Updated: Nov 8
By Dr. Sakshi Tickoo (BOTh) and Dr. Kathryn Ellis (OTD)
Stories have recently moved centre-stage in social thought: as the pathways to understanding culture; as the bases of identity; as the tropes for making sense of the past. We all hold a variety of narratives in our minds that reflect the variety of our identities - like man, woman, parent, friend, lover, relative, and professional. Some of my story is about how I came to study and advocate for humans as sexual beings and learned why this is difficult to implement in India...
Sexuality narrative and healthcare practices in India
The stories and narratives around sexuality from an Indian perspective remain problematic, because of India’s predicament between tradition and modernity, coupled with religious tension.
Indian Nationalists tend to be anxious and shameful about the western description of India, being the ‘land of the Kamasutra and Tantra’. These anxieties date back to systemic colonial disapproval and instatement of colonial “obscenity” laws, which have led to construction of societal frameworks of “right and wrong” sexual behaviours. On the contrary, architecture, sculptures and paintings to the old texts of Kamasutra (and other ancient literary material references) evidence that ancient India accommodated a whole range of sexual behaviours. This largely contradicts the modern belief that monogamous heterosexual marriage is the only form of permissible sex and all other forms of sexual orientation or gender expression are unacceptable.
This hetero-patriarchal, hegemonic ideology has erased spaces and created new subjectivities for expression of sexuality. In turn, this negates the grand narrative of Indian nationalism in terms of sexuality and gender expression.
It seems as though dialogue is loosening and widening, to attempt to redefine the dynamic nature of sexual behaviours, re-administer new tolerance and trust amongst the community - and change policy and laws. This shift in dialogue in turn sheds light on the category of regions, their perceptions and evaluations on the complexities of the evolving biases of sexualities and identities in contemporary India. So, while progressive households or regions endeavour to abridge the communication gap, others remain silent and unconducive to these matters. Hence, significant and serious gaps still remain in sexual knowledge amongst teens and adults, leading to engaging in risky sexual behaviour - including rape, violence and abuse, unplanned pregnancies, and STIs, which are relatively common among the population now.
Now, the real question that arises is...
Are occupational therapists, representing this diverse community, prepared to take the onus on initiating and discussing concerns of clients in this domain of intimate ADL?
Not surprisingly, the tensions evident in public addressal relating to sexuality are reflected in the healthcare setting. However, given that occupational therapists frequently work with clients whose illness or disability impacts upon their ability to express their sexuality, it is important that therapists are prepared to respond appropriately.
While no studies were identified specifically focusing on how occupational therapists in India address sexuality, an informal survey among 91 occupational therapists in Mumbai was carried out by the first author of this article. The responses indicated an uneasy balance between traditional conservative teachings and liberal experiences - not to mention a serious dismissal by a few towards sexuality as a substantial part of activities of daily living.
How can a sexual narrative be therapeutic?
We are heavily influenced by how we construct our own stories. This is particularly true for sex, as owning and sharing our narratives as they relate to sex can either liberate us or continue to repress us.
By recreating associations to sexual identity through narratives, one tends to...
gain insights to pleasant or unpleasant feelings (anxiety, confusion related with the activity or any particular encounter(s))
boost body awareness
In a therapeutic setting, this not only creates a safe space to communicate these feelings but also benefits both the client and the therapist, to reach a mutual decision and set up a plan for therapy. It is essential in some circumstances to recondition both the mind and body to think of desires differently and reinforce them as sexual beings again. Desensitising negative memories or experiences that were uncomfortable and triggering - replacing them with new sensory associations, to enhance body awareness and exposure to safe sexual experiences - is helpful in creating possibilities for a sexual future.
As therapy progresses, clients can change, modify or evolve his/her/their sexual narrative. Client-therapist collaboration, coupled with the foundation of this therapeutic setting, allows for resetting of intentions at every stage of therapy.
What is needed to improve current occupational therapy practice in this area?
In the informal survey I conducted, participants were asked about their views on:
barriers experienced during everyday practice, towards clients’ sexual health concerns
The primary aim of this survey was to consider occupational therapists’ views toward addressing sexuality in an Indian context.
A large majority of participants acknowledged the need for Occupational Therapists to adopt more open attitudes towards sexuality and its inclusivity as a vital goal of rehabilitation. The need for avoiding superimposition of self-values and beliefs (due to socio-cultural influence) was highlighted as another factor potentially hampering a holistic client-care approach.
Suggestions offered by survey respondents to achieve a change in practice included:
clear demarcation and description of roles for each profession and when referrals should be made to them (Occupational Therapists)
the inclusion of questionnaires relating to sexuality as part of a standard initial evaluation process
educating and informing clients on the scope of occupational therapy practice in this domain
improved training for occupational therapists, to equip them with relevant skills
When occupational therapists do not address the sexual needs of individuals with disabilities it can perpetuate the social construct that they are not sexual beings. Such views align to a narrow understanding of sexuality - emphasising only its reproductive function and excluding clients’ wishes to express their sexuality in other ways, beyond the act of penetrative intercourse. Additionally, occupational therapy professionals and clients need to be assured that raising or discussing concerns relating to sexuality, in the context of healthcare interactions with mutual consent, is appropriate.
Implementation of these suggestions can reflect a commitment by occupational therapy professionals to prioritise sexuality and sexual health. Occupational therapy professionals in India can reflect in their practice the progressive movements to acknowledge humans as sexual beings in all forms of sexuality and gender expression, in order to serve the needs of the populations they serve.
Dr. Tickoo is an Occupational Therapist (BOTh) and Certified Personal Counselor from Mumbai (India), currently working at a special school. She aspires to not only extend her research in the fields of psychosexual rehabilitation in the context of occupational therapy, but also continue her further education in Sexology and Mental Health Rehabilitation.
Dr. Ellis is the owner and founder of The Institute for Sex, Intimacy, and Occupational Therapy, which offers online education courses to help occupational therapy professionals build their skills addressing the sexuality and intimacy concern of their clients, to help their clients thrive in these meaningful occupations. Visit her website to take a course and hone your skills!
Resources and References:
Informal survey conducted by Sakshi Tickoo (first author) and Dr Kathryn Ellis (co-author): Pilot survey conducted in Mumbai, India on exploring views of Occupational Therapists towards addressing sexual health and potential barriers (unpublished data; contact first author with questions)
Sexual health as per National Health Portal, India: www.nhp.gov.in/sexual-health_pg
Sexual assault statistics in India: https://en.wikipedia.org/wiki/Rape_in_India
Sexually Transmitted Diseases (STDs) statistics in India: www.nhp.gov.in/disease/reproductive-system/sexually-transmitted-infections-stis
Sexual health policy discourse in India: https://yourstory.com/socialstory/2019/06/sexual-health-reproductive-health-policy-discourse
I have relied on the works of the following people to further learn and explore the current works being done in the field. Below are links to few of them:
The Institute for Sex, Intimacy and Occupational Therapy: www.sexintimacyot.com
In Plainspeak by TARSHI: A digital magazine on sexuality in the Global South www.tarshi.net/inplainspeak
OT after Dark - a podcast run by two Occupational Therapists, for adults only: https://otafterdark.com