S e x u ality of Older A dult s W ith A rthritis : T he D e v e lopm ent of an Interv ie w S c he du le

In t ro du c t i o n - P ro b l e m S t at e m e n t

In the occupational therapy profession , sexual expr ession is con sider ed an activity of daily living (Uniform T erminology T ask - force, 1994), and Neist adt (1993) empha- sizes that sexuality is an important aspect of self - esteem an d identity . Accor ding t o Conine et al. (1979), t w enty - one out of t w enty - six r egister ed occupational th er -

apist s agr eed that sex uality w a s an import ant dim en sion of activities of daily living an d, ther efor e, ev aluation and tr eat - m ent for in dividual ' s sex ual functioning should be included in the r ehabilit ation pr oces s of older adult s. A number of studies found that sex ual int er est and th e need for phy sical intim acy did not diminish with age or disability ev en though sexu al activity m ay hav e declin ed (Levy , 1994;

Neistadt , 1993; St arr and W ein er , 1981).

S e x u ality o f Olde r A du lt s W ith A rth rit i s : T h e D e v e lo pm e n t o f an In t e rv ie w S c h e du le

K an g D ae - hy u k , M .S ., O .T .R ., R ow lan d A u r or a , M .S ., O .T .R ., M iller P atr icia , E d . D ., O .T .R ., F .A .O .T .A .

Dept . of Occu pation al T h er apy , Colleg e of P hy sician s an d Su r g eon s of Colum bia U n iv er sit y

국 문 요 약

미 국 노 인 층 관 절 염 환 자 들 의 성 생 활 : 면 담 을 위 한 질 문 서 개 발 강 대 혁 , 로 우 랜 드 오 로 라 , 밀 러 패 트 리 시 아

콜럼비아대학교 대학원 작업치료학과

일상생활동작(activities of daily living)을 주요 목적이자 치료 수단으로 사용하고 있 는 작업치료사들이 그 활동 중의 하나인 성적 욕구의 표현(sexual expres sion)에 대해 체계적인 접근이 미진하다는 지적을 극복 하고자 본 연구가 계획되었다. 특히 만성 장 애가 있는 65세 이상 연령층의 성생활에 대해 기술적으로 접근하는 방법을 고안하는 것은 상당한 임상적 의미를 부여 할 수 있다. 본 연구의 주된 목적은 관절염이 65세 이 상의 미국인의 성생활에 미치는 영향과 대책에 대한 논의를 작업치료사의 입장에서 자 연스럽게 유도하기 위한 질문내용을 고안하는데 있다. 본 연구자들은 광범위한 문헌연 구를 바탕으로 7개항의 질문을 작성하여 10명의 노인학 전공 작업치료사들에게 비평을 의뢰하였다. 7명의 작업치료사들이 전문가로서의 세밀한 답변을 해주었고 그들은 공통 적으로 일상생활 중의 하나인 성생활이 삶의 질을 향상시키는데 매우 중요한 역할을 함을 강조하였다. 이들 전문가들의 조언을 바탕으로 새로운 질문서가 완성되었다.

핵 심 단 어 : 일상생활동작; 성생활; 노년층; 관절염.

How ev er , ther e w as paucity of lit er atur e about occupational ther apist s ' r ole w ith people who hav e secondary sexu al pr ob - lem s accompanyin g phy sical or m ent al disability . Based on these findin g s, th e r esear cher s of this stu dy believ e that occu - pation al ther apist s, as holistic car e pr o- vider s with a belief in facilitatin g quality of life, should be pr epar ed t o addr es s sex - uality issues with their older adult patient s.

On e m ethod of addr essing issues of sex - uality w as thr ough the dev elopm ent of an int erview a ssessm ent , which identifies whether or not people hav e concern s about their sex uality and elicit s the natur e of those concern s. T his w ould enable occu - pation al ther apist s t o int erv ene in sec- ondary pr ev ention , that is, scr eening for pot ential pr oblem s, making r eferr als when indicat ed, and beginnin g tr eatm ent if th e occupational ther apist has the kn owledg e and skills.

Surv ey r esear ch (Conin e et al, 1979;

Miller et al, 1993) has been conduct ed r egar ding sexu al r eh abilitation . How ev er , ther e hav e not been studies t o specifically identify how occupational ther apist s should appr oach this sen sitiv e issue in assessin g older adult s w ith arthritis - - which is the m ost pr ev alent disablin g disease am on g th e older population (Bu sh et al, 1994; W alz and Blum , 1987).

T her efor e, this study addr essed the following question s : 1) T o what ext ent does arthritis r estrict or alt er sexual activity am on g older adult s? ; 2) Wh at kinds of int erv ention s can be pr ovided by occupational ther apist s for older adult s with arthritis t o enh ance their en gagem ent in sexual activity ? ; and 3) Wh at kinds of qu estion s should occupational ther apist s

ask older patient s about their sexu ality in or der t o dev elop an appr opriate occupa - tional ther apy assessm ent of this ar ea of function ?

T he m ain purpose of this r esear ch w as t o dev elop an int erview which occupational ther apist s can u se t o a ssess sexuality in older adult s w ith arthritis in or der to incr ease th e likelihood of effectiv e int er - v ention in this dom ain of functioning .

T h e o re t i c a l F o u n da t i o n

T his study w as based on the following theor etical m odels - - the activities health m odel (Cynkin an d Robin son , 1990), the biopsy chosocial m odel (En gel, 1980), and the continuity m odel (At chley , 1989).

T he activities health m odel (1990) is r elev ant t o the sex ual health of older adult s, since they defin e activities health as a st at e of w ell- being in w hich th e individual is able t o carry out the activities of ev ery day living with satisfaction and comfort , in patt ern s and configur ation s that r eflect sociocultur al norm s and idiosyncr atic v ar - iation in number , v ariety , balan ce, an d contex t of activities. (Cynkin an d Robin son , 1990).

Resear ch has show n that sex uality is an

import ant component in the quality of life

of m ost older adult s (Geor ge and W eiler ,

1981; Starr and W ein er , 1981). T he purpose

of occupational ther apy is t o r est or e,

m aint ain , and pr om ot e the quality of life of

individuals. T he activities health m odel

support s this philosophy by en cour aging

the widest r an ge of activities thr ou gh

which hum an s gr ow phy sically and emo-

tionally , thu s enh ancin g their quality of

life. A ctivities health of an individual is expr essed and att ained thr ough engag ement in activities. It may be said th at the individual is in a st at e of activities health when he or she can perform sociocultur ally accept ed activities with satisfaction an d comfort (Cynkin and Robin son , 1990).

T he biopsy chosocial m odel un der st an ds the hum an being a s on e who is vulner able t o injury an d illnes s, an em otional bein g with thou ght s an d v alues , an d a social being who liv es with other s in an envir onm ent (Mosey , 1974).

T he biopsy chosocial m odel is based on a sy st em s appr oach . Each sy st em h as it s own lev el of or ganization which implies qu alities and r elation ship s. How ev er , in con siderin g this hier ar chy as a continuum , each lev el of or g anization is both whole and a part of the sy st em , m eaning , each lev el of or ganization is of equ al import an ce within the sy stem .

T he biopsy chosocial m odel ha s en abled other disciplines t o r ecognize the impor - t ance of psy chosocial component s in the tr eatment of an in dividual (En gel, 1980).

