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Title: Sexuality and severe brain injury

Total Pages: 2 Words: 824 Works Cited: 2 Citation Style: APA Document Type: Essay

Essay Instructions: Read the case study located in the UOP Library: Case Study: Sexuality and a Severely Brain-Injured Spouse, (2010) Hastings Center Report, May/June 2010, p 14-15 and the commentary by Kirschner and Brashler and the commentary by Dresser. Address the grading criteria in a scholarly narrative.

Write a paper in which you answer the following questions:

Describe the ethical issue involved in the case using scholarly, discipline specific references.
Explain ethical principles involved in the case and how the principles are involved using scholarly, discipline specific references. Include autonomy, beneficence, non-malfeasance, and justice.
Identify the consequences of possible actions associated with the case AND the "goodness" associated with each consequence.
Suggest a decision making model for the case (reference the model).
Articulate an action of choice (state the action you would choose)

Please read the attached
Article below:

Sexuality and a Severely Brain-Injured Spouse/commentary/commentary/commentary
Kirschner, Kristi LView Profile; Brashler, RebeccaView Profile; Dresser, RebeccaView Profile; Levine, CarolView Profile. The Hastings Center Report40.3 (May/Jun 2010): 14-5.
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Abstract (summary)
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Since her discharge from the rehabilitation facility, she has been living at home with her husband and her four-year-old twin sons. Putting aside concerns about pregnancy, if severely disabled adults do not lose the right to refuse or accept r medical care due to cognitive impairment (via substituted judgment and best interest standards of proxy decision-making), it seems logical that they also do not lose the right to refuse or accept the opportunity to engage in intimate contact with a spouse. [...] assuming that Mrs. Z does not show fear or evidence of negative behaviors in the presence of her husband, we favor giving them a second chance with some safeguards in place due to the patient's vulnerable status.n Mrs. Z will never be the person she used to be.

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Mrs. Z is a twenty-nine-year old woman who sustained a severe traumatic brain injury five years ago when she was hit by a car whose driver was drunk. She spent six months recovering, first in the hospital and then in a rehabilitation facility. Since her discharge from the rehabilitation facility, she has been living at home with her husband and her four-year-old twin sons. Mrs. Z is unable to speak, dependent in all mobility and personal care, incontinent, and has a feeding tube. Although alert and able to respond to visual, auditory, and tactile stimuli, Mrs. Z is clearly unable to participate in even basic decisions. She requires twenty-four-hour care.

A few months ago, Mrs. Z suffered abdominal discomfort, and her doctor discovered that she was pregnant. The pregnancy was terminated after physicians consulted on her case and determined that continuing it would compromise her health. Mrs. Z's parents are deceased, but her two older brothers have accused Mr. Z of rape. They contacted the local police asking that eliminai charges be filed and have retained a lawyer to begin guardianship proceedings. Based on their sister's severe cognitive impairments, they do not believe that Mrs. Z can make any reasonable sense of what is happening to her and think that any sexual contact with a minimally conscious woman is inappropriate. They believe Mr. Z is abusive and his views self-serving.

Mr. Z is adamant that his wife would have wanted to maintain a physical relationship with him and that what takes place in the privacy of their bedroom is not something that should interest the probate courts or the police. As evidence of his fidelity to his marriage vows he argues that he did not divorce his wife when she became disabled and that he still loves her and finds her attractive.

A guardianship agency is reviewing the case fot the judge and asks consultants to give theit opinions on these questions: Does Mrs. Z's inability to provide consent to sexual intercourse override Mr. Z's claims of marital privacy? Does Mrs. Z's prior sexual relationship with het spouse constitute clear and convincing evidence that she would want her partner to continue this relationship, even if she is only a passive participant? Should Mrs. Z remain with her husband, or should her brothers be given the authority to remove her from her home?

by Kristi L. Kirschner and Rebecca Brashler

While conversations about sexuality after disability are commonplace in rehabilitation, this particular case is unlike any we can recall. It is not like those of patients after spinal cord injuries, where the focus is on changed physiology, fertility, and ways to rediscover intimacy. It is unlike cases involving patients with developmental disabilities that prompt us to assess their understanding of sexuality and the consequences of intercourse and their ability to protect themselves from unwanted sexual advances. It is also unlike cases involving patients with severe cognitive disabilities who live in institutions - such as the young girl in a vegetative state who was raped by a staff membet - where we address protection. Discussions about sexuality with the spouse of a person who is unconscious, minimally conscious, or as severely brain injured as Mrs. Z rarely occur.

That doesn't mean, though, that we don't discuss physical touch. We encourage family members to help range and massage stiff limbs, for example, and to show their loved ones affection. We teach family caregivers to participate with catheterization and bowel programs. But initiating a frank discussion about sexuality has not felt appropriate with these couples. This case makes us question the wisdom of that practice because of the risks associated with pregnancy and the possibility of rape charges.

In reality, we don't know much about the normative sexual practices of couples when one member has a severe brain injury. How often does sexual contact occut? Do spouses hope, as popular literature might lead us to believe, that the power of their touch might "awaken" the injured brain? Current research may shed light on this.

