**7. New research**

228 Rheumatoid Arthritis – Etiology, Consequences and Co-Morbidities

This model also shows when the health professional needs to refer the patients to colleagues with more experience concerning sexual health, since the different steps clearly shows how far the discussion has reached. As a standard, persons with psychosexual problems should be referred to a psychosexual therapist, and persons with relationships difficulties should be referred to a counselor. For many patients the permission-step and the limited informationstep is sufficient to improve their sexual health (McInnes 2003). There is an extension of the PLISSIT-model, the EX-PLISSIT which includes reflection to raise self-awareness to challenge assumptions and requires review of all interactions with patients (Taylor and

The core of the **Recognition Model** is the recognition that disabled persons have sexual needs and desires (Couldrick, Gaynor, and Cross 2010). The Recognition Model identifies the existing skills among health professionals that can be used to promote and protect sexual health for persons with disabilities and is intended to be used by multi-professional teams. The step of recognition is important, especially if the health professionals´ expertise is within disability, rather than sexual health. The Recognition model also aids in what is

The steps in the Recognition model might overlap and it is important that the team ensures that all steps are included in the service given by the team around the patient. Sexual health issues should be employed with persons that express their sexuality in a different ways, not only with those persons that seem to be relevant, such as younger persons living in relationship with a partner of the opposite sex. Examples of persons expressing their sexuality in other ways can be persons who have chosen not to be sexually active or persons,

The following steps are described in the Recognition Model (Couldrick, Gaynor, and Cross

1. Recognition of the service user as a sexual being. This step requires patient centeredness and acknowledgement of the patient as a sexual being, with sexual needs and desires. All team members should be able to have a positive approach to direct questions of sexual health asked by the patient. If the team has a specific person with expertise in sexual health issues, a referral to this person could be done for example like this: "I understand you have sexual concerns that you wish to discuss. It is not my area of

2. Provision of sensitive, permission giving, strategies such as indirect questions, and printed information. An example of an indirect question that can be used is the following: "Some persons also have questions about sex. If you have anything you wish to ask, I am happy to discuss your concerns." The aim of this step is to invite persons to

3. Exploration of the sexual problem/concern. This step includes exploring what issues are of importance to the patient. For some it might be issues of fatigue or pain and for others it might be maintaining an intimate sexual relationship. Other questions may concern how soon sexual intercourse can be resumed after hip replacement. This step of exploration is essential to give the appropriate advice and information to the person

1. Address issues that fit within the team´s expertise and boundaries. This step includes the specific competencies of different professionals, for example the occupational

included in each professional role when it comes to addressing sexual health issues.

persons having several partners or persons attracted to the same sex.

expertise, but I can ask my colleague to speak with you."

The first three steps can be performed by all team members.

speak about sexual issues if they wish and still respect their privacy.

Davis 2006).

2010):

with RA.

The field of sexual health and intimate relationships is moving forward within rheumatology. Advances include self-strategies and cognitive behavioural therapy within physiotherapy as ways to improve sexual health (Helland et al. 2011; Breton, Miller, and Fisher 2008). The self-strategies showed great variety including postponing sexual activities during flares, ignoring restrictions, adapting positions, using alternative locations, using painkillers, initiating less strenuous sexual activities, engaging in sexual activities despite lack of desire and being creative during the sexual act. The efficacy of the strategies is not researched and further knowledge is needed in this field. The initial results from cognitive behavioural therapy to improve sexual health are promising (Breton, Miller, and Fisher 2008), but needs further investigation. Research on ways of coping with RA are also of interest in relation to sexual health, since the decrease in sexual health seems to be persistent during the disease.
