Tailoring pleasure by decoding Desire and Arousal in Occupational Therapy:
Haven’t we all heard and used these two words interchangeably before? I am pretty sure most of us have. I have it too! I would like to blame many people but I will save that diatribe for another day. Before I dive into the role of Occupational Therapists in this area, I would clarify the difference between these two terms.
Desire refers to a baseline interest in sex, and may also be referred to as sexual appetite or libido. Arousal, on the other hand, refers to the physiological response to sexual/non-sexual stimuli. In other words, if the desire is a feeling, arousal is our body’s reaction to those feelings which doesn’t necessarily have to be sexual!
DECODING DESIRE & AROUSAL
Arousal and desire are not one-size-fits-all. These are ever-developing key characteristics of everyone’s sexuality. I would like to believe that there is no normal when it comes to desire and arousal. Every person and body is different, so are their choices and preferences. Hence, we’d like to believe that desire and arousal go hand in hand. However, they do not! You may feel like engaging in any sexual activity, but you are not feeling aroused. Your body maybe prepared, but your feelings are not feeling in sync with what your body needs. You can make as many combinations as possible with these two elements.
The lesson to remember here is, desire and arousal are two independent and interdependent characteristics of our sexuality. They are like pedal and brake of our car, a balance between the two is what ensures a safer, smoother ride. Having ebbs and flows or mismatched desire and arousal is normal and only human. What isn’t normal is you waiting for one or both of them to change to get your car moving. Each of them has a separate, significant role to play which, is reflected as a manifestation of each other.
The understanding of these two as a feeling and response, together and separately, is essential when addressing/assessing it with our clients. Why? Because it is highly likely that these core feelings have a direct impact on our somatic experiences. The aftermath of negative experiences, associations, learnings, trauma, assault, toxic environment, or relationship(s), and/or lack of exposure mirrors in our desire and arousal patterns. It then becomes a core understanding for the therapist to separate it as a physiological or psychological limitation/response of an individual to holistic engagement in their occupations of sexuality.
WHY SHOULD OCCUPATIONAL THERAPISTS CARE?
Occupational Therapists always have an educational approach to learning about body and its capabilities despite physiological or psychological barriers.
Desire fuels our drives and motivation helping us to evolve and create. It steers our pleasure pursuits of food, joy, self-expression, sex, intimacy, and connection. It strives to help us understand the needs and wants of our body- physically and emotionally- to create a more fulfilling, meaningful, conscious union with self and others.
This desire usually reflects as a manifestation of arousal. Hence, desire isn’t only a bodily feeling, but also a state of excited feelings or interests.
Over the years, we have received so many negative messages about our body that we and our clients often forget, it needs to be prioritized and valued just like every other ADL. Moreover, these key components have such a diverse role to play. Every person, in some way or the other, wants to feel desirable or has some desires. When we move away from function and focus on the pleasure, we emphasize new ways of reconnecting, reshaping, and rekindling relationship(s), intimacy, and sexual activities (penetrative and non-penetrative) with ourselves and our partner(s).
We as therapists need to readjust our occupational lens to reconsider, and re-prioritize the connection with the body not only therapeutically but also tailored to our client’s desires & pleasure. So, let’s start from there, shall we?
Mapping is a general function between two objects or structures. It is a way one can relate to self, and others all while being a part of the big circle (meaning community). Desire and pleasure mapping could be a legit treatment modality enhancing the understanding and relation of one’s needs from their body, concerning that of their partner(s) and the community they belong to. Like I mentioned earlier, this does not always have to be sexual. It can be but does not necessarily require a sexual perspective. Moreover, this technique is applicable to all people despite their age, gender identity, sexual orientation, and/or limitations/disabilities/impairments,etc.
In the context of OT, I incorporated the idea of mapping as an amalgamation of both- top-down and bottom-up approaches- where we bring attention to feelings, emotions, and desires first to adapt and achieve participation in desired areas of intimate and social living.
Step 1: Assessment
Begin with an initial set of questionnaires and self-assessment scales depending upon the concerns that are stated by the client. These assessment scales should also reflect on the socio-cultural values, beliefs, interpersonal factors, and the importance it holds for the client. This serves as a tailored yet holistic approach where a therapist and a client come together to explore, map, and point the multi-faceted areas of clients’ life that hold meaning for them.
Example: If you use the Ex-PLISSIT model to assess your clients, there also needs to be a section which talks about their current presenting complaints, their culture, gender, and sexual identity and past sexual experiences.
Step 2: Open ended questioning
Explore and assess the client’s responses to the following questions concerning body structures and functions (arousal, orgasm, satisfaction, excitement, erogenous zones, etc). It plays a crucial role in determining what additional follow-up questions, referrals, or adaptations would be required to assess risk and identify opportunities for sexual health habilitation either as a singular or collaborative process.
Example: Build upon the questions that you have asked earlier. This section will include questions about sexual activity preferences, solo/partnered experiences, pleasure, satisfaction, consent, orgasm/ejaculation, etc.