T his m odel pr ovides a guide in ap - pr oaching sex uality of older adult s with an illn ess su ch as arthritis. T he bio- psy chosocial m odel enables th e clinician t o ext end the application of the scientific m eth od t o daily pr actice n ot deem ed accessible thr ough a scientific appr oach alone (En gel, 1980). T his m odel encour ages the clinician t o becom e m otiv at ed and m or e skillful in psy chosocial ar eas of patient car e w hich support s the holistic philosophy and mission of occupational ther apy .

T he continuity m odel contributes t o know ledge r egar ding p sychosocial aging st ating that , as people age, th ey begin t o

dev elop cert ain char act eristics which define their per son ality an d behavior thr oughout life. T hey t en d t o pr eserv e th eir familiar int ernal an d ex tern al structur es in making adaptiv e ch oices. A s such , if they had an int er est in th eir sexuality in th e young - adult and middle- ag e y ear s, this int er est is likely t o continue a s they age (At chley , 1989).

D e f in it i o n s

Con c eptu al D e finiti on s

・Assessment - T he u se of skilled ob serv ation or ev aluation by the admini- str ation and int erpr et ation of st andar dized or non st an dar dized t est s and m easur em ent s t o identify ar eas for occupational ther apy services (Uniform T ermin ology T askfor ce, 1994).

・Sensitive Questionnaire - A set of qu estion s designed t o elicit m or e genuin e r espon ses on a t opic that m ay elicit decep - tiv e r espon ses or r efu sals t o an sw er (Judd et al, 1991).

・Sexuality - T he expres sion of sexual r eceptivity or int er est (W eb st er ' s Ninth New Collegiat e Diction ary , 1988).

・Sexual Expr ession - Engagin g in desir ed sex ual an d intim at e activities (Uni- form T erminology T askfor ce, 1994).

・Osteoarthritis - Noninflammatory de-

gener ativ e joint disea se occurrin g chiefly in

older per son s, char act erized by degen -

er ation of the articular cartilage, hyper -

tr ophy of bone at the m ar gin s, and

chan ges in th e synovial m embr an e. It is

accompanied by pain (u su ally befor e

pr olon ged activity ) and stiffness, (partic -

ularly aft er pr olonged activity ) (Dorland ' s

Illu str at ed Medical Diction ary , 1994).

・Rheumatoid Arthritis - A chr onic sy st emic disease prim arily of the joint s, u sually poly articular , m arked by inflam - m at ory chang es in the synovial membr an es and articular stru ctur es and by atr ophy and r ar efaction of the bones (Dorland ' s Illu s - tr at ed Medical Dictionary , 1994).

Ope rati on al D ef init ion s

・Sexuality - Sexuality is defined as the con sciou s u se of th e body inclu ding car es s and gestur e in or der to shar e or pr ovide pleasur e for on eself or another with or without sexual int er cour se (Miller et al, 1993).

・Older Adult - Older adult is defined as any individual, male or fem ale, ov er the chr on ological age of 65 year s (Miller et al, 1993).

・Arthritis - Arthritis refer s to either ost eoarthritis or rheumatoid arthritis.

・Intervention - T he planned therapeutic pr oces s that incr eases patient s ' knowledge r egar ding th e effect s of arthritis on sex - uality and specific r ecomm endation s t o enhan ce sexual activity of patient s w ith arthritis.

・Interview - T he process of gathering v alid and desir ed data by en gaging in conv er sation with an individu al. F or this study , the int erview will elicit inform ation r egar ding the older per son ' s int er est in engag ement in sexu al expr ession , any difficulty in sexual perform an ce, the natur e of difficulty , and th e ex t ent to which arthritis int erfer es or impedes sexuality .

L it e rat u re R e v i e w

T he lit er atur e r eview begin s with gener al fact s about sexuality in older adult s along with v ariou s fact or s that could influen ce sex ual activity . Am on g the m any v ariables that can affect sexuality of this population , the r esear cher s will focu s on the effect s of arthritis sin ce it is the m ost pr ev alent disablin g disease am on g th e older population . Occupational ther apy int erv ention s that can assist patient s with arthritis in enhan cing their sexual activity will follow . T h e m eth ods and pr ecaution s for dev elopin g sen sitiv e qu estion s for occupational ther apy a ssessm ent in th e ar ea of sexual ex pr ession will be described.

In addition t o discu ssing principles and pr ecaution s for the dev elopm ent of sen - sitiv e qu estion s, ex amples of question s which hav e been u sed by occupational ther apist s will be inclu ded.

S e x u ality in Olde r A dult s

Earlier studies r egar ding sexuality of older adult s r eported that both sex ual int er est and the fr equency of sexual activity ten ded t o decr ease w ith age t o som e degr ee althou gh sexual activity per sist ed in lat er life (F r eeman , 1961;

Kin sey , New man an d Nichola s, 1960;

P om er oy , an d Martin , 1948, 1953). Since

the subject s of these studies w er e

r andomly select ed, the finding s m ay hav e

support ed a public misper ception that

people ar e less inv olv ed or less int er est ed

in sexual activity as they get older and

this notion might hav e been per ceiv ed as a

pr oces s of agin g . How ev er , this per ception

w as challeng ed by surv ey r esear ch con -

ducted by Starr and W einer (1981) w hose

subject s con sist ed of 800 m en and w om en

60 t o 91 year s of age. Contr ary t o pr eviou s

studies , m or e than 65 per cent of the r espon dent s r eport ed that their int er est in sex a s w ell as their actual sex life r em ained st able compar ed t o when they w er e y oun ger . T hese fin din g s w er e support ed by lat er studies statin g that the m ajority of phy sically healthy m en and w om en r em ain sexually activ e on a r egular basis int o their sev enties an d beyond, indicating that the aging pr ocess it self w as not a m aj or fact or affectin g sexual activity (Geor ge and W eiler , 1981; Kaplan , 1990;

Rotber g , 1987).

S om e r esear cher s suggest ed that a r eduction of sex ual activity in lat er life w as m ainly cau sed by other fact or s such as the unav ailability of a partner , ster - eotyped psy chosocial pr essur e, and dis - abilities as sociat ed with adv ancin g ag e (By er s, 1983; Gupt a, 1990; Levy , 1994;

W eiss and Mellinger , 1990; Yeaw orth and F riedem an , 1975). T r aditionally , w om en m arry m en about four year s older than them selv es an d liv e longer th an their spou ses. T h ese fact s make it alm ost impossible for the older w oman t o find anoth er hu sband or a socially accept able partner (By er s, 1983). America ' s y outh - orient ed cultur e also discour ages older adult s fr om being sexu ally activ e (Yeaw orth and F riedem an , 1975). T h e adv ancing year s m ay slow down older adult s, h ow ev er , only phy sical illness pr esent s th e m ost challen ging ob st acle t o r em aining sexu ally activ e in th e lat er y ear s (W alz and Blum , 1987).

Recently , r esear cher s hav e begun t o see sexual function as an int egr al part of tot al w ell bein g of older adult s (Gupt a, 1990;

Neistadt , 1986a ; Rotber g , 1987). S exu ality encompasses mu ch m or e than a phy sical

act and it in cludes the lov e, car e, sharing and w armth ex pr essed bet w een in dividuals (By er s, 1983). P eople en gage in sex ual activity for many r eason s, on e being t o help dev elop and m aint ain a r elation ship with another per son and pr ovide a form of communication (Sidman , 1977). It is w idely believ ed that sexual pleasur e and satisfaction in old ag e do not r equir e sexual int er cour se or r epeated or g asm s.

