to our talk here this afternoon slash morning, depending on where you're at. We came up with a topic called Sex on the Rehab Unit, a multidisciplinary team approach to addressing sexual education on the inpatient rehab unit. Just like to introduce who will be speaking today. First, it will be myself doing the general introduction and acting as the moderator today. Feel free to post any questions that you may have in our Q&A section, and we'll be trying to answer those as we go through. And hopefully we'll also have some time left at the end of the presentation in order to answer those questions as well. So first again, I'm Dr. Kelly Crawford. I am the Medical Director and Fellowship Director of Brain Injury Medicine at Carolinas Rehabilitation in Charlotte, North Carolina. I also welcome Dr. Wendy Contreras, who is a clinical faculty physician who used to be with us for her fellowship training last year, but is now on staff at Beaumont Hospital in Taylor, Michigan. And Dr. Latanya Loftin, our Medical Director of our Spinal Cord Injury Program here at Carolinas Rehabilitation. And Jennifer Myatt, our Psychotherapist or our Licensed Clinical Mental Health Counselor here on our Brain Injury Unit on Carolinas Rehabilitation as well. So again, we welcome you and feel free to ask any questions as we go along. First, I'd like to just get this out of the way for all of us. None of us have any disclosures throughout the presentation. So no need to worry about any of that. Just to go through our learning objectives. First, we hope that you will be able to formulate a management plan addressing sexual dysfunction in the traumatic brain injury, spinal cord, and stroke population that we see regularly on the inpatient and outpatient units. We hope that you will be able to describe We hope that you will be able to describe and address the psychological considerations of sexual dysfunction in the patient with neurological injury. And we also hope that you can identify and describe the ethical considerations and management of sexual dysfunction in this population as well. In addition, we hope that you are able to identify and address special considerations and needs of sexual dysfunction and management of the LGBTQ community and following neurological injury. Just going over a brief session outline, I'll finish up my introduction here in a few minutes, but then we'll go into going specifically into the brain injury and stroke population. In addition, we'll go into spinal cord injury effects and emotional consequences, and the psychological considerations in dealing with this patient population. And this may be a little bit of a long presentation, and this may be a little hard to read, but this is kind of an outline of where and why we came up with this topic. If you can see there at the top, this is kind of where we started from in our own program. It actually led to quite a few meetings discussing our populations and the different needs to address this specific sexual dysfunction. If you can see there at the top, it might be very difficult to read. I try to scrunch it into one slide, but at the beginning, it goes through the medical nursing therapy assessments. And first off, going through, does the patient have capacity? Now, my specific arena in which I deal with brain injury, this is kind of where the line stops for me in a lot of cases, because a lot of times my patients do not have capacity. So in this formation, especially on the inpatient unit, this is kind of where we have to stop and kind of consider to re-engage the patient as time goes on and recovery occurs. Also have to address, does the patient display inappropriate sexual behavior? Again, a large consequence of our brain injury population as well. And again, if that answer is a yes, then we do kind of redirect and discourage any inappropriate behavior in intimate time at that time. And then again, continue to readdress as time goes by. However, if the patient does have capacity and is not exhibiting inappropriate behavior, then of course, as a provider, and as our therapy team go on, we do know that sexuality can be impacted by the disease and disability, and we are more than willing to discuss it at that time. Is the patient interested in discussing this? So that's another aspect. Sometimes patients are kind of focused on their recovery at that time, and kind of wish to maybe hold off on that conversation at the time. If they are interested, we always do coordinate and address the personal and specific needs, whether that be with the patient and the significant other, whether it be physical accommodations that need to be made, or any emotional or spiritual aspects that need to be addressed at this time. And that kind of ends where that green slide demonstrates there. And I think at the time, when we came together in different programs on our rehabilitation unit, I think this is kind of where we were all on the same page. It's very clear on the brain injury population. If somebody doesn't demonstrate capacity, you kind of stop there. Now, as Dr. Loftin will just talk about further on in her discussion, you don't always deal with the same issues on the spinal cord population. So there's a little bit more area to advance during this time. But I think when you go into the yellow slide, this is kind of where we started to diverge. Now, with the different populations, specifically, again, on our unit, the spinal cord versus brain injury unit, there's a very different consequence from a physiological standpoint and motor function standpoint. So this is where our ideals and our ideas kind of diverged as far as what our therapy program entailed. And why I say that is, especially, again, in the patient population of brain injury, there's often a desire to express or a desire for intimate time. However, in the brain injury population, a lot of times, if we're ready to tackle the intimate time, it's also kind of coincides with their time that they can go home. And a lot of times, we're dealing more with the cognitive and the behavioral aspect and not necessarily the functional aspect that the spinal cord injury program patients are dealing with. So this is where our program started to diverge and where we discussed possibly doing therapy and or education regarding intimate time and allowing that in the inpatient unit. So as you can see, there are a lot of different ideas being tossed around and really different opinions, depending on which provider was involved and what the patient population was. So as we kind of delved into this, we did find that there are different needs for the different patients on our inpatient unit, whether that be the general rehab, the stroke and brain injury patients and or the spinal cord patients. This is kind