Critically Appraised Topic (CAT)

Evidence Based Practice Question:

Do occupational therapy practitioners (P) routinely address sexual activity with patients (I) as
part of comprehensively acknowledging a clients occupational needs (O)?
Clinical Scenario:
Occupational therapy is a holistic field that is focused on client-centered care, enabling
individuals to engage in the activities that they want to, need to, or are expected to participate in.
Sexuality is essential to inner peace and personal fulfillment for many individuals. Sexuality was
broadly defined by the researchers for purposes of this study, as an aspect of the human
experience which can include intimacy, relationships, gender roles and identity, sexual
orientation, reproduction, sexual activity and pleasure.
Occupational therapists working in adult settings should feel comfortable and competent in
addressing sexuality with clients. The literature review concluded that occupational therapists
face barriers that should potentially be addressed at a university level to break these barriers.
Search Methodology & Terms:
PICO Question Categories

Search Terms Used

Population:
Occupational therapy practitioners

Include applicable search terms for each

category.
Occupational therapist,
occupational therapy assistant,
occupational therapy practitioners

Intervention:
Routinely addressing sexuality with clients

Address
Sexuality
Evaluation
Assessment
Protocol

Comparison: N/A

N/A

Outcomes:
Sexuality
To comprehensively acknowledge a clients Quality of life
occupational needs
Assessment
Evaluation
ADL
Occupation
Sexual health

Databases and Sites

Searched
CINAHL
Cochrane Database of
Systematic Reviews
MEDLINE
OT Search

Search Terms

Limits Used

Occupational therapy and

sexuality

Peer review only

Occupational therapy and

intimacy

1990- Present

Full text only

Occupational therapy and

evaluation
Sexuality and health care
Sexuality and ADL

Inclusion Criteria for Articles:

Adult populations (ages 18+)
All clinical disciplines that address sexuality
A variety of medical settings and geographical locations
Perspectives from both clients and healthcare professionals
Clients quality of life, health, and wellbeing.
Exclusion Criteria for Articles:
School based therapy
Specific interventions
University curriculum
Review Process:
Level of Evidence

Study Design

High quality RCTs or Systematic Reviews

(SR) of these studies, Meta-analysis

II

Small-scale RCTs, non-randomized

studies with a control group such as
cohort studies, case-control,
pretest-posttest designs or SRs of these
studies

III

Non-randomized studies without a control

group such as pretest-posttest designs,
time series or longitudinal studies,
cross-sectional studies

Number of Articles
Included

IV

Descriptive studies including single

subject designs, case studies, normative
studies, and survey studies

Expert opinion, literature reviews,

laboratory research (research not
performed on human subjects)

Qualitative
Studies

Examples include: phenomenology,

ethnography, grounded theory

TOTAL ARTICLES REVIEWED: 5

The following study/paper was identified as the best evidence and selected for critical
appraisal. Reasons for selecting this study were:
Occupational therapists perspectives on addressing sexual concerns of older adults in
the context of rehabilitation
This article discussed the barriers that occupational therapy practitioners face when
addressing sexuality. The research on their perspectives lead to a greater interest on
whether or not sexuality is being addressed at all by practitioners or if the barriers that
occupational therapists face is preventing holistic care.

SUMMARY OF BEST EVIDENCE

Description and appraisal of Occupational therapists perspectives on addressing sexual
concerns of older adults in the context of rehabilitation by (McGrath, Lynch, 2014)
Aim/Objective of the Study/Systematic Review:
The purpose of the study was to determine occupational therapists views about
addressing sexuality with older adults.
Study Design
A phenomenology study design was used to investigate occupational therapists
perspectives on sexuality of older adults. This was an appropriate design because the
participants were able to self-report experiences and perspectives through multiple focus

groups. The focus groups took place in a comfortable environment that would allow
participants to feel relaxed and able to participate in the discussion.
The main method of data collection and analysis were through focus groups with
occupational therapists. The researchers then discussed how the findings emerged from
the data. The discussions of the focus group were recorded and transcribed word for
word. Once the authors gathered the necessary information they separately coded the data
into categories. The authors then compared their findings to solidify that the categories
were supported by the data.
Setting
Participants from the focus groups were recruited were working in rehabilitation, primary
care, and acute care settings. Data collection occurred at a time and place that was
convenient for participants. Focus groups were held in locations such as hospitals and
health centers where participants would feel comfortable and where privacy was ensured.
Participants
A comprehensive record of occupational therapists working in older adult populations
was compiled. This record was derived from the phone directory, professional bodies,
and senior managers in the health and rehabilitation field. From this record, 22
occupational therapists were selected were purposefully selected from this list using the
principle of maximum variation. The participants that were recruited were working in
rehabilitation, primary care, and acute care settings (18 females and 4 males).
Informed consent was obtained from each participant prior to each purpose group. The
study followed standard ethical research principles stated in the Declaration of Helsinki.
Intervention Investigated
Control (N/A)
No intervention was given to the participants.

