Experiences, attitudes, and needs related to sexuality and service delivery in individuals with traumatic brain injury

Experience of adapted cognitive behaviour therapy to address sexuality problems after traumatic brain injury: A qualitative study

Although sexuality has been shown to be negatively impacted in up to half of individuals who sustain traumatic brain injury (TBI), few studies have sought to evaluate the efficacy of targeted interventions. Gaining insight into the participant experience of undergoing treatment for post-TBI sexuality changes is a crucial aspect of intervention evaluation. This study aimed to investigate participants with TBI experience of undergoing eight sessions of a novel CBT intervention designed to help both couples and singles improve sexual wellbeing after TBI. Eight participants (50% male) with moderate-severe TBI, and a mean age of 46.38-years (SD = 13.54), completed a qualitative interview. A six-phase reflexive thematic analysis approach was used. Despite variability in participant characteristics, the findings suggested that participants with TBI experience reflected that of a positive treatment journey characterized by high levels of enjoyment and satisfaction. Key themes identified included contextual factors that preceded treatment, factors that facilitated treatment engagement, outcomes derived from the treatment experience, and feedback provided on reflection. The results not only provide an enriched understanding of the client experience of the intervention but provide corroborating preliminary evidence of efficacy for this novel CBT intervention in addressing complex and persistent sexuality problems after TBI.

Methodologies to measure access to care post-discharge in adults with serious injury-related disability: a scoping review

PURPOSE

This scoping review examined the methodologies used to measure access to care in serious injury-related disability populations, for whom access to care post-discharge has significant implications for patient outcomes and rehabilitation trajectories.

METHODS

Four electronic databases were searched for literature published between 1 January 2000 and 15 February 2022. Relevant articles needed to relate to access to care in adult community-dwelling trauma and rehabilitation populations.

RESULTS

The initial search identified 679 articles. Following de-duplication, the title/abstract screening was completed on 533 articles, and 56 full-text articles were reviewed. Thirty-eight articles met the eligibility criteria and were included in this review. Of the 38 studies included, there was large heterogeneity in the methodologies used to measure access to care. Two articles used multidimensional measures of access to care.

CONCLUSIONS

There is an urgent need to establish the use of multidimensional measures as standard practice in access-to-care research. Failure to account for the multidimensional nature of access to care limits the full realisation of access for people with serious injury-related disability and prevents the implementation of processes that could improve access to health, rehabilitation, and support services and enhance the quality of care for individuals with a serious injury-related disability.

Unmet Need for Sexual Rehabilitation after Acquired Brain Injury (ABI): A Cross-Sectional Study Concerning Sexual Activity, Sexual Relationships, and Sexual Rehabilitation after ABI

In relation to brain injury rehabilitation, research has stressed the importance of including sexuality issues due to increased risk for sexual dysfunctions after Acquired Brain Injury (ABI). This study aims to explore experiences after non-stroke ABI concerning individual and relational aspects of sexuality, received information about sexuality at rehabilitation, and gender differences. A postal nationwide survey was conducted in Sweden, 2018–2019. The sample included individuals who had participated in brain injury rehabilitation 2014–2016, response rate 40% (250/624). Among all participants 78% had resumed sexual activity, and there was a significant difference between males (84%, 118/140) and females (69%, 76/110, p = 0.004). Among all participants, 95% reported physical intimacy as important, 80% considered sex as important on an individual level, and 91% stated sexuality as important for the relationship (no gender differences). Significantly more females (52%) than males (22%) reported that they had tried sexual aids (p = 0.000), and more males (29%) than females (16%) reported that professionals addressed sexuality issues during brain injury rehabilitation (p = 0.024). However, only a few participants were offered specific sexual counseling during brain injury rehabilitation, such as individual counseling (3%), couples counseling (2%), and group counseling (3%). To conclude, the vast majority valued both individual and relational aspects of sex and sexuality highly, and more males than females had resumed sexual activity. Few had received information about sexuality after ABI, and even fewer females compared to males reported that the issue was raised during rehabilitation. Clinical implications are discussed in relation to sexual rehabilitation.

A qualitative study on the attitudes and approaches of Australian clinicians in addressing sexuality after acquired brain injury

PURPOSE

Studies indicate that up to 50% of survivors of acquired brain injury (ABI) experience persistent changes in sexuality. However, research on clinicians' perspectives in addressing sexuality issues post-ABI is limited. This study explored the attitudes and approaches, barriers and facilitators, and training preferences of Australian clinicians in addressing sexuality in individuals post-ABI.