The question of capacity to consent is enormously difficult in this kind of situation. Consent typically involves verbal communication, while intimacy often involves subtle nonverbal cues. The Alzheimer literature tells us that when couples have been together for years, the familiar patterns of physical intimacy may be a comfort - a source of support and reassurance amidst an otherwise frightening and disruptive disease.

In this case it seems critical to balance Mrs. Z's privacy, best interests, and need for prorection. Does she recognize her husband and welcome his sexual advances? Short of videotaping them in the privacy of their bedroom, we cannot think of a way to discern whether intercourse is consensual, or at least not harmful. We know she cannot take steps to protect herself, and that by allowing her to become pregnant, her husband was at least negligent. But is his negligence criminal? Is it substantial and grievous enough to remove her from his care forever?

Putting aside concerns about pregnancy, if severely disabled adults do not lose the right to refuse or accepr medical care due to cognitive impairment (via substituted judgment and best interest standards of proxy decision-making), it seems logical that they also do not lose the right to refuse or accept the opportunity to engage in intimate contact with a spouse. Premorbid wedding vows and a sexual history with a spouse may constitute clear and convincing evidence that the individual desired a physical relationship with their partner. Having a spouse who believes that he married for better or worse, and could seek divorce but does not, seems like a blessing - exactly what many of us would hope for if we sustained a severe brain injury. In the end, assuming that Mrs. Z does not show fear or evidence of negative behaviors in the presence of her husband, we favor giving them a second chance with some safeguards in place due to the patient's vulnerable status.

by Rebecca Dresser

This case presents two major legal questions. One is whether the law would classify Mr. Z's actions as sexual assault. Many U.S. jurisdictions have rejected the old rule that rape cannot occur in a marriage. One rationale for the old rule was that consent to marry signified consent to intercourse throughout the marriage. That reasoning is now questioned, with many arguing that married women should have the same right as single women to decide about each instance of sexual contact.

Nevertheless, her severe mental disability leaves Mrs. Z incapable of giving valid consent to intercourse. The legal standard for consent varies among the states, but at minimum, a woman must be able to understand the physical nature of the sexual act and that she has a right to refuse to engage in it. Underlying the concern about capacity to consent is knowledge that people with mental disabilities can be exploited by individuals seeking sexual gratification.

On the face of it, Mr. Z's actions could constitute sexual assault under the law. Nevertheless, I believe that few prosecutors would pursue charges in this situation. There is no clear evidence of physical or psychological harm to Mrs. Z from the encounters. And although it could be self-serving, Mr. Z's explanation for his behavior provides a plausible alternative story to exploitation. If we take him at his word, he believed intercourse was part of their relationship and was consensual in some sense. Although one can argue that this belief was unreasonable, the story he tells makes it possible to distinguish this case from the conduct targeted by sexual assault laws.

The remaining legal question is whether Mrs. Z should be cared for at home or somewhere else. Two standards are available to assist in resolving this question. The substituted judgment standard seeks to determine what the impaired individual would choose if she were capable of decision-making and aware of her current circumstances. To apply the standard, we must consider whether the evidence about Mrs. Z's beliefs and behavior before her injury points to a particular result.

The available evidence fails to tell us much about what Mrs. Z would choose, however. Her prior sexual behavior fails to indicate whether she would prefer to continue a sexual relationship with her husband in this drastically different situation. And because of his personal interests in the matter, we cannot rely solely on Mr. Z's claim that she would want to continue having a sexual relationship with him.

When substituted judgment fails to supply clear answers, the best interest standard comes into play. Case law on sterilization for individuals with mental disabilities offers guidance on how to think about Mrs. Z's placement. In those cases, courts consider the potential benefits and harms of the procedure and compare them to the potential benefits and harms of available alternatives, such as long-term contraception. They choose the approach that would produce the greatest net benefit from the disabled woman's perspective.

In deciding where Mrs. Z should live, the judge should consider the potential benefits and harms of keeping her at home, as well as the potential benefits and harms of placing her in anorher setting. This will require an evaluation of how Mrs. Z responds to her husband and children and how she responds to other potential caregivers. If her behavior suggests that she is most content with Mr. Z and the children, the judge could reasonably allow her to remain at home on a trial basis. With close monitoring to protect Mrs. Z's welfare, keeping her at home could be the best alternative.

by Carol Levine

The language of ethics sits uneasily in the realm of intimate human relationships. Describing sex as a partner's duty, obligation, right, or any other normative word seems both to diminish its meaning and elevate it to an unchallengeable principle. Even the word consent seems misapplied in this context; it implies that one person asks and the other accedes to the request. Nor does the language of science work much bettet. Locating the pleasure centers in the brain stimulated by sexual activity (and chocolate?) may tell us something about cognition but not much about how to live one's life as a person with a brain injury, or as that person's partner. We lack the words - and, more important, we lack the wisdom - to know what enhances human dignity and respect in these situations.

