September 22, 2026 by Haley Hansen, PT, DPT
Steve Kerschke: Welcome to the studio, Sarah and Zoe. If you were with us last year, this topic was requested, I guess. So there was a lot of feedback after our presentation last year on sexuality. Zoe and Sarah are leaders of that within our organization. So thank you for being leaders and thank you for joining us today and preparing this. If you are new to QLI, just a quick overview. QLI is based in Omaha, Nebraska. We’re really known for our post-acute rehab program, but we also are slowly gaining traction with our outpatient telerehab program. So we specialize in rehabilitation for individuals with traumatic brain injury, spinal cord injury, chronic pain, limb loss, and stroke. So again, those of you who are familiar, welcome back. We always appreciate seeing some familiar faces every month when we do our webinar series. And then in terms of today, we all know your CEUs are important to you, so we will definitely get you those.
Reminder to use the Q&A throughout the presentation. Laura and I will monitor that. And in terms of the CEUs, we just ask that you spend the majority of the presentation with us. There will be one poll question at the end of the presentation, so that will be denoted by a slide. So if you’re thinking throughout the presentation midway through, I haven’t seen that poll question, you’re not missing anything, it’s at the very end. So we will call that out, we’ll launch that, you need to answer that. And then upon leaving the webinar, you will get prompted to fill out a feedback form. And that feedback form, once you hit submit, will automatically give you your CEUs and slides all in one document. So you should have everything you need from us by the end of the presentation. If you have issues, reach out to Laura or myself.
Don is not with us today. We’ll miss you, Don, but you can always reach out to Don. He loves hearing from you too if he’s a familiar and safe person. So with that, I’m going to turn it over to you two.
Sara Waid: Awesome. Well, we are going to today talk about four main topics related to sexual health in the neurologic injury. And first we’re going to identify some physical, cognitive, and emotional impacts or domains of post-spinal cord and stroke that impact sexual functioning and intimacy. We’ll discuss some barriers that are related to integrating sexual health within the rehab setting and the process and to also provide some solutions for how that might be integrated a little bit better. And then demonstrating some conversational frameworks that help to initiate some discussions and then send you guys off with some resources.
So to set the stage for the foundations of sexual health, when we talk about sexual health, we’re not just talking about physical intimacy. I think that’s what most people think about when they hear the phrase sexual health. We’re really talking about the bigger picture of quality of life, someone’s identity, participation in life. And so this is really not separate from the rehab journey. It’s important to remember that for a lot of the young adults that at least we serve in our population here at QLI, they’re often dealing with these injuries. At the same time, they’re also trying to determine who are they, navigating relationships, what does independence look like in life and how they see themselves. And as we will see, sexual health isn’t just owned by one discipline, it’s really multidisciplinary in its practice. And so we really can’t show up siloed when we discuss this topic.
So the four main topics or domains that we are going to address within the neurologic injury is the physical domain. So how does the body itself change secondary to neurological injury? This is most likely in relation to sensation or motor changes. Cognition, so how has the mind or the way that we’re thinking and processing information changed and one’s ability to generate messages and also receive messages from their partner or from medical providers. The emotional side, this is really closely tied to self-esteem, body image, identity, especially for the young adult. And for many, many people, they’re grieving a lot of changes in their body and how they see themselves. And so this emotional piece really is a big factor when it comes to the sexual health. And lastly is the social relational side. Again, as we mentioned in the very beginning, sexual health is more than just the physical intimacy, and so we will take a look at more of the general social setting as well.
Zoey Bertsch: So diving a little bit deeper, breaking it down. So in terms of stroke, sexual health concerns are common, but really under discussed, especially with our young adults. Stroke can affect the brain and body in very specific ways, which means again, sexual health changes might look different from person to person. So on the physical side, stroke can affect strength, coordination, sensation, endurance, motor planning, which also may change positioning, comfort, maybe even confidence during sexual activity. Paralysis might be impacting ease of getting into different positions or even getting into the bed in general. Fatigue, spasticity, pain, medication side effects can also play a significant role in changes after stroke. On the cognitive communication side of things, people might experience changes in attention, processing speed, executive function, insight into what deficits might be impacting sexual health. Things like aphasia, dysarthria or apraxia can affect how someone is communicating desire, providing consent or vocalizing discomfort, making supported communication especially important when it comes to sexual health post-injury.
Emotional identity side of things, many people are experiencing grief, frustration, anxiety related to sudden changes in their body or abilities. Again, changes in body image and confidence can really influence intimacy and willingness to engage in relationships post-stroke. On the social relational side of things, stroke can alter relationship roles, really shift who’s caring for who. Confidence can strongly influence intimacy and willingness to, again, engage in those activities. We oftentimes will see partners become caregivers and naturally step into that role and forget to stay in that partnership, wife role, girlfriend role, whatever that is. So again, dating intimacy and renegotiating these roles within established relationships often really requires intentional support and open communication between everyone. So overall, again, sexual health after stroke is not just about the physical recovery, it’s really about communication, identity, connection, and addressing these concerns early and collaboratively really helps support participation and quality of life for our young adults.