of where we knew this was gonna be a very important topic and to really start to regulate what our program was going to be doing for education and what may be not as needed as much. And so why did we think this is important? Well, I think we can all agree that sexuality is a very important part of life, but also in the rehab world, the World Health Organization... Hello? I'm going to get a call because our tech kit keeps coming out. So I will carry on. But as you can imagine, we've evolved since 2006 and we are starting to address this more and more. Okay, I'm here, I'm good now, so I apologize. So we are doing better at addressing this, but this is one area that I feel that we probably do have areas of improvement. Again, why is this important? The body has not been given much attention in the rehabilitation process. It is important for the rehabilitation team to treat psychosocial and sexual issues before the individual reenters the community. Now again, as spinal cord injury may be addressing this more on the inpatient unit, a lot of times this is left to the rehab doctors in the brain injury population to do more on the outpatient setting when the patient makes a little bit more recovery from a cognitive aspect. And of course, appropriate education and availability of resources can play an important role in helping survivors and their families cope with sexuality issues after neurologic injury and thus can increase self-awareness and decrease in disinhibited behaviors. But what continues to be the barrier? So really, although it is clear that patients would welcome sexuality issues being routinely incorporated into the rehabilitation process, the evidence suggests that it may be healthcare professionals like ourselves who are more inhibited about discussing sexual issues with patients due to embarrassment, a lack of training, or other related factors. And in particular, lack of training and comfort level were demonstrated in a study by Keller and Oxman, which demonstrated embarrassment was found to be a contributing factor in deterring nurses from discussing topics such as sexuality with patients. In addition, a similar study was done by Kautz et al. reported that the discussion of such issues was avoided by nursing staff for fear of causing unnecessary patient distress and anxiety or because they believed the patient did not wish to discuss sexuality issues as part of their recovery program. As we're learning more and more, however, this is something that patients are wanting to discuss more. And with that, we hope to provide the educational tools with this topic so that you can create your own management plan, whether it be in the inpatient setting or in the outpatient clinic setting. So with that, I would like to introduce Dr. Wendy Contreras, who is, again, the faculty physician at Beaumont Hospital in Taylor, Michigan, and she will be discussing the effects of brain injury and stroke on sex. Thanks, Dr. Crawford. All right, I'll just get started here. I'll be talking about the effects of brain injury and stroke on sex. So I'll briefly touch base on the physical, behavioral, and emotional effects. So strokes can be very debilitating. We know the obvious physical effects commonly reported, such as hemiplegia, hemiparesis, spasticity, and pain syndromes that can interfere with sex. It's understood that other physical factors can directly affect sex as well. In a large systematic review, the prevalence of sexual dysfunction was significant. So on average, about 64% of stroke survivors reported sexual dysfunction. Many studies reported a decline in libido for both men and women. There was erectile dysfunction reported in men, orgasmic difficulty for both men and women, and absent or decreased vaginal lubrication in women. Another concern reported was urinary incontinence, which can lead to avoidant behaviors and cause discomfort or embarrassment during sex. For behavioral effects, stroke survivors' behaviors become affected as well. The attempt to even return to sexual activities can take up to three to six months after the stroke event has occurred. Between 49% to 70% of stroke survivors reported a decrease in coital frequency, even one to two years after surviving a stroke. Dysfunction in stroke patients has an impact on sexuality as well. Patients with aphasia are not able to have intimate conversations with their partners that could ultimately lead to sex. So the slide we've been talking about so far has highlighted on hyposexuality, but the opposite can occur as well. So here's a case study of a 62-year-old male who had a right basal ganglion hemorrhage. Before the stroke, he was sexually active about once per week. After the stroke, though, he became very insistent on having sex with his wife, almost becoming very obsessed with wanting to hold her or hug her constantly. So he became very sex-driven after a stroke, the opposite of what we've been talking about so far. For emotional effects, how do stroke survivors feel about sexuality? Sex is considered to still be important, but dissatisfaction is commonly reported. Anxiety and mood disorders, such as depression, may also play a role in sexual dysfunction. Patients learned that hypertension, AFib, and other risk factors may have been the cause of a stroke. So a lot of patients reported being afraid of having another stroke because of the increase in heart rate and blood pressure during sex. And this slide's very important because of the silence from medical professionals on the topic of sexuality. So it's the clinicians who don't ask the questions. The patients are often not prepared on how this will impact their sexuality. Medical professionals often think another provider may be better equipped to help them, so they'll often defer to a psychiatrist or a primary care physician or a rehab specialist. So it's this ongoing circle where patients don't know who to talk to about sexuality. Stroke survivors become hesitant and ultimately stop asking questions. So how do we help our patients out? Jennifer will talk to us about how we can overcome this issue and help our patients out later on. More research is needed in sexuality in stroke patients. There are many studies on men alone, some studies that focus on both men and women, but very few studies that focus on women alone. More research is needed on our younger population as well, since we know that younger patients can also have strokes. There is no consensus regarding the location of the lesion and the degree of sexual dysfunction, with reports showing no correlation between left or right hemispheric lesions, while others do show some correlation. Now I'll jump into the effects of traumatic brain injury on sex, looking into the physical, cognitive, behavioral, and emotional