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350 British Journal of Occupational Therapy August 2006 69(8)
Introduction
The profession of occupational therapy has, for the last
20 years, been working towards the construction of an
occupation-based scientific paradigm to inform clinical
practice, research and education (Whiteford et al 2000,
Molineux 2004). An emphasis on occupation as the core
concept of occupational therapy and a commitment to
holism are among the main features of this emerging
paradigm (Molineux 2004). People are considered as
occupational beings with an inherently spiritual nature
rather than as mere disease entities and their views and
feelings need to be respected and addressed (Egan and
DeLaat 1997, Urbanowski 2003, Kielhofner 2004).
The conceptualisations of holism and its place in
occupational therapy vary (Finlay 2001). This polyphony
regarding the meaning and the importance of holism
might account for its inadequate application in clinical
practice. Abberley (1995) offered an analysis of holism
as a guilt aversion construct, which serves to remove the
culpability for a potential failure from therapists and
attributes it to the complex nature of the situation.
What ought to be a professional responsibility, holism,
becomes thus an excuse for unsuccessful interventions.
Finlay (2001) and McColl (1994) have both pointed
to a gap between the holism mandate and actual practice
in occupational therapy. Molineux (2004) argued that
occupational therapists might not appreciate or fully
understand the concept of occupation and that this
might be one of the reasons for the dissonance observed
between theory and practice.
Despite research indicating its importance (White et al
1992, Northcott and Chard 2000), sexuality is often
ignored in occupational therapy. Uncertainty as to both its
connection with occupation and its importance in the life
of the individual might be one of the reasons for this.
Moreover, the perceived misfit between sexuality and
spirituality (for a detailed discussion, see MacKnee 1997
and Helminiak 1998), which is a basic concept in holistic
care, might impede the inclusion of sexuality on the
agenda of the profession.
The purpose of this paper is to illuminate the
occupational and spiritual nature of sexuality and to
present it as a legitimate area of concern for occupational
therapists. First, an exploration of the concept of sexuality
and its connection with occupation, spirituality and
meaning is presented and, then, the link between sexuality
and occupational therapy is explored. This paper aims to
stimulate discussion on the topic and does not claim to
provide an exhaustive account of sexuality and its
relevance to occupational therapy theory and practice.
Sexuality
Sexuality develops throughout one’s life and is an integral
part of everyday thoughts, feelings and behaviour
(Couldrick 1998a). It shapes gender identity, contributes
to self-esteem and social role formation and relates to a
whole spectrum of attitudes, behaviours and activities
(Weeks 2003). In turn, it is shaped and influenced by the
cultural context (Caplan 1987). Green (1974, cited in
Shively and De Cecco 1977, p41) defined it as the ‘individual’s
basic conviction of being male or female’, while Miller
(1984, p173), an occupational therapist who worked as a
sexual health clinician, defined it as ‘the gestalt of all
Holism is perceived to be one of the major tenets of occupational therapy. This
article discusses the relevance of sexuality to holistic health care and contributes
to the continuing discussion regarding the legitimacy of sexuality as an area of
concern for occupational therapists. Sexuality is an important part of the human
experience and is linked closely with spirituality. However, it is often neglected
by occupational therapists.
The article explores the occupational nature of sexuality and demonstrates
its connection with the core concept of occupation. Moreover, considering the
importance of spirituality in holistic care, the article also presents an overview
of the relationship between sexuality and spirituality and illustrates sexuality
as a dynamic identity component. It is proposed that occupational therapists
should recognise sexuality and its importance in the individual’s life and
incorporate it into therapy.
Sexuality and Occupational Therapy:
Exploring the Link
Dikaios Sakellariou and Salvador Simó Algado
351
British Journal of Occupational Therapy August 2006 69(8)
dimensions of sex functioning; related to private experiences
and public expressions which indicate to oneself and others
that one is a man or a woman’.
Power is a central concept in Foucault’s (1978/1990)
analysis of sexuality. According to Weeks (2003), power
can operate through several axes, with those of gender,
class and race being the most influential. The axis of
health should be added to these. Several studies have
demonstrated that disabled people are often perceived as
asexual (Tepper 1999, Guldin 2000, Milligan and Neufeldt
2001). Moreover, while the sexuality of disabled
heterosexual men has received some attention from
researchers, Shakespeare et al (1996) have observed a
telling silence regarding the sexuality of women and
homosexual men (recently there has been some research
on female sexuality and disability; see, for example,
Lysberg and Severinsson 2003, Singh and Sharma 2005, and
Li and Yau 2006). For the purposes of this article, sexuality
is conceptualised as a dynamic identity component that
gives meaning to and is expressed through engagement in
sexual activities (for example, petting, sexual intercourse
or masturbation), sexual relationships and culturally
prescribed roles (for example, spouse).