On the traumatic brain injury side of things, TBI is often affecting multiple systems at once. So again, sexual health concerns are showing up across all of these disciplines. Again, can be especially challenging for young adults who are still forming their sense of identity and independence and figuring out who they are as a person. On the physical side, again, changes in arousal, sensation, fatigue, headaches, pain might affect sexual activity, sleep disruption, and reduced endurance can also play a significant role even when it might look like mobility is relatively intact. People might be interested, but their bodies might not even be responding the way that they want them to is sometimes a challenge we come across. On the cognitive communication side of things, again, changes in attention, impulse control, insight, judgment, social communication can again affect things like consent, boundaries, decision-making, when is the appropriate time? Some individuals might have difficulty recognizing those social cues or understanding how their behavior is being perceived by others.
Emotional and identity side of things, TBI can lead to changes in mood, emotional regulation, self-esteem and confidence. People might struggle with feeling different from their pre-injury self or uncertain about their identity. Am I still attractive or what is my role in this relationship now? Relationship dynamics, again, often shift after TBI, especially when there’s changes in someone’s independence or emotional regulation. They may need more support in these areas. Maybe we’re seeing changes in who is initiating sexual activity and touch, or maybe they’re both wanting to bring up the topic, but no one’s initiating that conversation first. Maintaining relationships might feel more complex after a traumatic brain injury, particularly when navigating things like disclosing their injury. I have had a traumatic brain injury or setting boundaries with changes in their social skills. I think something that’s really important to highlight is non-sexual touch is just as important if not more important than sexual touch.
And I think sometimes we think about sexual health, we think about, okay, right down to it, but there’s a lot more that goes into intimacy after injury. Supporting this area requires awareness, consistency, and collaboration across the whole rehab team.
Sara Waid: So from the spinal cord injury perspective, we know that, again, this is often a primary concern for individuals after they have experienced their injury, and yet it is often overlooked and oftentimes individuals don’t know how to bring up this conversation. And so understanding these domains will help us be able to better serve the people that we work with. So from a physical side, there are changes in sensation. For some individuals, this might look like hypersensitivity. And so sensations that were once maybe pleasurable or felt good are now noxious. They maybe actually cause other things like spasticity to occur. There’s also individuals that experience diminished or maybe even non-existing sensation below their level of injury. And so this really can impact their ability to, again, sense different touches, tactile input, and that can really impact things like arousal. Bowel bladder function is another impact to the body from the spinal cord injury.
And so considering things like timing, timing of bowel program around sexual activity, considering when to empty the bladder, and those are things that have to be addressed and discussed amongst the individual and their partner. Pain is a big one for this population, both neuropathic and musculoskeletal. So understanding what type of pain someone’s experiencing and how they best manage that pain is going to be really important. Fatigue, as we’ve talked about with every other, both the stroke and brain injury, I think this is something that goes across the different injuries. And so fatigue is another factor, managing time of day, managing the overall endurance and energy conservation, and then positioning, positioning changes as well. From a cognitive domain, cognition, I think for a lot of our individuals after a spinal cord injury is typically intact. And so even if there’s not a direct impact to the brain causing some cognitive changes, there is so much change.
There’s grief, lots of emotions, and not to mention the trauma that’s often associated with these injuries. And so because of the overwhelming amount of information that they are being told and being thrown at them, an individual can experience cognitive overload, cognitive fatigue or fog. And so even if this isn’t maybe a direct impact to the brain, this cognitive component is important to recognize. This could impact in education, their ability to understand or take in information. This can impact their understanding of what does safety look like after these injuries when it comes to experiencing sexual health and sexual intimacy. And then being able to, again, communicate clearly what their wants and needs are. From an emotional side, this I think is something we found through some of the focus groups that we’ve done to be maybe one of the bigger impacts to sexual health in this population.
These changes impact someone’s, the body image, how they see themselves, their confidence. I’ve heard individuals say, “I’m half a man because I don’t have my legs. My legs are no longer working.” And so this really impacts their identity, this impacts how they see themselves, and then how they can therefore show up in their relationships. And so they’re grieving a lot of loss, and so redefining what intimacy looks like in sexuality post-injury is really important. And then lastly, the social side of it. Spinal cord injury can shift relationships, it can shift roles, someone’s privacy, independence, and so understanding how to navigate dating, when to disclose information about their injury, and just again, how to overall communicate with their partner is very important.
One special consideration for the spinal cord population is a term we call autonomic dysreplexia. This might be a new term for some people, so just as a brief understanding of what this is. So because there is changes in someone’s sensation and motor abilities below their level of injury, this is the body’s warning system to say, “Hey, something’s not right.” Usually we look at things like is there a kink in their catheter? Maybe their bowel or bladder is backed up, maybe they have tight clothing on. And the signs and symptoms of this would be increased blood pressure, pounding headaches, sweating, nausea, maybe even rash that forms. And so this is really an important piece of education in general for this population, but specific to sexual health, AD can be caused by intense stimulation, vibration, tight clothing, or even an orgasm. And so knowing that orgasm and AD can present similarly, it’s really important for individuals to listen to their body, to know their body, to know the difference between those signs and symptoms for them specifically.
And if an individual does experience AD, just as we would for any other reason they might be experiencing it, we would stop activity, sit upright, remove tight clothing, and if those symptoms don’t subside, then we would seek medical attention.
