Introduction

Sexual wellbeing is a term that is beginning to be used more frequently to encompass sexuality and sexual health issues [1]. For individuals who have an acquired disability or chronic illness, issues relating to sexual wellbeing may include low self-esteem arising from loss of control over their lives and a change in their roles [2, 3]. They may not be able to resume sexual activity because of their impairments, or they may feel unattractive, unloved and not able to talk openly about their feelings [4–6]. Alternatively, they may have difficulty with existing relationships or in establishing new ones [7–10]. The original PLISSIT model developed by Annon [11] has been widely used over the past 30 years by health care practitioners working to address the sexual wellbeing needs of individuals with acquired disability or chronic illness. The PLISSIT model sets out four levels of involvement that can be used to help healthcare practitioners identify their role in the assessment and evaluation of an individual’s sexual wellbeing needs.

The acronym PLISSIT signifies the four levels of intervention:

  • Permission (P)

  • Limited Information (LI)

  • Specific Suggestions (SS)

  • Intensive Therapy (IT)

According to Annon [11], most people experiencing sexual problems can resolve them if they are given Permission to be sexual, to desire sexual activity and to discuss sexuality, if they receive Limited Information about sexual matters, and are given Specific Suggestions about ways to address sexual problems. As the level of intervention increases, greater knowledge, training and skills are required. Recognizing that practitioners are not necessarily confident or competent to function at all levels in all situations, they should refer patients on to others who are able to meet the specific need.

This paper discusses the limitations in the way practitioners use the PLISSIT model and proposes the Ex-PLISSIT model [1] as a tool for practitioners in addressing the sexual wellbeing needs of individuals with an acquired disability or chronic illness.

Problems in Using the PLISSIT Model

In our experience as nurse educators running post-qualifying courses for healthcare practitioners, the Permission level in PLISSIT is often bi-passed. For example, some practitioners describe providing Limited Information in the form of a booklet that contains some written information about the impact of the condition or treatment on individuals’ sexual wellbeing. These practitioners presume that the patient would raise the subject of their sexual wellbeing if they wanted to discuss it, taking the patient’s silence as a sign that they have no concerns. This implicit Permission-giving does not signal to patients that it is appropriate to discuss their sexual wellbeing. Indeed, the practitioners’ silence on this subject may suggest to individuals that it is not appropriate to discuss their sexual wellbeing needs.

A further problem in the way practitioners interpret the PLISSIT model is in believing that giving Permission once is sufficient. If the patient does not voice issues in relation to sexual wellbeing after Permission is given, it may be assumed that they do not have any concerns.

Practitioners can also interpret the PLISSIT model as one-way process. There is no explicit discussion in PLISSIT of reviewing interventions with clients, resulting in some practitioners presuming that they have been effective in meeting all the patient’s needs.

The Extended PLISSIT Model

The Ex-PLISSIT model extends the original model by emphasizing the role that Permission-giving plays at all stages, therefore each stage of Limited Information, Specific Suggestions and Intensive therapy is underpinned by Permission-giving. For this reason, each stage in the Ex-PLISSIT model has Permission-giving at its core. All interventions should begin with Permission, and it is essential that this Permission-giving is explicit, giving individuals the opportunity to ask questions or voice their concerns (Fig. 1).

Fig. 1
figure 1

The Ex-PLISSIT model [Reproduced from Davis S, Taylor B: From PLISSIT to Ex-PLISSIT. In Rehabilitation: the use of Theories and Models in Practice, Davis S (ed). Edinburgh, Churchill Livingstone, 2006, p.111, with permission from Elsevier Ltd. This model is an extension of Annon’s original PLISSIT model [11].]

Full size image

This Permission-giving involves normalizing sexuality; for example, by stating ‘many people with this condition have concerns about sexuality. Is there anything you would like to talk about or ask?’’ Or, ‘many people experience impotence as a side effect of this drug. Is this something you have experienced?’ Having given Permission once, practitioners should not assume that a lack of enquiry by the patient indicates a lack of concern about their sexual wellbeing; further Permission-giving is needed.

