Sexual Health Education for SCI Clinicians
SCI can have consequences on many different domains, including sexual health. A variety of health professionals (e.g., psychologists, physical therapists, nurses, physicians, sexual health clinicians) may be involved in treating these domains, as well as discussing the impact of SCI on aspects of sexual function. In fact, research shows that patients expect their health care professionals to bring up sexuality and sexual health, but health care professionals can be reluctant to do so because of their lack of knowledge, fear of offending the patient, or discomfort in asking questions that address sexual concerns (Althof et al. 2013).
People with disabilities often express their sexual health concerns to the people they feel most comfortable with, so it is recommended that all persons working with people with spinal cord injury understand the effects of SCI on sexual function (Biering-Sorenson et al. 2013, p. 613). Education and support to health professionals is critical to ensure that these professionals are able to comfortably and knowledgably address relevant patient concerns about sexual health.
Author Year; Country Score Research Design Total Sample Size |
Methods | Outcome |
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Fronek et al. 2005; Australia |
Population: Staff from an SCI rehab service; Treatment group (n=44): 31 nurses, 1 medical practitioner, 6 allied health staff, 6 community staff; Control group (n=45): 32 nurses, 2 medical practitioners, 5 allied health staff, 6 community staff; Previous sexuality training: yes (n=25), no (n=50); Previous SCI sexuality training: yes (n=18), no (n=57). |
At 2 year follow up:
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Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data
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Sawyer et al. 1983; USA PEDro=5 RCT Level 1 N=22 |
Population: 22 graduates in rehabilitation counselling. Methods: participants were randomized to experimental (micro-counselling) and control groups (didactic lecture) to test the effectiveness of this training approach in counsellors’ ability to respond appropriately to sexual concerns expressed by SCI women. Micro-counselling group (n=11) was shown a videotape modelling specific counselling skills followed by discussion, demonstration, and role-play. Didactic lecture group (n=11) had traditional lecture and classroom discussion. Outcome Measures: micro-counselling interaction rating scale (developed using the same response cues that appeared on the video model). |
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Simpson et al. 2006; New Zealand Prospective Controlled trial with pre- and postevaluation Level 2 N = 99 |
Participants: 74 rehabilitation staff and a control group of 25 other staff members. Treatment: Two workshops were held at major rehabilitation centres in New Zealand (control group did not attend). Outcomes: The Sex Attitude Scale, as well as a knowledge test, a self-rating inventory of skills and clinical activity, and a single-item measure of the degree of staff comfort. |
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Fronek et al. 2011; Australia Follow-Up study Level 4 N=37 |
Population: 37 of the original 89 participants from Fronek et al. 2005 who completed all three previous assessments. 23 nurses, 1 medical practitioner, 3 allied health staff and 10 community staff. Treatment: None – follow-up of trainees in Fronek et al. 2005.v Outcomes: The KCAASS was administered approximately 4 months later (no significant differences re: scores on the KCAASS between those who participated at 2 year follow-up and those who did not). Focus group – participants were asked to comment about the benefits and challenges of the training. |
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Burch 2008; USA Pre-post Level 4 N=402 |
Population: 402 health care professionals who provided services to SCI patients. PTs (n=176), OTs (n=93), speech therapists (n=46), PT assistants (n=22), OT assistants (n=8), nurses (n=50), physicians (n=7). Methods: A pre-intervention questionnaire to assess levels of knowledge, attitudes, and selfefficacy providing care to SCI persons who may be LGBT. Videotape for health care professionals on providing services to LGBT persons was shown and a post-briefing diversity-training questionnaire was given. Outcome Measures: pre- and post-intervention questionnaires on knowledge, attitudes, and self-efficacy. |
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Tepper 1997; USA Pre-post Level 4 N=18 |
Population: 18 staff who worked ≥50% of the time in SCI rehabilitation; nurses (n=10), psychologists (n=2), OTs (n=1), physiatrists (n=1); Time working in SCI rehab: 9 months to 22 years. Methods: An interdisciplinary continuing education and training curriculum addressing the provision of comprehensive sexual health care for professionals was implemented as a 3- day experiential, massed-learning pilot workshop. Outcome Measures: For evaluating the workshop: 1) matched pre- and post-test (summative evaluation) 2) participant journals, 3) participant observation by research assistant, 4) Objective Structured Clinical Examination (OSCE), 5) post-workshop program evaluation (formative evaluation) 6) 5 month follow-up (questionnaire and phone interview). |
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Cole & Stevens 1975; USA Pre-post Level 4 N=199 |
Population: 199 SCI professionals; counsellors (n=142), social workers (n=9), nurses (n=8), psychologists (n=7), OTs (n=6), physicians (n=2), speech therapists (n=1), clergy (n=1), other (n=23). Methods: Creation and implementation of a 1- day seminar on sexual function in SCI for rehabilitation professionals. Outcome Measures: questionnaires pre- and post-seminar. |
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Held et al. 1975; USA Pre-Post Level 4 N= 95 |
