Normal human sexual response

One must have an understanding of the normal human sexual response cycle before one can explore the relationship between sexuality and disability. Masters and Johnson⁴⁸ divided the human sexual response cycle into four segments: (1) excitement, (2) plateau, (3) orgasm, and (4) resolution. In each phase, definite physical changes occur in both sexes. During the excitement phase, physiological reactions occur because of somatosensory or psychogenic stimulation. In females, the nipples become erect, the vagina swells and becomes lubricated, the clitoris and the labia minora and majora swell, and the uterus and cervix retract. In males, the penis grows erect and the testes rise. In both sexes, blood pressure and heart rate increase.

During the plateau phase, respiration increases and blood pressure and heart rate escalate further. In females, the areola surrounding the nipple swells, the orgasmic platform forms (vasocongestion of the outer two thirds of the vagina), and the color of the labia minora deepens from pink to red. In males, a full erection is achieved as the testes elevate further and the Cowper gland secretes preejaculatory fluid.

Orgasms differ between the sexes; some women can achieve multiple orgasms. In both sexes, peak pulse rate, blood pressure, and respiration increase, as does muscle tone. Rhythmic contractions of the orgasmic platform and the uterus occur in women, and rhythmic contractions of the penis project semen forward in males.

Masters and Johnson⁴⁸ recorded cardiac response and found peak heart rates of 110 to 180 beats per minute during orgasm. However, the mean maximum heart rate during sexual activity was 117.4 beats per minute in a study of middle-aged men with postcoronary disease.³⁴ During sexual activity, systolic and diastolic pressure increase (from 30 to 80 and 20 to 40 mm Hg, respectively). Respiration rates of up to 40 breaths per minute have been recorded, depending on the level of intensity and duration of sexual activity.⁴⁸

The resolution phase is characterized by the return to preexcitement status, including reductions in blood pressure, heart rate, and respiration. The genitals and breasts return to preexcitement size.

Sexuality and neurological function

Sexual function is controlled by the brain, spinal cord, and peripheral nerves, whereas control of libido and sexual pleasure are mediated by several areas in the cortex, midbrain, and brainstem.⁵⁶ Men experience reflexogenic and psychogenic erections. Reflexogenic erections are caused by direct stimulation to the penis and may occur without conscious awareness, even in the absence of penile sensation. Psychogenic erections originate from mental activity such as sexual fantasies and stimulating visual input and do not require direct penile stimulation. Reflexogenic erections are controlled by the nervous system through the sacral roots, and psychogenic erections involve the sympathetic nerves between T11 and L2. Female sexual function is similar to that of males regarding nerve innervation.⁷⁷ The parasympathetic nerves S2 to S4 influence the clitoris and vaginal lubrication. “Contraction of the vaginal sphincter and pelvic floor occur with stimulation of the somatic aspect of the pudendal nerves (S2-S4),” according to Zasler.⁷⁷ Neurological disability can cause organic impotence by altering the blood flow needed for penile erection and can cause problems with emission and ejaculation in males and with lubrication, clitoral engorgement, and orgasm in females. Some of the subcortical structures theorized to be involved in the neurology of sexuality are the reticular activating system and the hippocampus, amygdala, and hypothalamus. According to Zasler,⁷⁷ the thalamus and basal ganglia are hypothesized to be involved with the mediation of sexual function. Some of the cortical areas involved are the frontal lobes and the nondominant temporal lobe. “Lesions in the dominant hemisphere may produce aphasia or apraxia, both of which could impede sexual activity. Nondominant hemisphere injury may result in . . . visuoperceptual deficits, denial, and impulsiveness, all of which could impede expression of sexuality,” according to Zasler.⁷⁷ Sexual stimulation is caused by stimulation of the brain or peripheral nerves, the former of which results from thoughts and psychological processes and the latter of which results from direct physical stimulation.^54,72

Effects of stroke on sexual function

The literature shows that common effects of stroke on sexual function are decreased libido, impaired erectile and ejaculatory function, decreased vaginal lubrication, impaired ego and self-esteem, and depression. The motor, sensory, cognitive, and physiological effects of stroke have been shown to affect the desire and ability to engage in sexual activities in many ways. Some research has been focused on relating sexual dysfunction to the location of the lesion. Some of the scientific literature recommends counseling for patients following stroke but does not provide specific interventions.* As a result, therapists are left with insufficient information to treat sexual dysfunction adequately.