Noncoital activity - - kissing , t ou ching , and huggin g - - an d self stimulation m ay pr ovide the mu ch needed sexu al satisfaction in lat er life (Gupta , 1990). Kaplan ' s (1991) explicit st at ement dispels the pr ev ailing myth s about sexuality of older adult s - - sex m ay becom e m or e import ant in a per son ' s life w ith the pa ssage of tim e becau se sex uality is am ong the last of th e pleasur e- giving biological pr ocesses t o det erior ate. It is a pot entially enduring sour ce of em otional w ell- bein g at a tim e when m or e and mor e losses mu st be accept ed an d few er an d few er gr atification s r em ain av ailable.

T h e E ff e c t s of A rthriti s on S e x u al A c tiv ity

S ev er al studies inv estigat ed the fact or s that could affect sexual activity in older adult s (By er s, 1983; Gupt a, 1990; Levy , 1994; Moor adian and Gr eiff, 1990; W eiss and Melling er , 1990; Yeaw orth an d F riedem an , 1975). Ev en thou gh psy cho- logical ch anges and social envir onm ent affect ed sex ual activity , phy sical illn esses r elat ed t o aging w er e the prim ary ar eas of con cern for the r esear cher s of the studies.

Sidm an (1977) and Katzin (1990) discu ssed

som e pr ev alent phy sical illn esses that

r estrict or alt er sexual activity among older adult s. T he v ariou s effect s of chr onic illn esses - - such a s arthritis, heart disease, pulm onary disease, and diabet es - - on sexuality w er e addr essed an d m anagem ent of the effect s w a s suggest ed. Of these disea ses, it has been r eport ed that arthritis w as identified as th e leading cau se of disability in older adult s (Bu sh et al, 1994);

and that appr oxim at ely 30% of people ov er 65 w er e limit ed by arthritis and rh eu - m atism (Laflin , 1990); and that arthritis comprised 48% of th e specific disabilities which affect ed sexuality in older patient s (Goldstein and Runy on , 1993).

Arthritis is ch ar act erized by inflamm ation of any joint of the hum an body . T h e most fr equent form s of arthritis ar e rheum at oid arthritis and ost eoarthritis. Rheumatoid arthritis is a chr onic inflamm at ory disease of periph er al joint s and cervical spine wher eas ost eoarthritis is a noninflammatory disea se that m ay inv olv e any joint but u sually inflamm ation occur s as a secondary con sequ ence (Melvin , 1989). In older per son s, m or e than one form of arthritis is oft en pr esent simult aneou sly (W alz an d Blum , 1987), ther efor e, arthritis is u sed as an int egr at ed t erm in this paper .

Most of the studies about the con - sequences of arthritis on sexuality agr ee that joint pain an d stiffness ar e the m ajor symptom s of arthritis which disturb sex ual activity ev en thou gh the degr ee of sexual dy sfunction v aries depending upon the affect ed sit es in th e individuals (Blake et al, 1987; Her st ein et al, 1977; Malek and Br ow er , 1984). Accor ding t o Goldst ein and Runy on (1993), rheum at oid arthritis is a m or e dev ast ating condition than osteo- arthritis becau se it is a chr onic sy st emic

disea se char acterized by r emission s an d ex acerbation s. Other disor der s that ar e included in th e rheum atic diseases may sev er ely int errupt sexual activity . P oly - myalgia rheumatica cau ses sev er e pain an d stiffn ess in shoulder s an d hips, especially at night (Davis, 1986). W om en with either of Sj ogr en ' s syndr om e or scler oderma oft en experien ce a m arked v agin al dryness.

P atient s with Sjogr en ' s syndr om e suffer fr om x er ostomia, dryn ess of the m outh due t o saliv ary gland dy sfunction , which w ill not r esult in incr eased saliv ary flow upon stimulation . T his sympt om with the associat ed r apid dent al caries m akes or al- genit al activity painful. Similarly , atr ophic pr octitis, inflamm ation of the r ectum , makes an al inter cour se impossible at tim es (Ehrlich , 1978). Men with scler oderm a m ay fr equently experien ce a con dition called P eyr onie ' s disease, that cau ses a painful er ection pr ecludin g sexual activity (W alz an d Blum , 1987). Accor din g t o Ev an s (1987), t empor om andibular j oint inv olv em ent occur s in mor e than half of all cases of rheum at oid arthritis. Sin ce a deep passionat e kissing is likely t o cau se a sev er e pain , a gentle closed m outh kissing without pr essur e on the low er lip is highly r ecomm ended in this case.

Mech anical impedim ent s inv olv ed w ith

hips, kn ees, or back m ay also affect sexu al

activity in m any w ay s. Hip pr oblem s ar e

con sider ed m ajor limit ation s in sexual

functioning for w omen . On the other han d,

arthritis inv olv ed with upper extr emities

- - deformities of the finger s, poor m otion of

wrist s, elbow s, an d shoulder s - - m ay also

be limiting and pr ev ent sub stitution of

m asturbation as a sex ual outlet (Ehrlich ,

1978). In addition , it should be n ot ed that

m edication s u sed

ex ual desir e (Ehrlich , 1978; W eiss and Mellinger , 1990).

Other factor s contributing t o sexual dy sfunction ar e identified thr ough psy ch - osocial e

Int er estingly , som e positiv e effect s of sexual activities on arthritis h av e been found. P atient s w ith arthritis h av e r eported that th eir s or e joint s w er e r eliev ed a s a r esult of sex ual activities and th ey w er e helped t o m aint ain r an ge of m otion of th e limb s . It h a s been found that s exual activities stimulat e adr en al gland pr oduction of cortisone which ha s been u sed t o tr eat symptom s of rheumatoid arthritis (Laflin , 1990; W alz and Blum , 1987). S or en sen (1981) agr ees that sex can be u s ed a s a ther apeutic and pr ev entiv e appr oach in chr onic condition s su ch a s arthritis .

Interv enti on s f or A rthriti s t o Enh an ce S ex u al F un ct i onin g

Ov er the pa st 15 y ear s , health pr o- fes sion als hav e become m or e aw ar e of the r ole sex uality play s in the ov er all r ehabil- it ation pr oces s (Dahl, 1988; Neist adt , 1986a ). It ha s als o been widely a ccept ed that sexual a dju stment w a s a fun dam ent al

a spect of patient s ' m edical and psych o- social r ehabilit ation (Conine et al, 1979).

W ith in cr ea sing opportunities t o under st and sexual dy sfunction , h ealth pr ofes sionals hav e becom e activ ely inv olv ed in r est oring or impr oving sex ual function of older patient s (Kaplan , 1991).

In pr actice, health pr ofes sionals should r espect individual differ en ces am on g th eir older patient s . T hose wh o ar e sex ually inactiv e and comfort able with that ad - ju stm ent should not be ma de t o feel inadequ at e, but those who ar e struggling with sexual pr oblem s ought t o be helped t o ov er come th em (Yeaw orth and Friedem an , 1975). In the same v ein , only those ther apist s who ar e comfortable discu s sing sexuality with their patient s should int erv ene in this ar ea . Other wise, it is suggested that th ey r efer their patient s t o a qualified st aff m ember for coun seling

(Neist adt , 1986a).

A ccor ding t o Kaplan (1991), the fir st

st ep is t o pr ovide older patient s w ith

accur ate inform ation about the effect s of

the agin g pr ocess an d the disease on

sexuality as w ell as t o encour age u se of

their r em aining capacities. T he secon d st ep

is t o try t o h elp patient s t o accept bio-

logical changes in their sexuality in a

con structiv e, positiv e, an d r ealistic m anner .