effects. Physical effects of TBI. A systematic review studying TBI patients with sexual dysfunction looked into how sex can be directly affected in this population. Both sexes reported a decrease in sex drive and pain during sex. Problems with masturbating was reported in women, and erectile dysfunction was often reported in men, both acutely and chronically. Fatigue is also an issue. So TBI patients have sleep-wake disturbances, sleep apnea, and a lot of times report fatigue. Fatigue is correlated with how often sex is desired and the importance of sex for TBI patients. Interventions for fatigue may improve sex life after TBI. A lot of patients who sustain TBI are often on medications for mood, such as depression or anxiety, that can have side effects. An example are SSRIs, which are commonly prescribed. SSRIs can decrease libido or cause ejaculatory dysfunction. Ritalin is interesting because it can be used for inattention or issues with the executive function, et cetera, but can cause priapism in certain patients. And this slide just shows that even after one year, after a sustaining HMI brain injury, patients still reported a decrease in frequency, low desire or sex drive, and dissatisfaction. Looking at cognitive effects, cognition is a common issue in TBI patients, which can indirectly affect sex. Patients can be disinhibited, have impairments in judgment or problem-solving. Patients can be unmotivated or even be unaware of their own deficits. The opposite may occur too, where patients are very focused on other aspects of sexuality, such as masturbating or pornography. Patients with TBI are dissatisfied with sex frequency compared to before the TBI. Other behavioral disturbances are exhibitionism, obsession with sexual language or the act itself, and inappropriate behaviors due to the lack of inhibition. For emotional effects, this is a bidirectional relationship between depressive symptoms and sexual difficulties, whether depressive symptoms lead to sexual difficulties or vice versa. And this slide here looks at a table that focuses on emotional effects in TBI patients versus control. And the highlighted area here, I'm not sure if you guys can see my mouse, but looking into emotional effects, low confidence, feeling unattractive, limited access to intimate social contact with people. And this other table here from another article asks the question, reasons for discomfort and discussing issues of sexual functioning with medical providers. The TBI patients reported feeling embarrassed or just being afraid, or it felt too personal for them to ask. But here it shows that one out of five patients would bring up the topic of sexuality only if a provider specifically asked. So if we're not asking, we can't help our patients. And this slide here looks into the brain injury questionnaire of sexuality. So this study looked at patients with TBI and compared them to healthy controls. They were asked questions such as, were you in a relationship before your TBI or 12 months ago for healthy controls? And asked questions based on sexual functioning, self-esteem, and mood. So the three bars on the left are the subscales with the scores, and they add up together to give a measure of total sexuality on the right side. This showed how the TBI population scores much lower in all three domains, including total sexuality, when compared to healthy controls on the right side. So that concludes stroke and TBI, and these are my references. And I will be moving this along to Dr. Lofton, who is the Director of Spinal Cord Injury at Carolinas Rehabilitation. Thank you, Dr. Contreras. My name is Dr. LaTanya Lofton, and I will be speaking about the effects of spinal cord injury on sex and our experience with initiating a sex education program on our inpatient rehab unit. I would like to begin by looking at our first poll question, which asks, how many of you have a formalized sex education management program as part of your inpatient rehabilitation program for patients with spinal cord injury? Your options are A, we do not have any formal educational program, but evaluate or educate based on individual needs, B, we have a formal education program, but do not allow sexual activity of any kind, C, we have a formal program, and we allow participation in sexual activity in our program, or D, we do not offer sex education or practice in any form in our hospital. So we have a few answers coming in, and it looks like so far, people do have some sort of formal educational program, but it is assessed on individual needs. While we wait for a few more results, I'll remind you that sexual function is one of the most highly rated priorities dictating quality of life satisfaction in our patients with spinal cord injury. So again, it looks like most people have A, we do not have a formal educational program, but evaluate or educate based on individual needs. There are a few of you who do not offer sex education or any sort of educational program or practice in any form in your hospital. Quality of life surveys of patients with chronic spinal cord injury often point out that patients who have tetraplegia look at sexual function and sexual satisfaction as second only to regaining hand and arm function. If you look at patients who have paraplegia, they often report that sexual satisfaction is one of their primary factors in evaluating their quality of life. We recognize that the spinal cord injury can impact all aspects of sexual function, particularly as it relates to sexual desire, attractiveness, as well as self-image and sexual self-esteem. We are able to use the physical examination to help us to assess or prognosticate what this patient's sexual dysfunction may be. For example, if the patient has intact pinprick sensation at S2 to S4, this patient may be able to attain psychogenic arousal and subsequently achieve ejaculation. Additionally, preservation of sacral sensation or voluntary sacral control at S4, S5 often correlates with the ability of this patient to attain reflexogenic erection or vaginal lubrication. Regardless of the level or completeness of the injury, a lot of our patients are still able to achieve orgasm after their spinal cord injury. Loss of anal sensation to pinprick and absence of voluntary anal contraction often correlates with absence of genital orgasm, but the possibility of non-genital orgasm remains. We often see three main primary issues associated with sexual dysfunction in a male patient after spinal cord injury. This includes erectile dysfunction. If a patient has a complete upper... These patients typically retain the ability for reflexogenic erections. If the patient has a complete... Typically retain the ability for psychogenic erections. If the patient's injury is incomplete, these