Sexuality and Healthcare

Patients have the universal desire to have information regarding sexual function but at the same time reluctant of asking healthcare professionals about it (Stern et al 1991).

The aim of the piece of work is to define sexuality first. It will then appraise the different models of sexuality. The Ex PLISSIT model will be used in a case study of Lynda. And finally the discussion will focus on the advantages and the limitations of using the model.

Sexuality is a dynamic process and is the right of all individual (Sakellariou & Algado, 2006). Sexuality is not just about “having sex” but includes making relationships, self esteem (persons’ view of their body image), tactile expressions and need for intimacy and closeness which are not only important in the life of disabled but also for the general population (Wells 2002 and Barnes & Ward 2005). Sexuality as a part of holistic care has been advocated by several authors (Wells 2002 for palliative care patients, Sakellariou & Algado 2006, Summerville and McKenna 1998, Couldick 1998 &1999, Northcodd and Chard 2000, Kingsley and Molineux 2000 for the Occupational Therapists and Davis & Taylor 2006). The therapy and the nursing professions are still ambiguous about the issue of addressing client sexuality (Watson 1991 and Couldrick 1998). Hence sex and sexuality is the most ignored and least discussed of disability issues, Barnes et al (2005). However the intervention models which can be used in sexuality were discussed by few authors (Annon 1976, Davis & Taylor 2006 and Taylor & Davis 2006). The PLISSIT model was being suggested as a model of sexuality first (Annon 1976). Irwin (1997) described the PLISSIT model as meta- model due to its informative- educative emphasis. The acronym PLISSIT signifies:

Stage 1: “P”- Permission giving.
Stage 2: “LI”- Limited Information.
Stage 3: “SS”- Specific Suggestions.
Stage 4: “IT”- Intensive Therapy.
The model gave a framework for intervention to healthcare professionals to address sexuality (Davis & Taylor 2006). The model asks for sequential application of the stages which can be viewed as its limitation. Also the other limitations of the model can be argued as the lack of research using the model and its individualistic nature (Irwin, 1997). Davis & Taylor (2006) argued against such a linear format and discussed the “permission giving” process in the model to be very ambiguous and implicit. Davis & Taylor (2006) critiqued further by arguing PLISSIT as a one way interaction model which gives ample scope for assumption for the healthcare professionals. Considering the limitations of PLISSIT model the alternate the Extended PLISSIT (Ex PLISSIT) model was proposed by Davis & Taylor (2006). It addresses some of the limitations of the PLISSIT model as “Permission giving” is more explicit and also the model does not follow a linear format. The model emphasises the need to reflect and review at all stages. Ex PLISSIT model was proposed by Davis & Taylor (2006) as an interactive and dynamic model to address concerns of client sexuality. The use of model can be understood by an example.

Lynda was referred to the Occupational Therapy department (Appendix). The Occupational Therapist (OT) saw Lynda in the Outpatient Clinic. In the first appointment, the OT completed the physical assessment which also included hand assessment. The appointment also included educating Lynda about Rheumatoid Arthritis and also how the condition affects sexuality of clients, i.e... The OT discussed sexuality in context (Davis & Taylor, 2006). The context can be seen as during the educational session. The OT also included in the discussion the affect of Disease Modifying Anti Rheumatoid Drug (i.e. Methotraxate) on sexuality. The educational session can be seen as “Permission giving” Lynda to talk about her sexuality and relationships. At first Lynda was in tears and she said to the OT that she fears her relationship with her partner (John) may break-up, due to her condition. The OT at this stage provided Lynda “Limited Information” by issuing leaflets on Sexuality and Arthritis. This was done in order to reinforce the discussion and also to help Lynda to empower John. The clinic room was an isolated single room which provided Lynda the privacy for the discussion. Davis & Taylor (2006) discussed the need of privacy while discussing sexuality with clients.
Lynda was back for her follow up appointment in two weeks. The OT “reviewed” by asking Lynda if the leaflets had all the information and if there were further issues in her relationship that she would like to discuss. This can be seen as further “Permission Giving” Lynda to discuss her sexuality issues. At this point, Lynda mentioned some of the positions to be particularly painful during sexual activity. The OT explained Lynda that experiencing pain during sexual activity is not unusual for the condition. This can be viewed as “Normalising patient experience” by the OT (Davis & Taylor 2006).The OT than provided “Specific Suggestion” by discussing alternative positions during sexual activity. On “reflection” the OT felt a referral to General Practitioner (GP) may be appropriate. After getting Lynda’s consent a letter was sent to GP for review of pain medications.
When Lynda came to see her OT for her fourth week appointment, the OT “reviewed” by asking if she has seen her GP prior to this appointment. The OT explained the aim of GP referral was to give her adequate pain relief which in turn would help during sexual activity. This can also be seen as further “Permission Giving” Lynda to talk about sexual issues. Lynda then reported that the GP saw her and asked her to take pain medications not more than three times in a day. She also reported that the GP changed some of the pain medications she was taking. Lynda confirms further that with the change of medications her pain and stiffness is better controlled yet the sexual activity not completely pain free. On “reflection” the OT thought Lynda might benefit from continued suggestions. The OT contacted the GP and on her advice, provided Lynda with “specific suggestion” further. The OT advised Lynda to take one of her pain medication dose at night, two hours before going to bed.
Lynda then came with John, for her eight week therapy appointment. The OT “reviewed” Lynda’s progress by asking if having her pain medication at night is helping her. This can also be seen as OT giving further permission to both Lynda and John. Lynda report she feels better yet anxious that the pain and stiffness will come back. John too sounded anxious about Lynda’s pain. The OT on “reflection” thought anxiety to be the issue for Lynda and John. Hence felt at the stage that Lynda will benefit from “Intensive Therapy”. The OT identified that probably for Lynda and John, Lynda’s altered “body image” in future was the concern. Hence discussed with them how they would feel if a referral is sent to a Clinical Psychologist. This can also be viewed as a part of “strategy development” by the OT to help Lynda, for future. Lynda and John agreed to it. In the end, Lynda felt without the help of the team she would have been in lot of pain and discomfort, which could even have affected her relationship with John.
It is noteworthy to recognise that there could have been a situation when Lynda might have refused to discuss her sexuality concerns with the OT. The key than would have been to leave all “channels of communication open” (Davis & Taylor, 2006). The OT in that situation could have said that I am providing you with some of the information on the affect of arthritis on sexuality. In future if you change your mind you can come back and discuss any issues of concern (in sexuality) with me. By doing so the OT not only ensured that the intervention was client centred but also left all channels of communication open, for future.