T hen , appr opriat e compen sat ory and ther a -

peutic t echniques an d positiv e con structiv e

attitu des ar e r ecomm ended as t w o key s t o

succes sful r est or ation of sexual functioning

in older patient s. In or der t o achiev e a

m aximum tr eatm ent out come, a v alid

ev aluation which includes an assessm ent of

both or ganic and psy chological par am et er s

of the individual' s pr oblem should be

administ er ed (Kaplan , 1990).

T her e ar e sev er al m odels w hich can be applied by th er apist s t o det ermine the m eth od of coun seling . One m odel devised by Ann on (1974) (cit ed in Goldst ein and Runy on , 1993; Neist adt , 1986a ) is th e PLIS SIT m odel which con sist s of four lev els , and th e fir st thr ee lev els ar e appr opriat e for occupation al ther apy int er - v ention . T he fir st lev el is the permission lev el. In this lev el, the ther apist list en s t o a patient in a nonjudgm enal, knowl- edgeable, an d r elax ed m ann er . T he patient s n eed the assur an ce that they ar e not alone and their con cern s ar e norm al.

T he second lev el, limit ed inform ation , is con cerned with pr oviding inform ation t o the patient r egar ding specific sexu al con cern s an d offering su ggestion s which could minimize these concern s . T he thir d lev el, specific sug gestion s , allow s the ther apist t o dev elop specific interv ention s based on the individual ' s sex ual history . T he patient mu st pr ovide the ther apist with his or her brief sexual history in or der for the ther apist t o dev elop a tr eatment plan which is m ost effectiv e for the per son . T his lev el, in particular , can be u sed by occupational ther apist s t o de- t ermin e the types of int erv ention s for spe- cific disabilities, su ch as arthritis (Neist adt , 1986a). T he fourth lev el, int en siv e ther apy , inv olv es the application of th e long - t erm ther apy t o the patient . T his lev el of tr eatm ent should be performed by a certified sex ther apist or psy chologist s an d psy chiatrist s with expertise in this ar ea.

In the case of arthritis , patient education is critical. Kn owledge of the phy siologic chan ges associat ed with agin g pr oces s and arthritis can gr eatly enhance adju stment and enjoym ent of sex ual ex pr ession (Laflin ,

1990). T he education in cludes edu cating about timin g an d positioning . An ex ample of a m et aphor r egar ding sexu al expr ession is that a m atinee m ay be pr eferr ed ov er early morning , night , or ev ening hour s since sev er e pain u sually att ack s the victim ar ound bed tim e, during the night , and upon aw akening in the m orning (Ehrlich , 1978). Laflin (1990) pr ovides an ext en siv e set of pain r educing position s that can be intr oduced during the coun - seling session s. It is essential th at sex ual partner s communicat e openly about w hich sexual activities ar e pleasur able an d which m ay cau se pain (Arthritis F oun dation , 1990;

W alz and Blum , 1987). T h e following int erv ention s can be intr oduced by occu - pation al ther apist s in addition t o coun - seling .

・Home ex er cise pr ogr am (St en str om , 1994) for j oint m obility an d joint pr ot ection t echniques. T he individual who is in good phy sical condition and engages in r egular ex er cise will be able t o engag e in sex ual activity sooner than the sedent ary indi- vidual (Sor en sen , 1981).

・Application of thermal modalities - - ice or heat (Laflin , 1990).

・Use of a w aterbed (Walz and Blum , 1987).

・Placing pillow s under painful limb s (W alz and Blum , 1987).

・Various pain reducing positions avail- able

・Emptying the bladder before sex can facilit at e m or e comfort able lov e play and sexual ex change (Laflin , 1990).

・Providing emotional support (Melvin , 1989).

・T aking analgesic or anti- inflammatory

m edication s thirty minutes t o one h our prior t o en gagin g in sex ual activity (Enrlich , 1978).

Occupational ther apist s ar e in an ex cellent position t o pr ovide inform ation on sexual functioning (Neist adt , 1993) an d if occupational ther apist s becom e familiar with sex ual component s in differ ent r ealm s of society , they can be bett er pr epar ed t o assist the patient in this activity of daily living (Dahl, 1978).

T h e D ev e lopm e nt of Qu e s t ion s R e g ardin g S e x u ality

In dev eloping an asses sm ent t ool, one mu st clearly con struct question s w hich can be under stood by th e r espondent s. T he goal in dev eloping question s is t o learn what the r espondent s know , feel, ex pect , pr efer , or hav e done concerning th eir sexuality (Judd et al, 1991). T he r espon se pr oces s of the patient is the ba sis for the dev elopment of the qu estion s. T he dev el- opm ent of these question s should con sider what might be sen sitiv e for the patient . T he termin ology in th e qu estion s should be ex act , r eflecting what th e question cont ent m ean s. How ev er , at the sam e tim e, t erm s mu st be simple. Ambiguou s w or ds and biased w or ds should be av oided (Judd et al, 1991) since they hav e th e pot ential of cau sin g confu sion and difficulty in an - sw ering the question .

In the dev elopm ent of question s one mu st con sider many fact or s. T he lev el of specificity is an import ant fact or in dealing with attitudes and beliefs (Ju dd et al, 1991). T he len gth of tim e is also important in asking question s ; th e short er the

int erv al, the bett er . T he number of qu estion s can also affect the r espondent ' s behavior . Startin g the question is an import ant part of th e dev elopm ent of qu estion s. T his can r educe bias in the r espon ses giv en by the r espondent s. Som e r espon dent s may r espond t o the structur e of th e question s r ather than th e question it self. In dev eloping th e structur e of a qu estion , qu alification s and con dition al clau ses should com e fir st . It is also import ant t o simplify the r espon dent ' s t ask when dev eloping the structur e of the qu estion . F or ex ample, in st ead of asking the per cent age of sexual experiences an individual h as, it is pr efer able t o ask for m onthly sex ual experiences which allow s the individual to r espond without difficulty (Judd et al, 1991).

In dev eloping question s, one mu st de-

t ermin e if the question s will be open - ended

qu estion s, closed- ended question s or a

combination of both . Although open - ended

qu estion s ar e mor e tim e- con suming and

ar e less cost efficient th an closed - en ded

qu estion s, th e ben efit of ch oosin g open -

ended question s is in giving th e r espon -

dent an opportunity t o r elat e his or h er

feelin g s m or e complet ely w ithin a r elev ant

contex t and cultur e. T o extr act the

inform ation of per son al int er est fr om the

older per son , u se of closed - en ded question s

m ay not be feasible. Unlike open - en ded

qu estion s, closed- ended question s giv e the

individual either th e for ced choice of yes

or no or mor e than t w o option s and the

r espon dent mu st choose the option closest

t o the r espondent ' s agr eem ent . Open - en ded

qu estion s do not limit th e in dividual ' s

r espon se an d they ar e often m or e m oti-

v ating t o r espon dent s (Judd et al, 1991)

which is an import ant fact or in this r esear ch . In dev eloping question s, gener al qu estion s should com e fir st befor e specific qu estion s. T his will r educe the r espon - dent ' s anx iety in trying t o deciph er what the int erview er is asking . T he sequ encing of qu estion s also play s an import ant part in the r espondent ' s feedback . If th e r espon dent finds th e question s difficult t o follow , this discour ages the r espon dent fr om completin g the int erview (Judd et al, 1991).

In dev eloping qu estion s, a cognitiv e appr oach , which inclu des four st ages - - compr ehen sion , r etriev al, estim ation and judgem ent , an d r espon se, ha s been pr ov en effectiv e in incr easing r espon se r at e (Jobe and Min gay , 1989). T he t echnique u sed t o under st and this cognitiv e appr oach is based on a pr ocedur e called the v erbal r eport . T his inv olv es thinkin g alou d, which encour ages the subject s to v erbalize their thought s as they an sw er the qu estion s posed to them . T he patient mu st hav e th e ability t o int erpr et the question in or der t o r ecall r elev ant inform ation and judge the qu estion posed, ther eby giving a r espon se.

