Approach to supporting sexuality

Sexuality is defined by the World Health Organization as:

“…a central aspect of being human throughout life encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors.” 

Sexual health is defined by the World Health Organization as: 

“a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” 

Frameworks for supporting sexuality

The Sexual Rehabilitation Framework (SRF) encourages all disciplines to be involved in SCI rehabilitation in the same manner as they would other activities of daily living. It addresses the major biopsychosocial areas of sexuality to create a plan of action for the person with SCI.

The original PLISSIT and Extended-PLISSIT models are useful frameworks to guide multidisciplinary teams in addressing the sexual wellbeing of people with SCI. The models empower healthcare professionals to integrate sexuality into routine care, recognizing that it is a fundamental part of life.

In the original PLISSIT model, the name PLISSIT is an acronym representing four levels of intervention:

• P – Permission: Create a safe, non-judgmental environment that encourages patients to discuss sexuality.
• LI – Limited Information: Provide specific, relevant information related to the client’s concerns.
• SS – Specific Suggestions: Offer tailored strategies based on the individual’s needs. This requires a more in-depth understanding of the person’s situation and the impact of spinal cord injury on sexuality.
• IT – Intensive Therapy: Offer therapy where this is within professional scope or refer to a specialist if the issue is beyond scope.

The Extended PLISSIT (Ex-PLISSIT) model modifies and improves upon the original by:

• Emphasizing “Permission-giving” at all stages, not just the first.
• Incorporating reflection and feedback loops, encouraging practitioners to be more self-aware and person-centred.
• Recognizing that sexuality is a lifelong, dynamic part of human experience, even after events like spinal cord injury or chronic illness.

The Ex-PLISSIT model
Source: Taylor and Davis (2007)

Core principles for supporting sexuality

Sexual and reproductive health is a vital part of overall well-being and should be included in routine healthcare and rehabilitation planning. Health professionals can support people with spinal cord injury (SCI) and their partner/s, where relevant, by following these key principles:  

• Recognise individuality: Every person is unique, with their own identity, relationships, life experiences, needs and preferences.
• Use inclusive and respectful language: Communicate in a way that is open, respectful, and accessible to everyone, regardless of gender, sexuality or relationship status.
• Offer holistic and team-based support: Ensure that sexual health education and support are available from the broader multidisciplinary team and consider physical, psychological, and social factors, within a biopsychosocial model.
• Include sexual health in routine care: Discussions should address areas such as sexual desire, function, fertility, contraception, body image and relationships.
• Promote a positive culture: Foster a work environment that values sexual well-being and encourages staff to seek training in sexual health and sexuality in the context of SCI and disability.

Assessing sexual health and function

Comprehensive SCI care includes access to a health professional whose scope of practice includes the assessment of sexual health and function. This assessment may include:

• Taking a thorough history: Include questions about sexual function, concerns, goals, and any changes since the injury.
• Conducting a physical exam if needed: This helps assess physical changes and establish a baseline for future care.
• Encouraging routine screening: Include health checks such as cervical screening tests, breast exams, and testicular or prostate exams.

Promoting safe and healthy sexual activity

• Provide clear education: Talk about consent, contraception options, and the use of condoms to reduce the risk of sexually transmitted infections (STIs) and unplanned pregnancies.
• Support informed decision-making: Help people with SCI understand their sexual health options and empower them to explore what works best for their individual situation and relationships.