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Chapter 14
Handbook of
Health Social
Work, 2nd
 Freud’s pleasure principle, introducing the concept of libido,
has influenced many social worker’s professional thoughts
about sexual development.
 Libido includes sexual desire, fantasy, and the initial sensations of
being sexually stimulated
 Believed that libido was concerned with pleasure seeking to relieve
sexual tension
 Presented theory that seems devoid of many of many interpersonal
processes, such as love seeking, comfort, and receiving pleasure
from another person.
 Incongruent with social work’s philosophy of preserving and enhancing the
quality of life
 Erickson’s work on the formation of a person’s identity from
childhood to adulthood better represents sexuality and
physical intimacy as aspects of the human experience by
which people connect and communicate their thoughts and
 At each developmental stage, people express their wish to be close
to others through displays of physical affection, comforting, and at
times, sexual desire.
 The gap between Freud’s and Erickson’s perspectives may
arguable be bridged by the work of W. Ronald D. Fairbairn,
who suggested that libido was not concerned with simply
seeking release by rather an object or person with whom to
intimately connect.
 Begins with birth and professes to the parent’s initial
bonding experience with the infant.
 Parental love is communicated through touch
 The foundation of empathy as the parent searches for the
right response to her infant’s cry
 As baby’s cry is interpreted, the baby develops a sense of
trust un the world
 Because parents must help their infants with all basic needs,
their attitude toward her baby’s body becomes reflected in
the baby’s own attitude about his body and is the foundation
of body image.
 Body image is ultimately refined to include the
establishment of gender identity
 As the growing child becomes more certain of his
gender identity, he develops self -esteem and feels
 Children with atypical gender expression may encounter
overt hostility, condemnation, and withdrawal of affection by
their parents and same-aged peers.
 They become more aware of their effect on other people and
realize that their words and actions impact others
 Begins the process of learning how to manage power within
relationships with others
 As child enters puberty, they develop a sense of
“owning” themselves
 Begin to discover the parameters of autonomy and the
concept of interdependence with others as an aspect of each
being his own person
 Adolescence is a time of sexual exploration
 Key part of this journey of sexual development is the
creation of sexual fantasies and masturbation.
 Zoldbrod’s milestones ground sexual development in
an interpersonal perspective – the parent-child
 Milestones naturally progress from the love and touch of
caring parents to loving and sexual relationships with others
as adults
 Parental touch responds to the needs of preverbal infants,
both emotionally and physically, and becomes the
foundation for empathy and trust
 First notions of body image
 The pleasure of being touched is the basic foundation of
human sexuality and physical intimacy
 People with medical conditions are often sexually
disenfranchised by the medical establishment
 Healthcare professionals tend to wait for patients and their
partners to raise issues of sexuality and do not themselves
initiate them (Esmail, Yashima, & Munro, 2002)
 Silence further isolates patients and partners
 Discomfort with issues and discussion of sex may be
based on cultural or religious beliefs
 Health social workers need to be educated about these
 Collaborate with faith-based leaders
 LGBT persons may be uncomfortable discussing their
sexual behaviors with social workers outside their
 Lesbian: Woman who identifies as someone erotically,
romantically, and af fectionately attracted to other
 Gay: Individual who identifies as someone erotically,
romantically, and af fectionately attracted o the same
 Typically used by men and frequently interpreted as referring
to men but is also commonly used by women
 Bisexual: Individual who is erotically, romantically, and
af fectionately attracted to both genders
 Used both as an identity label and adjective to describe
 Transgender: Often used to describe all gender -variant
persons; clinically used to describe a person who lives
or identifies as a gender other than that expected
based on their anatomical sex
Other self Identifiers
 Gender Identity: Person’s sense of being male, female, or other
 Gender Variant: A person who; either by nature or choice, does not
conform to gender-based expectations of society
 Intersexed: A person born with ambiguous genitals may self identify as being a member of both genders
 At times this is used to self-identify a woman with an elongated clitoris or
a man born with a micropenis and undescended testicles
 Transsexual: describes those who have surgically modified their
secondary and/or primary sexual characteristics to match their
gender identity
When in doubt, always ask the client to define the term they use to
describe themselves or their behaviors in a respectful and open
 Health social workers need to be equally comfortable
discussing sexuality and intimacy issues with patients and
their partners to fully assess and address patient’s
psychosocial issues as well as to ef fectively plan programs
and services.