A loud silence
Here I (first author) want to recount an incident that
happened less than 10 years ago while I was an
undergraduate student in Greece. My first placement was
in a large facility that comprised a special school and
prevocational and vocational training centres for young
people with learning disabilities. Sexuality was not viewed
as a valid identity component of these young people and
they were closely monitored for ‘inappropriate’ behaviour
(for example, kissing or hugging, anything beyond
holding hands). The therapists did not acknowledge the
importance of sexuality in the occupational life of the
clients and, upon asking, I was told that ‘these people
should not be encouraged to engage in sexual activity’.
Therefore, safe sex and contraception were not dealt with
in this setting. It was believed that discouraging clients
from engaging in sexual activities would effectively
suppress their sexuality, which was a taboo issue. The
therapists and educators working in this setting chose to
ignore sexuality because of a fear of legitimising it. This
silence regarding sexuality was likely to have had major
implications for the lives of these young people.
It is to be hoped that nowadays this example might
ring unfamiliar to many occupational therapists
(although not all, and this greatly depends on the cultural
context and the setting in which clinical practice takes
place). Therapy, however, takes place within a certain
sociocultural context (Wilcock 1998, Milligan and
Neufeldt 2001) and, therefore, occupational therapists
often carry socially shared beliefs and behaviours as well
as prejudices into their practice. This means that, along
with the wider society, occupational therapists may not
view their clients as sexual beings and, therefore, the topic
of sexuality can be either neglected or not fully addressed
in therapy (Li and Yau 2006). Research, however, has
shown that sexuality is an important area of concern for
disabled people (White et al 1992, Kreuter et al 1994, Li
and Yau 2006).
Through a review of the literature dealing with
sexuality and its relevance to occupational therapy, it
became apparent that the majority of the occupational
therapists believed sexuality to be a legitimate and
important area of concern for the profession and
considered service users as sexual beings (Miller 1984,
Couldrick 1998b, 1999). Most of the occupational
therapists, however, did not deal with sexuality in their
clinical practice, with lack of education being the main
reason given, perhaps highlighting the inadequacy of
educational curricula (Couldrick 1998b). Many of them
shared concerns regarding the sensitivity of the issue
and agreed that occupational therapists should deal with
it in a delicate way (Summerville and McKenna 1998,
Couldrick 1999).
The occupational therapists who reported engagement
with sexuality issues were dealing mainly with issues
pertaining to physical performance (for example,
positioning or energy conservation) (Yallop and Fitzgerald
1997). It is interesting that occupational therapists
reported significant disparity between the attention given
and the attention that they wished to give to issues of
sexuality during intervention (Engquist et al 1997).
The occupational nature of sexuality
Sexuality is one of the main concerns of disabled people,
as many studies have revealed (Alexander et al 1993,
Kreuter et al 1994, Phelps et al 2001). Several authors
have suggested that therapists should learn about
sexuality and what it means to their clients and must
acknowledge sexuality as a valid area of concern (Novak
and Mitchell 1988, Summerville and McKenna 1998,
Couldrick 1999). The American Occupational Therapy
Association (2002) has classified sexual activity as falling
under the domain of activities of daily living and thus
belonging to an area of concern for occupational
therapists. Although this might signify that the profession
has started to acknowledge the importance of sexuality,
reducing it to sexual activity might indicate that sexuality
only becomes an issue in occupational therapy when
sexual functioning is perceived as problematic.
It is now generally acknowledged that occupation lies
at the core of occupational therapy and is both the means
and the ends of intervention (Trombly 1995, Pierce 2003).
Occupations appear to possess several qualities that
distinguish them from non-occupational activities: they
have identifiable start and end points; they are repeatable,
intentional and consciously executed; they tend to be
meaningful within the context of a person’s life; and they
are culturally identified (Yerxa et al 1990, Larson et al
2003, Pierce 2003).
Sexuality is expressed through many activities that can
be classified as occupations according to the above
characteristics. Dating or having sex, for example, both
352 British Journal of Occupational Therapy August 2006 69(8)
have a start and an end point; they are repeatable,
intentional and consciously performed; they can have
meaning in a person’s life; and, finally, they are named and
labelled within a specific cultural group. Occupation does
not refer to a narrowly delineated area of human
experience. According to Wilcock (1998), occupation
refers to all doing that has extrinsic or intrinsic meaning
and thus sexuality has an inherently occupational
dimension, which can be expressed through a variety of
meaningful occupations such as dating, grooming or
having sex. A role of occupational therapists as enabling
occupation can be very broad and refers to all aspects of
people’s occupational lives.