Numerous studies have found that among men and women who had sustained strokes, libido was decreased, abilities to achieve erection and vaginal lubrication were impaired, and the frequency of intercourse was diminished.^{11,38,40,41,53,73} In contrast, at least one study documented that a small group of stroke survivors (19 of 192 patients studied) indicated an increase in libido following stroke.⁴¹ Isolated cases of hypersexuality and abnormal sexual behavior have been found to occur in individuals with temporal lobe lesions and concurrent histories of poststroke seizure activity.^28,54 In a study of 13 female stroke survivors, the most common complaint was found to be a decreased desire for sexual activity after the stroke; only 5% of the women reported actual impairment in the production of vaginal secretions after the stroke.² Most of the women reported no changes in their abilities to achieve orgasm or in their menstrual periods. In addition, although the stroke impaired sexual desire, physiological function remained unimpaired. The authors concluded that nondominant hemispheric stroke is related to decreased desire; five of seven patients with decreased desire had right brain involvement.

The authors of several studies have attempted to determine cerebral hemisphere dominance related to sexual function. Although some investigators found a greater decline in sexual function with left-sided cerebrovascular accident, others found little or no difference between right and left cerebral hemisphere strokes.* One study of 109 men poststroke revealed that lesions in the right hemisphere resulted in a significant decline in sexuality functioning poststroke, including desire and frequency.³⁶ Garden²⁵ concluded, “There seems to be an overall consensus that stroke patients maintain prestroke sexual desire but commonly experience sexual dysfunction including erectile and libido problems. Changes in coital frequency and libido are also common. As a result there can be great potential for depression and loss of self esteem.”

The individual’s prestroke sexual activity is usually a better indicator of poststroke activity.^{7,26,29,33,42,73} If the individual was leading an active sex life before a stroke, the likelihood of returning to sexual activities is good. Younger age is also a predictor of resumption of sexual activity, although less so.³³ Individuals who were without a partner before a stroke have less opportunity to develop new partnerships and resume sexual activity after a stroke. This decreased opportunity has to do with the effects of stroke itself and an individual’s impaired social contact, possible placement in a nursing home or other long-term setting, depression, altered self-image, and the multitude of psychological effects caused by stroke. In a study of 192 stroke survivors and 94 spouses, the decline in sexual activity after stroke was associated largely with individuals’ attitude toward sexuality, fears including erectile dysfunction, and the inability to discuss sexuality issues.⁴¹

Erectile dysfunction may occur as a direct result of stroke* and also may occur in men whose sexual partners have sustained strokes because of fear of causing another stroke or hurting the partner or averse feelings toward the disabled partner.^26,28,29,30 In women, vaginal lubrication may be insufficient, causing painful intercourse.^{2,11,25,26,40,73}

The presence of nocturnal erections indicates psychological versus organic reasons for erectile dysfunction. In a study by Korpelainen, Nieminen, and Myllyla,⁴¹ all of the male subjects did experience nocturnal erections after stroke, although 55% had impaired nocturnal erections. Individuals with a history of taking cardiovascular medications and those who had diabetes mellitus exhibited a greater frequency of erectile dysfunction after stroke than those without. Bener and colleagues⁵ found similar results in a study of 605 men following stroke; the likelihood of erectile dysfunction increased with cardiovascular medications and comorbities including hypertension, hypercholestermia, and diabetes. Similarly, impaired vaginal lubrication was more common in women who had taken cardiovascular medications prestroke.⁴¹

Initiation of sexual activity after discharge from the hospital may be difficult. A couple may delay sexual activity because each partner waits for the other to initiate sex.^29,30 In a study by Goddess, Wagner, and Silverman,²⁹ one couple put off sexual activity for 15 months after the husband’s stroke. The man was unsure whether his wife would find him attractive or a suitable partner, and the wife was concerned that sexual play for her husband may be unsafe.