patients often retain the ability for both psychogenic and reflexogenic erections. Ejaculatory dysfunction is also a common issue in our patient population. The majority of our men with spinal cord injury are unable to ejaculate with sexual intercourse. This is certainly more difficult for our patients with spinal cord injury and very difficult for us to treat. However, there may remain an option for penile vibratory stimulation for use for sexual pleasure in this patient population. There are other options for erectile dysfunction, which include vacuum erection devices as well as PDE5 inhibitors, which could potentially be used on the inpatient rehab unit. Poor sperm quality is also a common issue that we have, and this is thought to be impacted due to issues with recurrent urinary tract infections, epidermitis, chronic denervation, or even changes in hormones after the spinal cord injury. When we look at our female sexual response and dysfunction after spinal cord injury, sexual dysfunction and orgasmic difficulties tend to be the primary issues that we see. But our female patients remain interested in sexuality and sexual function despite these difficulties. Typically, the issues that we see that interfere with them enjoying sexual activity and sexual intercourse are related to difficulty with positioning, issues with increased vasticity, lack of enjoyment, lack of lubrication, which ultimately can result in worsening pain with intercourse. Similarly to our female patients, our male patients are also interested in sex after their injury. However, many of them report that their level of desire may actually decrease, and oftentimes they also report that the frequency of sexual activity also decreases after their injury. Additionally, patients often report that their preference for the type of sexual activity may also change after their injury. For example, prior to their injury, most patients report that they actually engaged more in sexual intercourse or coitus. After their injury, patients report that they frequently engage more in oral sex, kissing or hugging as their primary means of sexual expression. We cannot negate the impact of the spinal cord injury on the psychosexual effect of their injury. For example, patients who have spinal cord injuries often have issues as it relates to changes in their sexual self-esteem. They may see themselves differently because of the injury. There may be issues with redefining roles as lovers and partners after the injury. Additionally, cultural and religious beliefs may also play a role. We also have to look at the patient themselves may be dealing with issues of not having enough sexual satisfaction. They may be dealing with whether or not they feel that they can adequately satisfy their sexual partner. Has the partner lost interest? Does the patient still feel sexually attractive? Or is there too much emphasis on actual physical function? So now we move into our next poll question. What do you think is the biggest barrier to initiating a sexual management plan for sexual dysfunction after spinal cord injury on the inpatient rehab unit? Our options are A, hospital staff is not comfortable or their education is inadequate. B, patients are not interested in sexual activity. C, the length of stay is too short to allow for sexual activity as part of the rehab program. Or D, patients are not medically cleared yet for sexual activity. So it looks like your experience is very similar to our experience. Hospital staff is not comfortable. That's giving us the majority. And then length of stay is too short. Of a sexual health rehabilitation program is to maximize sexual function after spinal cord injury and to promote sexual adaptation and adjustment after the injury. It should be a part of a comprehensive rehabilitation program in our attempt to manage and meet the needs of the whole patient. Given that the majority of our patients were relatively healthy adults prior to their injury, many of them enjoyed a very active sexual life prior to their injuries. As stated earlier, sexual satisfaction is a very important factor in quality of life after spinal cord injury. With that being said, we also have encountered several barriers with regards to initiating a management plan in our hospital. One main issue has certainly been nursing and therapy staff turnover such that oftentimes we don't have staff who have been adequately trained or who feel fully competent in their ability to educate patients about sexual dysfunction because they themselves are not comfortable with this issue. Additionally, in more recent years, there has certainly been an increase in a push for decreasing length of stay. With decreases in length of stay, we've run into the issue that patients may have medical issues that may prevent us from initiating practical application of a sexual health plan or patients may not yet be cleared for any sort of physical activity of sexual nature. They may have weight-bearing restrictions or lifting restrictions, or they may be increased risk for orthostasis or autonomic dysreflexia. I would dare say that despite these challenges, our patients still remain interested in learning more about sexual dysfunction after their injuries. So how do we manage this and what is our first step? So the first step is always patient readiness. Not every patient is ready to engage in sexual activity during their acute inpatient hospitalization. However, the patient certainly may be interested in having a discussion or they may be open to a discussion where they address some of the anticipated problems that they may have. How do we find out if the patient is ready? We ask. Secondly, we have to identify members of the team who will talk to the patient about sexual dysfunction and intimacy after their spinal cord injury. As stated previously, not every staff member is going to be comfortable with talking with patients about sexual dysfunction or sexual health. In our team, we accomplish this goal by initiating education about spinal cord injury and sexual dysfunction as part of their spinal cord injury education series. This class is taught by the chaplain and further taught by the psychologist to address some of the more common psychological issues that can impact intimacy and sexual dysfunction after spinal cord injury. After we've done that, then several members of our team, including the spinal cord injury physician, the therapist, both physical and occupational therapists, as well as our clinical care coordinator, meet with the patient to discuss their individual issues related to their level of injury and based on their level of interest. Oftentimes, in collaboration with the therapist, if the patient is ready to proceed with my approach, sexual intimacy