In the PLISSIT model, it is often assumed that Intensive Therapy is provided when intervention via the lower three levels has not been effective. The Ex-PLISSIT model indicates that Intensive Therapy may be offered at any stage. It is important that practitioners recognize their own strengths and limitations and acknowledge the limits of their own comfort zone and competence, where necessary, referring patients on to others who are more able to address their individual needs. Therefore, if, having given the patient Permission, the practitioner is challenged with something they feel unable to deal with, it is important that they refer the patient to a colleague who is more able to discuss the patient’s sexual wellbeing needs. This may involve providing Limited Information or Specific Suggestions, at the same time making explicit further Permission-giving.

Unless the Permission-giving stage is addressed first, the information that is given will be general and will not address the needs or concerns of each individual. The information that is provided needs to be inclusive and not restricted to assumptions made about the patient or their sexual preferences. For example, if the information given to a woman about differing sexual positions to combat muscle spasm only discussed vaginal intercourse, it would not meet the needs of a woman who practiced anal intercourse.

The information that is given needs to be of relevance to the individual and the practitioner cannot assume that individuals will feel able to disclose all their issues and concerns at once. Hence the need for further Permission-giving.

As in PLISSIT, the Specific Suggestions stage is based upon a problem-solving approach to address an individual’s particular problem, and requires more knowledge and skill than providing Limited Information. In order to make Specific Suggestions that meet an individual’s needs, the practitioner needs to take a sexual history to identify problems, concerns and expectations.

If the need for Intensive Therapy is identified, it is possible to refer the individual on without passing through the other stages first. Intensive Therapy involves referral for specialist intervention. This not only refers to therapies such as psychosexual therapy or relationship counselling, but may also includes urology, genito-urinary medicine, gynecology or continence advice.

A further extension of the original PLISSIT model that Ex-PLISSIT offers is in promoting a comprehensive learning cycle of reflection and review, challenging assumptions in order to develop knowledge and self-awareness. There are two elements to reflection and review. The focus of the first is the patient, and the focus of the second is the practitioner.

Once the topic has been discussed with the patient, practitioners should not assume that sexuality has been fully addressed, for sexuality is a dynamic concept and issues will change in response to changes in physical, social and psychological circumstances. For effective review, practitioners need to seek the patient’s perspective. This, by nature, involves further Permission-giving, as the patient is given further opportunities to voice any issues that they might have. Examples of reviewing interventions with patients include asking:

‘What might your partner feel about that?’

‘Are there any other things that you have thought of?’

‘What have we not covered fully?’

Review not only occurs at the end of a consultation, but also takes place at future consultations by referring back to the earlier discussion. For example, by asking:

‘When we last spoke, you mentioned … and we discussed … how has this been since then?’

‘How helpful was the leaflet I gave you in answering your questions about sexuality?’

‘Was there anything that surprised you?’

‘Do you have any further questions or concerns?’

In addition to reflecting and reviewing interventions with individuals, Ex-PLISSIT also requires practitioners to reflect on their own attitudes and the impact that these might have had on the consultation. This reflection can occur alone or with peers, either informally or through clinical supervision. This learning cycle element of the Ex-PLISSIT model enables practitioners to work together as a team to address patients’ sexual wellbeing needs. By reflecting and reviewing their interventions with patients, practitioners can begin to explore their own assumptions and challenge these individually or as a team.

Conclusion

The sexual wellbeing needs of individuals with an acquired disability or chronic illness are often not effectively addressed by practitioners. Annon’s [11] PLISSIT model has been a useful framework in the past to help practitioners identify the level they feel comfortable at, however it is interpreted differently by practitioners and does not include the elements of reflection and review. The Ex-PLISSIT model features Permission-giving as being the core feature of all stages and enables practitioners to use reflection and review in order to develop their own practice.