Zoey Bertsch: So beyond the cognitive, physical, and emotional changes we’re seeing, again, there’s real life, social and relational challenges that we really need to consider. So many of our young adults are navigating the dating world for the first time after their injury or reentering it with new limitations or changes to their bodies or cognition, communication, things like that. So there might be anxiety about disclosing their injury or again, attraction. What is intimacy going to look like for me? I think a lot of times we think about, yeah, dating, another layer to that is dating apps. In our world, we’re always talking about, oh, are you on the dating apps? That’s a thing that these young adults are experiencing as well. I think existing relationships too, a lot of people are experiencing stress as these roles are shifting. Caregiving dynamics are coming into play. There’s changes in physical function, altered intimacy patterns can strain relationships.
Gosh, this isn’t what it used to be. How do we get back to where we were? Or how can we as a rehab team start to help them redefine what that looks like? Another layer to that is relationship issues before someone’s injury. Preexisting challenges can become magnified after somebody experiences an injury. So supporting communication between those two people, offering counseling or referral pathways to counselors back home to help that transition or mediation might be needed in these scenarios with another layer of injury.
Sara Waid: Some individuals want to reclaim who they were before injury. This might look like their sexual preferences, their confidence, their ways of connecting with their partner, and this will take time and support. And unfortunately, as for many other areas of life post-injury, returning to their preexisting identity or roles may look different, and that’s really hard.
There’s a lot of grief that comes with that. And so our role as professionals is to help them see what is possible, what is possible in returning to maybe some of those preexisting identities or roles or how have those shifted and how can we see that as a positive thing and good in that. Social reintegration is also really important. Again, going beyond just that romantic relationship, dating, sexual health, all of these things intersect with a broader participation of meeting new people, attending social settings, social events, navigating independence, rebuilding confidence. This is why we do a lot of community reintegration at QLI for individuals that maybe we are going to a sports event and they are thinking about how do I eat in this new environment? What kind of equipment do I need to take with me? If I need to use the restroom, who’s helping me with that?
And then we’re able to tie that to their future of when we’re not with you any longer, who’s helping you with these things and how are you reintegrating into the social setting? Being able to reintegrate into these settings can really gain people confidence in who they are, confidence in their own skin, even navigating going to coffee shops or restaurants and gaining confidence and comfortability and asking for help. Many individuals maybe need help opening doors or navigating around tables or need some special assistance at the coffee shop or the restaurant. And so being able to gain confidence and comfortability in these settings can be really important to their overall sexual health as well. And then finally, women’s health considerations. So things like period management, what does this look like? What does this look like based on their abilities? How do we help them navigate that? Birth control, pregnancy, not just the fertility side of it, but also pregnancy can exacerbate other problems related to injury.
So things like pressure on your bowel or bladder, a woman without a neurological injury is using the restroom really frequently. And so if you don’t have the ability to sense your need to use the restroom or maybe you’re on some sort of a schedule to use the restroom because that’s what your body is needing, then how is that changing because of pregnancy? Pressure points change, center of gravity. So for your ability to walk or your ability to do transfer safely, that can all change. And so it’s really important to consider these things. And finally, menopause, how our body changes in relation to hormones and all of those things can impact recovery as well. So sexual health is not just about function, it’s about navigating identity, connection, participation in life. So now that we kind of know why this is important and that health professionals can be a safe place, let’s talk a little bit more about why we tend to not address this topic.
Zoey Bertsch: Yeah, so we know this is a super important topic. Sexual health is a part of our everyday lives, but it’s rarely fully integrated into rehab practice. So several common barriers we see across disciplines. A lot of times providers or clinicians feel like they maybe lack the training or skills or they’re not sure what to say or they’re worrying about offending the patient by bringing up this topic. Clinicians might feel pressure because they don’t have all of the answers or worry about crossing a professional boundary. There might also be time pressures and these busy rehab schedules can make it feel impossible to have these conversations. Where do I squeeze in the time to really sit down and carve out space for this person to feel comfortable in this conversation? Another thing that we see a lot, sexual health can still feel like a taboo topic. Oh, we don’t want to talk about that in some settings, which can really discourage both providers and also patients from initiating this discussion.
A lot of times our patients are thinking about it and they might want to bring it up, but if we’re still feeling like it’s a taboo topic, how are they going to feel comfortable bringing that up? Time constraints is another thing that we see. So rehab sessions are often really packed with the physical, cognitive, functional goals, so sexual health can be unintentionally deprioritized. I think another thing that comes up is who’s going to bring it up? Is it speech? Is it OT? Is it psychology? Is it going to be the physician or is it someone else? Uncertainty about whose responsibility this is can lead to nobody bringing it up. Caregiver presence, maybe they’ve got family with them all of the time. Conversations like this might be difficult if the caregiver is always present or if private space isn’t available, making it harder to really assess that person’s needs and provide education confidentially.
So these barriers are real, but awareness that these barriers exist is really the first step. So even small actions like normalizing the topic, asking permission to discuss, or even just providing some simple resources can open the door to sexual health integration into the rehab setting.
Steve Kerschke: With where we sit, are we having people come from a hospital setting who have already been exposed to this conversation or would you say it’s the latter where most of them haven’t even had it addressed and were the first ones to bring it up or is it across?