Sensory impairment is common after stroke. Considering the significant role of touch in sexual expression, its dysfunction also may contribute to sexual dysfunction.^24,40 In subjective reports of 50 stroke survivors, 19% of the subjects reported sensory deficits as the reason for diminished sexual activity.⁴⁰ However, the research is inconclusive; a study by Aloni and colleagues¹ of 15 male stroke patients showed that disturbed superficial and deep sensation were not correlated with decreased desire.

Motor impairment can affect sexual function. Decreased range of motion, strength, endurance, balance, abnormal skeletal muscle activity, impaired coordination, and oral motor dysfunction may interfere with intercourse or other sexual activities. However, some research suggests that the degree of hemiplegic impairment is not a major factor in sexual dysfunction.^24,26

Cognitive deficits also may affect the stroke survivor’s social and sexual function. Fundamental cognitive abilities such as attention and concentration are prerequisites for social and sexual activities; distractibility and overstimulation may cause anxiety and agitation, which prevent interaction. Decreased initiation, impulsivity, poor memory, decreased speed of processing, and impaired executive functions are possible effects of neurological dysfunction and clearly can affect sexual relations.⁷¹

McCormick, Riffer, and Thompson⁵¹ noted that sexual activity is itself a form of human communication. When verbal or nonverbal communication is impaired, sexual activity may be affected.⁷⁷ One study found that sexual adjustment was easiest for physically intact individuals with aphasia with spared comprehension and nonverbal communication.⁷⁶ However, in one study involving 110 subjects, no correlation between aphasia and poststroke sexual activity was found.⁷⁰ Lemieux, Cohen-Schneider, and Holzapfel⁴⁴ reported that individuals with moderate and severe aphasia are not included in most studies because they are difficult to interview, so little is known about their sexuality after stroke. In their small study of aphasia and sexuality in six couples, the researchers developed pictograms to facilitate communication with aphasic respondents. Although the effects of stroke on sexuality in this study were similar to those of previous studies, almost all the aphasic persons and their partners reported that aphasia had a negative effect on their sex lives.

The effect of stroke on psychological function is enormous^11,28,36,42 (see Chapter 2). Studies by Giaquinto and colleagues²⁸ and Korpelainen and colleagues⁴⁰ found that the psychological impact of stroke was a greater factor in sexual function after stroke than associated neurological deficits. The loss of function, including hemiparesis, sensory and balance disorders, pain, and cognitive, perceptual, and impaired communication skills may have an enormous negative effect on an individual’s self-image. As Strauss⁷¹ noted, the formulation of relationships, sexual or other, requires some level of self-esteem. An impaired image of one’s body and appearance can affect the ability to make new relationships or maintain existing ones. Loss of confidence and decreased self-esteem may result from the following:

In addition to changes in self-perception, the stroke survivor suddenly may find a new role in relationships. For instance, a wife may discover that she is no longer able to carry out the functions related to her role as wife because of the effects of a stroke. The stroke survivor may depend more on other family members. Role changes could affect the quality of an existing relationship.^9,65 Such changes may be confusing and stressful for the patient and the partner, particularly if the stroke survivor requires assistance with self-care activities such as toileting or bathing. Dependence in ADL is a major predictor of decreased sexual activity level after a stroke. In a study by Kimura and colleagues,³⁸ subjects who demonstrated ADL impairments also exhibited a decline in sexual activity. Sjogren and Fugl-Meyer reported similar findings as early as 1982.⁷⁰