 Need to develop a sex-positive approach to people
 One that does not assume that everyone is heterosexual or that a person
is “too old” for sexual activity
 LGBT persons may be more inhibited than other people because of
fear of rejection or stigmatization
 Often require a level of intimacy that social workers in
other settings rarely experience
 In acute care medical facilities, patients are often in bed
wearing hospital gowns or sleepwear
 In outpatient and inpatient settings, health social workers
must often discuss a patient’s body and its functions
 Requires an acute sensitivity to patient’s need for
privacy and feelings of vulnerability
 Advised to ask the patient’s permission to join patient at the
 Knocking on the door (even if its open) shows sign of respect
 Some cultures prefer more formal ways of introductions and
being addressed
 Eye contact
 Sit at eye-level with patient
 Health social workers on the forefront of AIDS
intervention claimed as part of their professional roles
counseling to heterosexuals, bisexuals, and gay women
and men about safer sex practices and harm
 Counseling used a sex-positive approach
 Social workers accomplished this task by assessing a person’s
sexual practices with acceptance and respect and viewed the
process as an integral part of their work
*Berkman & Zinberg, 1997; Christ, Moynihan, & Gallo-Siler, 1995; Gallo-Silver, Raveis, &
Moynihan 1993; Weiner & Seigel, 1990
 Psychosocial assessment of a person challenged by any illness or
injury that fails to address sexual issues is incomplete
 Health social worker’s focus is on emotional coping skills and practical
problem solving
 Social work relationship provides the most comfortable and safe
environment and opportunity for patients and partners to discuss issues of
sexuality and physical intimacy
 Natural time during an assessment to ask patients if they are
sexually active and if they have partners is when discussing
relationships and social supports*
 Assessments provide health social workers with opportunities to
convey the message that sexuality and physical intimacy are
natural and normal parts of life**
*Fuentes, Rosenberg, & Marks, 1983; Gallo-Silver & Parsonnet, 2001; Weerakoon, Jones, Pynor, & Kilburn-Watt, 2004
** Andrews 2000
1. A patient’s demographics enable the health social
worker to integrate questions about sexuality and
physical intimacy into a psychosocial assessment.
2. Assessing a couple’s emotional intimacy is the first
step in assessing their sexual relationship
3. Patients define sexual activity and physical intimacy in
an individual way
4. Patients will want to share sexual material with
healthcare professionals because they have concerns,
worries, and distress about the impact of their illnesses
or injury on their sexual functioning
5. Sometimes a patient’s concerns are not specifically
about how their body functions, but how they look to
others and their received loss of attractiveness and
 Social workers must be particularly attentive to the additional
stressors and barriers faced by patients who are LGBT because of the
lack of national legal recognition of their relationships.
 Members of the LGBT community may use expressions such as “boyfriend” and
“girlfriend” to describe their partners, even if they are in committed long -term
relationships, while some patients may use “husband” and “wife,” even if the
relationship is not legally recognized where they live
 The patient’s partner is an important participant in the understanding
the sexual and affectionate aspects of their relationship
 Interviewing the partner can elicit more information about a person’s life functioning before the illness or disability*
 Partners may be reluctant to approach issues of sex or physical
intimacy out of the belief that by doing so they are selfishly placing
their own needs before those of their ill or disabled partner
*Cagle & Bolte, 2009; Lemieux, Kaiser, Periera, & Meadows, 2004
**Soloway, Soloway, Kim, & Kava, 2005; Wimberly, Carver, Laurenceau, Karris, & Antoni, 2005; Zunkel, 2002
The EX-PLISSIT model of assessment has been developed
and enhanced by nursing professionals and is often used by
health social workers.
 EX tended
– Social workers need to take a well -paced,
ongoing, approach to helping people with sexual issues
 P ermission
– Social workers need to give patients
permission to talk about and consider sexual issues
using generalization and normalization interventions
 L imited I nformation
– Social workers need to father
limited information to capture the patient/family
education aspects of a sexual assessment
 S pecific S uggestions
– Social workers need to provide
specific suggestions and recommendations to the patient
and the couple based on their sexual activity before their
illness or injury
 I ntensive T herapy
– Social workers may suggest and
intensive therapy address and identified need through an
appropriate referral
The CARESS model was originally designed to
assess sexual issues for patients receiving
palliative care or at the end of life care.