Zoey Bertsch: Yeah, I think that’s a good question. I would say a lot of times I work mostly with TBI and stroke. It’s something that people haven’t even really thought about yet. They’re thinking about, can I eat again? How do I get back to thin liquids and regular food versus, gosh, I haven’t snuggled in bed with my partner yet. So I think a lot of times in that acute setting, they’re focused on, okay, the building blocks to this, how do we get you back to functioning out of the hospital bed, things like that. And so I see on my side at least it not being brought up yet. Usually we’re kind of initiating those conversations. I don’t know on the spinal cord injury side of things.
Sara Waid: Yeah, I would say it’s a little bit of a mix on the spinal cord side. I think there are some individuals that have actually done a lot of their own research. That’s actually what we find a lot of times that when we bring it up, they will say, “Well, I’ve looked this up on my own, but I do actually have some questions.” And I think there are some of the referral sources that we have that do bring this up and at least say that it’s an opportunity to talk about, but most people are not ready to talk about it that early on. And so when we are able to re-bring it up into the forefront of their mind is when I think a lot more of those discussions occur.
So one of the biggest ways that we can overcome these barriers is by creating a clear and interdisciplinary workflow that addresses sexual health. So having some sort of sexual health screener is really important. So screening should be done intentionally, it should be done routine, and should be done in a way that is sensitive and has a level of empathy to the patient that you’re working with. There are various types of screeners out there specific to sexual health, and some are even specific to sexual health within a brain injury or a spinal cord injury population. Building trust is really important. In order to be able to present these screeners, a level of trust really should be present knowing that this is a sensitive topic and patients are going to be more likely to disclose information, to disclose what they’re concerned about or what they want to learn more about if they feel like there’s a safe space to do so and they feel respected within that.
Once a concern or an issue is brought up to a team member, it’s really important then that we communicate that across disciplines to make sure that everyone’s aware and that there’s some sort of consistent support that’s being provided to the patient. And then one example of this would be, let’s say someone comes in and has aphasia and paralysis. A speech therapist might look at some of the cognitive awareness initiation barriers or communication barriers that limit the ability to give consent while PTs and OTs might look more at the physical challenges that might be impacting sexual activity, so positioning, wedges, adaptive equipment. So they might even loop in the medical team and say, “What are some medications that might help increase this experience for someone?” And so again, that’s where that interdisciplinary workflow can come into play. So at QLI, we have a sexual health team and we have created the sexual health team to really have some ongoing discussions about how do we improve workflow, how do we support sexual health within our setting?
And so when we initiated this team, it’s comprised of PTs, OTs, speech therapists, our family services providers, our medical providers, nursing team. And really when we are looking at this, we started at probably a monthly every month that we were meeting, bringing in individuals that are trained on sex therapy, they’re experts in this field, individuals that are working with people, helping teams develop these types of flows within the workplace. And that really provided a lot of education to us. We became more confident in talking about these topics, and then we’ve really created how is this implemented at QLI? I think it’s something that’s an ever-changing way of doing things, but we are really trying to be more intentional to be able to provide, like we said, those screeners that are consistent, they’re intentional, and we’ve met less frequently as we’ve gone on and we started it about two years ago.
And so now it is more making sure that the team, the greater team knows that we exist, who we are, and we are able to empower other individuals to address this topic with people, or we get pulled in to address this topic when it comes up.
Zoey Bertsch: Yeah. So even when we’re starting to recognize sexual health as an important part of the rehab process, documenting it can sometimes feel a little bit tricky. Different disciplines are focusing on different aspects, but we all need to be communicating this clearly in the chart to support care and collaboration. So from a speech therapy perspective, we often focus on communication competence, cognitive readiness, capacity for consent. Social pragmatics can also be key. Can the patient express their preferences? Are they understanding boundaries, navigating conversations with their partners again? So documentation might include these observations, maybe strategies or interventions we’re using to support communication regarding sexual health.
Sara Waid: From a PT/OT perspective, we are going to be looking a little bit more at the physical function and how that directly impacts sexual activity. So PTs and OTs might document things like physical positioning. So again, are we using wedges? Is there different adaptive equipment that would be of assistance to an individual? Maybe it’s energy conservation techniques to assist with some of the endurance deficits. Adaptive equipment itself, there’s a lot of different adaptive equipment out there, not just for positioning, but that would assist with sexual activity. And then it’s important to remember that self-cares are foundational to sexual health, so they’re really closely tied to confidence. Being able to participate. And so we can record these interventions as well from a PT and OT standpoint.
Zoey Bertsch: So again, sexual health is rarely something patients bring up on their own. Many might feel embarrassed, they might feel unsure. They might again think it’s inappropriate to be discussing in rehab, but when providers take the initiative, it really builds trust and starts to normalize sexual health as a standard part of care. So initiating the conversation also ensures that our care is safe and holistic, addresses the physical, cognitive, and emotional and social needs rather than leaving gaps in their program or their rehab journey. So even a brief respectful conversation sends the message that sexual health is legitimate, important, and a part of everybody’s recovery.
