Sexuality and Disability

, Volume 37, Issue 1, pp 41–61 | Cite as

Sexuality Re-education Program Logic Model for People with Traumatic Brain Injury (TBI): Synthesis via Scoping Literature Review

  • Dahlia KhajeeiEmail author
  • Donna Smith
  • Brittany Kachur
  • Najwa Abdul
Original Paper


Acknowledging the heightened risk of psychological, physical, and sexual harm for people with brain injury promotes sexual health and safety. Ignoring sexuality concerns is a serious deficit of modern-day rehabilitation programs. This article utilizes a disability lens to form the basis for our scoping review by illustrating how institutions can repress people with disabilities. The literature regarding brain injury shows socio-cultural characteristics undermine efforts to address sexuality programming for people with brain injury. The authors examine the effects of traumatic brain injury (TBI) and explore the components for a sexuality re-education program by building a Logic Model. A content analysis approach is used to form a literature map for the Logic Models’ inputs, outputs, and outcomes. Key themes to the sexuality re-education of people with TBI include: anatomical vocabulary, sexual safety, resiliency and rejection, social skills training and communication, and sexual self-identity, amongst others. This article supports the healthy and safe sexual re-adjustment of people with brain injury. Full disclosure through human sexuality re-education ensures people with a brain injury remain active citizens by maintaining equality with their community members.


Disability Sexuality Education Program Plan Logic Model Brain injury Canada 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Medlar, T.: Sexual counseling and traumatic brain injury. Sex. Disabil. 11(1), 57–71 (1993)Google Scholar
  2. 2.
    Dombrowski, L., Petrick, J., Strauss, D.: Rehabilitation treatment of sexuality issues due to acquired brain injury. Rehabil. Psychol. 45(3), 299–309 (2000)Google Scholar
  3. 3.
    Johnson, C., Knight, C., Alderman, N.: Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment. Brain Inj. 20(7), 687–693 (2006)Google Scholar
  4. 4.
    Sander, A., Moessner, A., Kendall, K., Pappadis, M., Hammond, F., Cyborski, C.: Sexual Functioning and Satisfaction After Traumatic Brain Injury: An Educational Manual. Baylor College of Medicine, Houston (2011)Google Scholar
  5. 5.
    Higgins, A., Sharek, D., Nolan, M., Sheerin, B., Flanagan, P., Slaicuinaite, S., McDonnell, S., Walsh, H.: Mixed methods evaluation of an interdisciplinary sexuality education programme for staff working with people who have an acquired physical disability. J. Adv. Nurs. 68(11), 2559–2569 (2012)Google Scholar
  6. 6.
    Eisenberg, N., Andreski, S., Mona, L.: Sexuality and physical disability: a disability-affirmative approach to assessment and intervention within health care. Curr. Sex. Health Rep. 7(1), 19–29 (2015)Google Scholar
  7. 7.
    Bond, M.: Assessment of the psychosocial outcome of severe head injury. Acta Neurochir (Wien). 34(1–4), 57–70 (1976)Google Scholar
  8. 8.
    Kreutzer, J., Zasler, N.: Psychosexual consequences of traumatic brain injury: methodology and preliminary findings. Brain Inj. 3(2), 177–186 (1989)Google Scholar
  9. 9.
    Florian, V., Katz, S.: The other victims of traumatic brain injury: consequences for family members. Neuropsychology 5(4), 267–279 (1991)Google Scholar
  10. 10.
    Taleporos, G., McCabe, M.: Relationships, sexuality and adjustment among people with physical disability. Sex. Relatsh. Ther. 18(1), 25–43 (2003)Google Scholar
  11. 11.
    Zasler, N., Martelli, M.: Sexual dysfunction. In: Silver, J., McAllister, T., Yudofsky, S. (eds.) Textbook of Traumatic Brain Injury, pp. 397–414. American Psychiatric Publishing Inc., Philadelphia (2011)Google Scholar
  12. 12.
    Brain Injury Canada. Brain Injury can happen to anyone. Accessed 14 July 2018
  13. 13.
    Strauss, D.: Biopsychosocial issues in sexuality with the neurologically impaired patient. Sex. Disabil. 9(1), 49–67 (1991)Google Scholar
  14. 14.
    Simpson, G.: Addressing the sexual concerns of persons with traumatic brain injury in rehabilitation settings: a framework for action. Brain Impair. 2(2), 97–108 (2001)Google Scholar
  15. 15.