Population: 1st Sample = 76 people with SCI/their partners; 2nd Sample = 119 Rehabilitation professionals; 3rd Sample = 51 Rehabilitation professionals). 51% men, 49% women. Treatment: Sexual attitude and Sexual counselling workshops for spinal cord injured adults, their partners and rehabilitation professionals. Slides, films, panels and large/small group discussions. The 3rd workshop (sexual history taking/sexual counseling) included an interview demonstration and practice for participants in small groups. Outcome Measures: 1 st sample – (post- only) asked participants did they enjoy, learn, and would they recommend. 2nd sample – (pre-post) asked about involvement in sexual counseling and education and how the seminar affected. 3rd sample – survey re: attitudes towards sexual activities completed before and 6 weeks after the workshop. |
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Milligan & Petchers 1988; USA Pre-Post Level 4 N =609 |
Participants: 609 participants completed pretest and post-test questionnaires (response rate = 73.5%). 123 participants answered the followup telephone survey (15%). Trainees included physicians, nurse practitioners, clinic assistants, social workers, educators, and residential program managers. Treatment: 37 different workshops on aspects of sexual health, including one workshop specifically on issues re: the physically disabled. Outcomes: Pre/post-test measuring knowledge and skills. Follow-up interviews, asking whether workshops resulted in improved knowledge and skills on the job and how they used/disseminated information on the job. |
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Giannoten et al. 2006; Netherlands Pre-Post Level 4 N=302 |
Population: 302 rehabilitation professionals attended at least one training session. Participants were nurses (36.2%) physicians (15.1%), occupational therapists (14.3%), physical therapists (13.6%), psychologists and social workers (9.3%), speech/language therapists (2.5%), and other disciplines (8.9%). Their (mean) experience in rehabilitation was 9.1 years and 11.2% had attended post-study courses in sexology before. Treatment: The training consisted of seven modules (based on the PLISSIT model) and was offered in six sessions of three hours. Lectures, discussions, role-playing, and simulation of cases/team meetings, and homework consisting of talking about sex with their rehabilitation patients. Outcomes: Each participant completed 3 questionnaires (pre-, post-, and 3-4 months after training) and a Dutch translation of the KCAASS. |
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Post et al. 2008; Netherlands Pre-Post Level 4 N=283 |
Participants: 283 Participants were nurses (35.2%), physicians (14.3%), physical therapists (14.0%), occupational therapists (13.7%), psychologists and social workers (10.2%), and other disciplines (12.6%). Mean age was 39 years, 83% were female and their mean experience in rehabilitation was 9.1 years (same sample as Giannoten, 2006). Treatment: The training for physicians, psychologists, and social workers was three units of 3 h each and for the other disciplines two units of 3 h each. The training used exercises on actively ‘‘talking sex’’ and roleplaying exercises with volunteer patients. Outcomes: Each participant completed 3 questionnaires (pre-, post-, and 3-4 months after training) and a Dutch translation of the KCAASS (same measures as Gianotten et al. 2006). |
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Pieters et al. 2017; Netherlands Pre-Post Level 4 N = 74 |
Participants: 74 participants completed the preand post-test questionnaires. Participants included 13 medical (doctors, nurses, physician assistants), 13 psychosocial (5 psychologists, 7 social workers, 1 chaplain), and 48 paramedical (24 physiotherapists, 18 occupational therapists, one cognitive therapist, one dietician, four speech therapists). Treatment: Training, based on the PLISSIT model, consisted of six half-day sessions and multiple modules, including some disabilityspecific sexual health information. Interactive teaching, exercises, role-playing, presentation of sexual aids, and information delivery. Outcomes: A pretest-posttest design used the Dutch adaptation of the KCAASS, as well as two questionnaires where participants would rate the number of times sexual issues were discussed and how good they were at recognizing and treating problems. |
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Chubon 1981; USA Pre-Post Level 4 N=15 |
Participants: 15 students from graduate programs and rehabilitation agencies in the Greater Pittsburgh area, representing the fields of rehabilitation counseling, special education, social work, counselor education, psychology, and physical therapy. Treatment: A full 2 credit elective course including broad range of topics re: Sexual Health, including the Impact of Spinal Cord Injury. Information delivery, modeling, small group/class discussions, role play, films, all intended to aid with desensitizing students. Outcomes: State-Trait Anxiety Inventory Form, Irvine Sexual Attitude and Knowledge Inventory, Marlowe-Crowne Social Desirability Scale, Personal logbooks, a course evaluation survey, and a multiple choice exam for testing knowledge. |
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Mims et al. 1974; USA Pre-post Level 4 N = 143 |
Participants: 143 Medical, Nursing and Health/Social sciences students at graduate and undergraduate level. Treatment: 5 days of didactic sessions, films, role plays, and small group discussions on topics of human sexuality including sex and the handicapped. Outcome: Sex Knowledge and Attitude test (SKAT) |
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Cohen et al. 1994; Canada Pre-Post Level 4 N = 164 |
Participants: 164 Undergraduate students in 4 programs at McMaster University – Medicine, Nursing, PT and OT – completed the course and both pre-and post-tests. Treatment: A two-day interprofessional workshop in sexuality using lectures, audiovisuals, and small group discussions. Outcome: The Sexual Opinion Survey (SOS) and a 46 item sexual knowledge test were administered pre- and post-workshop. |
