Importance of sexual rehabilitation for all clients including psychiatric clients

The World Health Organisation (WHO) (in Couldrik 1998a) recognises sexual expression, regardless of illness or disability, as a fundamental human right. Pan American Health Organisation and WHO (in Higgins et al. 2012) list people’s sexual rights as being:

• The right to express one’s full sexual potential
  
• The right to sexual autonomy, privacy, equity and pleasure
  
• The right to make free and responsible reproductive choices
  
• The right to comprehensive sexual health education
  
• The right to sexual health care

Kitzinger (in Couldrik 1998a) states that people who do not have sexual relationships are seen as abnormal. Disability does not alter humans’ need for affection and intimacy (Northcott & Chard 2000). If disability prevents or inhibits the full expression of a person’s sexuality or is of concern to the individual, then these aspects should be addressed.

Sexuality is an integral part of humankind. According to Weiss and Diamond (in Agnew et al. 1985), patients who avoid realistic acceptance of their own sexuality also fail to accept their disabilities. Agnew et al. (1985) found that not only clients’ attitudes but also the negative attitudes of professionals towards clients’ sexuality are thought to play an important role in hindering a person’s ability to adapt to physical disability. In a study by Northcott and Chard (2000), clients explained that their condition affected their sexual functioning. They believed that they should have received sexual rehabilitation as a routine part of their health care and that they should not have had to seek this out themselves.

There is a correlation between the sexual well-being of disabled people and life satisfaction (Gatens in Couldrik 1998a), and satisfaction in sexual relationships is regarded as a component of a quality life. Therefore, sexual difficulties can have a profound influence on the well-being of the whole family (Christopher in Couldrik 1998a).

According to numerous studies (Agnew et al. 1985; Evans 1985; Kennedy 1987; Novak & Mitchell 1988; Couldrik 1998b; Kingsley & Molineux 2000), it would appear that occupational therapists are in agreement that sexual rehabilitation should fall within an occupational therapy regime. Novak and Mitchell (1988, p. 110) go so far as to state that:

A therapist who advocates treatment designed to assist the patient in achieving the highest level of functioning but does not consider the interdependence of a patient’s sexuality and his/her other areas of functioning in the treatment model, is not practising from an occupational therapy perspective of holistic care.

Additional reasons for occupational therapists to provide sexual rehabilitation are briefly discussed from the theorist’s point of view as follows:

• Occupational therapists treat their clients holistically. However, there seems to be limited evidence of the incorporation of sexuality into models used by occupational therapists. In the Model of Human Occupation (1995), Kielhofner specifically excludes sexual expression as he is of the opinion that it cannot be viewed as a human activity (Couldrik 1998b). However, when reviewing the Model of Human Occupation, roles are stipulated as part of the habituation subsystem. Being a wife or husband implies having specific tasks, and sexual functioning should be incorporated.
  
• In the Reed’s Model of Adaptation through Occupation (Couldrik 1998b), sexual expression is included in the performance area on self-care, while the Person–Environment–Occupation–Performance Model incorporates sexual needs into a physical component of a person (Couldrik 1998b).
  
• Occupational therapists work with activities and enable people to engage in activities that have value, meaning and purpose. This is intrinsic to occupational therapy. Sexual expression can be classified as an activity, and it is closely linked to social roles (Couldrik 1998a), thus making it part of an occupational therapist’s role.
  
• Turner et al. (1996) make a case for first addressing sexuality and sexual needs as it occurs on the lowest level of Maslow’s hierarchy. This implies that if the therapist wishes to provide effective treatment, he/she should address the client’s physiological needs (these have the strongest drives) first, before addressing higher needs (e.g. increasing self-esteem) in treatment. The physiological needs encompass basic bodily drives such as the need for food, drink, air, sleep and sex.
  
• According to the American Occupational Therapy Association (2008), sexuality is seen as being part of a client’s activities of daily living (ADL). It is incorporated in the personal ADL where it is described as ‘sexual activity’ and ‘care of personal device’, that is, contraceptives and sexual devices. When a broader perspective of sexuality is held, the following aspects of personal ADL also address sexuality, namely, personal hygiene and grooming. On a level of instrumental ADL, caring for others and even communication devices can be incorporated. Therefore, for an occupational therapist to treat the client’s ADL (both personal and instrumental) comprehensively, these aspects should be incorporated into standard assessment and treatment programmes.

It can be argued that if occupational therapists advocate holistic client care irrespective of the client population, and sexuality is considered as part of the scope of occupational therapists in the physical field, then it must form part of the occupational therapy treatment of psychiatric clients. There are additional unique reasons why sexual rehabilitations should be addressed in psychiatric clients.

According to the DSM-5 (American Psychiatric Association (APA) 2013), the diagnostic criteria and clinical features of some psychiatric disorders, for example, major depression and bipolar disorder, include a decrease in libido in the depressed client and an increase in the client’s libido when in a manic state. These symptoms will have a direct influence on the client’s sexuality and his/her relationship with his/her partner. The majority of medication prescribed for psychiatric disorders have side effects that influence the clients’ libido and sexual performance. For example, some antidepressant medication may inhibit erection in men and vaginal lubrication in women (Barrett 1999). Clients diagnosed with major depression experience poor libido and isolate themselves. The client may not understand the role the disorder and medication play, as he/she only experiences the decreased libido, social isolation and the physical problems caused by the medication. The partner may not understand his/her partner’s withdrawal and decreased libido and could feel no longer attractive. The client’s feelings of guilt and a sense of worthlessness are exacerbated, and the partner feels hurt and rejected, which in turn damages the relationship.