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Chapter 14 HUMAN SEXUAL HEALTH Handbook of Health Social Work, 2nd Edition DEMYSTIFYING HUMAN SEXUAL DEVELOPMENT: EARLY THEORIES OF SEXUAL DEVELOPMENT 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 feelings. 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. ZOLBROD’S MILESTONES IN SEXUAL DEVELOPMENT 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 accepted. 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 relationship 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 COMMUNICATION AND THE HEALTHCARE TEAM 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 issues Collaborate with faith-based leaders LGBT persons may be uncomfortable discussing their sexual behaviors with social workers outside their community TERMS USED WITHIN THE LGBT COMMUNIT Y Lesbian: Woman who identifies as someone erotically, romantically, and af fectionately attracted to other women Gay: Individual who identifies as someone erotically, romantically, and af fectionately attracted o the same gender. 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 behavior 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 gendered 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 manner. THE SOCIAL WORKER’S ROLE 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 THE INTIMACY OF HEALTH SOCIAL WORK 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 bedside 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 OBTAINING A SEXUAL HISTORY 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 reduction* 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 SUGGESTED SOCIAL WORK ASSESSMENT STRATEGIES FOR PATIENTS 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 desirability 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. Counseling Assessment Research Education Strategies Sustainment CHILDHOOD SEXUAL ABUSE 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 system* 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 HUMAN SEXUAL RESPONSE The hormonal stage during adolescence increases the skin’s sensitivity to touch* Sensitivity to touch remains intact in the face of aging and illness** Human sexual response can also be seen as a neurological process 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 fantasies Masters and Johnson (1966, 1970) divided the human sexual response into interdependent phases: a. b. c. d. 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 stimulation 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 intimacy *Gallo-Silver, 2000; Kaplan, 1974, 1983; Schover & Jensen, 1988 A DEVELOPMENTAL PERSPECTIVE OLDER ADULTS 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 cancer** 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 orgasms 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 males* 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 YOUNG ADULTS Adolescence is a time of rapid emotional and physical change 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 sexuality 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 SPECIFIC ISSUES RELATED TO WORKING WITH COUPLES THE “PARENTIFICATION” OF THE WELL PARTNER 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 PHYSICAL INTIMACY AS AN ASPECT OF COUPLE’S COMMUNICATION 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 communication Couples often need to relearn how to listen to each other so they can rekindle the physical intimacy Speaker/Listener technique THE EFFECTS OF MEDICAL ILLNESSES AND TRAUMATIC INJURIES IMPACT ON SEXUALIT Y AND PHYSICAL INTIMACY 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 perspective 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 IMPACT ON STAMINA The loss of overall physical stamina caused by an illness or disability can impair the body’s ability to respond to sexual stimulation* Energy conservation is a crucial element in enabling people with a medical illness or injury to resume or return to sexual activity 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 IMPACT OF COMPLICATIONS FROM MEDICATIONS 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 concerns Social workers also help people learn how to communicate with their physicians about sexual issues SEXUAL REHABILITATION OF THE MEDICALLY ILL OR TRAUMATICALLY INJURED PERSON Sex therapy addresses pervasive problems and obstacles to physical intimacy, which may be psychogenic or emotional in nature 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 Back-writing “Red-light-Green-light” The prolonged kiss and the second kiss Self exploration and self-pleasuring to discover enjoyable sensations CREATING SEX-POSITIVE ENVIRONMENTS OF CARE 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