Impaired bladder function also may affect sexual activity. Stroke often occurs in the elderly who may have underlying genitourinary dysfunction (prostatic hypertrophy, stress incontinence). Proper evaluation by a urologist is indicated.^47,62 Marinkovic and Badlani⁴⁷ recommended treatment of incontinence before addressing sexual dysfunction. Medications used to treat incontinence have side effects such as dry mouth, which can make kissing or other oral activities unpleasant. If the individual takes additional medication for other reasons (for example, diuretic agents), urine output may be increased. For the individual with mobility impairments, quick and frequent access to the bathroom may be difficult, resulting in episodes of incontinence. Incontinence may affect self-esteem and may be a source of embarrassment.³⁷ Bowel incontinence is less common after cerebrovascular accident because stroke patients typically are constipated because of immobility, inactivity, and poor food and fluid intake, which can cause bloating and discomfort.⁷⁵

Hypertension is a major risk factor for stroke, and research indicates that hypertension is associated with sexual dysfunction in men and women. Burchardt and colleagues⁸ reported a higher incidence and greater severity of erectile dysfunction in men with hypertension compared with an age-matched population without hypertension. The study also suggested that the erectile dysfunction was linked to the hypertension and not to side effects of antihypertensive medications. Grimm and colleagues³¹ also found that “sexual dysfunction in hypertensive individuals may be related more to hypertension level than to drug treatment.” Hypertensive women also report decreased lubrication, less frequent orgasm, and more frequent pain with sexual activity than women without hypertension; again, the effects were not related to the type of treatment.¹⁹

Individuals who have had strokes often have a history of other medical problems, including heart disease, which alone can cause functional impairments related to sexual activities. Often individuals with a history of myocardial infarction or bypass surgery fear the resumption of sexual activities.^31,45,55 Muller and colleagues⁵⁵ studied 858 patients who were sexually active in the year preceding myocardial infarction and found that although the risk of myocardial infarction increases in the two hours following sexual activity, the risk is almost equivalent in patients with and without heart disease. The research indicated that the risk of myocardial infarction caused by sexual activity is two in one million for a person with heart disease and that individuals who experience periods of anger or heavy exertion have a greater increase in actual risk because these behaviors occur with more frequency than sexual activity. However, the overall risk of myocardial infarction is lower for patients who engage in regular exercise, which has been shown to decrease the amount of cardiac work required during sexual activity.

“At its peak, sexual activity is about as physically strenuous as walking two to four miles per hour. The greatest levels of ‘exertion’ actually occur during orgasm, which lasts only a brief amount of time.”⁶⁷ Studies to determine cardiac expenditure are often performed on treadmills. Palmeri and colleagues⁶⁰ compared cardiac response during sexual activity to treadmill testing; results indicated that the amount of “work” during sexual activity was half the maximal found on treadmill testing and that there are different physiological responses to upright (i.e., treadmill testing) versus supine activity (i.e., sexual activity). Average heart rates ranged from 108 to 128 beats per minute. From a cardiac rehabilitation perspective, a patient is “safe” to resume sexual activity when the person can climb two flights of stairs or walk the length of a city block or its equivalent at a brisk pace with no discomfort.^34,45 This parameter may be difficult to assess in some stroke patients because of mobility deficits, and alternative activities may have to be explored (for example, propelling a wheelchair at a brisk pace with the use of unaffected arms and legs). The effect of stroke on sexual function is difficult to assess without examining the types of medications patients are taking. Antihypertensive agents have been found to cause erectile dysfunction, impede ejaculation, and decrease libido.^{10,13,23,24,26} Some β-blockers are known to affect erectile function and cause depression. One antihypertensive diuretic medication, spironolactone, is known to cause breast tenderness, galactorrhea (excessive secretion of the mammary glands), and gynecomastia (overdevelopment of the mammary glands), which is not always reversible in men.¹³ In a study by Aloni, Schwartz, and Ring,² six of the seven women who reported decreased sexual desire were taking anticoagulant drugs, suggesting that the medications may affect sexual function. Medications other than those prescribed for stroke management or hypertension may have additional side effects such as rashes and feelings of fatigue that may affect a patient’s desire to participate in sexual activities. Considering the potential side effects of various medications on sexual function and informing patients as necessary is the rehabilitation team’s responsibility.