Step 3: Goal-setting
Goal-setting is the last layer to set the foundation for our mapping intervention strategy. Consider limitations, environment, and personal factors when you are setting goals. Personally, COAST goals are beneficial as they help in focusing performance components associated with possible occupations that are perfect for screening and activity analysis. Additionally, focus on examining roles and routines, relationships, activities of daily living, and accessing the community.
I will discuss this further using a sample case study towards the end to better inform and understand this approach in pleasure mapping.
DESIRE MAPPING AS MEANS TO INTIMATE OCCUPATION
When clients get clear about how they want to feel, the pursuit of pleasure itself becomes more satisfying and meaningful to them. OT intervention in exploring & enhancing desire and arousal using pleasure mapping can look the following ways (the list below is non-exhaustive and only means to provide an overview of the range of OT intervention):
· Understand the impact and manifestation of Desire and Arousal on the client
· Stress management and relaxation techniques
· Use of somatic exercises to improve internal awareness (dancing, movement therapy, stretches, progressive relaxation, etc)
· Reconnecting the client with their body through the therapeutic use of touch (outside of any sexual activity) which can facilitate self-love and pleasure. Focus on a variety of tactile sensations all over the body (temperature, texture, pain, etc)
· Explore incorporating tactile and proprioceptive play (positioning to cuddle, hug, foreplay, etc)
· Task and environmental modifications like scheduling sex/pleasure, using an appropriate amount of sensory-stimulating environment for engaging in intimate activities
· Positioning aids to place them in an optimal and safe environment
· Assistive devices like toys, lube, vibrators, ropes, slings, etc to enhance independence, kink, arousal, or sensations depending upon the needs of the client
· Explore alternatives to penetrative sex and sexual play via erogenous zones, sensory play, engagement in other intimate acts such as kissing, tantric sex play, self-pleasuring, etc
The idea is to explore and deviate from experiencing sex and orgasm as an end goal and for it to be a means of reconnecting with ourselves and/or with our partner(s) for pleasure. Try (re)exploring what goal may might be trying to achieve through intimate activities and tailor your goals & interventions accordingly.
SAMPLE CASE STUDY:
ABC is a 39-year-old married, heterosexual, cisgender female who presents complains of low arousal and painful penetration for over six months now. She works as a marketing strategist and is the mother of two children, and the youngest one is four years old (FTND, no complications reported). They resumed engaging in penetrative sexual activities for about two years now. Initially, she was experiencing problems with achieving an orgasm which resolved after they extended stimulatory play. Lately, she has also been experiencing associated low back pain, especially with penetrative sexual activities. She wishes to engage in penetrative sex but feels that her body is limiting her to perform in ways unlike before.
We do have quite a clear picture of what ABC is experiencing and wants to explore in this intimate ADL. However, this information is not enough to set actionable steps to reach the goals ABC has for herself.
Additional questions to explore:
· What does ABC mean by the word arousal?
· How often does she engage in solo and partnered activities? Does the experience the same kind of limitations while engaging in them?
· Positions preferred and home environment (type of mattress, room décor, living area, etc)
· Inquire about postpartum pelvic rehab/scar mobilization
· Pregnancy plans, Contraception methods (if any)
Assessments and Evaluations to include (not limited to):
· Pain scale
· Manual muscle testing
· Range of motion
· Sensory assessment
· Posture assumed in various settings
Goal Setting: COAST goals
A preview of what your COAST goals should be like:
· Client will demonstrate/perform/complete…?
· Occupation/activity you are writing this for?
· Assistance level/independent
· Specific conditions under which they’re performing
· Time (Instead of focusing on the time lines under which they will achieve the goal, I usually use this area for the client to decide and set the context for themselves)
Depending upon what goals you wish to set for this client, categorize them as short term and long term. Now, we switch to top-down approach as we are exploring and setting goals for improving occupational independence and engagement.
Long Term Goals:
Client will be able to engage in pain-free penetrative sexual activity using ________(adaptive device/equipment/modification) in 4 weeks to increase functional, restriction-free engagement in intimate activities.
Short Term Goals:
1. Client will be able to self-stimulation with 1-3/10 pain using _______ (fingers or any equipment) for in _______ (position + adaptations/modifications suggested), as desire/week for 2 weeks.
2. Client will be able to perform partnered penetrative activity with 1-3/10 pain using _______(adaptive device/equipment/modification) to compensate for ____ weakness/tightness in ______ (position(s)+environment modification) after somatic exercises, as desired/week for 2 weeks.
Note: The views, information, and suggestions shared above are based on the results of tracking my client’s (n=8) assessments, intervention, and feedback over 6 months. This is not a published study hence; I have refrained from sharing the types of tests and questionnaires that have been used. However, I wanted to present an overview of how desire and pleasure can be used in top-down and bottom-up approaches to facilitate adaptation & independence in client considered meaningful occupations. These learnings have been inspired and integrated from my counseling practice and presented here in the context of Occupational Therapy.
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