-In my opinion, the advantages of the Ex PLISSIT model can be seen as its non prescriptive nature, highly flexible to use and being holistic in sexual care. Reflections and reviews at each of the stages helps and permission giving being paramount.

-However the limitations of the model can be seen as its application could be too repetitive and time consuming. The model puts high expectation on individual practitioner and also it needs further research to be established.

Conclusion
This article has critically discussed the need to address clients’ sexual needs by the healthcare professionals. The PLISSIT and Ex PLISSIT models can be used to address concern areas in sexuality. The essay used the Ex PLISSIT model in a case of Lynda. The sexuality models although discussed in relation to Occupational Therapy can however be used by other healthcare professionals in practice. The discussion ended by considering the advantages and limitations of using the model.

References:
-Annon J (1976): The PLISSIT model: a proposed conceptual scheme for the behavioural treatment of sexual problems. Journal of Sex Education Therapy 2, 1-15.
-Barnes MP and Ward AB (2005): Sex and sexuality, chapter- 8. Oxford Handbook of Rehabilitation Medicine, 1st edition, Oxford University Press Inc, New York.
- Couldrick L (1998): Sexual issues within occupational therapy, part1: attitudes and practice. British Journal of Occupational Therapy, 61(11), 493-496.
- Couldrick L (1999): Sexual issues within occupational therapy, part2: Implication for education and practice. British Journal of Occupational Therapy, 62(1), 26-30.
-Davis S and Taylor B (2006): From PLISSIT to ExPLISSIT, In: Davis S (Ed.). Rehabilitation: The use of Theories and Models in Practice, Edinburgh: Churchill Livingstone, Chapter6.
-Irwin R (1997): Sexual health promotion and nursing. Journal Of Advanced Nursing, 25, 170-177.
-Kingsley P, Molineux M (2000): True to our philosophy? Sexual orientation and occupation. British Journal of Occupational Therapy, 63(5), 205-210.
-Northcott R and Chard G (2000): Sexual aspects of rehabilitation: the client’s perspective. British Journal of Occupational Therapy, 63(9), 412-418.
-Sakellariou D and Algado SS (2006): Sexuality and Occupational Therapy: Exploring the link. British Journal of Occupational Therapy, 69(8), 350- 356.
-Stern SH, Fuchs MD, Ganz SB (1991): Sexual function after total hip arthroplasty. Clinical Orthopaedics, 269, 228- 235.
-Summerville P, McKenna K (1998): Sexuality education and counselling for individuals with a spinal cord injury: Implications for Occupational Therapy. British Journal of Occupational Therapy, 61(6), 275-279.
-Taylor B and Davis S (2006): Using the Extended PLISSIT model to address sexual healthcare needs. Nursing Standard, 21(11).
-Watson C (1991): Sexual roles in nursing care. Nursing, 4(44), 13-14.
-Wells P (2002): No sex please, I’m dying. A common myth explored. European Journal Of Palliative Care, 9(3), 119-122.

Appendix: A case of Lynda
Lynda, 35 years female, was referred to Outpatient Rheumatology OT following recent diagnosis of Rheumatoid Arthritis, by the Rheumatology registrar. Her problems included pain during her daily activities and early morning joint stiffness. She was started on Disease Modifying Anti Rheumatoid Drugs (DMARD) and pain killers. She recently has been living with her new partner (John) after she had a relationship of 5 years with her ex boyfriend. Coincidently the diagnosis of her disease was following her split. She was anxious that due to her condition she might have another unsuccessful relationship and wanted help from healthcare professionals.