Experimental (N/A)
No intervention was given to the participants.

Outcome Measures

The researchers independently participated in open coding, creation of categories, and

abstraction of meaning during data analysis. The two researchers then engaged in
discussion to ensure the data supported the codes and categories. The researchers returned
to the data when disagreement occurred, and was resolved by consensus.

Main Findings
The findings suggested that sexuality was rarely discussed with older adults in an
occupational therapy setting. They found major themes: socio-cultural expectations
relating to sexuality, perceived competence and to address sexuality and the impact of
resources regarding the inclusion or exclusion of sexuality from rehabilitation (McGrath
& Lynch, 2014).
They found that many people felt the topic was private and should not be
discussed.
Many participants stated they did not feel competent enough in the subject to
discuss it when patients asked.
Lastly, the participants felt they didnt have the resources in their setting to
address the topic

Original Authors Conclusions

The study concluded that although there are stereotypes in Irish culture that cause older
individuals to be perceived as not having sexual needs, these views are slowly starting to
change. Since these views are changing, the article suggested that there is a need for a
framework for healthcare professionals to follow when faced with addressing these
sexuality needs. Since there is no specific way to address sexuality in practice
occupational therapists are required to break through a barrier on their own with nothing
to refer to for help.
Some of the main limitations of the study were that there is no national database for
occupational therapists the researchers had to create their own. The study also was
lacking in addressing all of the potential barriers when addressing an individual's
sexuality.
Critical Appraisal
Interpretation of Results

From these findings, it was determined that Occupational Therapists are not addressing
sexuality. The authors concluded 3 themes that contribute to their findings. The first
theme they found was that many people felt the topic was private and should not be
discussed. Many participants stated they did not feel competent enough in the subject to
discuss it when patients. Lastly, the participants felt they didnt have the resources in their
setting to address the topic.
The authors findings are consistent with the literature review that has been conducted.
The topic of sexuality, in many cases, is viewed as a private matter and should not be
addressed clinically. The participants lack of competence in the subject is consistent with
the previous literature as well. Clinicians do not feel as though they have the ability to
address sexuality with their clients nor do they have the resources to find out more
information on how to address sexuality with their clients.
Summary/Conclusion
This study used focus groups to interview occupational therapists to determine if
sexuality was being discussed. They determined that sexuality was rarely discussed in
everyday practice. The researchers found that the majority of occupational therapists
discussed 3 common recurring barriers that contribute to why practitioners are not
addressing sexuality. These findings correlate with the current literature that was
previously reviewed prior to analyzing this article. The literature states that occupational
therapists are not addressing sexuality in their practice settings due to a variety of
barriers. This article highlighted several of the barriers that may be hindering
occupational therapists ability to provide holistic treatment to their clients.

The following study/paper was identified as the best evidence and selected for critical
appraisal. Reasons for selecting this study were:
Older residents perspectives on aged sexuality in institutionalized elderly care: A
systematic review
This systematic review encompasses many studies specifically related to our research
question. The conclusions of this paper support the redundancy of the researchers
findings regarding relevant current literature.

SUMMARY OF BEST EVIDENCE

Description and appraisal of Older residents perspectives on aged sexuality in institutionalized

elderly care: A systematic literature review by Mahieu, L. & Gastmans, C. (2015).
Aim/Objective of the Study/Systematic Review:
The aim of this systematic review was to investigate how institutionalized older people
perceive, experience and engage in sexual behavior and aged sexuality within
institutionalized long-term care settings for older people.
Study Design
Systematic review
Search strategyCinahl, Medline, Pubmed, Embase, Web of Science and Invert were the databases used to
search the literature. The search strings used were the same in each database and are as
follows: ((sexuality OR intimacy) AND (older people OR older age OR residents)) AND
(long-term care OR nursing home); and ((sexuality OR intimacy) AND (older people OR
older age OR residents)) AND (long-term care OR nursing home) AND (attitudes OR
knowledge OR experience) (Mahieu & Gastmans, 2015). If no results were found using
these search terms, additional searches were conducted in order to broaden the results.
Selection criteriaInclusion criteria:
Types of studies
Qualitative, quantitative and mixed methods studies, articles published as
journals, published between January 1980 and October 2014 and in
English, Dutch, French and German language were all included.
Exclusion criteria:
Types of studies and study designs
Dissertations, books, book chapters, conference papers, theoretical articles,
overview articles, reviews and editorials, published dates outside of
inclusion timespan, language outside of inclusion and case reports, case
studies and retrospective studies focusing on care records were excluded.
Medical and pharmacological research focusing solely on sexual
(dys)function did not qualify for inclusion. The same is true for studies
that deal with the wider context of social interactions and social support
without substantially touching upon the topic of intimacy or sexuality and
studies that solely seek to describe expressions of inappropriate sexual
behavior or hypersexuality by older residents with dementia. Case reports,
case studies, and retrospective studies that lacked the lived experience
component were also excluded.
Methods -