Sara Waid: So one of the frameworks that is well documented is the PLISSIT model. We’re going to speak specifically to the PLISSIT model. The Ex-PLISSIT model really is the same. It’s just throughout as you move through the steps, you’re getting more feedback, you’re confirming permission to continue to move down the pyramid. And so from the PLISSIT model, it is a top-down approach, and so we would start with gaining permission. The first step is really just saying, “Hey, is this a topic that we can talk about?” And we want to normalize the topic at this point. We want to make sure that the individual knows that it’s safe to talk about these concerns without any sort of judgment from the health professional.
If they say, “Yes, I want some information,” we can move to that limited information part. And this is going to be basic education. This is going to be general, even the foundations pieces that we talked about at the beginning. It’s just general information about how this injury can impact sexual health. And then if they say, “Yes, I want more information than that, and how is this tied specifically to me?” Then we can move into that specific suggestions. And this is going to be more practical, individualized strategies that are tailored to the patient’s goals, to their abilities, to whatever context that they’re in. And so this might look like specific strategies for positioning, communication tips, how to gain consent, or even those adaptive equipment recommendations. There are few and far between that get down to the bottom part of the triangle just because this is, as it says, it’s the most intensive.
It is intensive therapy, it’s referral to specialized intervention. This might look like sexual health professionals, sex therapists, psychologists, maybe even urologists or other specializations that can assist someone with more, again, of that intensive therapy that goes beyond the clinician’s ability.
Zoey Bertsch: Yeah. So here’s a couple examples of some things we might say to give that gentle permission and really start to open up the conversation and normalize the topic. So something like, “Many people with injuries like yours notice changes in sexual function. Is this something you would like more information about?” This approach starts to open that door without pressure, makes it clear that you recognize this as a common concern, but doesn’t force this information upon them. They can politely decline, but now they know, okay, I can bring it up later. I feel comfortable. This is something that we can talk about. Another example might be part of whole body wellness includes intimacy. If you ever want to discuss this, I’m really here to support you. Again, this phrasing emphasizes that ongoing support, framing sexual health as a part of overall recovery and giving them that permission to bring it up again in the future should they choose to.
Using simple, respectful language can reduce embarrassment for the patient and again, helps to build trust from the start. You don’t have to cover everything at once. Starting the conversation is really what matters most here. So we kind of broke it up a little bit further, just some more specific sample opening lines for traumatic brain injury and stroke. A couple of examples, changes in communication can affect romantic relationships too. How has that been for you? More specific to maybe speech therapists being able to open up that topic or brain injuries can affect emotions and relationships. I want to make sure we’re supporting all areas of your life. And that could be anyone. We’re all kind of touching on that emotional aspect of grieving and injury. Have there been any changes in how you feel about dating since injury? Rehab and recovery can sometimes shift roles in a relationship.
How are you both navigating that a natural way to bring in a partner and start to open up those conversations too?
Sara Waid: From a spinal cord injury side, asking some of those general questions of do you feel comfortable in your body? Is there a part of your routines that you wish you could complete more independently? That’s getting at more of those emotional barriers that might affect their sexual health that we could dig into this topic a little bit more with them.
Sometimes we have individuals that their significant other is coming to visit, and so being able to use that as an opportunity to say, “Do you feel comfortable and confident having open and honest dialogue with your partner about sexual health and what intimacy looks like after injury?” That can open up a lot of doors to just start more conversations and maybe even allow the time that their significant other is here to be able to have more conversations with them. I think one way that it flows pretty easily to bring up the sexual health conversation is when we’re working on other bowel bladder function. So being able to say something like something tied closely to bowel and bladder functionality, how informed do you feel on this topic and how your injury has been impacted by it? And so those are some examples of how we’ve opened up conversations and how they seem to flow more easily into, again, those open conversations with patients.
Zoey Bertsch: Yeah. So now that someone has maybe opened up, trusted you, shared some more information, asked for some guidance, how do we close the loop professionally and reassure them that, again, this is a safe space. These conversations can be ongoing, these conversations might change as your rehab progresses. So some different examples, just simple statements. Thank you for trusting me with that. I’m glad you brought that up. This is an important part of recovery. Let’s make sure you have the right supports. Just really, again, reassuring them that this is okay to talk about.
So moving in to bringing everything together, some case applications, what are some things that we have actually seen, we’ve actually done? I think one top of my mind, this happened recently, I had a significant other say to me, “I just want to be able to lay in bed and snuggle with my significant other again.” She’s thinking about, “Gosh, the way that we were intimate and close before was snuggling in bed and watching a movie.” And she told me, my partner, he’s like, “Oh, then I have to press the call button.
They have to help me get into bed. I got to take my shoes off.” He’s thinking about all the logistics. So that I think is a good example of they’re on very different pages. They’re thinking about very different things. And so we as a team started to come together and open up those conversations with each of them and start to navigate what does this look like? How can we help you feel more comfortable and confident getting into bed alone so that that’s not a barrier on your mind? Knowing that that was something he also enjoyed, just wasn’t trusting himself enough yet to be able to do that.
Another example, Joe did a lot of the date night. He had Wernicke’s aphasia communication was super hard for him. It was really hard for him to plan things out again. And so our speech therapy sessions consisted of, we took a couple of speech therapy sessions and really planned out a date night, texted the significant other together, show up at the house at this time, wear a nice dress, I’m going to surprise you with something. And he was able to pull up that address to the restaurant he made reservations for and show her himself. And I think that was just opening his world up again to be able to say, “I can still be in this role. It might look different, it might feel different, but I can still be that partner to my partner.” Another example, maybe the patient is starting to initiate sexual intimacy and the partner wasn’t ready yet.