T he int erview is a m ean s of identifying the st ages that pose pr oblem s for the individual ' s r espon se (Ber cini, 1992). T he v erbal r eport t echnique r epr esent s the clinical or ev aluativ e appr oach of cognition . In applyin g the cognitiv e appr oach it has been sh own to r edu ce the r espondent ' s err or in health surv ey s (Jobe and Min gay , 1989; Willis et al, 1991).

T he ability of the int erview er to hav e a succes sful int erview is depen dent on the con struction of w ell- dev eloped question s . T his leads th e t opic int o th e dev elopm ent of int erview skills which facilit at e the

int erview pr ocess and r esult s in a succes sful int erview r espon se. T he other import ant aspect in th e pr ocess of int erviewing is cr eating a frien dly atm o- spher e. T he intr oduction should be brief in the ex planation of the purpose of th e study , the agency spon sorin g the r esear ch , and the intr oduction of the r esear cher s (Judd et al, 1991). An import ant fact or in asking question s t o the r espondent is the t one u sed in askin g the qu estion s. T he int erview er has to be pr epar ed t o ask qu estion s conv er sationally r ather than asking them stiffly . T he int erview er should be cautiou s in the appr oach of r ecor ding the r espon ses in or der t o minimize bias.

P ar aphr asing the r espon se dist ort s the m eaning of the r espondent ' s an sw er s t o the question s.

In dev eloping question s, on e mu st hav e a

clear conceptual idea of the v alidity of the

assessment . T his support s the import ance

of pr et estin g in the dev elopm ent of

qu estion s (Ber cini, 1992). An import ant

m eth od of av oiding unw arr ant ed assump -

tion s when devising question s is t o ask a

pr eliminary question pert aining t o the

r espon dent , and follow with the question of

int er est if the r espondent falls int o this

cat egory . Dir ect questioning on sen sitiv e

t opics, su ch a s sex uality , m ay elicit a

deceptiv e r espon se (Ber cini, 1992). On e of

the m ost import ant a spect s w hen

int erviewing people r egar ding their sex -

uality is dev eloping a good r apport with

the r espondent . Jobe and Mingay (1989)

suggested that , in askin g qu estion s based

on priv at e or sen sitiv e issues, the best

r esult s com e fr om lon g question s r ather

than sh ort qu estion s, and open - en ded

qu estion s r ather than closed- ended ques -

tion s. T hese question s should also be posed in thir d per son r ather than fir st or secon d per son . An ex ample w ould be som e people hav e difficulty with their sexual activity in the ev ening . Do y ou shar e this pr oblem also?

Lit er atur e r ev ealed sev er al inv ent ories that att empt ed to m easur e som e a spect of sexual beh avior . T hese included S exual Int er action Inv ent ory (LoPiccolo and St eger , 1974), Index of S exual S atisfaction (Hu dson , Harrison , and Cr osscup , 1981) and Sex ual Adju stm ent Questionnair e (W aterh ou se an d Met calfe, 1986) all of which u sed scales or true or false m eth ods . T hese inv ent ories may be efficient in collectin g quantit ativ e dat a of sexual behavior for purposes of r esear ch . How ev er , these self - r eport , closed- ended qu estion s m ay limit th e in dividual ' s r e- spon se an d m otiv ation in a clinical settin g (Judd et al, 1991).

S ev er al att empt s hav e been made t o assess sexual fun ctionin g in the occupa - tional ther apy pr ofession . T he widely u sed m eth od is the u se of a self - r eport pr oblem checklist (An dam o, 1980). Andam o' s checklist included concern s about all ar eas of occupational perform an ce such as hou sekeeping , fear of un employment , r e- duced social life and w orries about sexual activity due t o arthritis. If the patient show s concern about his or her sexuality , occupational ther apy int erv ention should be addr essed. How ev er , it can be ar gued that the checklist appr oach does not lend it self t o th e patient s ex pr essin g their concern s about sexuality . An dam o (1980) r ec - omm ended a natur al w ay of initiatin g discu ssion about the patient ' s sex uality - - T oday , w e begin with an ev aluation t o

identify the abilities and limit ation s y ou m ay hav e in cert ain activities that ar e necessary in y our r e- entry t o the community an d the perform ance of your v ariou s r oles , as a h om em aker , a sexual partner an d oth er r oles. Neist adt (1993) shar ed the similar per spectiv e with Andam o in appr oaching sexu ality issues . T hey sugg est ed a con cr et e intr oduction st at em ent as an opening betw een the patient an d the th er apist . P eople who h av e been in the h ospit al f

rien cing difficulties like y our s oft en hav e question s about sexuality . I hav e som e inform ation about sexuality and disability , so I could try to an sw er your qu estion s. If I do n ot h av e the an sw er s t o

an sw er s for y ou or r efer y ou t o som eon e on staff wh o know s m or e about this ar ea than I do (Neist adt , 1993). How ev er , she pointed out that a simple closed - en ded qu estion , such as Do y ou h av e any con cern s about sex ? w ould be m or e appr opriat e for older adult s with limit ed cognitiv e abilities. Kligm an (1991) also r ecomm ended that clinician s u se n on - judgm ent al, open - ended question s in or der t o elicit sex ual concern s.

T he Canadian Occupation al P erform ance Measur e ev aluation t ool (Law et al, 1991) assesses sexual functioning thr ough the u se of closed - ended qu estion s su ch as Can y ou engage in sex ual activity ? and Ar e you satisfied w ith th e w ay you engag e in sex ual activity? How ev er , closed - en ded question s hav e been criticized for their inappr opriat eness in appr oaching priv at e or sen sitiv e issues (Jobe and Mingay , 1989).

Occupational th er apist s can initiat e a

qu estion about sexuality by asking Many people with arthritis oft en hav e concern s about their sex ual function . Please tell m e about any concern s y ou hav e at this tim e (Goldstein and Runyon , 1993). If the patient r ev eals his or her concern s, the th er apist can ask additional question s , but if the an sw er is No , the occupational ther apist should let the patient know th at they ar e alw ay s av ailable sour ces for assistance in this ar ea an d the ther apist w ould be happy t o discu s s any sexu ality issues further or m ake a r ecommen dation to an expert in sexual dy sfun ction , eg . a ur ologist (W alz and Blum , 1987).

M e t h o do l o g y

S tu dy D e s i g n

T his study w a s an explor at ory , descrip - tiv e study . Some lit er atur e ha s been published on the t opic of sexuality an d older adult s . How ev er , scant r esear ch h as been conduct ed in the dom ain of sexuality r egar ding people ov er 65 y ear s of age w ho hav e arthritis. T he purpose of this study w as t o dev elop sen sitiv e qu estion s for older adult s with arthritis r eg ar din g their sexuality . T h e question s ar e t o be u sed a s an occupational ther apy ev alu ation t ool which m ay be incorpor at ed into an activities of daily living (ADL) a ssessm ent for older adult s with arthritis. T his r esear ch described the pr ocess of dev el- opin g sen sitiv e question s r egar ding sexuality

tient s with arthritis.

T his pr ocess w a s based on an inv es - tigation of the lit er atur e, and inform ation fr om sexuality questionnair es u sed by health car e pr ofession als wh o focu s on

geriatric is sues and older adult s with arthritis, and per sonal communication with occupational ther apist s who ar e specialist s in ger ont ology/ g eriatrics or wh o incorpor at e sexuality issues int o their ADL ev aluation .