Relevance of sexuality to occupational
therapy
A series of articles (Jackson 1995, Kingsley and Molineux
2000, Williamson 2000, Harrison 2001) has discussed
the relevance of the sexuality of gay, lesbian or bisexual
people to occupational therapy. Both Jackson (1995) and
Williamson (2000) have demonstrated that sexuality
can influence participation in occupation and give
meaning to it, an issue discussed later in this article.
Similarly, Jessop (1993) observed the significance of
many occupations (including activities of daily living
and work) in expressing sexuality and highlighted the
role of occupational therapy.
This view is not accepted unanimously within the
profession. Couldrick (2005) presented two opposing
opinions, one for and one against the inclusion of
sexuality as an area of concern for occupational therapy.
The argument against the inclusion of sexuality in the
occupational therapy agenda has been expressed by
Kielhofner (1993, p138), who asserted that ‘sexual activities
are rooted in the biologic requirements of the individual
and the species’ and cannot be called occupations.
Sexuality, however, is much more than a biological
requirement. It has been described as a cultural script and
as a cultural phenomenon (Laumann and Gagnon 1995).
According to Foucault (1978/1990), it is an historical
construct that influences the way that people behave and
interact within society, while Weeks (2003) asserted that
there are many ways to express sexuality and that the
activities through which such expression occurs may
occupy a very wide gamut.
By this, there is no wish to deny the biological
component of sexuality; rather, there is an intention to
show that many authors have suggested that sexuality is
much more than an instinct or a basic drive. What may
have begun as a basic biological need for reproduction has
evolved into a complex social phenomenon, which is an
integral part of the identity of the individual.
Sexuality and gender
Men and women are expected to act according to the
expectations of a normative society (Caplan 1987).
A failure to conform might lead to marginalisation. Who
can do what, when and how depends upon gender, and
sexuality can be thought of as a gendered fiction (Peplau
2003, Weeks 2003).
Male sexuality and masculinity are often conceived as
performative and instrumental and are perceived as being
embodied in physical assertiveness and productive work
(Connell 1995). Linschoten (1969/1987) described man
as homo faber, highlighting the importance of occupation
in male identity formation, and Beagan and Saunders
(2005) explored the production of masculinity through
engagement in occupation.
Women, on the other hand, are expected to be caring
and nurturing figures and it is thought that they value the
emotional and dialectical aspects of sexuality over the
physical (Weeks 2003). Moreover, occupations like child
rearing or household maintenance are thought of as
female and, in the past, women have been denied access
to occupations on the grounds of a gendered division of
roles (Wicks and Whiteford 2005).
These cultural stereotypes demonstrate that sexuality
and gender are expressed through participation in
occupations. Weeks (2003) argued that sexuality is not
fixed but is constructed through what people do in their
daily lives.
Spirituality, meaning-making
and sexuality
Spirituality remains an elusive concept in occupational
therapy and there exists considerable disagreement
regarding its exact nature and role in therapy (Udell and
Chandler 2000, Hammell 2001, Wilding 2002). According
to Howard and Howard (1997) and Egan and DeLaat
(1997), spirituality may be expressed through
participation in occupation and permeates every aspect of
one’s life. In this paper, Urbanowski and Vargo’s (1994)
conceptualisation of the term is used and is perceived as
the experience of meaning in life.
Unruh et al (2002) demonstrated that spirituality was
a multifaceted concept and suggested that it should
concern occupational therapists to the extent that it has
an impact upon the occupational identity of the client.
Occupational identity is conceptualised as ‘a composite of
one’s occupations over time’ (Unruh 2004, p292) and can
provide a sense of coherence and meaning in the life of
the individual (Christiansen 1999).
An important concept closely related to spirituality and
occupational identity is resilience. Resilience helps people
to find meaning in traumatic experiences and to view
them as a chance to become better and advance towards
maturity. Urbanowski (2003, p102) defined spiritual
resilience as ‘the successful completion and entrenchment
of meaningful occupations that one engaged in prior to a
life changing event occurring, or to engage in new
occupations to create a post-event trajectory’. In order to
achieve that, people either try to reconnect with their
occupational identity as it was experienced before or seek
353
British Journal of Occupational Therapy August 2006 69(8)
therapy. Providing sexual counselling, for example, is
beyond the professional role of occupational therapists
and thus inappropriate and perhaps unethical.