METHOD

Purposive sampling was used to recruit 20 Australian multi-disciplinary clinicians from a related survey study. Semi-structured interviews were conducted and qualitatively analysed using thematic analysis.

RESULTS

Three broad themes were identified: ABI results in multi-faceted changes in sexuality; there is a fundamental discomfort in talking about sexuality; and, strategies proposed by clinicians may help to improve sexuality support. Participants also provided suggestions for sexuality training, which they believed should start at university.

CONCLUSION

Most clinicians are aware of sexuality issues post-ABI but fail to adequately address sexuality in individuals post-ABI due to personal levels of discomfort, perpetuated by institutional factors. Therefore, participants believe that changes made at individual and institutional levels may increase sexuality support for individuals with ABI. However, further research on the causes and treatment of sexual problems and patient perspectives is required to provide the evidence-based guidelines and training programs that clinicians require.Implications for rehabilitationUp to half of individuals experience changes in sexuality after ABI that restrict quality of life and relationships.The consequences of ABI and their impacts on sexuality are understood by Australian clinicians but remain largely unaddressed due to individual discomfort, perpetuated by institutional factors.This study suggests that professional training targeted towards understanding, assessing and treating sexuality issues post-ABI may help to reduce the discomfort.Adjustments should also be made at individual, policy and procedural levels to ensure that sexuality is addressed within rehabilitation post-ABI.

Survey on the experiences, attitudes, and training needs of Australian healthcare professionals related to sexuality and service delivery in individuals with acquired brain injury

Following acquired brain injury (ABI), sexuality, self-esteem and practices are often negatively impacted. Whilst sexuality is recognized as an essential part of a person's life regardless of medical condition, it is poorly understood in the ABI rehabilitation context. This study examined current assessment and treatment practices for sexual health and wellbeing in ABI rehabilitation, including perceived barriers and facilitators to discussing sexuality with individuals after ABI. We also assessed the need for further education and training in this area. Two hundred and thirty-nine Australian healthcare professionals predominantly working with both traumatic brain injury (TBI) and stroke populations completed an online survey comprising thirty-four questions. The 12-item sexuality attitudes and beliefs survey (SABS) was included as an additional objective outcome measure. Findings suggest that healthcare professionals infrequently raise sexuality with individuals with ABI. Inadequate education and training, not knowing whose role it is and when to raise the topic, and the view that individuals with ABI will ask for the information were all identified as key barriers contributing to poor sexuality management after ABI. More education and training opportunities with greater access to resources are needed to facilitate the incorporation of sexuality into routine practice across the continuum of ABI care.

Pregnancy After Concussion: A Clarion Call for Attention?

OBJECTIVE

Emerging research shows that women who sustain a mild traumatic brain injury, also termed concussion, have a higher risk of menstrual irregularities and sexual dysfunctions. However, no research exists on how these reproductive disruptions affect women's subsequent pregnancies. The objective of this study was to evaluate pregnancy outcomes after concussion in a cohort of reproductive-aged women (aged 18-45 years), 24 months post-injury. We hypothesized that, compared with their extremity-injured peers in the same cohort, women with concussion will have lower incidence of pregnancies.

SETTING

Emergency department of a level 1 trauma center.

PARTICIPANTS

Women of reproductive age (aged 18-45 years) seeking care for concussion or extremity injury.

DESIGN

Longitudinal cohort study that used data collected at 3 distinct time points: t0, baseline: an original cohort of 245 women recruited in January to July 2017 for exposure assessment; t1, 6(+4) weeks post-injury: evaluation of self-reported postinjury menstrual and sexual changes for subgroup analyses-data collected in March to September 2017 ( n = 135); t2, 24 months post-injury: March 2020 chart review for documentation of pregnancies/pregnancy-related events ( N = 245).

MAIN MEASURE

Poisson regression estimates used to model the incidence rate (IR) of pregnancies, comparing concussion with extremity injury.