after my injury, the therapist can then make recommendations for assistive devices or tools that can be used to help overcome the physical limitations that our patient may be experiencing as a result of their spinal cord injury. Additionally, the clinical care coordinator meets with the patient to discuss options for management of bowel and bladder and hygiene to also assist or facilitate with enhancing intimacy after their injury. Step five involves practical application. The key difference here between the brain injury service and the spinal cord injury service is where does practical application take place and where is it reasonable for this to occur? I first present to you a case that we encountered. This is a 27-year-old male who has a history of C6 spinal cord injury. He was admitted to our inpatient unit 12 days after his initial injury. He was managed non-operatively. Although his injury was initially complete, this patient did convert to incomplete during his acute rehab stay. Now, this patient expressed an interest very early in resuming sexual activity. So we met with the patient and in combination and collaboration with occupational therapy and physical therapies, as well as with our nursing staff, we came up with a plan for how this patient could pursue or explore further intimacy and sexual activity. The patient was counseled by the physician and ultimately a trial of Sidenafil was initiated for this patient. And the patient was allowed to trial this medication during their TLS stay three to five days prior to discharge. Now, of note, this patient was admitted to our inpatient unit for about eight weeks. So when this patient discharged, they had already been hospitalized about 75 days. And this trial of initiating sexual intercourse during the rehab stay was accommodated for this patient at that time. This case was about 10 years ago. We'll move to a more recent case where we have a 30-year-old male with C7 age impairment scale C, incomplete spinal cord injury. This patient underwent surgical fusion for his injury and was placed in a cervical collar for 12 weeks. He was admitted to the inpatient rehab unit seven days post-injury. He also expressed an interest in resuming sexual activity very early during the hospitalization. Again, in combination with the physical therapists, the occupational therapists, and nursing, we were able to make recommendations for adaptive equipment that could be used to help this patient. However, given that this patient discharged home 21 days after his inpatient admission, practical application was deferred to the home setting. Now, unfortunately, I do not have a case involving a female patient because we rarely had female patients who were interested in pursuing initiation of a plan during their acute inpatient hospitalization stay. So I leave you with reminders that sexual satisfaction is a major quality of life factor for our patients with spinal cord injury, and it should be a part of a comprehensive inpatient rehabilitation program. Optimal management of sexual dysfunction after the spinal cord injury will require a multidisciplinary approach so that the patient can have the most optimal outcome. And now we'll show you a few of our references that we use on our inpatient unit. So PVA Guidelines has a guide for patients as well as for healthcare providers that provide significant education on sexual and reproductive health after spinal cord injury. Additionally, Pleasure Able is a manual that is downloadable for free online. It's a sexual device manual for persons with disabilities. This manual is produced in Canada, but I found it to be a very vital resource for many of our patients with regards to adaptive equipment that can be used to assist with positioning for sexual function. And now it is my pleasure to introduce you to our psychotherapist, Jennifer Myatt, who will talk about the psychological considerations of sexual dysfunction. Jennifer? Hi. So now we're going to talk about the psychological considerations of sexual dysfunction as well as some approaches to addressing this topic. So research has found that for both men and women, relationship quality, mood, and level of independence are actually more predictive factors of sexual satisfaction than genital functioning. So we do a great disservice to our patients if we fail to provide adequate sexual counseling and education as a component of the rehabilitation process. So first I'd like to start with a poll question to identify how often you guys are actually having these conversations with your patients at this time. So never once do you defer to other members of the team or do you wait for the patient to bring it up? Or do you feel like this is something that you actually address during the majority of your patient encounters? So if we can go ahead and take a moment to respond to the poll question. And while doing that, just thinking about throughout the continuum of care opportunities, so not just the inpatient acute setting, but also outpatient follow-up visits, thinking about all the various opportunities we might have. And sometimes when we bring up this topic, you know, think about do you bring it up with the patient alone? Do you usually wait until their partner is present? Do you wait for their partner to direct the conversation? So it looks like the majority of the attendance today bring it up about once as part of the education process. We'll have some responses. All right. Yeah, the majority it looks like one time. So let's talk a little bit more about the factors that play into adjustment around sexual functioning, as well as some approaches to addressing this and why it's so important. So there are a multitude of factors that can mitigate how well someone adjusts to sexual dysfunction following brain injury or spinal cord injury. Higher levels of sexual satisfaction have been associated with being in an enduring relationship, so a relationship that has maybe been present for longer. The couple may have been through some ups and downs together and have had to adapt to things together. Higher levels of sexual satisfaction are also associated with greater financial means. Oh, I'm sorry. There we go. That's where I want to be right now. So thinking about economic factors, you might have some great recommendations for your patients and their needs, but do they have access to those resources? Can they afford those resources? Specifically in males, lower levels of sexual satisfaction have actually been associated with men feeling very rigid in their need to adhere to social scripts. So there are beliefs about gender norms, there are identity beliefs about accepting assistance and behavioral expectations within the family system. And this can also sometimes be impacted