 Researchers estimate that one in three women and one in
seven men were sexually abused as children*
 Umbrella designation for a series of behaviors that include**:
vaginal and anal penetration by a penis, finger, hand, or other object
receptive or active oral sex
fondling and masturbation
Invasion of privacy when bathing and toileting
Sexually provocative behavior and nudity
Exposure to and involvement in pornography
*Finkelhor, 1984; Maltz, 2001, 2003; Russell, 1999
**Johnson, 2004
 Survivors of sexual abuse often feel violated by the healthcare
 The requirement that patients remove their clothes, undergo tests that
require them to stay still or posed in certain ways, and receive invasive
examinations all can evoke feelings and thoughts about childhood
sexual abuse that had previously been avoided or not acknowledged
 Helping a patient feel safe in these circumstances is achieved by
increasing their sense of control over a given situation
 All medical procedures require some form of consent
 The ability to respond empathetically to the patient’s disclosure
of their abuse is the social worker’s most important skill when
working with this population
*Jehu, 1992
 It is both respectful and supportive for survivors of childhood
sexual abuse to know that their histories are hard to hear
 Pacing of the questioning is essential because survivors can
overwhelm themselves and be retraumatized by sharing too
much information at one time
 Keeping pacing in mind when sharing information will help the
survivor feeling cared for rather than rejected when the health
social worker sets a limit on how much material will be
discussed in any one session*
*Gallo-Silver & Weiner, 2006; Schacter et al., 2004
 The hormonal stage during adolescence increases the skin’s
sensitivity to touch*
 Sensitivity to touch remains intact in the face of aging and
 Human sexual response can also be seen as a neurological
 Centers of the brain interpret stimulation and send messages to the
body to respond
 Brain interprets both touch and non-touch types of stimulation
 Brain is the repository of learning, experience, and recollection, all
of which have a memory component
 Brain stores a variety of sexual memories including memories of
the physical sensations related to excitement, arousal, and orgasm
*Neufield, Klingbell, Borgen, Silverman, & Thomas, 2002
**GelFland, 2000; Kingsberg, 2000
 Masturbatory fantasies are thought to change only superficially as
people mature
 Basic concept remains constant throughout the life span
 The ability to retrieve these memories can help medically ill and injured
people enhance their sexual responsiveness through the use of masturbatory
 Masters and Johnson (1966, 1970) divided the human sexual
response into interdependent phases:
The desire phase – encompasses the feelings and thoughts about sex and
sexual feelings
The excitement phase – involves increased blood supply to the genitals,
erection of the penis, and lubrication of the vagina during sexual
The orgasm phase – rapid muscle spasms, increased heart and respiratory
rates, changes in body temperature, and ejaculation
The resolution phase – marked by the body’s return to a resting heart rate
and decrease in the supply of blood to the genitals
 Medical illnesses and injuries can disrupt some of these phases, but it
is rare for all to be markedly disrupted
 Because not all phases are disrupted, sexual rehabilitation for people with
medical illnesses or injuries is possible
 Sexual rehabilitation is the process of helping a medically ill or injured
person restore and resume sexual functioning.
 Rehabilitative approach identifies the phase or phases that remain intact and
helps patients maximize their responsiveness and enjoyment by building on the
strengths of the remaining phases*
 It is easy for a patient challenged by a changed body and functioning
to be discouraged about and fearful of sexual issues
 Strengths-based approach presents this patient with a measure of hope and
possibilities for a different approach sexually
 Rehabilitation approach would focus on the interpersonal and intrapsychic
issues that likely represent obstacles to comfort the enjoyment of physical
*Gallo-Silver, 2000; Kaplan, 1974, 1983; Schover & Jensen, 1988
 After a certain age, women begin to produce less estrogen
 Diminishes vaginal lubrication, walls of the vagina may become
thicker and less elastic
 Desire might diminish and some women report less intense orgasms
as they age*
 However hormonal replacement therapy remains controversial due to
empirical evidence that it can increase risk for breast and ovarian
 Premenopausal women may benefit from vaginal lubricants or
facilitate comfortable sexual intercourse
 As men age, they may require more tactile stimulation to
achieve erections and erections may be less rigid
 May also require longer periods of time to achieve erections following
 Erectile dysfunction medications are said to be effective
*Dennerstein & Lehert, 2004; Dennerstein, Lehert, Dudley, & Burger, 1999
**Aubuchon & Santoro, 2004; Chen et al., 2004; Ching & Lip, 2002; Durna et al., 2004
 Laumann and colleagues (1994) suggest that partner availability might
be a more important obstacle to sexual activity for older adults than
the physical sequence of aging
 Older adults who do not have partners may use masturbation as their
primary sexual activity
 Masturbation is often a part of their sleep ritual
 There is evidence to suggest that masturbation among older adult
women without partners is almost as high as that of adolescent
 Social workers can educate staff about masturbation in older adults
and, in process, help normalize the experience
 Persons in congregate living situations at times form sexual
relationships with other residents
*Laumann et al. 1994
 Adolescence is a time of rapid emotional and physical