RESULTS

We reviewed the charts of 254 women from the t0 cohort. After excluding 9 patients who were either deceased or missing relevant data, we had the 245 (96.5%) charts of 102 concussed and 143 extremity-injured study participants. After adjusting for race and obstetric history, women with concussion had 80% lower incidence of pregnancies than their extremity-injured peers (adjusted [adj] IR = 0.20; 95% CI: 0.07-0.59; P = .003). When we excluded women who were using birth control, the IR of pregnancy for women with concussions was 76% lower than for those who had sustained extremity injuries (adj IR = 0.24; 95% CI: 0.07-0.81; P = .02). Pregnancy incidence remained consistently lower for concussed women in additional sensitivity analyses excluding assault/domestic violence victims and those with a prior/new concussion at t0 and t2. Subgroup analyses of the 135 women who had experienced menstrual and/or sexual dysfunctions at t1 showed 84% reduced incidence of pregnancy for women with concussions compared with those who had sustained an extremity injury (adj IR = 0.16; 95% CI: 0.04-0.73; P = .02).

CONCLUSION AND RELEVANCE

Our study potentially serves as a clarion call to understand the long-term reproductive effects of female concussions.

Resilience and Sexuality After Concussion in Women

Background

Previous findings from our group show that in the acute (ie, 6–10 weeks) post-injury period, women with concussions have a 70% greater risk of sexual dysfunction than those with extremity injuries. There are currently limited treatment options for the clinical management of concussions. Resilience is a protective, modifiable psychological construct that has been shown to improve concussion-related sequelae. To date, however, no research has evaluated how resilience impacts sexuality outcomes after concussion in women.

Aim

Evaluate if resilience offers protection against negative sexuality outcomes in a cohort of reproductive, aged women with a concussion, seeking care in the Emergency Department of a Level-1 Trauma Center. We hypothesized that women with low resilience will be more likely to experience negative impacts on sexuality and that increasing levels of resilience will be associated with more positive sexuality outcomes.

Methods

Secondary data analyses.

Measures

Resilience was evaluated with the Resilience Scale (RS), and the Brain Injury Questionnaire for Sexuality (BIQS) was used for sexuality.

Results

Of the 299 participants recruited for the parent study, 80 with concussion had complete follow-up data and were included in these secondary analyses. Less than half (42.5%; n = 34) had low resilience (score≤130 on the RS), and the remaining 46 (57.5%) had high resilience (score>130 on the RS). In crude linear regression models, 1-unit increase in resilience was associated with a 4% increase in sexuality outcomes (β = 0.04, 95% CI:0.01, 0.05; P = .008). The effect estimate remained similar in post-concussion-symptom-adjusted models (β = 0.03, 95% CI:0.002, 0.06; P = .03). Mood-adjusted models showed a statistically significant interaction term (P < .0001). After stratifying by mood, findings showed that unit increases in resilience were associated with a 6% increase in sexuality outcomes for women in the high risk mood group (HADS score ≥11; PCS-adjusted β = 0.06, 95% CI:0.02, 0.11; P = .009).

Conclusion

Longitudinal studies are needed to evaluate how these improvements in resilience translate to patient recovery measures following concussion.

Anto-Ocrah M, Oktapodas Feiler M, Pukall C, et al. Resilience and Sexuality After Concussion in Women. Sex Med 2021;9:100297.

Traumatic Brain Injury and Sexuality: User Experience Study of an Information Toolkit

Background

After having sustained a traumatic brain injury (TBI), individuals are at risk of functional impairments in information processing, abstract reasoning, executive functioning, attention, and memory. This affects different aspects of communicative functioning. Specific strategies can be adopted to improve the provision of health information to individuals with TBI, including the development of written materials and nonwritten media.

Objective

A user-centered design was adopted to codevelop four audiovisual presentations, a double-sided information sheet, and a checklist aimed at informing individuals about post-TBI sexuality. The last phase of the project was the assessment of the user experience of the information toolkit, based on the User Experience Honeycomb model.

Methods

Overall, two small group discussions and one individual semistructured interview were conducted with individuals with moderate to severe TBI.

Results

The participants mentioned that the toolkit was easily usable and would have fulfilled a need for information on post-TBI sexuality during or after rehabilitation. They mostly agreed that the minimalist visual content was well-organized, attractive, and relevant. The information was easily located, the tools were accessible in terms of reading and visibility, and the content was also considered credible.

Conclusions

Aspects such as usability, usefulness, desirability, accessibility, credibility, and findability of information were viewed positively by the participants. Further piloting of the toolkit is recommended to explore its effects on the awareness of the potential sexual repercussions of TBI in individuals and partners.