by their religious and spiritual beliefs and how they conceptualize the situation. As Dr. Contreras mentioned earlier, some of the medications that we might prescribe to help with mood issues related to adjustment overall can also contribute to sexual dysfunction. So it's important to learn some about the contributing factors to the anxiety and depression. If sexual dysfunction is one of the primary issues, then giving a medication that could further diminish that functional ability for the patient might not be the best option. If you are giving medications for mood stabilization, also providing resources to the patient to work with a mental health professional to work on the underlying causes of the mood to adapt some additional adjustment and coping strategies is very valuable. So consider the patient's relationship status at the time of injury as well when addressing this topic. Individuals who are already in a relationship at the time of their injury, it'll be very important to normalize and address the shifting roles that occur within the family system. We did have a question about how important partner education is. It's extremely important, especially if that's the person's partner. They're going to be assisting them maybe not only physically, but also helping them to cope as they continue to progress through their recovery process. So providing education to both the patient and the partner is very valuable. They can also then reinforce it with one another. They can identify opportunities to work on any sexual issues that they may be having. Sometimes some of the issues that have arisen are the caregiver or partner who becomes the caregiver may not see the patient as viable. They might feel like they're fragile or ill and not want to burden them by trying to broach the topic of sexuality. And oftentimes the person who's recovering may not want to bring it up because they feel like they're already very demanding on their partner for all their other needs. However, if a long period of time goes by with lack of intimacy or sexual activity, often that can lead to additional feelings of guilt. Sometimes if patients try early on to initiate sexual activity and they don't have a good experience, that can discourage them from continuing to try. So it's really important for us to bring this up and share with them that it's normal to have some challenges. It's normal to have a process of returning to a satisfying sexual lifestyle and just letting them know that it's a process. For our individuals who are not in a relationship around the time of their injury but are interested in initiating one, it's important for us to talk to them about their access to socialization and opportunities to actually find partners and initiate new relationships. Of course, the adjustment that Dr. Loftin mentioned earlier too about impact on self-esteem, self-image, that can make people not feel as confident putting themselves out there to try to initiate new relationships. They might not feel sexually desirable. They might not feel that they can perform well for a partner. So working on how to help them process those thoughts, feelings, and beliefs and identify appropriate ways to access those opportunities. For couples interested in family planning, that can be a very motivating factor to work through sexual challenges. But if they're struggling in any way, it can also add a significant amount of anxiety around pressure to perform. So again, making sure that we're giving opportunities to these couples to have the education on what resources and approaches could be helpful to them in achieving their goals and returning to having a sexually satisfying lifestyle with each other. Okay, so how do we approach this topic? It's encouraged in the literature that an interdisciplinary approach is better than a multidisciplinary approach. The big difference between those is a multidisciplinary approach has a multitude of professionals, like our rehab teams do, with each professional really focusing on their own area of expertise. However, this has led to a lack of education in the past when no provider feels like sexual functioning falls within their area. So interdisciplinary really emphasizes each provider on the team addressing the topic of sexuality regularly, and providing education at whatever level is consistent with their level of knowledge and expertise, and of course, for anything that doesn't fall within their knowledge base, referring to another provider on the team to further address that issue, or even referring to a specialist outside of the team to help meet the patient needs. All staff are encouraged to normalize sexual functioning as a topic that's okay to discuss with the team, just like any other bodily function that could be impacted by injury. So this is the PLCIT model of addressing sexual functioning. It was developed in 1974 by Anon. It has four levels of intervention, beginning with broad interventions that all members of the treatment team should be able to provide, and then narrows down to more specialized interventions. So the top stage is permission giving. The objective of this stage is for providers to just create space for patients to bring up sexual concerns. This is as simple as just bringing up the topic and saying, do you have any questions or concerns about intimacy or sexual functioning during your recovery, or is this something that's come up as a concern for you when you think about the future? Just because the patient raises concerns does not mean you have to have all the answers. That's the opportunity to connect that person and say, well, that's a really good question. That's a really appropriate concern. Let me direct you to another member of our team who can further provide resources for you. The next stage down is limited information giving. So this can be in the form of a more specific conversation. It can also be written materials, pamphlets, handouts, educational material. Oftentimes, programs may have an educational binder or booklet that they give out to patients that might have a section on sexuality. Specific suggestions are more targeted and discipline-specific interventions based on actual presenting problems or issues endorsed by the patient, and we'll talk about that a little bit more in another slide. Intensive therapy is referring to a specialist who can provide a targeted, in-depth intervention to address a very specific patient need. So this could be a psychologist, a sex therapist, maybe a urologist, a gynecologist, pelvic floor specialist, whatever would appropriately address the patient's concern. So that model's been around for a while. Back in 2007, Taylor and Davis decided to do some research because they were finding that there was still a big