T his w as also a m eth odological study becau se the int erview schedule dev eloped by these r esear ch er s thr ough this study is expect ed t o be u sed in ev aluating the ar ea of sex ual ex pr ession in ADL assessm ent for patient s w ith arthritis

r s of ag e.

S ubje c t s

T he subject s in this stu dy in cluded t en occupational th er apist s ; som e of whom hav e specialized in w ork with the older population , and other s w ho hav e expr essed int er est in sexuality of older adult s. T hey w er e asked t o m ake r ecomm endation s as t o wh at question s they deem ed appr opriat e and t o pr ovide feedback on the fir st dr aft of the int erview schedule dev eloped by these r esear cher s.

P ro c e dure

T he m ethod of dev eloping an int erview schedule for patient s with arthritis r e- gar ding sexuality included sev en st eps.

T he fir st st ep included a thor ough lit er - atur e r eview r egar ding sexuality of older adult s. T he secon d st ep inv olv ed g athering and an alyzing sexuality questionnair es curr ently u sed by health car e pr ofession als.

T he thir d st ep inv olv ed studyin g how to dev elop a sen sitiv e interview schedule. T he fourth st e

d askin g occupational ther apy expert s wh at question s they w ould r ecomm end in

exu ality issues.

T he fifth st ep entailed the dev elopm ent of

an int erview schedule based on th e liter atur e r eview , an d teleph one conv er - sation s with tw o occupational ther apy expert s, and the ju dgem ent of these r esear cher s . T he sixth step con sist ed of sending a package which included a cov er lett er , a demogr aphic qu estionn air e, the fir st dr aft of th e int erview schedule, and a comm ent ary form to t en occupational ther apist s who hav e either had an int er est in sexu ality of older adult s or hav e specialized in car e of older adult s. T he occupational ther apist s w er e asked t o critiqu e the int erview schedule and offer their suggestion s for m odification of the int erview schedule. T he sev enth and fin al st ep inv olv ed the r evision of the int erview schedule based on r ecomm endation s fr om the occupational ther apist s, the r esear ch advisor of this study , an d fr om these r esear cher s ' view point s.

R e s u lt s

P relim in ary Int e rv i e w S ch e dule R e v ie w e d by Oc c upation al T h e rapy E x pe rt s in Geriatric s - Geront ol o g y

W e w ould gr eatly appr eciat e your com - m ent s an d r ecomm endation s r egar ding the int erview qu estion s att ached. A form for your comm ent s follow s the int erview qu estion s. T he purpose of this assessment is t o identify pr oblem ar eas (phy sical, psy chological, or social) th at limit sexual activity of older adult s with arthritis. Aft er administ ering the following int erview schedule, th e occupation al ther apist should be able t o det ermine whether further occupational ther apy tr eatm ent is indicat ed (eg . sugg estion s for positioning ) or a

r eferr al is necessary ba sed on the finding s.

Int erv ie w

① Occupational therapist s are interested in helpin g people accomplish all their daily activities t o the gr eat est ex tent possible.

Many people with arthritis oft en hav e con cern s about their sex ual functioning . Could y ou t ell m e about any concern s about performin g sexual or intim at e activ - ities y ou m ay hav e at this tim e or con cern s y ou hav e had in the past y ear ?

Pr obe question s m ay follow r egar ding arthritis, eg . A ) How does pain limit y ou sexually ? ; B) How does m ov em ent limit you sexually ?

② T o what extent is sexual activity m eaningful or import ant t o y ou now ?

③ In the past , how important has sexual activity been t o y ou?

④ How do you feel about your current sexual activity in t erm s of fr equency ? Is it as oft en as you w ould wish?

⑤ How do you feel about your current sexual activity in t erm s of satisfaction?

Could you t ell me m or e about why you feel this w ay ?

⑥ Some people, as th ey get older , complain of a v ariety of thing s w hich limit intim acy or sexual engag ement , n ot ju st about arthritis. F or ex ample, n ot havin g a partner or fear of not being an adequat e sexual partner . Do any of these limit ation s in participating in sexual activity apply t o you? Does anything else com e to min d?

D e m o g raphic R e s ult s

T en occupational ther apist s r eceiv ed the

int erview schedule and feedback form .

T her e w er e eight r eturn s, how ev er , one

r espon dent did not feel experien ced in this

domain , leaving sev en r espon ses. T w o r es - pon dent s hav e specialized in ger ont ology/

geriatrics for m or e th an t w enty - fiv e year s.

On e r espondent has specialized in per cep - tual/ cognitiv e dy sfunction s in the adult population for t w enty y ear s. F our other r e- spon dent s specialized in adult r eh abilitation

setting s with experiences r angin g fr om one and a half t o eight year s . F iv e out of sev en ther apist s r esponded that they oft en addr essed issues of sex uality in the clinical setting , while they alw ay s addr essed these issues in an academic setting .

T able 1 . Demogr aphics of occupational th er apy ex pert s

(Res -

pon - dent s)

T itle Specialty Ar ea as Reported by

Respon dent s

Year s in Pr actice 1. Dir ect or , Community Health Edu cat or Education , Ger ontology 25 2. P er diem T her apist ; Adjunct F aculty ,

O.T . Pr ogr am Subacut e Car e; T eaching 4

3. A ssist ant Pr ofessor and Dir ect or ,

O.T . Pr ogr am Aging 27

4. Pr ofessor , O.T . Pr ogr am Neur or ehab ; Ment al Health 5

5. Supervisin g T her apist Long - t erm Rehab 1.5

6. A s sist ant Dir ector Adult Phy sical Disabilities 8

7. A s sist ant Pr ofessor , O.T . Pr ogr am P er ceptual- cognitiv e Dy sfunction in

Adult s 20

T able 2 . T h er apist s ' u se of sexuality in clinical pr actice and/ or t eaching

(Res -

pon - dent s)

Q# 6. How oft en do you per son ally addr ess issu es of sexuality w ith y our client s?

Q# 7. How oft en do y ou t each about assessm ent of sexu ality t o student s?

Q# 8. How oft en do you t each about int erv ention in sexuality t o student s?

1. r ar ely N/ A

N/ A

2. oft en/ som etimes often often

3. oft en often often

4. N/ A

alw ay s alw ay s?/ oft en ?

5. oft en alw ay s alw ay s?/ oft en ?

6. oft en alw ay s alw ay s

7. oft en alw ay s alw ay s

*

Not applicable

R e s po n dent s ' Com m e nt s on th e Int erv ie w S c he dule

Q# 1 . W hat do y o u like ab out th e int e rv i e w s c h e dul e ?

* It t aps crucial question s and u ses a limit ed number of question s.

* Open - en ded question s. A ssum e the client does hav e a sexual history an d a curr ent inv olv em ent in sex uality .

* T hat y ou ' r e doing it .

* It is gener ally open - ended an d sen - sitiv ely w or ded.

* T he int erview inclu des a hist ory , pr esent st atu s an d futur e hopes in sex - uality . I also like the open - en ded question s which can lead int o a m or e det ailed dis - cu ssion .

* I like it ' s ability t o be u sed for any per son in the geriatric population . P eople who hav e a v ariety of differ ent int er - pr et ation s of sex ual beh avior and/ or life- styles w ould n ot be ex cluded fr om this int erview . T his w ay the question s an d intr oduction t o the interview ar e phr ased is v ery sen sitiv ely st at ed.