The reviewers in this study attempted to identify all relevant studies. This review
included multiple methodologies that enhanced the depth to this study. Some of the
studies included were qualitative, quantitative, and mixed approach methods. Examples
of these were: interviews, observational, ethnographic, focus group, vignette, and other
survey studies. The reviewers only included studies that were relevant to their focus. The
studies the reviewers used in this process stayed focused on the perspective of residents in
institutions.

Setting
The settings of studies within the systematic review include, assisted living facility,
residential or retirement facility or nursing home. Geographical locations include the
United States, Israel, Poland, Netherlands, Canada, Germany, Spain, Taiwan, United
Kingdom and Australia.
Participants
Inclusion population: Older men and women within institutionalized long-term care
settings (assisted living facility, residential or retirement facility or nursing home). The
authors did not define an age for an older adult. No diagnoses were excluded from the
review.
Exclusion population:
Studies including older men and women in hospice, acute care, and community dwelling
settings were excluded. Studies that included residents living in both residential long-term
care and community dwelling settings were only included only if there were separate
results for each group.
Intervention Investigated
Control
N/A
Experimental
N/A
Outcome Measures

The most relevant subjective outcomes of interest in this systematic review that are
related to our study question include
Exploring staffs and residents experiences of barriers to sexual expression in
residential aged care facilities
Investigating and comparing the reactions of staff and residential care facility
residents toward opposite-sex sexual activity in private spaces within the facility
Developing a comprehensive sexuality training curriculum for long-term care
staff addressing the topic of aged sexuality
Exploring the characteristics and the contexts related to sexual behavior among
older long-term care residents with dementia
Exploring how sexuality and sexual expression permeate the lives of assisted
living residents (the staff working with them and residents family members)
Analyzing psychosexual needs of nursing home residents and investigate whether
and how these needs are satisfied
Determining the knowledge and attitudes of well older people living in a
retirement home toward aged sexuality, to explore the influence of demographic
variables on sexual knowledge and attitude scores
Describing the relative importance of social, intellectual, emotional and physical
intimacy for older men living in a nursing home, to delineate the contribution of
these four components of intimacy to quality of life (Mahieu & Gastmans, 2014)
(See results section for conclusions about the above outcome measures)
Other subjective outcome measures, all looking at the institutionalized older adult
population, that were also addressed in this study but are not specifically relevant to our
research question are summarized below.
psychosocial challenges for homosexual individuals
determining the clients knowledge of sexuality
sexual interest and behavior
non-heterosexual sexual orientation opinions
opinions regarding sexual expression
impact of institutionalization on sexual experiences
experiences related to sexual and loving relationships
descriptions of sexual interest, activity, and satisfaction
the relationship between different variables and sexual activity (Mahieu &
Gastmans, 2014)
Main Findings
The areas of main findings identified by Mahieu and Gastmans that are most related to
the research question include sections of the systematic review titled as follows: Sexual
expression in institutionalized care settings; Sexual interests, behaviors, and
satisfaction; Attitudes toward sexual expression in institutionalized care settings;