Societal attitudes

Attitudes on the part of the public or the patient’s family members also may affect the patient emotionally or psychologically. Although the Americans with Disabilities Act has resulted in some improvement in public attitude, the fact remains that many persons still harshly judge individuals who appear “different” from the rest of society and regard disabled individuals with fear and shame. Stroke survivors and persons with other disabilities perceive these attitudes and, as a result, avoid social or public situations. The media seldom depict persons with disabilities as full partners in sexual relationships. The stroke patient and partner, family members, and others may share the view that persons with disabilities are sexless, “different,” and undeserving of social and sexual fulfillment. These attitudes can affect patients’ existing relationships and their willingness to pursue new relationships.

Role of occupational therapy

When persons experience changes in sexual function, they may require professional intervention to cope with these changes in sexual function and sexuality. What is the role of occupational therapy in sexuality intervention for these patients, and what is required to fulfill this role?

Sexuality long has been considered an appropriate area for occupational therapy intervention. Andamo³ stated that “sexual function should be included in the occupational therapy evaluation as it relates to the identification of the patient’s abilities and limitations in his daily living necessary for the resumption of his various roles.” Neistadt⁵⁶ noted that as “holistic caregivers, dedicated to facilitating quality lives, occupational therapists should be prepared to address sexuality issues with their adolescent and adult patients.” Couldrick¹⁵ argued that “with awareness and skill development, occupational therapists can affirm sexual identity, they can listen, and, with sometimes simple measures, they an address issues that fall within their professional roles.” The American Occupational Therapy Association has continued to confirm the role of occupational therapy by including sexual activity as an ADL within the areas of occupation in the Occupational Therapy Practice Framework.⁵⁹

Occupational therapists are well-prepared to address sexuality problems in stroke patients; the sensory, motor, cognitive, and psychosocial impairments that interfere with sexual function are the same ones that affect other performance areas addressed by occupational therapy, including other ADL and work and leisure activities. Occupational therapists’ skills of activity analysis and adaptation, holistic orientation, and knowledge of biological and behavioral sciences help them deal effectively with patients’ sexual difficulties.²¹ Research indicates that dependence in ADL is a major factor in decreased sexual activity after stroke,^38,70 further supporting the role of occupational therapists in sexual rehabilitation by restoring patients to the highest possible level of independence and role function.

Most occupational therapists receive some training in sexuality intervention. Even before the American Occupational Therapy Association listed sexual activity as an ADL, the authors of a 1988 study reported that 88% of 50 occupational therapy programs included formal classroom training about sexual function, with an average of three and a half hours of class time devoted to this subject.⁶³

Team approach

Although occupational therapists must be involved in sexual health care, effective sexual rehabilitation, like all rehabilitation, requires a team approach. The rehabilitation team must address all the individual’s problems in a holistic way, and all team members should be knowledgeable about sexual issues and treatment options.^46,77 If each member of the treatment team is educated and skilled in this area, the patient can choose the team member with whom he or she is most comfortable to address sexual issues. In addition, each team member has different expertise from which the patient may benefit. The physician may best address problems related to erectile dysfunction, relationship changes may require social work intervention, and the speech and language pathologist may best address communication difficulties.

In reality, the health care team often ignores sexuality issues, especially for the stroke population. A support group of 37 wives of stroke patients at a Veterans Administration center reported that no one had spoken to them about poststroke sexuality.⁵¹ In a 1988 study of sexuality counseling in an inpatient rehabilitation program, only 20% of non–spinal cord injured patients (55% of whom had a diagnosis of stroke) had received written materials on sex. Sexuality information was given voluntarily to 32%.¹⁶ Rehabilitation professionals cite various reasons for not addressing sexuality with their patients, with the most common responses being that another team member is responsible for this intervention and that their knowledge is inadequate.^51,57 In a pilot study of health care professionals who treat stroke patients, including occupational and physical therapists, lack of training and experience were cited as reasons to not address sexuality. Over half felt that they would be inhibited by either potentially offending or embarrassing the patient. Perceptions of which team member is responsible for addressing sexual function varied.⁵¹ The physician, social worker, and psychologist most often are cited as responsible for sexuality intervention.