So the partner actually came to us and said, “Gosh, he’s wanting to do this, but I am not ready. I’m not in a head space to be in that mindset. I don’t even know where to start.” So in that situation, we are talking with the partner, we’re talking with the patient, we’re starting to open those conversations up individually and then eventually brought them together to get them on the same page and give them a safe space to be able to share how they’re feeling, knowing that I don’t want it to feel this way forever, but I’m just not ready yet. And wow, the patient was like, “Oh my gosh, I didn’t even realize I was coming on so strong.” He had a traumatic brain injury, so awareness of his social interactions was something that he wasn’t quite there yet, but these conversations really started to build that for them.
And then eventually they got to the space where they can have those conversations together and they feel comfortable starting to navigate open communication about those things. Another thing we did for them is finding private space, private time. In a rehab setting, you often got people knocking on your door, coming in, not giving you much time. So figuring out what does that look like for them to be able to spend some time, uninterrupted time together again and start to build intimacy with each other. I think aphasia in general can sometimes be tricky when it comes to sexual health and intimacy. So making sure that we’re developing communication supports in this area as well and starting to model supported conversations surrounding intimacy with the patient and their partner. Again, I touched on this a little bit earlier, but dating apps, vulnerability, that’s something that’s come up. We have a patient here and gosh, he’s on the dating apps in the area.
He is not even from here. So how do we start to have those conversations of, gosh, how much do you share about your injury? When do you disclose that? Information sharing in general, are you giving out your address? All the things that can come up when it comes to traumatic brain injury and stroke.
Steve Kerschke: Yeah, you’ve mentioned the dating apps a few times. So are we literally sitting down and saying, let’s look at your profile and let’s adjust that or not?
Zoey Bertsch: What
Steve Kerschke: Does that actually look like?
Zoey Bertsch: We have definitely done that in the past. I’ve had some very open conversations. I think trust, again, is a big component here. I had a young man in the past who I was able to get to the point where we could sit down and discuss, okay, I know you want to be dating again. I know this is something that you were doing before. What does that look like? How are the questions that you’re asking coming across? And we actually would, yes, occasionally pull up some conversations because he trusted me as a therapist to help guide him, knowing that I have his best interest at heart as well. And we know we’re not going to avoid that forever. So yeah, it definitely can look like actually sitting down, pulling up the dating app, reading through some conversations, reflecting, maybe even scripting some questions or comments to have ready to go. Yeah.
Sara Waid: So a couple cases from the spinal cord side. I think just to start with, wanted to talk a little bit about just the women’s health side. I think this is something that, again, doesn’t maybe get brought up a lot, and so wanted to start there. So I had a young gal who was teenager and she started to get her period back once after her injury, and she was asking a little bit about how she could manage this. And so she had pretty limited hand function. We knew that managing in the wheelchair was not an option. She was not able to do even clothing management in the wheelchair. And so we talked a lot about what could this look like from your shower chair or from the bed? And at that time, she really wasn’t open to trialing a lot of different things and said, “I’ll just let my mom handle it for now.” Fast-forward a couple years, she came back and said, “I’m ready to do this.
I want to find independence here. I’m ready to head off and get out of the house and no longer be requiring my mom’s assistance at all times.” And so this allowed us to trial different strategies, techniques, what could work, what didn’t work. We ended up finding that period underwear was the best solution for her, and this was able to make her as independent as possible, again, thinking about all of the components of skin health and her desire of what socialization looks like too in her day-to-day activities. And that really gave her a lot of confidence as well.
When it comes to pregnancy and family, I had a middle-aged gal who her identity was being a mom, and that’s all she ever wanted to be. And she had a two-year-old, and then this injury came up. And so we knew that this was really, really important to her. We knew that this was an identity piece, and so we just brought up the topic. We just said, “How are you feeling about the future? How hopeful are you about having more kids?” And she really opened up and said, “It’s not really been a thought of what it actually looks like to have sexual intimacy. I’m really just trying to figure out how do I look good in my own skin? I look in a mirror and I don’t recognize who I’m seeing in the mirror.” And so we started a lot of conversations with her on how does she get more comfortable in her skin and how do we start there before even approaching deeper conversations?
Another area that came up a lot with her specifically was how does she manage her bladder? And so she was really concerned that if she got a suprapubic catheter, that this would really affect how she could be intimate with her husband. And so she, again, made decisions of having her mom help her cath. She didn’t want her husband. She wanted to keep that as a husband-wife role, not as a caregiver role. And so that was the way that she chose to manage that. But again, these are all conversations that are coming up as we’re talking about the sexual health components. And then the last case study for the women’s health. So I had a gal who was in her early 60s, and unfortunately in her accident, her significant other passed away. And so we knew that that was a sensitive topic for her. We knew that that was something she was grieving on top of her injury.