    Prince, M.: Absent Citizens: Disability Politics and poliCy in Canada. University of Toronto Press, Toronto (2009)Google Scholar
  16. 16.
    Kreuter, M., Dahllöf, A., Gudjonsson, G., Sullivan, M., Siösteen, A.: Sexual adjustment and its predictors after traumatic brain injury. Brain Inj. 12(5), 349–368 (1998)Google Scholar
  17. 17.
    Colquhoun, H., Jesus, T., O’brien, K., Tricco, A., Chui, A., Zarin, W., Lillie, E., Hitzig, S., Straus, S.: Study protocol for a scoping review on rehabilitation scoping reviews. Clin. Rehabil. 31(9), 1249–1256 (2017)Google Scholar
  18. 18.
    Julian, D., Jones, A., Deyo, D.: Open systems evaluation and the logic model: program planning and evaluation tools. Eval. Progr. Plan. 18(4), 333–341 (1995)Google Scholar
  19. 19.
    Tregaskis, C.: Social model theory: the story so far. Disabil. Soc. 17(4), 457–470 (2002)Google Scholar
  20. 20.
    Barnes, C., Mercer, G.: Implementing the Social Model of Disability: Theory and Research. The Disability Press, Leeds (2004)Google Scholar
  21. 21.
    Paterson, K., Hughes, B.: The social model of disability and the disappearing body: towards a sociology of impairment. In: Barton, L. (ed.) Overcoming Disabling Barriers, pp. 101–117. Routledge, New York (2006)Google Scholar
  22. 22.
    Ballan, M.: Disability and sexuality within social work education in the USA and Canada: the social model of disability as a lens for practice. Soc. Work Educ. 27(2), 194–202 (2008)Google Scholar
  23. 23.
    The Commission on the Accreditation of Rehabilitation Facilities (CARF).: Medical rehabilitation standards manual,” (Tucson, Arizona, 2018)Google Scholar
  24. 24.
    Colquhoun, H., Levac, D., O’Brien, K., Straus, S., Tricco, A., Perrier, L., Kastner, M., Moher, D.: Scoping reviews: time for clarity in definition, methods, and reporting. J. Clin. Epidemiol. 67(12), 1291–1294 (2014)Google Scholar
  25. 25.
    Arksey, H., O’Malley, L.: Scoping studies: towards a methodological framework. Int. J. Soc. Res. Methodol. 8(1), 19–32 (2005)Google Scholar
  26. 26.
    Davis, L., Abramson, W.: More common than we think: recognizing and responding to signs of violence. Impact 13(3), 8–9 (2000)Google Scholar
  27. 27.
    Brain Injury Rehabilitation Trust. Information and Support. (2018). Accessed 12 May 2018
  28. 28.
    Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P., Stewart, L.: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst. Rev. 4(1), 1–9 (2015)Google Scholar
  29. 29.
    Creswell, J.: Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Sage Publications, Thousand Oaks (2017)Google Scholar
  30. 30.
    Hsieh, H., Shannon, S.: Three approaches to qualitative content analysis. Qual. Health Res. 15(9), 1277–1288 (2005)Google Scholar
  31. 31.
    Heighway, S., Webster, S.: STARS: A Social Skills Training Guide for Teaching Assertiveness, Relationship Skills, and Sexual Awareness. Future Horizons, Arlington (2008)Google Scholar
  32. 32.
    Haag, H., Caringal, M., Sokoloff, S., Kontos, P., Yoshida, K., Colantonio, A.: Being a woman with acquired brain injury: challenges and implications for practice. Arch. Phys. Med. Rehabil. 97(2), S64–S70 (2016)Google Scholar
  33. 33.
    Brain Injury Association of America (BIAA).: Brain injury information. (2018). Accessed 21 Oct 2018
  34. 34.
    Sandel, M., Williams, K., Dellapietra, L., Derogatis, L.: Sexual functioning following traumatic brain injury. Brain Inj. 10(10), 719–728 (1996)Google Scholar
  35. 35.
    Chandler, B., Brown, S.: Sex and relationship dysfunction in neurological disability. J. Neurol. Neurosurg. Psychiatry 65(6), 877–880 (1998)Google Scholar
  36. 36.
    Aloni, R., Katz, S.: A review of the effect of traumatic brain injury on the human sexual response. Brain Inj. 13(4), 269–280 (1999)Google Scholar
  37. 37.
    Zasler, N., Katz, D., Zafonte, R.: Brain Injury Medicine: Principles and Practice. Demos Medical Publishing, New York (2012)Google Scholar
  38. 38.