In yet another study on sexuality counseling following spinal cord injury, patients indicated a preference to speak with their occupational or physical therapist or nurse about their sexual concerns. Participants reported a positive response to therapists who used an open and direct style of communicating and otherwise were frustrated, embarrassed, or intimidated by therapists who did not. Although many of the subjects were not ready to discuss sexuality early in their rehabilitation, they concurred that knowing resources were available when they needed them was vital.⁴⁹

Besides being neglected in the clinic, sexual rehabilitation has received little attention in research. However, a general positive correlation has been found between successful sexual rehabilitation and positive adjustment to disability. The literature shows that patients with disabilities are interested in the inclusion of sexuality in rehabilitation and give sexuality a high priority.²⁷ Studies confirm that stroke survivors and their partners are interested in information and/or counseling about sexuality after stroke.^20,41

In clinical rehabilitation, “a job title does not always define competencies,” and “no job title . . . excludes discussion of sexuality,” according to Chipouras and colleagues.¹² The qualities necessary in a competent sexuality counselor for persons with disabilities have been described variously. Chipouras and colleagues¹² emphasize comfort with sexuality, including one’s own, comfort with disability, empathy, nonprojection of one’s own morals onto the patient, awareness of available resources, basic knowledge of human sexuality, and awareness of one’s own competency and willingness to refer to others as necessary. The foundation of sexuality counseling consists of awareness and knowledge, which one can gain through reading, in-service education, coursework, and workshops. Therapists must develop skill in sexuality counseling through practice, as for all clinical skills. Discomfort in dealing with sexuality need be no different from discomfort with other difficult disability issues. Occupational therapists address many personal and sometimes painful issues with their patients. Increased competency, skill, and comfort comes with practice. Practice of sexuality interventions through role play with other staff members may be helpful in achieving greater comfort in conducting sexuality interventions.

Permission, limited information, specific suggestions, and intensive therapy

The therapist may use various frameworks and models to address sexuality issues in health care. Among the earliest and most prevalent is the PLISSIT model, developed by psychologist Annon.⁴ PLISSIT is an acronym for four levels of intervention: Permission, Limited Information, Specific Suggestions, and Intensive Therapy (Fig. 25-1). Using this model, the practitioner can determine the type and extent of sexuality intervention needed, whether he or she has the skills to perform the intervention, and whether to refer to a more qualified counselor.

Figure 25-1 The PLISSIT model. PLISSIT, Permission, Limited Information, Specific Suggestions, and Intensive Therapy.

Developing competency

Competency in sexuality intervention comprises three elements (see Box 25-1): comfort, knowledge, and skill. These elements are interrelated; individuals are more comfortable with things they know well (knowledge) and do well (skill). Suggestions for improving these competencies follow.

Comfort

Reading (See resources and references at end of chapter.)

Films (Be aware that many are related to spinal cord injuries.)

Disability literature

Knowledge

Readings (See resources and references at end of chapter.)

Lectures

In-service education

Skill

Role playing with other staff members

Acquiring skill through practice

Seeking a mentor for private supervision who specializes in sexuality

Specific suggestions for treatment

Many impairments that occur after cerebrovascular accident may affect sexual function and sexuality. These deficits include sensorimotor, cognitive, communication, and psychosocial changes. With sexuality, as with other ADL, determining the underlying causes of the performance problem can be challenging. The following section comprises a list of suggestions one may use during treatment.

Hemiparesis/sensory loss

Patients with hemiparesis or sensory loss and their partners may try the following suggestions:

Having the hemiplegic partner lie on the affected side frees the uninvolved side for touching; this position also provides support, permits active movement, and focuses attention on the intact side. Early treatment by the rehabilitation team (occupational and physical therapy) should include instructing the patient to lie comfortably on the affected side (Fig. 25-2).