Mild traumatic brain injury/concussion and female sexuality, a scoping review of the literature

Background

The American Congress of Rehabilitation Medicine (ACRM) in 2010 called for more head injury research on gender disparities to bridge the gender gap for the short-and long-term effects of TBI, including sexual and reproductive outcomes. In this paper, we review the state of the literature before and after the ACRM announcement, and evaluate how research teams have considered females and mildly injured TBI(mTBI)/concussion groups in post-TBI-related changes in sexual functioning.

Methods

The research question for this scoping review was “what is the state of the literature in the evaluation of post-TBI sexual changes for women, and individuals with mTBI?” Using the 2010 ACRM call for action as a line of demarcation, we compared our findings before and after the 2010 announcement.

Results

We identified 9 research studies that addressed sexual functioning changes in females and mTBI/concussion groups. Four of the nine were published before the 2010 ACRM announcement, and five were published after. The representation of female research participants increased steadily over the 28-year timespan. The proportion of individuals with mTBI included in the post-2010 era was higher than the earlier time period. Consistently, women with mTBI reported more adverse sexual outcomes compared to male cohorts, orthopaedic, and non-injured comparison groups. This observation persisted regardless of recruitment site (rehabilitation center/Emergency Department (ED)/Community) or time of outcome assessment (acute versus chronic). The findings also remained despite the heterogeneity of survey questionnaires used to evaluate sexual functioning outcomes. Excluding the most recent 2019 study, none of the research groups compared the findings by TBI severity, making it difficult to fully understand how concussion-related sexual changes compare to more severe forms of the head injury. The long term impacts of the sexual changes, such as infertility and relationship discord were also absent across all studies; even though most evaluated outcomes chronically (some as far out as 20 years post injury).

Conclusion

The number of publications in the era before the ACRM call for action and afterwards were almost identical. In order to tailor interventions for the appropriate groups of TBI patients, more neurosexuality research is needed to increase awareness of the importance of sexuality as a health outcome for individuals with neurodisabilities.

Co-creation of a post-traumatic brain injury sexuality information toolkit: a patient-oriented project

AIM

Different studies and two clinical practice guidelines emphasize the necessity to provide patients undergoing rehabilitation with information about commonly occurring changes in sexuality following traumatic brain injury (TBI). The purpose of this study was to co-create information resources for individuals with moderate to severe TBI and their partners to consult during rehabilitation.

METHODS

An iterative user-centered design was used, combining focus group and individual interviews. A convenience sample of individuals with TBI and life partners was constituted.

RESULTS

The needs and expectations of these participants in terms of form and content of an information toolkit on post-TBI sexuality were explored. The subjects that matched the interests and needs of participants were numerous and supported by the literature. Contrasting with existing written resources, the participants' views oriented the creation process toward the development of a toolkit including five audiovisual presentations, a double-sided information sheet, and a checklist.

CONCLUSIONS

A similar approach of co-creation could be used to develop other information packs aimed at patients with other disabilities. The created material is expected to be a usable and useful tool for individuals with TBI, which can support clinicians in addressing the subject of sexuality.Implications for rehabilitationThe central role held by individuals with moderate to severe traumatic brain injury, in identifying the sexuality related topics to be addressed and the form of resources to be created, led to a better understanding of their needs.This patient-centered research brought solutions to difficulties related to the understanding of health information, prevalent among patients.This patient-oriented project highlights the necessity for adequacy between the health information provided by rehabilitation professionals and the capacity of their patients' to seek for, process, and understand its content.

What is known about sexual health after pediatric acquired brain injury: A scoping review

BACKGROUND

Positive sexual development is a core task in the transition from childhood/adolescence to adulthood. Little is known about the extent of research addressing this topic after acquired brain injury (ABI).

OBJECTIVE

To identify publications (1980 to 2016) addressing positive sexual health among children/adolescents with ABI.

METHODS

A scoping review.

RESULTS

A search conducted using OVID and PubMed databases yielded 2021 citations with 28 publications meeting the inclusion criteria (six reviews, one expert account, 19 observational and two intervention studies). Teenagers with ABI reported poorer body image, feeling less sexually or physically attractive than sex and age matched non brain-damaged controls. The one study with findings on sexual orientation, reported 15% of adolescents with ABI identified as lesbian, gay or bisexual. Precocious puberty was a rare outcome from ABI, but the most common focus of the publications (14/28). Finally, two case studies (genital touching and classroom masturbation respectively) found that behavioral interventions were an effective means of extinguishing inappropriate sexual behaviour after childhood ABI.