    Moreno, J., McKerral, M.: Towards a taxonomy of sexuality following traumatic brain injury: a pilot exploratory study using cluster analysis. NeuroRehabilitation 41(2), 281–291 (2017)Google Scholar
  39. 39.
    Strizzi, J., Landa, L., Olivera, S., Tangarife, R., Rodriguez, I., Agis, I., Arango-Lasprilla, J.: Sexual function in men with traumatic brain injury. Sex. Disabil. 35(4), 461–470 (2017)Google Scholar
  40. 40.
    Strizzi, J., Landa, L., Pappadis, M., Olivera, S., Tangarife, R., Agis, I., Perrin, P., Arango-Lasprilla, J.: Sexual functioning, desire, and satisfaction in women with TBI and healthy controls. Behav. Neurol. 2015, 247479 (2015). Google Scholar
  41. 41.
    Downing, M., Ponsford, J.: Sexuality in individuals with traumatic brain injury and their partners. Neuropsychol. Rehabil. 28(6), 1028–1037 (2016)Google Scholar
  42. 42.
    Aloni, A., Keren, O., Cohen, M., Rosentul, N., Romm, M., Groswasser, Z.: Incidence of sexual dysfunction in TBI patients during the early post-traumatic in-patient rehabilitation phase. Brain Inj. 13(2), 89–97 (1999)Google Scholar
  43. 43.
    Walker-Hirsch, L., Champagne, M.: Circles revisited: ten years later. Sex. Disabil. 9(2), 143–148 (1991)Google Scholar
  44. 44.
    Zasler, N., Kreutzer, J.: Family and sexuality. In: Williams, J., Kay, T. (eds.) Impact of Head Injury on the Family System: An Overview for Professionals. Paul Brookes Publishers, Baltimore (1990)Google Scholar
  45. 45.
    Sander, A., Maestas, K., Pappadis, M., Sherer, M., Hammond, F., Hanks, R.: Sexual functioning 1 year after traumatic brain injury: findings from a prospective traumatic brain injury model systems collaborative study. Arch. Phys. Med. Rehabil. 93(8), 1331–1337 (2012)Google Scholar
  46. 46.
    Godwin, E., Chappell, B., Kreutzer, J.: Relationships after TBI: a grounded research study. Brain Inj. 28(4), 398–413 (2014)Google Scholar
  47. 47.
    Blackerby, W.: A treatment model for sexuality disturbance following brain injury. J. Head Trauma Rehabil. 5(2), 73–82 (1990)Google Scholar
  48. 48.
    Taylor, B., Davis, S.: The extended PLISSIT model for addressing the sexual wellbeing of individuals with an acquired disability or chronic illness. Sex. Disabil. 25(3), 135–139 (2007)Google Scholar
  49. 49.
    Gougeon, N.: Sexuality education for students with intellectual disabilities, a critical pedagogical approach: outing the ignored curriculum. Sex Educ. 9(3), 277–291 (2009)Google Scholar
  50. 50.
    Oddy, M.: Sexual relationships following brain injury. Sex. Relatsh. Ther. 16(3), 247–259 (2001)Google Scholar
  51. 51.
    Medlar, T.: The sexuality education program of the Massachusetts Statewide Head Injury Program. Sex. Disabil. 16(1), 11–19 (1998)Google Scholar
  52. 52.
    Nguyen, T., Liamputtong, P., Horey, D., Monfries, M.: Knowledge of sexuality and reproductive health of people with physical disabilities in Vietnam. Sex. Disabil. 36(1), 3–18 (2018)Google Scholar
  53. 53.
    Ponsford, J.: Sexual changes associated with traumatic brain injury. Neuropsychol. Rehabil. 13(1–2), 275–289 (2003)Google Scholar
  54. 54.
    Connell, K., Coates, R., Wood, F.: Sexuality following trauma injury: a literature review. Burns Trauma 2(2), 61–70 (2014)Google Scholar
  55. 55.
    O’Reilly, K., Wilson, N., Peters, K.: Narrative literature review: health, activity and participation issues for women following traumatic brain injury. Disabil. Rehabil. 40(19), 2331–2342 (2017). Google Scholar
  56. 56.
    Bivona, U., Antonucci, G., Contrada, M., Rizza, F., Leoni, F., Zasler, N., Formisano, R.: A biopsychosocial analysis of sexuality in adult males and their partners after severe traumatic brain injury. Brain Inj. 30(9), 1082–1095 (2016)Google Scholar
  57. 57.
