Sunday, September 26, 2010
Let's Talk about Sex
I thought I would post on what I hope will turn out to be an occasional series on sexuality here on Pallimed. We've covered sexuality some before. A post that leaps to mind is one by Christian in 2007 about the controversy that arose over a case where the staff at the world's first hospice designed specifically for young adults openly deliberated and decided to facilitate a 22-year-old patient's request to have sex before he died.
So, my foray is on an article that came out in the July-September 2010 issue of Sexologies. This English-French bilingual publication is, and I quote, "the official organ of expression of the European Federation of Sexology (EFS), published with the scientific cooperation of the Inter University Hospital Association of Sexology (AIHUS), which has gathered French academic teachings of Sexology since 1983." So, it's scientific, it's academic and it's French. Need I say more?
It turns out, that this article actually was available online this past April, but there's no time like the present. Titled, "Sexuality of individuals in the end-of-life stage," it was authored on this, our very own continent by M.-I. Rothenberg, PhD, a psychotherapist and clinical sexologist in private practice in Orlando, FL and A. Dupras, PhD, a professor in the Department of Sexology, Université du Québec, Montréal, QC.
The article is a theoretical and often psycho-dynamic discussion with case studies, which uses the Kübler-Ross "Five Stages of Death" model as a framework. I particularly appreciated the part in the introduction that highlighted the common experience of reticence and hesitancy on the part of professionals to address sexuality in palliative care, and that if we do address it, we tend to medicalize it, rather than offer information and support that is responsive, reflective and anticipatory. I also found that the narratives from the case studies were interesting, illuminating, some even compelling.
After our humanity, sexuality is our next great category of being, ranging from gender through sex roles, attachment and reproduction. It is at once social and deeply personal. The physiology of aging, life-limiting-disease pathology, pharmacology, surgery, radiation therapy, pain, family dynamics and existential suffering can all have bearing upon one's sexuality. Our reluctance to address these issues, to contextualize and normalize them, particularly our diffidence to even bring it up, creates a sound of silence that can be deafening.
The Kübler-Ross model has been criticized as non-scientific, i.e., that it did not arise as a predictive model accounting for validated, objective data of a phenomenon, but rather from reflection on global interviews of dying people. A lot of criticism also centers on attributions of progression and linearity. However, Kübler-Ross herself wrote that not everyone goes through every stage, that their order and direction is often fluid, alternating and circuitous, and above all individual. I think the main boon of the Kübler-Ross model, as a starting point, and this application of it with regard to sexuality is they lead us to give some thought and allow some room. They poise us to better grasp, accommodate and support the complex, individualized and sometimes confounding needs and behaviors that come up in taking care of patients and family members living with death and dying.
Rothenberg, M., & Dupras, A. (2010). Sexuality of individuals in the end-of-life stage☆ Sexologies, 19 (3), 147-152 DOI: 10.1016/j.sexol.2010.03.006
6 Responses to “Let's Talk about Sex”
September 27, 2010
Getting back to the young man with MD ... how did the hospice get around the fact that prostitution is illegal, and that they were essentially facilitating an illegal act? Also how did the ethics committee rationalize the exploitation of a commercial sex worker? I understand that the young man was at the center of the ethical debate, but these are acts that surely have consequences for others involved. Let me also say that I am not in favor of the criminalization of sex acts, but rather simply interested in the process the ethics committee undertook.
September 27, 2010
'Organ' heh heh. Yes, you may quote.
September 27, 2010
So I read this and I think to myself well yes, why in fact do we have a culture (within the HPM world) of addressing spirituality but not sexuality. And why do we medicalize it?
A couple thoughts: I agree completely we should routinely screen for sexual concerns amongst our patients.
I also think that in fact we should medicalize it. I mean, do you have particular training or competencies in addressing your patients' sexual issues apart from its 'medical aspects.' Do you have anyone on your interdisciplinary teams who can do this? I suspect most of us don't, really, although I'd be interested in what hospice/palliative care social workers and psychologists have to say about this. Most of us do, though, work side by side with professionals who are trained to address our patients' spiritual needs - that's a big difference there.
I think, for the most part, showing up, asking the questions, acknowledging our patients' emotions, and doing what we can medically is adequate, and what they want from us.
To Anon#1. I have to say in the rare instances I've come across similar situations I have been much, much, much more worried about my patients being exploited that vice versa.
September 27, 2010
Dear Anonymous 1,
With respect to the curious case of Mr. Wallis, I invite you to consult Christian's post for more specifics. But to be clear, these events occurred in the United Kingdom, and there across the Pond prostitution per se is, with certain provisos, legal. Living on this side of the Pond, and these days not an hour from Plymouth, I surmise at times that while the Puritan movement did originate in Great Britain, they seem, lo these many years, to have all migrated to these shores :)
Snark aside, I think that there is enough diversity of perspective on this matter as to make it rather complex, and not so straight forward at all. In fact, the delightful, Anglican nun, Sr. Frances Dominica, who runs the hospice in question is a subtle soul and took a very nuanced view of the matter.
September 27, 2010
Dear Anonymous 2,
Thank you, I couldn't resist.
Oh, the pitfalls of translation I'm afraid, ever grist for the joke mills.
September 27, 2010
Thanks Drew for the comments.
I think sometimes, some stuff is straight-forward medicalese on both sides of the conversation. What I mean to say is that our process can reflexively medicalize and inappropriately sanitize and denature something vital and pressing, much like preserving a specimen in formalin.
I believe in this biz, even just regular ol' physician biz, and all the more in H&PM, with time a-tickin' and prognoses being what they are, punting to the chaplain may be a fail. Sometimes there is only now and we are it, just a lil' ol' human caught wearing a doctor costume for a time. Same with sex and death. Sometimes there is only now.
So, I think bringing our whole-self to the game, and gaining a modicum of high-quality, stop-gap skizills, and an on-going willingness to deepen them, for that time when there is no more time left to call in special teams from the bench, refer out, or call in an outside pro, all that is just part of the gig.
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