* Holistic look at sex uality ; sex ual ac - tivity view ed in t erm s of it ' s m eaning t o the in dividual.

Q# 2 . W h at do y ou di s lik e ab out th e int erv ie w s ch e du le ?

* Isolat es sexuality as a separ at e issu e.

Doesn ' t acknow ledge that this is a difficult subject t o speak about ; doesn ' t pr ovide an easy out for those w ho do n ot wish to discu ss this subject .

* Doesn ' t put sexuality in a m odest contex t n eeds m or e emphasis on social.

* Some of th e w or ding is a bit clum sy .

I ' v e m ade some changes.

* S exu al functioning is ju st on e aspect of sex uality , and so when y ou say/ ask How does pain limit y ou sex ually? y ou ar e limiting th e int erview to be ju st about sex and not about other ex pr ession s of one ' s sexuality . F or in st an ce, if the ques - tion r ead, How does pain limit ex pr ession of y our sexuality ? - (of which sexu al functioning could be list ed as a part ). T his could t ake int o account a lot of oth er aspect s of this domain of fun ctionin g eg . putting on make up, dr es sing up, going out and socializing with pot ential partner s , etc.

Q# 3 . W h at w ould y ou delet e in th e int erv ie w s ch e du le ?

* Nothing - ch ange w or din g in question number one.

* Question number thr ee seem s irr el- ev ant t o client ' s curr ent needs, and may be con sider ed prying . Vague about sexual activity - what does this inclu de?

* Re- or der

* Question number four - emphasis in sexuality coun selin g should be on quality of intim acy , not qu antity .

Q# 4 . W h at w ould y ou add to th e int erv ie w s ch e du le ?

* Con sider a scale for number t w o an d number thr ee. Many people hav e pr oblem s becau se of medication side effect s, espe- cially m en . S om etim es they ar en ' t aw ar e the m edication is r espon sible.

* Could be clear er as to what a ssist ance

will be m ade av ailable to client s who do

hav e sexual concern s . What do y ou hav e

t o offer th em? If this isn ' t clear , th ey may

be r eluct ant t o sh ar e concern s . Eg . aft er

asking per son t o t ell m e about any

con cern s, y ou could ask if they ' d be int er est ed in writt en inform ation , gr oup education . You could ask if they might w ant this at som e other tim e t oo.

* S om ethin g that g et s the r espondent thinking about the v ast v ariety of sex ual activities, all the w ay s of ex pr essing lov e and affection . F or eg . if patient ' s m ain con cern is kissing , car essing or hugging , your question s may n ot elicit this infor - m ation .

* I w ould m ention befor e the interview that sex uality issues ar e comm on an d how an occupational ther apy could be h elpful (eg . what ar ea s of sexual functioning and/ or sexuality ), so that the client is

pr epar ed for the int erview .

* You might w ant t o furth er define intim at e activities becau se you separ at e it out fr om sexual activities. How do they differ ? I w ould add som e question s which w ould addr ess other aspect s of sexuality .

* Question one- as edit ed. T his question should be an open invitation t o either discu ss sexu ality or close the t opic of dis - cu ssion .

Q# 5 . Ov erall , do y ou c on s ider t hi s an ef f e ct iv e w ay t o elic it inf orm ation re - g ardin g s ex u ality ? Ex pl ain .

* Yes - I like the open - endedness of qu estion s.

* Yes - It ' ll open the door t o sexual con cern s. How ev er , one form at doesn ' t fit all. It m ay be t oo per son al for som e people and n ot supportiv e enough for other s.

* I n eed t o kn ow m or e- ar e y ou doing a focu s gr oup form at ? With cont ent analy sis?

* Gener ally - yes.

* Ov er all, y es. I w ould, how ev er , pr ovide

the client with th e option of a per son - t o- per son interview or t o fill it out I (this m ay hav e been con sider ed alr eady ).

* No, not t o elicit inform ation r egar ding sexuality but y es for elicitin g inform ation about sexu al fun ctionin g .

* Yes.

Q# 6 . Com m e nt s .

* Not clear at w hat point y ou will t ermin at e the question s. What happen s if they say no to question on e? Do y ou continue the interview ? I ' m n ot clear w hat the purpose of this int erview is - t o g ather inform ation or t o identify client n eed for clinical int erv ention on sexual function . Who w ill be doin g the interview (eg . r egular ther apist , student ?) What is the contex t ? How will it be intr oduced? T his affect s it ' s effectiv eness .

R e v i s e d Int e rv ie w S c h e dule

T he r evised int erview schedule w as dev eloped based on the r esear ch er s ' car eful study of the occupational ther apy expert s ' r espon ses.

Guide lin e s f or Oc c upation al T h e rapi s t

・A positiv e r apport bet w een the ther apist and the patient can be built while explaining the purpose of the int erview .

・T he interview schedule can be admin - ist er ed with other ar eas of ADL asses s - m ent .

・It is important that the occupational

ther apist inform the patient of possible

assist an ce which he or she can pr ovide

(eg . br ochur e, gr oup education , an d r efer -

r als).

・A period of silence should be permitted for any question which has t w o part s.

・If the patient should an swer n o t o qu estion s 1, 2, and 3, the int erview sh ould be t erminated.

* Intro du c ti on t o purpo s e of th e int e rv ie w s ch e dule

(W or ding should be adapted for the comfort lev el of both the ther apist and client an d for th e under st anding of the client ).

T he purpose of this int erview schedule is t o identify pr oblem ar eas (phy sical, psy chological, or social) th at limit sexual expr ession of older adult s with arthritis . Sex ual ex pr ession is defined as engaging in desir ed sex ual and intim at e activities which inclu de huggin g , kissin g , car essin g , m asturbation , and int er cour se. Occupational ther apist s ar e int er est ed in helpin g people accomplish all their daily activities t o the gr eat est ex tent pos sible. People with mu sculoskelet al pr oblem s oft en hav e con - cern s about how their bodies perform while expr essing th eir sex uality . F or ex ample, w e can help you with m oving about m or e comfort ably , an d w e hav e som e writt en m at erials w e can giv e y ou . I am going t o ask y ou som e question s so I can under - st and your con cern s. If y ou feel un com - fort able at any tim e durin g the int erview , you ar e w elcome t o termin at e this int er - view .

1) How import ant is sexu al ex pr ession t o you now ?

2) In the pa st fiv e y ear s, how import ant has sexu al ex pr ession been t o y ou?

3) Ar e fact or s such as difficulty m oving or pain limiting y our sexual ex pr ession? Is ther e anythin g else limiting your sex ual expr ession that y ou w ould like t o t ell m e about ?

(If all the abov e r espon ses hav e been an sw er ed n o t erminat e the int erview , other wise pr oceed with the question s)

4) How do y ou feel about your curr ent sexual ex pr ession in t erm s of fr equency ? Is it a s often a s y ou w ould wish?

5) How do y ou feel about your curr ent sexual expr ession in t erm s of satisfaction?

Could you t ell me m or e about why you feel this w ay ?

6) Som etim es m edication s can h av e an affect on y our desir e for sex ual expr es sion . What m edication s ar e y ou taking? Do y ou feel y our medication s m ay affect y our int er est in expr essin g your self sex ually?

7) S om e people, as they g et older , expr ess a v ariety of w ay s in which they ar e limit ed in their ability t o engage in sexual expr ession , for ex ample, not h aving a partn er or fear of not bein g an adequ at e sexual partner . Does this apply t o y ou?

Does anything else com e to min d?