CONCLUSIONS

Sexual health is a neglected area of research in post-ABI care for children/adolescents. A better understanding of the needs and challenges will help rehabilitation professionals and parents provide more informed and effective supports.

Towards a taxonomy of sexuality following traumatic brain injury: A pilot exploratory study using cluster analysis

INTRODUCTION

Clinicians need to understand the heterogeneity of sexual problems following traumatic brain injury (TBI) for their adequate identification and treatment.

OBJECTIVE

To systematically identify groups of individuals with TBI showing similar patterns of sexual functioning.

METHODS

Forty-two individuals with TBI with a mean age of 37.9 years (SD = 9.7) and an average of 3.3 years post-injury (SD = 4.3). We included four primary measures in the cluster analysis (sexual quality of life questionnaire, sexual desire inventory, generalized anxiety disorder scale, and the patient health questionnaire for depression) and two secondary measures for cluster validation (post-concussion symptom scale and dysexecutive questionnaire).

RESULTS

A hierarchical cluster analysis using the Ward method revealed the existence of two groups of individuals with TBI: a) with sexual problems who were older, showed lower levels of sexual quality of life and sexual desire, with significant symptoms of anxiety and depression, and b) without sexual problems who were younger, showed high levels of sexual quality of life and sexual desire, as well as low complaints of anxiety and depression.

CONCLUSIONS

Clinicians must be more proactive in assessing sexual concerns, mostly when emotional and cognitive difficulties are present in older individuals with TBI, regardless of gender, chronicity and injury severity.

Chronic impact of traumatic brain injury on outcome and quality of life: a narrative review

Traditionally seen as a sudden, brutal event with short-term impairment, traumatic brain injury (TBI) may cause persistent, sometimes life-long, consequences. While mortality after TBI has been reduced, a high proportion of severe TBI survivors require prolonged rehabilitation and may suffer long-term physical, cognitive, and psychological disorders. Additionally, chronic consequences have been identified not only after severe TBI but also in a proportion of cases previously classified as moderate or mild. This burden affects the daily life of survivors and their families; it also has relevant social and economic costs.

Outcome evaluation is difficult for several reasons: co-existing extra-cranial injuries (spinal cord damage, for instance) may affect independence and quality of life outside the pure TBI effects; scales may not capture subtle, but important, changes; co-operation from patients may be impossible in the most severe cases. Several instruments have been developed for capturing specific aspects, from generic health status to specific cognitive functions. Even simple instruments, however, have demonstrated variable inter-rater agreement.

The possible links between structural traumatic brain damage and functional impairment have been explored both experimentally and in the clinical setting with advanced neuro-imaging techniques. We briefly report on some fundamental findings, which may also offer potential targets for future therapies.

Better understanding of damage mechanisms and new approaches to neuroprotection-restoration may offer better outcomes for the millions of survivors of TBI.

Relationships between risky sexual behaviour, dysexecutive problems, and mental health in the years following interdisciplinary TBI rehabilitation

Little is known about the long-term consequences of traumatic brain injury (TBI) regarding risky sexual behaviour. The objectives of the study were (1) to compare risky sexual behaviour in a sample of individuals with TBI having received interdisciplinary rehabilitation with that of healthy controls, and (2) to explore the relationships between risky sexual behaviour, executive functions, and mental health in individuals with TBI. The study group consisted of 42 individuals with TBI with a mean age of 37.9 years (SD = 9.7), 12.8 years of education (SD = 3.3), and 3.3 years post-injury (SD = 4.3). Healthy controls consisted of 47 participants, with a mean age of 37.6 years (SD = 10.7), and 13 years of education (SD = 3). Risky sexual behaviour was measured with the Sexual Risk Survey and executive function with the Dysexecutive Questionnaire. Mental health measures included the Generalised Anxiety Disorder Scale, and the Patient Health Questionnaire for depression. Compared to healthy controls, individuals with TBI reported more dysexecutive and mental health problems, without differences in risky sexual behaviour. In individuals with TBI, risky sexual behaviour was associated with behavioural, cognitive and emotional dysexecutive problems, but not with anxiety or depression. It was concluded that special attention should be given to individuals with TBI showing difficulties in executive functions given their association with risky sexual behaviour.