And so really the way I opened up the conversation with her was we were working on transfers on and off her bowel chair and just used the opportunity to ask the question. Again, as I had mentioned in the opening lines, this is something closely related to bowel/bladder function, so where’s your head at when it comes to sexual health? Do you have questions? Do you have concerns? And she really said, “I have no interest in relationships right now at this time, understandably so,” but it did bring up a bigger conversation of menopause. She was on some hormone therapy prior, and so how is that affecting. We know our hormones are a big factor when it comes to recovery, and so how is that maybe affecting her now, and do we need to consider talking with medical providers about hormone therapy? And so we were able to connect her with her medical providers on that specific topic, and they were able to navigate that together.
I feel like this one probably comes up more often, but one specific situation that I’m thinking of, we had a young guy who had a longstanding relationship prior to injury, and he, at the time of his injury, just really didn’t know how am I supposed to pursue? This looks a lot different. I don’t think I can ask this woman to marry me because I’m different and she doesn’t deserve this. There was a lot of conversations with him on building confidence, talking about what is possible even after this type of an injury.
In more conversations, it came to the teen’s awareness that he was really concerned about what she was helping him with, and she was helping him with all sorts of cathing and showers and all these different cares, and he was really concerned about that because he didn’t want to feel a burden. He didn’t want to feel like she had to do that. And so with permission, he had one of our team members sit in on a conversation with he and his girlfriend, and they were able just to have an open dialogue on what this role looks like, and it came out that she really, really wanted to. It was a way that she could care and love for him, and so they were able to come to a conclusion on what parts of his cares both of them were comfortable with her performing, and that really allowed them to springboard their relationship forward.
We’ve trialed the questionnaires, as we had mentioned earlier. I think this one was really good and eye-opening, I think, for me to be able to sit down. I had offered this questionnaire up as either a self-reflection or something that we would just openly talk about, and the gentleman was like, “Let’s just talk about it.” And so I just posed a couple questions, again, about independence in his cares, about his family. He had a young son, knew that he wanted a big family, and so just asked questions about how he’s feeling about that, how educated he feels, and we were able to provide resources to him. He didn’t really have a lot of questions in the moment because that was not something that was on the forefront of his mind, but he wanted the resources to be able to continue to dig in more for himself, especially once he was farther into recovery and ready to really dig deep into that topic.
And then I think creating hope for future is really important when we talk about this. Again, roles change, this sexual health just looks different after injury. I had one gentleman who actually we were talking about, I think he had been talking about a previous relationship he had, and he was telling me all about it, and I just said, “Do you think about future relationships? What does that look like now that you’ve had this injury?” And he was able to share a little bit of some research he had done. He shared some thoughts, some things that he’s trialed himself, and then we were able to talk a little bit about where are some further places to go. He said, “I feel like I have the information I need for right now, but once I get into a relationship in the future, I do want to know where I can go for more questions that I might have.” We were able to talk about some people that he has on his medical team that he can go to, and then knowing too, that we are always willing to loop back and have conversations in the future with him as well.
Zoey Bertsch: Okay, so starting to wrap up here, there is lots of sexual health resources out there. We have some linked at the end of this presentation, so I won’t spend too much time on this slide, but different evidence-based websites, condition specific guides to go through, adaptive devices, accessible pleasure products, relationship and intimacy education, lots of things out there. So it’s definitely becoming more of a normalized topic, which I think is great. Yeah.
Sara Waid: And as we mentioned earlier in the PLCIT model, there is referral pathways that we can take. So I think it’s important for you to know who are your urologists, who are your social workers, your counselors, what is a local sex therapist that might be someone that you can refer people out to if this topic comes up and if it comes to the point of needing to refer out? So just again, knowing your resources where you’re at.
Zoey Bertsch: So key takeaways, addressing sexual health supports quality of life, identity, social participation, not just someone’s physical recovery, and all disciplines can really contribute within their scope. So whether you’re an OT, PT, SLP, nursing, psychology, social work, there are really ways to support sexual health without overstepping boundaries and continued collaboration, again, ensures patients receive coordinated care across all of the domains that we had previously talked about. Using conversation frameworks like the PLISSIT or EX-PLISSIT or scripted opening lines can help normalize the topic, even brief respectful discussions can open the doors and start to build trust with these people who are experiencing huge life changes. And then resources exist and are very accessible, so evidence-based websites, guides, adaptive devices, counseling options, all available, and knowing and sharing these resources can extend your impact even beyond the therapy session or the brief interaction that you might have. So starting the conversation using frameworks, collaborating with your team, and empowering patients and partners to address sexual health can safely and confidently make this a part of normalized rehab.
Steve Kerschke: All right, let’s do our poll question, and then we can open it up for questions if there are any. All right, so this is the one poll question during the presentation. Please take the time to answer that, and this is step one to get your CEU. Thank you both for the topics and the discussion. I think just sitting and watching and listening, these are not easy topics, but clearly you all are professionals at it. And so I loved hearing the practical examples, having scripts, that sort of thing I think is really important to train other people, train our other team members, train family members, that sort of thing. So yeah, thank you.
Zoey Bertsch: Of course.
