Addressing sexuality issues in rehabilitation

The writing was originally published in the Journal of Rehabilitation 1/2019 publication. ” The text is an abstract of the article.


Henna Kekkonen, Occupational Therapist, Rehabilitation Master’s Degree student, Specialist in Sexological Counselling (NACS)

Kaija Nevalainen, Special Occupational Therapist, Master of Health Sciences, Full-time teacher at Oulu University of Applied Sciences.


Sexuality is a part of humanity at all stages of life, and it changes and adapts with life stages and situations (WHO 2006). The existence of sexuality is not dependent on health or age, but sexuality is also a right and characteristic of the sick and disabled. Sexual rights are universal human rights and are based on freedom, dignity, and equality for all. Rehabilitation professionals work closely with a variety of illnesses and life crises. Sexuality should be addressed as part of holistic rehabilitation if professionals want to implement the encounters of different people holistically. (Rosenberg 2006, 283; Sengupta & Sakellariou 2014, 101; Stein et al. 2012, 1842.)

The sick person is always first a sexual person with an illness and not a sick person with a sexuality (Bildjuschkin & Ruuhilahti 2010, 13; Santalahti & Lehtonen 2016, 22). Clients should be treated equally, individually and with respect, even when they have needs and wishes related to sexuality and sexual health promotion. Their right to self-determination must be respected without discrimination based on sex, sexual orientation, age, disability, ethnic or national origin, language, or other personal characteristics. (Klemetti & Raussi-Lehto 2016.) Illness and the resulting changes in body and mind always cause a crisis. Sexuality, desire, and pleasure may go unnoticed. Physical body then has a very strong effect on the mind. (Bildjuschkin & Ruuhilahti 2010, 79; Santalahti & Lehtonen 2016, 165.) Serious illness and the resulting physical inability often lead to sexual health problems.

Studies show that sexual health challenges are more prevalent among sufferers than among the so-called healthy people (Kedde et al. 2012, 64). Ryttyläinen and Virolainen (2009, 2) state that diseases, medications, and treatment measures always affect a person’s sexual health individually. The client should have permission to talk and ask about sexuality — it should not disappear, under any measures. Discussing sexuality with a rehabilitation patient requires a confidential interaction relationship between the client and the rehabilitation professional. On the subject of sexuality, man is at his most exposed and at the same time the most vulnerable position. (Santalahti & Lehtonen 2016.) In order for a rehabilitation patient to become encountered, heard, and becomes understood as his or her own sexual being, the employee must be aware of their values and attitudes related to their own sexuality. According to Karkaus-Rikberg (2000, 293), barriers relating to sexuality and its realization include beliefs, taboos, attitudes, and stereotypes. Sexuality and disability together form a kind of dual sensitivity, as sexuality and disability evoke a wide range of emotions, thoughts, and perhaps even barriers. When talking about the sexuality of people with disabilities, we have to start from the fact that the sexuality of healthy and disabled people are more in common than that it would be in any ways different.

Sexual guidance and advice as a working method for a rehabilitation professional

Client guidance and counselling are an important part of a rehabilitation professional’s work. There is a growing consensus among healthcare professionals about the importance of addressing sexuality: it is an important part of the client’s comprehensive holistic care and for rehabilitation. Sexuality should always be taken into account in the planning, implementation and evaluation of client care and rehabilitation. (Sinisaari-Eskelinen et al. 2016, 290.) Nevertheless, sexuality is a well ignored and passed topic. Dyer and das Nair (2014, 1432) state in their study that when a topic is everyone’s topic, no one takes responsibility for it, but everyone assumes someone else is handling the conversation. “Everybody’s business is nobody’s business”. The end result is that no one will raise the issue, or to talk about it. All rehabilitation professionals play an important role in promoting client sexuality. Moreno et al. (2015, 115) and Dyer and das Nair (2014, 1432) most often state that the problem is that professionals expect the client to raise the topic themselves and do not themselves find suitable words for discussing the sexual issues. Raising sexual issues is complicated by, among other things, personal embarrassment, lack of knowledge and skills, lack of time, and lack of beliefs and tools. In Richards et al. (2016, 1480) study, raising the issues was influenced by the resources set by the work organization (including opportunities to spend time), the professional’s own perceptions of their own skills, and negative attitude toward the client and sexuality. One’s own attitude to sexuality also has either a positive or negative effect on the rehabilitation worker’s willingness to talk about sexual health with rehabilitation patients (Haboubi & Lincoln 2003). Everyone with a degree in social and health care should have sufficient knowledge and skills to offer sexual counselling.