An en din g st at em ent is r ecomm ended in the closur e of the int erview schedule. T he following st at em ent can be u sed as an ex ample, I kn ow this is the fir st time w e hav e t alked about sexu ality . If som ething should com e t o y our mind lat er , plea se discu ss this with m e anytim e in the futur e.

D i s c u s s i o n

T he comm ent s fr om the occupational

ther apy ex pert s in geriatrics/ g er ont ology

w er e con sider ed in the r evision of the

int erview schedule. How ev er , som e com - m ent s w er e r ej ect ed based on the lit er atur e r eview and the study purpose. T w o r espon dent s indicat ed the t erm , sexual activity , can be per ceiv ed in v ariou s w ay s . T he definition of sex ual expr ession w as clearly r e- stated in the r evised interview schedule t o minimize any confu sion . T h e r espon dent s appr eciat ed the structur e of the qu estion s bein g open - en ded which can be individualized in eliciting sen sitiv e issues.

One concern w as th e isolation of sex - uality issues. In r espon se t o this con cern , it w as encour aged that the r evised int erview schedule be administer ed w ith other ar eas of ADL as sessm ent . On e con - cern for the patient w as the limit ation of opportunity t o t erminate the int erview pr oces s. T h e r esear cher s acknow ledged this con cern by addr essing this issue in the intr oduction section of the r evised int er - view schedule.

Alth ough on e r espondent ar gued sex - uality issues should focu s on quality r ather than quantity , th e r esear cher s felt fr e- qu ency of sexual expr ession m ay be an import ant fact or for som e individu als. A r espon dent implied that past sexual expr ession w as irr elev ant t o curr ent needs.

How ev er , based on th e Continuity m odel (At chley , 1989), the r esear cher s decided t o include the qu estion s r eg ar din g sexual expr ession in the past . A r espon dent r ecomm ended the u se of a scale as part of the interview sch edule. T his idea w as r eject ed becau se the u se of a scale w ould limit the question s t o a closed - en ded for - m at which th e r esear cher s int ention ally av oided.

One r espondent sugg est ed the inclu sion of a question r egar din g th e effect of

m edication . T his idea w as w ell t aken by the r esear cher s an d included a s part of the int erview schedule. One concern r aised by r espon dent s w a s the clarity of as sist ance which w ould be offer ed by th e occupational ther apist such a s written inform ation and gr oup education . In the r evised int erview schedule, this concern has been incor - por at ed int o th e guidelines an d intr oduct ory st at em ent which the occupation al ther apist is t o follow . Most r espon dent s agr eed that the int erview sch edule w ould elicit infor - m ation r egar din g sex uality . One r espon dent qu estioned who w ould administ er the int erview schedule. Ultim at ely , this int er - view schedule will be administ er ed by the occupational ther apist . How ev er , the r evised int erview sch edule will be pilot ed by student s continuing this pr oject t o ascert ain v alidity of this int erview sch edule.

L im it a t i o n s

Alth ough the size of the sample w as sm all (n =7), the quality of the r espon ses w er e th oughtful and compr ehen siv e, yield - ing a v aluable outcom e. T he comm ent ary section w as limit ed to gener al r espon ses on the int erview schedule. T o en cour ag e m or e efficient r espon ses, the r esear ch er s could hav e had comment ary question s r elat ed t o each question of the int erview schedule.

How ev er , m any r espondent s chose to com - m ent on each question despit e the lack of r equ est for such .

In analy zing the r espon ses, the r esear ch -

er s pr ovided ju stification for r ej ecting

and/ or accepting comm ent s. How ev er , the

r esear cher s r ecognize that their judgem ent

m ay hav e been biased. In th e dem ogr aphic

qu estionn air e, the scale could hav e included the option of som etim es bet w een oft en and r ar e, leavin g the r espon dent s with m or e choices .

Older adult s w er e not included as ex pert s in dev elopin g the int erview schedule. T he r esear cher s hav e n ot yet pr ovided a m eth od of asses sing the v alidity and r eliability of the int erview schedule.

F urther r esear ch is indicat ed t o obt ain v alidity an d r eliability of th e int erview schedule.

In distributing information packet s to the r espon dent s , the r esear ch er s m ay n ot hav e clarified sufficiently the purpose of the study , the cont ext in which the interview schedule w ould be administ er ed, and the possible r ole of occupational ther apist s aft er administ ering the int erview schedule. T he r esear cher s dev eloped th e int erview schedule with the assumption that it w ould be applicable for older adult s in a v ariety of settin g s.

Im pli c a t i o n s f o r t h e O c c u p at i o n a l T h e ra py P ro f e s s i o n

T he m ost salient implication fr om the discu ssion of this r esear ch w as the n eed for an assessm ent t ool which w ould adequat ely ev aluate the sexuality of older adult s. A s a r espon se t o this n eed, the advisor an d the r esear cher s h av e dev eloped the r evised v er sion of the int erview schedule based on the comment s fr om occupational ther apy ex pert s in ger ont ology / geriatrics .

T he int erview schedule w ould pr ovide inform ation th at could be u sed in the fir st thr ee lev els of the PLIS SIT m odel ap -

pr oach : the fir st lev el, permission , the secon d lev el, limit ed inform ation , and the thir d lev el, specific suggestion s. T h e r esear cher s believ e if occupational th er a - pist s w er e kn owledg eable about the PLIS SIT model appr oach , they w ould be better pr epar ed t o administ er the int erview schedule in gatherin g r elev ant information about sexu ality of older adult s .

T he thr ee theories - - th e activities h ealth m odel, the biopsych osocial m odel, and the continuity m odel- employed in this r esear ch gav e the r esear cher s guidelines in addr ess - ing sex uality is sues with older adult s . It w as anticipat ed that the implication s for occupational ther apy w ould be far r eachin g as integr ation of the knowledge ba se of sexuality int o pr actice becom es a r eality . T his w ould fulfill the biopsy chosocial philosophy of occupational ther apy an d the pr om otion of activities health , w hile enhan cing the continu ation of quality of life for many older people.

T his int erview schedule is expect ed t o be utilized in futur e stu dies as w ell as in assessing activities of daily livin g for occupational ther apy int erv ention . T his study will be continu ed and the int erview schedule w ill be pilot ed in the next aca - demic y ear at Columbia Univ er sity .

Co n c lu s i o n

In the occupational ther apy pr ofession , sexual ex pr ession has been defin ed (Uniform T erminology T askfor ce, 1994) as an import ant function of activities of daily living . T he high r espon se r at e of r espon - dent s t o this stu dy r eflect ed this belief.

T he lack of an assessm ent t ool of sexual

functioning led the r esear cher s t o dev elop

an int erview schedule which could be incorpor at ed into an activities of daily living assessment .

T he m ain purpose of this study w as t o dev elop an int erview schedule for older adult s with arthritis r egar ding their sexuality . Occupational ther apist s ar e in a position t o act as liaison s betw een patient s and other m edical expert s since occupational ther apist s u sually spen d m or e time with patient s per ses sion than phy sician s. Occupational th er apist s t end t o dev elop close r elation ships with their patient s

efor e, allowin g the patient t o feel comfort able discu s sing sen sitiv e is sues such as sex uality . T he int erview schedule will allow occupational th er apist s t o det ermine if the patient is havin g pr oblem s socially , psy chologically , biologically or a combination of these dom ain s of function . T his int erview schedule will enable occupational ther apist s to appr opriat ely r efer patient s t o oth er m edical ex pert s when necessary and t o int erv ene appr o- priat ely . T hese r esear ch er s believ e th at it is helpful to include question s r egar ding sexual fun ctionin g as part of an ov er all assessment of activities of daily livin g .

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