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Cohen et al. 1996; Canada Follow-up (Post evaluation 18 months later) Level 4 N = 76 |
Participants: 76 students from the OT/PT, Nursing, or Medical programs that originally took part in Cohen 1994. Treatment: None (18 month follow-up to Cohen et al. 1994). Outcome: 3 questionnaires to assess Sexual Attitude, Comfort and Knowledge (same questionnaires as Cohen 1994), plus asking participants if they had participated in any additional education re: sexual health. |
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Hay et al. 1996; Canada Follow-up (Post Evaluation 18 months later) Level 4 N = 30 |
Participants: 30 Occupational and Physical Therapy students. 90% female with an average age 25 (some of the same participants from Cohen et al. 1994). Treatment: None (follow-up to workshop reported in Cohen et al. 1994). Outcomes: Same measures on Sexual Attitudes, Comfort, and Knowledge as assessed during original workshop collected at 18 month follow-up. |
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Neistadt 1986; USA Cross-Sectional Level 5 N = 288 |
Participants: 288 students from Boston school of OT at Tufts university who have taken the sexuality counseling module. Treatment: Three sessions of 3-hour each devoted to the knowledge areas and skills re: sexual health including the ways in which various disabilities might influence sexual functioning. Outcomes: Post-course evaluation |
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Cole, 1973; USA Cross-sectional Level 5 N= 55 |
Population: 55 participants, 20% paraplegic, 20% quadriplegic; 15% spouses of people with SCI; 45% = health professionals/friends of participants. Age = 16-59 (range). Time since injury – Range = 2-15+5 years; (90% more than 3 years since injury). Treatment: A 2-day program for people with SCI and able-bodied persons was developed to deal with sexual attitudes. Slides, speakers, panels and films were sequenced to introduce progressively more explicit and anxiety-evoking sexual material (e.g., pornography), as well as specific content re: aspects of human sexuality of the spinal cord injured person. Outcomes: Pre-workshop questionnaire assessed sexual knowledge, attitudes, and behaviors of the participants. A post-training evaluation asked if participants were glad they attended, and if it had been helpful or harmful. |
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Katzman 1990; USA Qualitative (Description of class and quotes from students only) Level 5 N = 78 |
Participants: 78 nursing students – 73 female, 5 male Treatment: A course focusing on the effect of illness, disability, and medical treatment on sexual functioning, as well as sex education of patients and clients. Outcomes: Post-course interview with participants. |
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Blanchard, 1976; USA Qualitative Level 5 N=56 |
Population: 56 nursing staff completed the program. Treatment: 4 meetings of 1.25 hours each dealing with a) personal taboos that prevent people from developing a healthy therapeutic attitude towards sexuality; b) misconceptions about sex and of vocabulary; c) identification of the sexual problems of the spinal cord injured patient; and d) how the knowledge gained could be used to help SCI patients. Outcomes: Evaluated the program by interviewing individual participants. |
Participants reported that after the program they: – enjoyed the class and felt it was worthwhile, though it was stressful at times, and that some participants became uncomfortable when peers freely shared sex experiences. – could respond with a calm and positive attitude when patients asked about sexual functioning. – appreciated having more factual knowledge to pass on to patients. – found that patients learned about the program’s existence and felt freer to ask the nurses about sex. – Found that nursing staff who did not participate were now interested in taking the program. – Head nurses felt that other health disciplines should also be knowledgeable re: sexual rehabilitation. |
Discussion
One randomized controlled trial demonstrated that one-day workshops could improve clinician knowledge, comfort, approach, and attitude towards sexual health counselling (Fronek et al. 2005, 2011). Another RCT (Sawyer et al. 1983) found that an interactive session on microcounselling would improve clinician’s ability to respond appropriately to sexual concerns of patients. One prospective controlled trial and multiple pre-post studies have shown that Sexual Health workshop participants show significant increases in knowledge, skills and comfort after workshops, and a number of these gains are maintained at three-month, six-month, and two year follow-up (Simpson et al. 2006; Giannoten et al. 2006; Tepper 1997; Chubon 1981; Mims et al. 1974; Cohen et al. 1994, 1996; Fronek et al. 2011).
Conclusion
There is level 1b evidence from 1 RCT (Fronek et al. 2005), level 2 evidence (Simpson et al. 2006) and level 4 evidence (Giannoten et al. 2006; Tepper 1997; Chubon 1981; Mims et al. 1974; Cohen et al. 1994, 1996) that educational workshops can improve clinician knowledge, comfort and attitudes towards sexual health counselling.
There is level 2 (Simpson et al. 2006) and level 4 evidence (Fronek et al. 2011; Giannoten et al. 2006) that gains can be in knowledge, attitudes, and comfort in addressing sexual health issues are maintained at six-month follow-up.
There is level 2 evidence from 1 poor quality RCT (Sawyer et al. 1983) that microcounselling sessions can improve clinician’s ability to respond appropriately to sexual concerns of patients.
Interactive educational workshops can improve clinician knowledge and attitudes towards sexual health counselling, as well as improve their ability to respond appropriately to the sexual concerns of patients.