Impaired motor control (limb and trunk) may require a change in coital positioning because the hemiplegic partner may find it difficult to assume certain positions. Alternatively, the unaffected partner may assume the superior position in bed or on a chair or lying on his or her side (Figs. 25-3 to 25-5).

Positioning for comfort with the use of pillows can be incorporated into foreplay.

Partners should discuss sensory loss beforehand; in hemiplegia, there may be absent or diminished light touch, impaired proprioception, kinesthesia, or loss of stereognosis. Stimulation on areas of intact sensation and incorporation of stimuli to intact senses (e.g., using scents, keeping lights on for visual stimulation, music, and stimulating language) may help improve sensory abilities.

Individuals with severe sensory deficits must consider skin protection during sexual activity to prevent skin breakdown.

In the case of impaired hand function, a vibrator can be attached with the use of Velcro to enable stimulation.

Treatment of weakened muscles of facial expression to improve body image and facial expression and strengthening of oral-motor muscles may enhance oral sexual activities such as kissing and oral-genital sex.

Figure 25-2 This position allows for genital fondling during rear entry vaginal or anal penetration and is appropriate for opposite or same-sex couples. Either partner can participate fully if lying on the hemiplegic side.

Figure 25-3 This position is appropriate as an alternative to lying on a bed or other surface; it is a nice alternative for wheelchair use and may break the barrier of the wheelchair being used only for transport.

Figure 25-5 This position is recommended if the male partner sustained motor or cognitive impairment and requires less endurance for the partner on the bottom.

Decreased endurance

Patients with decreased endurance and their partners may try the following suggestions:

Sexual activities should be planned. The patient should wait three hours after meals before engaging in activities and avoid sex when fatigued. Instead, this may be a good time for intimate cuddling, hugging, or participating in massage.

Partners can deemphasize intercourse through exploration of other sexual activities such as mutual masturbation and oral-genital sex.

Partners should consider sexual positions that use less energy (see Figs. 25-4 and Fig. 25-5).

Sexual activities may be easier to do in the morning, when energy may be greater, instead of the evening.

Figure 25-4 This position is recommended if the female partner sustained motor or cognitive impairment and requires less endurance for the partner on the bottom.

Program development

The therapist should have support, resources, and referrals available when addressing sexual issues. The therapist should inform supervisors and others on the rehabilitation staff of activities. Resources and referral services should be identified in other departments and outside the facility, if appropriate. The therapist should check the existing policies on sexuality (if any) at the facility and strive to be in compliance. The therapist should report experiences and provide education to others. If possible, an interdisciplinary committee should be formed to address sexual issues and develop appropriate programs.

Documentation and billing

Sexuality interventions may be billed and documented in various ways, depending on the billing system and the issues discussed. Appropriate categories include ADL training, patient and family education, discharge planning, and psychosocial training.

As in treatment, sexuality is best addressed in a multiproblem context. Patient privacy and confidentiality must be maintained. Examples of goals include the following:

Summary

All persons are sexual, and sexual activity is important to most persons throughout their lives. Interest in or desire for sexual activity does not necessarily diminish as persons grow older. Stroke may interfere with sexual expression by affecting the survivor’s desire, libido, erectile or lubrication response, orgasm or ejaculation, and sensorimotor, cognitive, psychosocial, ADL, and role function. Stroke also may affect the partner’s response or the patient’s ability to find a sexual partner. Research has shown that sexual desire most often is affected; however, prestroke sexual activity is the strongest predictor of poststroke sexual activity. Occupational therapists can use a holistic approach and training in activity analysis and adaptation to assist persons who have had strokes to regain their desired sexual function. A team model is best for sexual rehabilitation, with each team member knowledgeable about sexuality and providing special expertise. The PLISSIT model helps the practitioner identify the type of sexuality intervention required. All occupational therapists should be able to provide patients with permission, limited information, and specific suggestions and should be able to make appropriate referrals for sexual concerns related to stroke. Therapists must be sensitive to the multiple components of sex.

Review questions