Appropriate versus inappropriate sexual behavior; Heteronormativity and

homophobia; and Lets talk about sex.
Sexual expression in institutionalized care settings
Residents interest in sex depends on the individual. A majority of the studies
reviewed determined that sex is somewhat important when it is compared to other
everyday needs. The studies also found that sexuality in older individuals does not
necessarily need to include sex itself. The emotional component of sexuality was ranked
of higher importance than sex itself.
Sexual interests, behaviors and satisfaction
The review identified the following as sexual behaviors of older adults in
institutions; daydreaming, reminiscing, reading romantic or erotic books, dressing up,
making witty flirtatious remarks, giving compliments, proximity, hand holding, hugging,
touching, stroking or caressing, kissing, fascination, intercourse, oral sex and
masturbation. It was found that older populations still engage in these activities, more
often with a partner than solitary. Sexual history has an influence on current sexual
activity. Many studies showed a strong, positive correlation between their sexual history
and current sexual activity. For example, someone who was sexually conservative in their
youth, was likely to hold that attitude throughout life.
Attitudes toward sexual expression in institutionalized care settings
The idea of sex for a majority of the residents in the institutionalized care was
generally more positive than their attitudes about actual sexual behaviors in their current
age. Many residents believed the act of sexual behavior among other residents is viewed
as shameful. The article highlighted the fact that even though the residents
acknowledged sexual activity may occur among their peers, these residents still agreed
with the stereotypes that sex should be for young people.
Appropriate versus inappropriate sexual behavior
Appropriateness of sexual behavior by co-residents was determined by the
following: level of privacy, consent of roommate before engaging in own sexual
behavior, how committed the resident was to their partner, level of marital status of
co-resident, type of behavior, and disruptance from behavior. Compared to the staff, the
residents were also more likely to view sexual behavior within the facility as
inappropriate. Many of these attitude and beliefs stemmed from religious views.
Heteronormativity and homophobia
It was concluded from the literature that attitudes of the institutionalized elderly
towards non-heterosexual sexual orientations include a wide range of opinions. These
opinions range from disgust and extreme rejection to acceptance. Most residents did not
know if there were any lesbian or gay older adults living in their facility. One of the
articles studied found that older residents rarely express sexual orientation as a part of
their identity. Some lesbian and gay older adults may be fearful of being neglected or
abused by other residents or healthcare staff if they express their sexual orientation.
Lets talk about sex
While some older adults prefer to keep sexuality private, others wish to discuss
this with staff. One of the articles studied specifically supports this, and found that the

majority of their participants expect healthcare professionals to be open, knowledgeable,

and prepared to discuss sexuality with their patients.
Original Authors Conclusions
The authors concluded that the general assumption that adults become asexual with aging
is a myth. Contrary to common perception, institutionalized older individuals still think
about sex. Institutionalized older individuals had ranked sex as to be moderately
important in comparison to sleep and appetite which are inarguably considered to be
basic functions of everyday life. The second trend studied in this review, the idea that
sexuality expressed through sexual intercouse is a need or necessity for healthy ageing, is
also concluded to be a myth. The authors state that the truth about sexuality in older
adults is somewhere in the middle.
It is important for the sexuality of older adults to be neither over nor underestimated by
caregivers because stereotypes like these leave little room for these individuals to express
their own position on sexuality in later life. Older residents experience a lack of
understanding and respect from their care providers when these extreme stereotypes are
outwardly expressed.
The author suggests that to obtain holistic and client-centered care, aged sexuality must
be addressed with clients within institutions. When addressing sexuality, health care
professionals should investigate the clients individual needs and wants, rather than
making generalized assumptions of aged sexuality.
Critical Appraisal
Interpretation of Results
The results of this systematic review are favorable to the researchers literature findings
in supporting the redundancy of research on this subject. The effects of stereotypes of
healthcare professionals about sexuality in older adults is clinically significant in terms of
client-centered practice. This systematic review statistically displays the truth that
sexuality, a major part of the human experience, is being largely neglected by caregivers
of the institutionalized elderly population.
Summary/Conclusion
This systematic review looked at 11 quantitative studies and 14 qualitative studies with a
focus on sexuality in an all encompassing sense. These studies underwent specific
inclusion criteria with a focus on the older adult population residing in long-term care
facilities, nursing homes, assisted living facilities, and other institutional settings. The
evidence and conclusions of this systematic review analyzed many studies specifically
related to our research question. Mahieu and Gastmans study and conclusions support

the redundancy of the researchers findings regarding current and relevant literature
related to health care professionals, specifically occupational therapy practitioners,
addressing sexuality.

BOTTOM LINE & RECOMMENDATIONS:

Future research endeavors with a focus on education about OT and sexuality at the
university level is recommended.
Occupational therapists should feel empowered to routinely address sexuality with clients
as a key aspect of the human experience.
Rehabilitation companies and practice settings should provide resources to occupational
therapy practitioners in order to address sexuality with clients.
Practitioners currently addressing sexuality with clients should advocate for the topic to
be widely and routinely addressed.
Continuing education related to sexuality should be promoted in the workplace.
REFERENCES:
Mahieu, L. & Gastmans, C. (2015). Older residents perspectives on aged sexuality in
institutionalized elderly care: A systematic literature review. International Journal of
Nursing Studies, 52(12), 1891-1905 15p. doi:10.1016/j.ijnurstu.2015.07.007
McGrath, M., & Lynch, E. (2014). Occupational therapists' perspectives on addressing
sexual concerns of older adults in the context of rehabilitation. Disability &
Rehabilitation, 36(8), 651-657 7p. doi:10.3109/09638288.2013.805823
Name of Appraiser(s):

Date Completed:

Sarah Weihe, OTS

July 13, 2016

Alexandra McGee, OTS

Amalia Beltran, OTS
Mark Bianco, OTS