    Simpson, G., McCann, B., Lowy, M.: Treating male sexual dysfunction after traumatic brain injury: two case reports. NeuroRehabilitation 38(3), 281–289 (2016)Google Scholar
  58. 58.
    Yang, Y., Chien, W., Chung, C., Hong, K., Yu, Y., Hueng, D., Chen, Y., Ma, H., Chang, H., Kao, Y.: Risk of erectile dysfunction after traumatic brain injury: a nationwide population-based cohort study in Taiwan. Am. J. Men’s Health 1, 13 (2018). Google Scholar
  59. 59.
    Simpson, G., Long, E.: An evaluation of sex education and information resources and their provision to adults with traumatic brain injury. J. Head Trauma Rehabil. 19(5), 413–428 (2004)Google Scholar
  60. 60.
    Griffith, E., Lemberg, S.: Sexuality and the Person with Traumatic Brain Injury: A Guide for Families. FA Davis Company, Philadelphia (1993)Google Scholar
  61. 61.
    Gutman, S., Leger, D.: Enhancement of one-to-one interpersonal skills necessary to initiate and maintain intimate relationships: a frame of reference for adults having sustained traumatic brain injury. Occup. Ther. Ment. Health 13(2), 51–67 (1997)Google Scholar
  62. 62.
  63. 63.
    Khan, F., Baguley, I., Cameron, I.: Rehabilitation after traumatic brain injury. Med. J. Aust. 178(6), 290–297 (2003)Google Scholar
  64. 64.
    Sander, A., Maestas, K., Pappadis, M., Hammond, F., Hanks, R., Ripley, D., Moessner, A., Zollman, F.: Multicenter study of sexual functioning in spouses/partners of persons with traumatic brain injury. Arch. Phys. Med. Rehabil. 97(5), 753–759 (2016)Google Scholar
  65. 65.
    Moreno, J., McKerral, M.: Relationships between risky sexual behaviour, dysexecutive problems, and mental health in the years following interdisciplinary TBI rehabilitation. Neuropsychol. Rehabil. 28(1), 34–56 (2018)Google Scholar
  66. 66.
    Zencius, A., Wesolowski, M., Burke, W., Hough, S.: Managing hypersexual disorders in brain-injured clients. Brain Inj. 4(2), 175–181 (1990)Google Scholar
  67. 67.
    Bezeau, S., Bogod, N., Mateer, C.: Sexually intrusive behaviour following brain injury: approaches to assessment and rehabilitation. Brain Inj. 18(3), 299–313 (2004)Google Scholar
  68. 68.
    Rees, P., Fowler, C., Maas, C.: Sexual function in men and women with neurological disorders. The Lancet 369(9560), 512–525 (2007)Google Scholar
  69. 69.
    Kelly, G., Simpson, G.: Remediating serious inappropriate sexual behavior in a male with severe acquired brain injury. Sex. Disabil. 29(4), 313–327 (2011)Google Scholar
  70. 70.
    Brain Injury Alliance Washington.: Education. (2017). Accessed 6 May 2018
  71. 71.
    Moreno, J., McKerral, M.: Differences according to sex in sociosexuality and infidelity after traumatic brain injury. Behav. Neurol. 2015, 914134 (2015)Google Scholar
  72. 72.
    Bélanger, D.: Traumatic brain injury and sexual rehabilitation. Sexologies 18(2), 83–85 (2009)Google Scholar
  73. 73.
    Lawrie, B., Jillings, C.: Assessing and addressing inappropriate sexual behavior in brain-injured clients. Rehabil. Nurs. 29(1), 9–13 (2004)Google Scholar
  74. 74.
    James, A., Young, A.: Clinical correlates of verbal aggression, physical aggression and inappropriate sexual behaviour after brain injury. Brain Inj. 27(10), 1162–1172 (2013)Google Scholar
  75. 75.
    Garcia, J., Sellers, D., Hilgendorf, A., Burnett, D.: Evaluation of a health education programme about traumatic brain injury. Health Educ. J. 73(5), 588–599 (2014)Google Scholar
  76. 76.
    James, A., Böhnke, J., Young, A., Lewis, G.: Modelling verbal aggression, physical aggression and inappropriate sexual behaviour after acquired brain injury. Proc. Biol. Sci. R. Soc. 282(1811), 1–8 (2015)Google Scholar
  77. 77.