gap and a big need in the general population of individuals recovering from brain injury and spinal cord injury, and that they were not getting this education. So they found that a lot of providers were following the PLCIT model in a linear manner where they would kind of move from permission to limited information to specific suggestions and then, if needed, to the intensive therapy. However, this led to people only really doing the permission-giving stage one time, and they found in some cases, providers were skipping that stage altogether and going straight to limited information where they might provide a booklet or a handout to a patient during an interaction but not actually discuss it. And while the provider felt like this was bringing up the topic appropriately, the patients would come away with the idea that this was something that was not to be discussed during the clinical setting but to be researched more outside of that time. So they restructured the PLCIT model. This is called the extended PLCIT model, with permission-giving as the core feature. So what they want us to do is really give permission frequently. So think about when you assess other changes in symptoms. Anytime you do a symptom review, sexuality and intimacy concerns should just be on that list. So as often as you're bringing up other symptoms, you should be bringing up this as well. They also restructured it so that the limited information, specific suggestions, and intensive therapy can really be implemented at any point during the patient's recovery process. It's not that you have to move in a linear fashion from one to the other. They also emphasize reflection and review, with reflection meaning eliciting information from the patient, challenging the patient to reflect on their own experiences with sexuality and intimacy, and asking them to give feedback and updates on how that aspect of their recovery is going. Review is the provider reinforcing education and recommendations at the end of an encounter and also bringing it up again at any subsequent encounters with the patient to check in and see how things are working. The goal of this newer model is to help increase patient self-awareness and knowledge and challenge any assumptions that might come up throughout the process. So going back to our specific suggestion stage, this just kind of breaks down discipline-specific approaches with medical providers focusing on the symptoms and the medication management and potential side effects on sexuality. Therapy providers can work on positioning options, targeted energy conservation and recovery strategies as needed. Mental health providers help with adjustment and enhancing communication strategies, which we'll talk a little more about. And the patient's partner should absolutely be involved early and often in all education. If there is a partner engaged during your time working with the patient, they should be included as much as possible. So in working with the mental health aspect, one of the main objectives is normalizing the adjustment-related symptoms. So of course, it can be stressful having sexual dysfunction, validating that for the patients and then talking to them about coping strategies to help manage all those changes. For couples developing communication strategies to enhance their effective communication around the sexual dysfunction, for couples who have been in a relationship together for a very long time, there's often a lot of nonverbal communication that takes place where patients know each other, know their partners well, and there's a lot of understood things. But with all the change that occurs following an injury, especially with the shifting dynamics within the relationship, it's really important to encourage more overt communication and teach them how to do that. Couples may also need help redefining sexuality and intimacy, also exploring some of those other expressions of intimacy that Dr. Loftin mentioned earlier, and just discussing tools and resources that are available to help in this area. As patients are getting back into a sexually active lifestyle, we should encourage them to avoid having rigid goals and expectations about what will and should and shouldn't happen, just encouraging them to think about it as an opportunity to try new things with their partner, again, challenging myths and misconceptions, and just encouraging them to take it slow. A lot of individuals benefit from utilizing masturbation as a method to explore what works for them prior to engaging with a partner, and that just helps them learn their own body and can help them direct their partner when they do reengage in sexual activity. We can incorporate education about risks and warning signs, if there is potential for symptom exacerbation during sexual activity, if the patient is on a bowel or bladder program, encouraging them to utilize that shortly before any sexual activity to reduce the risk of incontinent episodes occurring, which can further discourage them from additional attempts in the future, and also educating patients and their partners about any tools or techniques that might be appropriate to promote reflexive stimulation of genitals, which includes vibration, massage, or incorporating areas of sensory sensitivity. So obviously we want to have an individualized approach to each of our patients. We don't ever want to make assumptions about a patient's preferences or sexual activity or partner, so it's very important that we approach all patients openly, ask what they prefer to be addressed as, ask open questions to learn about their relationship status, their partner, getting a clear history of their premorbid sexual functioning as well, so that you can identify opportunities for individualized education. You may encounter a patient who has had a gender reassignment surgery. It's important to be aware that this can have impact on some self-care activities, such as capping, as well as some of those alternate stimulation options that would incorporate other sensory areas. Also consider your educational materials. If you are going to give printed information, such as a positioning guide, does it match the sexual experience that the patient is looking to have? So just keeping that in mind and making sure that you have options for any type of patient that might be in your office. If you're not sensitive to the patient's personal experience and they feel judged or like they don't fit into some sort of cookie cutter mold of what you expect them to be like, they're not going to be very open to discussing their sexual issues with you. And some ethical considerations. So we did have a question about how to address this with youth populations as opposed to adults. Some of our patients are minors. We