esamil Y. Munro B. Sexuality and Disability: The Role of the Health Care Professionals in Providing Options and Alternatives for Couples. Sexuality and Disability. Vol. 19, No. 4. Winter 2001. Aizenberg D. Attitudes Toward Sexuality Among Nursing Home Residents. Sexuality and Disability. Vol. 20, No.3. Fall 2002. Stead ML, Brown JM. Lack of Communication Between Healthcare Professional and Women with Ovarian Cancer About Sexual Issues. British Journal of Cancer. 88, 666-671. 2003 Wylie K, Oakley K. Short Report: Sexual Boundaries in the Relationship Between Clients and Clinicians Practising Sexology in the UK. Sexual and Relationship Therapy. Vol. 20, No. 4, November 2005. Hayes SH, Chapter 13: Sexuality and Disability--Effective Communication, In: Patient Practitioner Interaction, CM Davis ed., third edition, 1998. Slack, Inc., Thoroughfare, NJ, pp 239-260. http://www.bartonscott.com/assets/images/PinkElephant.jpg