Learning from the client
Based on the principles of holistic health care, as outlined
by McColl (1994), this section explores the ramifications
of holism for addressing sexuality in practice. The first
principle states that the individual is the expert on his or
her condition. He or she is the one who experiences
disruption in an occupational area and not only knows
how it feels but is also aware of what needs to be done to
restore balance (McColl 1994). This first principle is
closely related to the second, which states that
‘occupational function or dysfunction is an experienced
phenomenon, rather than an objectively observable one’
(McColl 1994, p75).
These principles imply that therapists should seek to
learn from the individual if and how his or her sexuality
has been changed by an occupational life disruption.
Therapists should seek information as to how sexuality is
interwoven into the occupational trajectory of the
individual and the role that sexuality plays within this. It
is important that occupational therapists approach the
topic in a considerate and non-threatening way.
As Summerville and McKenna (1998) have suggested,
there are many ways to introduce the subject and gain
permission to talk about the issue. For example, the
therapist could mention sexuality while outlining the role
of occupational therapy. It should never be assumed that a
person is too old, too disabled or too overwhelmed with
health concerns to be sexual. Alternatively, the therapist
could ask the client during assessment whether he or she
has any concerns regarding his or her sexuality. This
should be done not only in the initial interview when
other issues might be more urgent, but also in follow-up
assessments. To facilitate the communication and sharing
of information, therapists must convey a feeling of
trustworthiness and a non-judgemental attitude
(Couldrick 1999, Harrison 2001), and if a client does
not feel ready or willing to share his or her concerns
then this should be respected.
It is suggested that occupational therapists
acknowledge the issue of sexuality early in the
rehabilitation phase and seek to obtain information
regarding the client’s values, beliefs and concerns because
this can facilitate the design of meaningful therapeutic
interactions (see, for example, Jackson 1998). Sexuality
needs to be a concern for occupational therapists not only
as a pathological entity but also as an identity component.
Thus even when sexuality-related problems are not
present, occupational therapists should examine the role
that sexuality has in the occupational life of their clients
and try to include it in therapy. This could be done simply
by acknowledging sexuality and its importance in the life
of the client. When engagement in sexuality-related
occupations is compromised, therapists can apply
problem-solving techniques to the specific issues that
to create a new, personally meaningful occupational
identity. Sexuality plays an important part in this process.
Jackson (1995) and Williamson (2000) have demonstrated
that sexuality can provide meaning to occupations and
contribute to identity formation.
For Merleau-Ponty (1962/2002), sexuality has a
metaphysical significance and it cannot be understood if
people are treated in a reductionist way. It cannot be
separated from the individual since it is an essential
quality of human nature; it is ever-present and both
permeates existence and is permeated by it (Merleau-Ponty
1962/2002). Thibeault (2003) and MacKnee (1997)
asserted that sexuality can transcend the existential and is
one of the paths leading to maturity and resiliency.
According to MacKnee (1997), sexuality and spirituality
are related aspects of the individual which cannot be
separated one from the other and they are both
characterised by a desire to fill an inner existential
vacuum and to advance in self-knowledge. Eastern
traditions speak of a sexual ideal ‘of self-discovery and
selflessness’, with the ultimate purpose being to ‘attain
self-knowledge and cultivate genuine union, a real
expansion beyond the persona’ (Thibeault 2003, p89).
Tantric and Taoist traditions, for example, view sexuality
and spirituality as interconnected and integral
components of the individual (Francoeur 1992).
Sometimes, however, sexuality is perceived as
tantamount to suppressing ideals of beauty and physical
performance. It can be reduced to ‘an autistic satisfaction
of genital lust’ (Linschoten 1969/1987, p176), and
‘servility’ along with ‘satiation’ are sometimes seen as the
raisons d’être of sexuality (Lazos 1997, Thibeault 2003,
p89). Sexuality can thus be rendered a mere physical
process, disconnected from the occupational identity of
the individual. Although possibly valid for some people,
this operative conceptualisation of sexuality can be
oppressive and meaningless for many others.
Sexuality is more than a carnal affair. It is an
indispensable part of a happy, meaningful and balanced
life and an integral component of the individual (Chicano
1989, Couldrick 1998a, Northcott and Chard 2000).
Sexuality has the potential to instil meaning in a variety of
occupations that people perform (Jackson 1995, Weeks
2003) and may help people to reconnect with their
occupational trajectory. It can be conceptualised as one of
the ‘rituals of daily life’ (do Rozario 1994, p50), which
infuse meaning in people’s lives.
Implications for occupational
therapy
Occupational therapists are not experts in sexuality. They
are experts in occupation and they must be very clear
about this. Therefore, occupational therapists need to be
very careful that they address sexuality in therapy in a way
that falls within the professional boundaries of occupational
354 British Journal of Occupational Therapy August 2006 69(8)
concern each particular client, as long as these issues fall
within the remit of occupational therapy (for example,
positioning, social outings or personal hygiene).
