How to be Trauma Informed Care when Addressing Sexuality

Trigger warning: discussion of traumatic experiences.

Trauma-informed care (TIC) practices are becoming more well-known and more widely-implemented in clinical practice. But what does this look like? And how can we as OTs provide TIC while addressing sexuality? In collaboration with OTD Student Hannah Zaininger, I recently did a deep dive into Trauma Informed Care approaches when addressing sexuality and intimacy.

The Substance Abuse and Mental Health Services Administration (SAMHSA) is an agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. They have developed a framework to help health providers understand the existence of trauma, as well as support and provide treatment to all individuals whether or not it is known they’ve experienced trauma. This model of care uses six guiding principles, which should be incorporated into health care practices. These principles are safety (1), trustworthiness and transparency (2), peer support (3), collaboration and mutuality (4), empowerment, voice, and choice (5) and cultural, historical, and gender issues (6).

SAMHSA’s Six Guiding Principles Explained

1. Safety- clients and staff feel both physically and psychologically safe and supported. There are no expectations or obligations associated with interactions. 
2. Trustworthiness and Transparency- there is a goal to build and maintain trust between healthcare providers and their clients. The rationale behind decisions is informative, encouraging honest and promoting trust.
3. Peer support- individuals have the opportunity to connect with others who may have shared experiences, thereby increasing support for the client and normalizing the process of healing and recovery. 
4. Collaboration and Mutuality- power differences between clients and staff are decreased to facilitate shared decision-making, giving the client the opportunity to see themselves as equal to their provider. 
5. Empowerment, Voice, and Choice- strengths are recognized, validated, & built upon. Choice is consistently offered and respected. Boundary-setting for both clinicians and clients fosters client-centered practice and comfortability. 
6. Cultural, Historical, and Gender Issues- stereotypes and biases are recognized and addressed, allowing for individuals to have a judgement-free space to share thoughts, ideas, identities, interests, and experiences.  

So where’s the connection between trauma and sexuality?

Enjoying sexual activity requires people to activate their parasympathetic nervous system - when people feel unsafe, stressed out, or unsure of their situation or world they’re living in, this kicks people into sympathetic mode and can reduce the overall experience or hinder engagement.    

How can we support conversations about trauma and sexuality?

1. Remember, communication is Key

Trauma itself can be hard to talk about! Whether it's partner to partner/s, client to practitioners, navigating this conversation can be stressful and even re-triggering for the individual that has experienced trauma. Then add in talking about sex, which we know requires some level of vulnerability…And we’ve got a delicate situation. How can we support our clients in discussing how trauma impacts their engagement in sexual activity? 

2. Acknowledge the trauma but give the client control to talk about it.

This means that we are still doing our due diligence to address barriers to occupational performance, but we are also offering the client the chance to take the reins on choosing how and when the trauma is discussed. Here is an example of what this could look like:

OT: “I know yesterday you mentioned experiencing sexual assault in college and you shared this makes engaging in sex hard. Do you want to discuss that further? For instance, would you want to elaborate about how you feel the experience affects your engagement or enjoyment of sexual activity so we can try to work through that?  It’s okay if you don’t want to do that today, but I want to make sure you’re feeling heard and that we are addressing challenges to engaging in sex”.  

Client: “Thanks, but I don’t really want to talk about that right now. I’m just not ready. Can we talk about something else?”

OT: “Absolutely, you’re not obligated to talk about anything you don’t want to! You’re in control here. Thanks for setting that boundary with me today”.

In this scenario, the OT has given the client space to talk about their trauma. They have addressed it as a potential barrier to sex, but they are not forcing their client to talk about it. Remember: talking about trauma could be traumatic itself. By giving the client the choice to lead the topic of conversation, you’re providing them with a secure environment and relationship and collaborating with them. In giving them control, you’re building the trust required to actually discuss these topics in therapy.  In this dialogue we have used three principles of trauma-informed care. Safety (1), Collaboration & Mutuality (2), and Empowerment, Voice, & Choice (3).

3. Offer breaks throughout the session.

This means that even if clients may not ask for one or think they need one, we are still giving them time and space to disconnect from conversations about heavy & distressing topics. When talking about trauma, it’s common to get overwhelmed, even in supportive and safe environments. Here is an example of what a clinician might say during a group session:

OT: “Okay folks, this has been a really productive conversation about sexual challenges after traumatic childbirths. Thank you all for sharing if you were comfortable to do so today. We are going to take some time away off from this group and reconnect back here in 5 minutes. The reason we are doing this is to give you space to take what you need at this moment. You can use these five minutes to practice mindful breathing, talk with group members, grab a snack, take a walk outside, or self-reflect on our dialogue today”

In this scenario, the OT has offered the group an opportunity to take a break from conversations about trauma. They have also explained why it may be necessary to do so. This gives the clients the choice to participate in an activity that may be emotionally regulating, such as deep breathing, moving around, connecting with peers who have similar experiences, or even just taking time for quiet self-reflection. The OT can also consider asking the client in a 1:1 session, “what non-verbal cues could I pick up on specific to you, that signal to me you might need a break.”  This again helps to build trust as in initial sessions the client might not feel comfortable asking for a break or might not be aware of when they might need one.  In this dialogue we have used four principles of trauma informed care. Safety (1), Empowerment, Voice, & Choice (2), Peer Support (3), and Trustworthiness and Transparency (4).