 Intense changing in body image and functioning due to the
development of pubic hair, breasts, and muscle mass
 Medical illness and injury further complicates young adult’s
relationships with their own bodies and their developing
 Healthcare professionals are obligated to inform patients that
recommended treatment may interrupt or impair fertility
 Social worker can advocate for complete and comprehensive
information to be given to patients, which is a crucial first step
in helping them cope
 The use of clear and accurate terms is essential in discussing
sexual issues to a population that may be sexually naïve
 Another psychosocial barrier that young adults may struggle with
are issues of attractiveness and desirability
 Body image issues can create crisis of self-esteem for people who do not
currently have partner or who have had limited sexual experiences*
 Amputation of a limb or facial disfigurement can be profoundly
disorganizing to a person’s self-esteem because the often have an
immediate impact on how other interact with the affected person
*Horgan & MacLachlan, 2004; Ide, Watanabe, & Toyonaga, 2002; Lawrence, Fauerbach, Heinberg, & Doctor; 2004; McCabe & Talesporos, 2003
**Horgan & MacLachlan; Lawrence et al,; McCabe & Talerporos; Monga, Tan, Ostermann, & Monga, 1997
 Medical illnesses and traumatic injuries place patients in a
vulnerable position and increase their dependence on others,
both physically and emotionally
 The well partner often must monitor the patient’s condition, supervise
medications, provide transportation to physician visits and
treatments, assist with bathing and toileting, and participate in
physical and occupational therapies
 As level of practical and personal care increases, partners often report
that they feel like parents rather than romantic partners
 Social worker’s awareness of “parentfication” can help diminish the
isolation and loneliness
 May consider ways to incorporate physical intimacy: massage to bathing or kissing when
helping the patient with meals
 Medical illness and traumatic injury can have an enormous
impact on couple’s ability to communicate, share, and
understand each other
 If communication problems existed before the health crisis, they
likely would not improve under challenge of poor health condition
 Physical intimacy for people with medical conditions requires verbal
 Couples often need to relearn how to listen to each other so they can
rekindle the physical intimacy
 Speaker/Listener technique
 Illness and injury often disrupt aspects of the human
sexual response, but rarely entirely
 Cardiovascular disease, hypertension, and diabetes
often diminish the body’s sensitivity to touch and
stimulation, secondary to diminished blood flow
 Has greatest impact on the genitals
 People in renal failure lose energy and stamina due to
the build-up of impurities in the blood that would
ordinarily be cleaned by the kidneys
 Pulmonary Disease robs the body of energy, which in
turn diminishes feelings of desire
 Cancer, which involves cells multiplying and growing
out of control, causes many problems depending on
the type of cancer
 Spinal chord injuries disrupt the individual’s ability to feel below
the injury
 Desire remains intact, and erections and lubrications occur, but the
individual is not able to feel these changes
 The social work profession encourages a strengths -based
 Supportive and educational social work interventions
 The social worker who is able to help people feel comfortable with
sharing their sexual feelings can help them locate reactions that
can serve as building blocks to more satisfying physical intimacy
 The loss of overall physical stamina caused by an illness or
disability can impair the body’s ability to respond to sexual
 Energy conservation is a crucial element in enabling people
with a medical illness or injury to resume or return to sexual
 Accommodations in love making transfer to more “work” of the
sexual intercourse to the well partner**
 Fatigue is a major obstacle to sexual activity
 Psychological phenomenon that does not respond to sleep or rest and
is often intensified by increased inactivity
*Ferrando et al, 1998; Harden, 2005; Parish, 2002; Schmidt, Hofmann, Niederwieser, Kapfhammer, & Bonelli, 2005; Walbroehl, 1992
**Haas & Haas, 2000
 Medicines that af fect sexual functioning are said to have
“sexual side ef fects”
 Antidepressant medication may diminish sexual desire
 Depression due to erectile dysfunction in men
 Chemo-therapy induced menopause
 Social workers should ensure that patients are aware of the
sexual side ef fects of their medications and medical regimes
and feel empowered to talk to their physicians about their
 Social workers also help people learn how to communicate with their
physicians about sexual issues
 Sex therapy addresses pervasive problems and obstacles to
physical intimacy, which may be psychogenic or emotional in
 Goal of sex therapy is to help patients establish a new, improved
baseline of functioning
 Sex rehabilitation counseling focuses on the impact of medical
illness or injury on sexual functioning and intimacy. Goal is to help
individuals restore or return to their baseline functioning or to
accommodate a changed baseline of functioning*
*Gallo-Silver, 2000
 Sexual rehabilitation counseling includes cognitive and
behavioral intervention
Safe-touch exercises and body mapping
The prolonged kiss and the second kiss
Self exploration and self-pleasuring to discover enjoyable
 Privacy is a major obstacle to physical intimacy in
institutional settings
 Policies and procedures that insist hospital room doors remain open
at all times are changed when patients have al communicable
infection or need protection
 Policies and procedures that frown on adult visitors climbing into bed
with adult patients
 Health social workers advocate for “bending the rules” on an
individual on a case -by-case basis