The first and important step in this direction is that the professional consciously seeks to understand his or her own sexuality and to think about the things that have influenced it. Sexual anamnesis is a great tool for getting to know your own sexuality, as well as for use with your client, for example as a first client form at the beginning of a partnership. Professional’s assumptions about the client’s age emerge from the saying “There are more important things than sex” that was intended to defend that there was no talk of sexuality. Older people as well as people with disabilities are treated as asexual people and their sex lives are not given attention. (Richards et al. 2016, 1480.) However, according to the FINSEX survey, older people’s perceptions of sexuality have changed recently. Seniors have more often than the previous generations perceived their sexuality in a very important way! Sexuality knows no age limit. 93% of women and 98% of men aged 50-59 are sexually active. 81% of women and 91% of men aged 60-69 are active. In the 70-79 age group, 79% of men and women are sexually active. (Kontula 2009, 749) Age discrimination should be avoided in all sexual guidance and the professional should offer the possibility to have discussions about sexuality regardless of the client’s age (Hautamäki-Lamminen 2012, 98).

Speaking of sexuality / addressing sexuality

The main responsibility for opening the discussion and giving permission is always with the professional, and this is what the rehabilitation patients are expecting. Professionals, in turn, expect the rehabilitates to open the conversation themselves. (Dyer & das Nair 2014, 1435; Richards et al. 2016, 8; Schmitz & Finkelstein 2015, 211.) If we don’t speak about the issues of sexual health it may even complicate the rehabilitation patients ‘ sexual problems and increase their chronicity (Pieters et al. Studies show that rehabilitation patients want professionals to take an active role in the conversations, but the rehabilitation patient determines whether the conversation is important or not. They are also allowed to decide at what precision level these discussions will take place. It is the employee’s responsibility to create an atmosphere where these discussions are possible to take place. Despite the fears, discussing sexuality issues does not eat up working time, rather at its best, discussions reduce the client’s pain, anxiety, and worries and, through this, potentially indirectly reduce symptoms and necessary treatment interventions. When the client feels heard, his or her own motivation for recovery may increase and cooperation may improve. (Bildjuschkin & Ruuhilahti 2010, 71, 80; Sinisaari-Eskelinen et al. 2016, 290.)

The correct timing of speaking about sexuality varies from individual to individual and assessing it requires professionalism. We can never know which are the rehabilitation patient’s own abilities at any stage of rehabilitation, so a professional should raise up sexuality at regular intervals.  It depends on the individual at what stage a conversation might be necessary. Professionals fear that bringing up a topic too early is offensive and that at the onset of the illness, acute medical issues often take precedence over everything else. The best time for a conversation would be when preparing emotionally and physically to return home. Returning to everyday life raises new questions and experiences. (Dyer & das Nair 2014, 1434; Rosenberg 2006, 282; Schmitz & Finkelstein 2015, 211; Stein et al. 2012, 1847.)