Steve Kerschke: Our audience is quiet today. Here we go. One question. Glad to hear you’re having the conversation. It’s not happening. Oh, do we offer telehealth in this area? So our telehealth program certainly could be applied in this area. What I would say is our clinicians on the telehealth side of things, our experts as well, and then if we need resources from our internal team, we would leverage it as needed. So our clinicians cross treat and are working side by side throughout the days and the weeks. So yes, it’s available, and then whatever resources we would need to be effective, we would use. There’s a question on the resources, maybe we can go ahead advance past the full question. We’re going to put up some of those. There’s a question on some of the questionnaires. Can you all talk about some of the questionnaires that we’re using?
Sara Waid: Do you want to start? Yeah, so there is a questionnaire that’s specific to spinal cord injury. The one that I had mentioned in the case study was specifically a sexual health in spinal cord injury. I think that’s honestly, if you Google that, you will find the questionnaire, and then I’m going to pull up the name. There’s another one, if you want to share yours. There’s another one. One specific to OT.
Zoey Bertsch: A couple times in the past, I’ve used more of a general quality of life after brain injury questionnaire. That’s literally what it’s called, and it has just a couple questions sprinkled throughout, so it makes it super natural to bring up the topic while also addressing every other area of quality of life after brain injury. And using that, I’ve had a couple people ask some more questions when that question comes up, or they kind of look at me and they’re like, “Can I actually talk about this?” And it gives a natural opportunity to do one of those gentle permission statements and open the conversation there too.
Sara Waid: Yeah, so the one I was thinking of, it’s called the Occupational Performance Inventory of Sexuality and Intimacy. So this is going to be more of an initial screener. It’s going to be more generalized, not specific to the neurologic injury necessarily, but can be used absolutely.
Steve Kerschke: There’s a question around funding, so I’m guessing. Well, so just some education. So at QLI, we are funded through a per diem, so these conversations, we’re not seeking specific reimbursement for them, and so I think our answer’s going to be a little bit nuanced because we’re not in the position where we’re having to really justify these conversations in order for payment. On the telehealth side, what I typically see is that we are having to justify these conversations using CPT codes, but they end up getting rolled up underneath an OT or a speech session or a PT session, and we are able to get those covered, assuming we’re tying it to larger goals, we’re tying it to function and things like that. So I think a lot of the same approaches apply in terms of being able to show progress and show how it fits the big picture.
Certainly, if it’s a work comp compared to a commercial insurance, I’m guessing you would see some differences there too. There’s a question on, can you repeat where to find the questionnaire that you guys mentioned?
Sara Waid: Yeah, so if you look it up online, I wonder if we could even. Is there a way we can edit the. I don’t think we included it in our resources. Do you think we could edit that and put that out or?
Steve Kerschke: We would have to do it after the fact. So what I would say is if you really want access to the questionnaire and you can’t find it, you could email Zoe and Sarah. Their contact information’s going to be at the end. You can also email me and I can get it for you. So that would probably be the easiest at this point, and otherwise we’re happy to help.
Zoey Bertsch: Same thing with the quality of life after brain injury questionnaire. It’s free, so if you look that up, it should come right up for you. But yes, feel free to email. We can share any of the resources, but here is some more resources for TBI and stroke too that are all included in the PowerPoint.
Steve Kerschke: There’s a question on CARF accreditation. Do you all recall as we’re preparing for CARF, is there anything that we’re having to answer on sexual health? It’s been a minute since I’ve looked at the CARF standards in this regard. We could get this answer for you. My guess is that we would probably put it in as here’s part of our program that you should know about. My guess is that there’s not a firm accreditation requirement, but that’s a speculative comment just because it’s been a minute since I looked at those. Deborah, we got you on the poll question since you’re here. Do our physicians ever make specific referrals following rehab related to this?
Sara Waid: I would say that we probably. I mean, I think following discharge or even when they’re here with us, we have a really good relationship with one of our local urologists, and so that actually a lot of our individuals go to the urologist at some point in their stay, and so that’s an opportunity for them to ask those questions and we prep them knowing that they can ask those questions in that setting. I don’t know that I’ve had anyone that’s been referred to a sex therapist or psychologist specifically for this. I don’t know if you have, Zoe.
Zoey Bertsch: Yeah, I think psychology sometimes touches on the intimacy between partners, and so we’ve definitely referred out for psychologists after QLI, but our medical team, I think, also does a nice job of touching on the topics too. Our patients are usually seen weekly on campus by our medical team, so they’re bringing up topics like birth control, women’s health, things like that naturally that sometimes they might refer out for that past their stay at QLI.
Steve Kerschke: This is more of a comment, Victoria Paul, thank you. She offered up another resource related to the amputee coalition. There’s a sex and intimacy guide. I don’t know that this is public to everyone, but if you want that, let us know and we can send that out on behalf of Victoria, so thanks for sharing. All right, I think that covers most of our questions. If you have additional questions, like I said, at the very end, you can get in touch with Sarah and Zoe via email. They’ve included their, excuse me, contact information. You can always reach out to me. I can facilitate that. We just appreciate both of you. Thank you for the discussion. Great information. One thing I will tell you in terms of what’s to come, we will not have a webinar next month. We have one in April, so we will have a month off, but we have a stacked lineup the rest of the year, so we’ll have many more to come.
So appreciate everyone joining. Yes, there’s only one poll question. Just a reminder, as you sign off, fill out the form.
October 14, 2026 by Haley Hansen, PT, DPT
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