The person and the environment
The third principle of holistic health care states that the
‘understanding of occupational dysfunction must be acquired
through a synthesis of the person in his or her environment
and not through an analysis of the subsystems comprising
the individual’ (McColl 1994, p75). This combines well
with Yerxa’s (1998) view of people as complex open
systems who interact with their environments.
This is also congruent with the conceptualisation of
disability as an integrated biopsychosocial phenomenon,
as proposed by disability theorists (Shakespeare and
Watson 2002) and upheld by the International
Classification of Functioning, Disability and Health
(ICF, World Health Organisation 2001). According to
the ICF, impaired body structures and functions (as,
for example, paralysis caused by spinal cord injury)
do not necessarily compromise participation in daily life.
Having quadriplegia or paraplegia does not necessarily
lead to sexuality-related problems. When sexuality-related
problems are present, the cause is not always the paralysis
but could be attributed to contextual factors, such as
negative societal attitudes (Shakespeare et al 1996,
Sakellariou 2006, Sakellariou and Sawada 2006, Sakellariou
and Simó Algado 2006).
It is vital that therapists acknowledge this, because
otherwise they might not be able to provide effective
services. For example, an occupational therapist acting
under the assumption that the sexuality issues of a person
with a spinal cord injury revolve around difficulty with
positioning may fail to acknowledge that the client’s
problems could result from his or her altered social status
or that he or she may not be able to find a partner.
Therefore, occupational therapists should not make
assumptions, but should listen to their clients.
Focusing on positive outcomes
The fourth principle of holistic health care suggests that
illness should be viewed as a learning opportunity
(McColl 1994). Occupational therapists have been
described as ‘search engines for potential’ (Yerxa 1998,
p413) and they focus on the positive outcomes, and not
on the negative consequences, of a disruption in the
occupational life of an individual. Therapists should help
service users to develop a resilient and meaningful
occupational life (Urbanowski 2003).
Several studies have suggested that disability may
influence a person’s sexuality positively and can lead to a
more meaningful sexual life (Shakespeare et al 1996, Cole
2004, Sakellariou and Sawada 2006). Some of the
respondents in these studies indicated that after their
injury they felt free to experiment with their sexuality and
to reinvent it in a personally satisfying way. By focusing on
the potential for a positive change, occupational therapists
could help clients to perceive sexuality in its totality and
not merely as a physical function. This could lead to the
transition from a performative notion of sexuality, dependent
upon the physical body, to an integrated one, connected to
the whole self of the individual.
Conclusion
In recent years, there has been a renewed interest by
occupational therapists in holism and client-centred
and occupation-based practice. Eager to provide best
practice, professionals have tried to reestablish occupation
as the basic therapeutic means of occupational therapy.
Also, a discourse has been initiated and several papers
have sought to illuminate the concept of holism and its
importance to the profession (McColl 1994, Finlay 2001).
Peloquin (2002, p517) urged occupational therapists to
reach ‘for heart as well as hands’. Mattingly and Fleming
(1994), in their clinical reasoning study, found that
occupational therapists viewed clients in a holistic way
and valued both the ‘lived body’ and the ‘body as a
machine’ (pp37, 64). Holism, however, has been found
to mean different things to different people (Finlay 2001).
It is an ambiguous term and this may account in part for
the discrepancy between theory and practice, as suggested
by McColl (1994). Therefore, intentions for holistic
practice do not always lead to holistic practice.
If occupational therapists wish to provide holistic
treatment then they cannot exclude integral identity
components, such as sexuality, from therapy. As practitioners,
therapists need to empower clients to reconnect with their
chosen occupational life trajectory, as argued by Urbanowski
(2003). Failing to view sexuality as an integral part of the
individual may compromise therapy and lead to suboptimal
therapeutic encounters and outcomes. Occupational
therapists may thus find themselves in the unfortunate
position of reinforcing disabling cultural scripts and
societal metaphors. This would be a paradox for a
profession that claims to be holistic and client centred.
Acknowledgements
The authors would like to thank Mrs Sarah Kantartzis, MSc, DipCOT, for
the insightful comments she provided on an earlier draft of this paper.
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Authors
Dikaios Sakellariou, MSc, BSc(OT), Occupational Therapist,Athinas 6,
Petroupoli 132-31,Athens, Greece. Email: dikaiossakellariou@yahoo.gr
Salvador Simó Algado, BSc(OT), Lecturer, University of Vic, Departament de
Terapia Ocupacional, Sagrada Familia 7, 08500 Vic (Barcelona), Spain.