    Mazmanian, P., Kreutzer, J., Devany, C., Martin, K.: A survey of accredited and other rehabilitation facilities: education, training and cognitive rehabilitation in brain-injury programmes. Brain Inj. 7(4), 319–331 (1993)Google Scholar
  78. 78.
    Doig, E., Fleming, J., Kuipers, P.: Achieving optimal functional outcomes in community-based rehabilitation following acquired brain injury: a qualitative investigation of therapists’ perspectives. Br. J. Occup. Ther. 71(9), 360–370 (2008)Google Scholar
  79. 79.
    Gill, C., Sander, A., Robins, N., Mazzei, D., Struchen, M.: Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners. J. Head Trauma Rehabil. 26(1), 56–68 (2011)Google Scholar
  80. 80.
    East, L., Orchard, T.: Somebody else’s job: experiences of sex education among health professionals, parents and adolescents with physical disabilities in Southwestern Ontario. Sex. Disabil. 32(3), 335–350 (2014)Google Scholar
  81. 81.
    Moreno, A., Gan, C., Zasler, N., McKerral, M.: Experiences, attitudes, and needs related to sexuality and service delivery in individuals with traumatic brain injury. NeuroRehabilitation 37(1), 99–116 (2015)Google Scholar
  82. 82.
    Poncet, F., Pradat-Diehl, P., Lamontagne, M., Alifax, A., Fradelizi, P., Barette, M., Swaine, B.: Participant and service provider perceptions of an outpatient rehabilitation program for people with acquired brain injury. Ann. Phys. Rehabil. Med. 60(5), 334–340 (2017)Google Scholar
  83. 83.
    Swango-Wilson, A.: Meaningful sex education programs for individuals with intellectual/developmental disabilities. Sex. Disabil. 29(2), 113–118 (2011)Google Scholar
  84. 84.
    Di Giulio, G.: Sexuality and people living with physical or developmental disabilities: a review of key issues. Can. J. Hum. Sex. 12(1), 53–68 (2003)Google Scholar
  85. 85.
    Degeneffe, C.: Family caregiving and traumatic brain injury. Health Soc. Work 26(4), 257–268 (2001)Google Scholar
  86. 86.
    King County. FLASH lesson plans: Sexual health education curriculum (2018). Accessed 4 Feb 2018
  87. 87.
    Hibbard, M., Gordon, W., Flanagan, S., Haddad, L., Labinsky, E.: Sexual dysfunction after traumatic brain injury. NeuroRehabilitation 15(2), 107–120 (2000)Google Scholar
  88. 88.
    Takada, K., Sashika, H., Wakabayashi, H., Hirayasu, Y.: Social participation and quality-of-life of patients with traumatic brain injury living in the community: a mixed methods study. Brain Inj. 30(13–14), 1590–1598 (2016)Google Scholar
  89. 89.
    Tucker, M., Degeneffe, C.: Future concerns among families following brain injury in the United States: views from the Brain Injury Association of America state affiliates. Aust. J. Rehabil. Couns. 19(2), 135–141 (2013)Google Scholar
  90. 90.
    Degeneffe, C., Green, R., Jones, C.: Satisfaction with post-acute-care rehabilitation services following acquired brain injury: family perspectives. Aust. J. Rehabil. Couns. 23(2), 90–97 (2017)Google Scholar
  91. 91.
    Moreno, J., Arango, L., Juan, C., Gan, C., McKerral, M.: Sexuality after traumatic brain injury: a critical review. NeuroRehabilitation 32(1), 69–85 (2013)Google Scholar
  92. 92.
    Ducharme, S., Gill, K.: Sexual values, training, and professional roles. J. Head Trauma Rehabil. 5(2), 38–45 (1990)Google Scholar
  93. 93.
    Ducharme, S.: Beyond the management of sexual problems: creating a therapeutic environment for addressing sexuality issues. In: Durgin, C., Schmidt, N., Fryer, L. (eds.) Staff Development and Clinical Intervention in Brain Injury Rehabilitation, pp. 211–227. Aspen Publishers Inc, Gaithersburg (1993)Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.School of Public Health and Health SystemsUniversity of WaterlooWaterlooCanada
  2. 2.Nutrition Resource CentreOntario Public Health AssociationTorontoCanada
  3. 3.Livewell COPD Program Chronic Disease ManagementSaskatoon Health RegionSaskatoonCanada
  4. 4.College of MedicineUniversity of SaskatchewanSaskatoonCanada

Personalised recommendations