It is important for a rehabilitation professional to identify what perspectives from sexuality are about to bring up with every rehabilitation patient. Each rehabilitation patient is individual as well as his or her other disability, illness, or disorder and those all set their own requirements for talking abou. t sexuality. A respectful and sensitive approach as well as involving a partner in the discussion is important. The terminology must be suitable for the customer’s needs — finding a common language is essential. In the shock and reaction phase, the discussion should always be clear and ready-made questions will make it easier for the client. In the shock and reaction phase, the discussion should always be clear and ready-made questions will make it easier for the client. It is important to say out loud things that the sufferer may be afraid of, and which he or she dares not raise up (Bildjuschkin & Ruuhilahti 2010, 94; Sawin et al. 2002, 31; Rosenberg 2006, 282.).

Clients will need guidance, information, and support from professionals to deal with sexual problems. People have a lot of prejudices and misinformation about sexuality in different life situations, which hinders for example, obtaining sexual satisfaction. Appropriate and positive tone presented information can play a significant role. For example, guidelines on how sex life changes when illness occurs, and how and when sex can be resumed after illness, help many couples. (Dyer & das Nair 2014, 1434; Ryttyläinen-Korhonen 2011, 12.) It is important to give the patient the opportunity to express the feelings which disability has caused. A genuine encounter also allows that the employee doesn’t have to know how or own the knowledge about everything. It is enough to dare to face the human with openly. (Bildjuschkin & Ruuhilahti 201, 79; Rosenberg 2006, 83.) Often, sufferers need direct information about having sex, the safety of sex, and the concrete problems of sexual intercourse (e.g., erectile dysfunction, postural difficulties, and talking about sex with a partner) and concrete solutions to them (Schmitz & Finkelstein 2015, 209).

Closing words

From the literature, we can note that sexuality is an important part of humanity even after illness. However, rehabilitation professionals still find it difficult to speak about sexuality and create a promising atmosphere for discussion. People easily approach the subject so that “someone else” is responsible for it and that “someone else” converses with the rehabilitation patient. However, as rehabilitation professionals, we are most closely involved with the rehabilitation patient’s daily life and their changing life situations. We also play an important role in the holistic encounter of people. The assessment methods used in rehabilitation focus much on mapping the activities rather than on the quality-of-life issues such as sexuality.

Official assessment tools and written information would make it possible to raise sexual issues. (Dyer & das Nair 2014, 1435; Stein et al. 2012, 1842.) In rehabilitation, however, sexual problems should be seen as a broader psychophysical social entity and not just as a physical achievement. (Schmitz & Finkelstein 2015, 210).In the future, it will be important to ponder the development of concrete assessment methods and interview forms for tools to rehabilitation professionals. And where sexuality has ​been brought up. When ready-made themes are at an interview, addressing issues are a natural part of a collaborative relationship. The most important tool for a rehabilitation professional to handle sexuality as well is the “not knowing” attitude. We cannot determine things based on value, we cannot know anything, and we cannot do our work on the basis of assumptions. Nor can we think that sexual issues aren’t important things to a rehabilitation patient unless we have never asked about it. Nor can we assume what sexuality means to anyone or how a rehabilitation patient carries out it in their own lives. When we adopt an attitude that we know nothing, it is easier to face the rehabilitation patient individually, openly, and acceptably, given his or her life situation, of which sexuality is an integral part. A good professional does not have to know everything and own the answers to all the questions. It is enough to be able to listen and, if necessary, tell the customer that does not know, but is willing to look for answers, and if necessary, direct the customer forward. Sexuality issues can be too difficult issues for yourself to address with and talk about, but those must not be a reason to leave the rehabilitation patient alone with their sexual issues. One of the most important tasks of a rehabilitation professional here is to reflect on their own attitudes, feelings and values related to sexuality. The statement that we cannot go with the client to where we have not been ourselves is very true. Accepting one’s own sexuality also promotes the recognition of sexuality in the rehabilitation patient. Knowledge of local actors and experts in sexology may be sufficient information for the rehabilitation patient. You can search for local actors, for example, in the expert search of the Finnish Sexological Society: . Väestöliitto, the Family Federation of Finland and the Sexpo Foundation annually train sexual counsellors and sex therapists if further training is of interest. Shorter sexuality training is also available throughout Finland.

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