might have teenagers. We may have young adults who are sexually active premorbidly and in the care of family. And it's very important to educate the parents or families, whoever the caregivers are, that this is a very normal area to be addressed. Some families might be resistant to it just depending on their family structure. But letting the patient know that this is something that may, again, just normalizing symptoms that can occur in the future and emphasizing with the family that we want to prepare them for getting back into an independent lifestyle. So I try to, how I address it, I like to try to tell families that this is something that could come up in the future. It doesn't mean that they have to do something actively right now. But we do want the opportunity to provide education so that when it does become an important aspect of their life again, that we have the knowledge base. They have the knowledge to navigate that appropriately. It is also important to educate families. If the patient has cognitive impairment, that might make them vulnerable to being exploited. If they were to go out and try to initiate sexual relationships with other people, that we provide resources and education about that as well. Sometimes we have patients who have abuse or trauma history and some of them, maybe their injury was the result of an abusive event. So if you have someone like this, bringing in your mental health professional on your team earlier than later when addressing topics of sexuality and intimacy is important because it could be a triggering conversation for them. Patients obviously have the right to refuse sexuality education based on their personal preferences or belief system. But again, that doesn't mean we should ask once and then stop. We should still continue to bring it up with our symptom review regularly throughout their care. As healthcare professionals, we must also be aware of our own attitudes and beliefs so we can stay as nonjudgmental as possible and respectful towards our patients and their needs. Okay. I have some case examples. If you guys have time to go back and review this on the recorded session, that would be great because we have one more poll and then I want to have time for a few questions. Okay. So following this presentation, we have one more poll here. Moving forward, how often do you plan to address intimacy and sexuality with your patients as they progress through the rehabilitation process? So there's several choices. And then just also as you're thinking about your answer to this, remembering what Dr. Contreras shared earlier about how only one in five patients really feel comfortable initiating this conversation with medical providers. So just keeping in mind that the mere act of mentioning it as a possible area of concern can normalize their experience and open the door for them to learn valuable information that could really greatly improve their quality of life overall. Okay. So that's that's great. You guys a lot. Most of you said once is what you're currently doing. It looks like a lot of you plan to increase that significantly in the future. So. All right. I'm going to move on so that we can answer a few more questions. So I tried to answer as many questions as possible as we went through the presentation. So if you look in the Q&A box, I think a lot of those have been answered and or I submitted in to Jennifer so that she could answer those during her presentation. She did a wonderful job. There is one leftover question right as of right now for Dr. Lofton and Dr. Lofton. That question is based on your personal experiences. Are there difficulties in obtaining coverage for sexual assistive devices, i.e. vacuum or E.D. pumps to be approved by insurance companies? Yes, typically it is not covered by insurance. However, if the patient has workman's compensation, oftentimes by writing a letter to the case manager or outlining in your notes the necessity of the device for sexual health, it often can be approved as long as you can document that the injury or the sexual dysfunction occurred as a result of the spinal cord injury which was a work-related injury. I have found, however, that the vacuum pump device certainly can be purchased online or out of pocket. You can buy a cheaper or less expensive form of the manual pump online on Amazon.com. However, I often recommend that patients at least get measured for ring size by urology prior to purchasing a vacuum pump over-the-counter. Additionally, the Pleasure Able sexual device manual that I showed a picture of in one of the slides often lists other devices and positioning tools that can be purchased out of pocket as well. Okay. I believe those are all the questions that I have. We can give a couple more minutes or seconds to see if anybody comes up with any others. Or if there's more explanation that you would like to a previous question, feel free to – oh, can you recommend resources specifically for stroke? And Dr. Contreras, I'll hand this one over to you since I know you did the stroke section. Yeah. There's a lot of information, the literature out there. If you go to AHA, the stroke guidelines, they do mention a couple blurbs there. But really, I would recommend speaking with your psychotherapist or neuropsychologist that are on the boards with you about having this conversation with your patients. And they also are a valuable resource for all of us, really, with more information that sometimes we as physicians don't have. And so I know that going along with our information, I was telling Jennifer how this is something I never thought about asking or even looking into before. And with conversations with her, it led me to think, you know, long-term-wise, it's something that I at least want to ask. And so stroke guidelines, you can mention them as well. And definitely using your personnel, so definitely talking to your psychotherapist or neuropsychologist for more information, too. There's also, and I just had to Google to make sure, an article that I read. It's called Sexuality After Stroke, Patient Counseling Preferences. And that is, it was published in 2013 by Joel Stein, Hillinger, Clancy, and Bishop. So I'll post that in the line under the question, too, to give you a reference. But that's also a good reference point just to kind of look at the counseling portion with stroke patients as well. Okay. All right. Well, thank you, everyone, for your time. We really appreciate it. And sorry for the intermittent technical difficulties, but those are the issues with the virtual assembly, right? But we appreciate your patience.

sexual education

dysfunction

rehabilitation units

brain injury

stroke

spinal cord injury

multidisciplinary approach

assistive devices

ethical considerations