🦀 Issue 126 - Dealing with Sex

Last week, I completed my second to last CPI. And I’m grumpy. I’m not grumpy about the result of the CPI, that went perfectly fine. I’m grumpy about the CPI, which is ableist and frustrating. Insomuch as anything above intermediate is judged by the ability to maintain a certain level of caseload. Let me explain.

I don’t know if everyone knows this about me, but I’ve sustained a couple of traumatic brain injuries. The most recent was 2019 and I’m still recovering. I don’t have the mental endurance to carry a full caseload. And I’m fine with that. I am getting close! And I’m proud of that. But I’m not there yet.

At a slow clinic (8-10 a day), can do. At a “standard” clinic (13-15 a day? From what I’ve seen), I’m out. At an insane clinic (18-25 a day that I know some of you work at) and I’m sorry you do), not a chance. There’s a lot to hash out on this topic, but overall I hope the new CPI that’s coming out does a better job of allowing for success for those with different mental capacities. Those who only can or only want to work part time need room in this profession and I’ve had to fight for it. I hope others don’t have to.

With all that behind, let’s talk about this week’s Crab. It’s about sex, a topic about which I’m very passionate because it’s an ADL! I’m so passionate that I’ve covered some of this a while back and will be expanding and refreshing it along with brand new stuff. We discuss inappropriate patient behaviors in the area of sex and sexual expectations and function before and after THA. Supporters also received no advertisements and two more articles, one on how LBP affects sexual disability and a second about the comfort level of PTs in addressing sexual issues with patients. Get all of that by supporting PT Crab here.

With that, let’s dive in!

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What Patients Think About Sex After THA

The Gist - We’ll start with a fairly short one, a prospective multi center cohort study of what patients expect of sex after having a hip replaced. They split participants into the “Sexual Activity-Expecting” group and the “No Sexual Activity-Expecting” group to do this analysis, with 605 in the former group and 347 in the latter. At one year, 44% of people who reported expected sexual activity to return after THA were disappointed. In the non-expectant group, 18% regained their sexual activity, mainly men. One won’t be surprised to hear that those who experienced post-operative sexual fulfillment tended to be younger, have fewer non-MSK comorbidities, and score higher on the SF-12, lower on the VAS pain score, and higher the Hip disability and OA outcome score. Basically, if you were better off after your surgery, you were more sexually fulfilled too.

In men in the lead-up to THA, pain was the main complaint that led to limited sexual function. In women, stiffness was more challenging. There are multiple reasons for this, but a major one is that women usually require more hip ROM (abduction and ER mostly) for sexual activity than men do. Fortunately, these positions present a low risk of dislocation after surgery but the pain associated with them can lead to limited ability for and expectations of sex before THA. This leads to increased time to get back into it afterward. And, as you know, sex is complicated. This kind of stuff is bound up with emotions, psychology, and more and you should definitely refer to a sex therapist if something more than physical is going on. If you don’t know your friendly neighborhood sex therapist, look them up! They’d love to hear from you.

Tell Me More - The whole grouping process in the study hinged on two questions, the Hospital for Special Surgery Questionnaire for Hip Arthroplasty item “What do you expect of sexual activity after surgery?” And a 5 point Likert scale of sexual activity expectations where 1 was “back to normal”, 4 was “slight improvement”, and 5 was “doesn’t apply to me.” This was asked again at one year to give us our study results. While a five point scale captures a fair bit again, there’s a lot bound up in there so it’s definitely more complicated than a simple question can elucidate.

A tough confounder of this study was age. They did some followup at 2.3 years post-initial survey with people under 60 and found that 95% had regained post-operative sexual activity and 70% “reported a better quality of sex life.”

The researchers close by saying “Clinicians should consider taking SA into account as a primary outcome of total hip arthroplasty and should inform patients (particularly older patients) to develop realistic expectations regarding postoperative sexual functioning.” Hard agree.

Paper? Full text available here.

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When Patients Get Inappropriate

The Gist - I probably don’t need to tell you this, but patients can gat inappropriate in clinic. Surprisingly at first, they’re less ina-pro-pro with pelvic health providers, though this paper elucidates that a bit since more experienced clinicians tend to have fewer inappropriate patient contacts and pelvic health practitioners tend to be more experienced. They also tend to work more with women than men which confers a protective effect. 33% of pelvic health PTs had experienced inappropriate patient sexual behavior in the 12 months prior to the survey while 48% of all PTs and SPTs surveyed had.

More experienced PTs also tend to use the more effective mitigation strategies of directly addressing the behavior. The survey found that the most successful mitigation strategies included “distracting or redirecting the patient, choosing more public treatment areas or treatments with less physical contact, speaking directly to the patient about their behavior, behavioral contracts or modification plans, transfer of care to another PT, and chaperone use at subsequent visits. Experienced clinicians were more likely to be direct, while novice clinicians were more likely to engage in the unsuccessful actions of ignoring and joking.”

It’s unclear what leads less experienced PTs to experience more inappropriate behavior, but 58% of SPTs and SPTAs experienced it in the last 12 months compared to 42% of the professionals. We can speculate on this, but I think it’s even more important to add this to PT curricula since it’s not really there already. We talked about this a tiny bit in my program, but not enough, did you in yours?

Tell Me More - I know you know this is serious stuff, but it’s extra serious. 15-30% of people subjected to inappropriate behavior report burnout, absenteeism, and resignation in its wake. 25-50% of all professionals who encounter it experience anger, guilt, fear, anxiety, and depression. So how do we prevent it? Surprisingly, chaperone use during pelvic health work didn’t effect the prevalence of inappropriate behavior. And that’s kind of all we know. This was a survey, so there’s not a lot in that regard. The authors do discuss it though:

At the very least, information on the likelihood of encountering such behaviors and offering strategies to address the behaviors would be prudent. Perhaps, with additional research on risks in working with this patient population best practices can be tailored to these specific situations. Knowledge is power and empowerment is a means of prevention. No practitioner should have to weigh safety or mental health concerns against working in a practice they are passionate about.

With all of this, I’m very reflective on my own life. I’m a masculine-presenting male who wants to work with primarily men in a pelvic health practice. I know that many women successfully treat men in pelvic health, but if I were female, or even more femme-presenting, I’d probably have safety concerns in this practice. Especially as I’m considering running a one-person shop by myself. I know male therapists are far from immune from inappropriate behavior, but it does seem to be a protective element. “ Women were more than twice as likely as men to have experienced IPSB (inappropriate patient sexual behavior), and clinicians who treated mostly male patients had almost a 400% greater chance of exposure to IPSB.”

Do you have any tactics or steps that would help prevent this from occurring? If so, let me know and I can distribute them to more people.

Paper? Got it.

And that’s our week! Thanks for bearing with me last week and I hope you enjoy this issue. Next week we’ll be talking lateral epicondylalgia and how we’re pretty bad at treating it. And the week after we’re going back into the head to see what new stuff we’ve learned about headaches recently.

See you then,
Luke