The essence of the sexual relationship between loving partners is not a contract, a vow in perpetuity, or a mechanical physiological response but a complex expression of their mutual commitment, love, and passion for each other. Sex in a marriage changes over time and often deepens in meaning as it decreases in frequency. Certainly illness and disability create the need for sensitive accommodation to the new reality. Serious brain injury is particularly challenging because it involves not a different body, but a very different self. Mrs. Z will never be the person she used to be. Her body may appear the same, but her ability to undetstand her identity and the way in which others can relate to her has changed.

Mr. Z does not seem to have accepted his wife's altered state and what that means for their relationship. He continues to see himself as het lover, when his primary responsibility to her now is to protect her from harm, enhance the quality of her life as much as possible, and add her responsibilities as a parent to his own. He has clearly violated the first responsibility by failing to protect her from a pregnancy that could compromise her health. Was he perhaps hoping for a miracle? Does he really believe that "finding her atttactive" makes his actions more acceptable? Divorce is not the only alternative. Some people in this situation are able to maintain their caregiving responsibilities only because they find companionship and intimacy outside the marriage. Mrs. Z's brothets, however, have compounded the problem by their actions. Are there other sources of their fury? Was this tension with Mr. Z part of the family dynamics throughout the marriage, or perhaps even earlier?

At its core this case is not about sex. It is about control. And it is a family tragedy, not just an individual ot marital tragedy. Who is looking out for the interests of the couple's two children? They have lost the love and nurturing of their mothet; their father is engaged in a bitter legal battle with their mother's family. How does this affect them emotionally?

Whatevet legal decision is reached about Mrs. Z's custody and placement, there should be a plan in place to counsel the whole family, separately if need be and ultimately as a unit. Pethaps a mediatot or other trained professional could assist them in putting aside their individual interests to provide a stable, loving environment for the children. If Mr. Z agrees that he is responsible for protecting the vulnerable people in his care, I would favor keeping Mrs. Z at home. Whether Mrs. Z as she is now would want to have sex with her husband or not, she would surely want her family to come together for the sake of her children.

Carol Levine directs the Families and Health Care Project at the United Hospital Fund and is editor of Always On Call: When Illness Turns Family Members into Caregivers (Vanderbilt, 2004).

Rebecca Brashler is a clinical social worker who directs care management and family support services and cochairs the clinical ethics service at the Rehabilitation Institute of Chicago. She is also an assistant professor at Northwestern University Feinberg School of Medicine.

Kristi L. Kirschner is professor at Northwestern University Feinberg School of Medicine and attending physician at Schwab Rehabilitation Hospital in Chicago.

Rebecca Dresser is Daniel Noyes Kirby Professor of Law and professor of ethics in medicine at Washington University in St. Louis.

Word count: 2302
Copyright The Hastings Center May/Jun 2010

Indexing (details)
Subject Marriage;
Families & family life;
MeSH Adult, Female, Humans, Legal Guardians -- legislation & jurisprudence, Rape -- legislation & jurisprudence, Sexuality -- psychology, Spouses -- psychology, Brain Injuries -- psychology (major), Mental Competency -- legislation & jurisprudence (major), Privacy -- legislation & jurisprudence (major), Sexuality -- ethics (major), Spouses -- legislation & jurisprudence (major)
Title Sexuality and a Severely Brain-Injured Spouse/commentary/commentary/commentary
Author Kirschner, Kristi L; Brashler, Rebecca; Dresser, Rebecca; Levine, Carol
Publication title The Hastings Center Report
Volume 40
Issue 3
Pages 14-5
Number of pages 4
Publication year 2010
Publication date May/Jun 2010
Year 2010
Section case study
Publisher Blackwell Publishing Ltd.
Place of publication Hastings-on-Hudson
Country of publication United Kingdom
Publication subject La

Excerpt From Essay:

Title: HIV and STD behavior interventional strategies for adolescents and youths

Total Pages: 12 Words: 4327 Bibliography: 12 Citation Style: APA Document Type: Research Paper

Essay Instructions: My final assignment is a seminar project that is the completion of a substantive written project. The project involves the development of a research protocol for assessing the evidence base for a given program/policy. The choice of program is to critically assess the effects of HIV and STD behavioral and interventional strategies for adolescents and youths ages 10-19. The format I chose for the project is the Cochrane methodology. The sample guide for this method is found at:

An example of the Spects/guidelines for this form of a project are:

Evidence-based reviews are conducted by examining what the literature says about the effects of a given intervention.

1. Most reviews usually start on the premise that although an intervention (e.g., abstinence-only programs to reduce teenage pregnancy or physical activity promotion to reduce obesity) may be receiving funding and support, we do not know whether it is effective or whether healthcare resources should be spent on alternative approaches.

2. Thus, to ascertain the evidence-base of the intervention (i.e., whether it achieves the impact it is purported to achieve), we undertake a systematic review, using either the Cochrane methodology or the CDC's Community Guide. I prefer the Cochrane method because it is much more structured and easier to follow for beginners.

3. The objective is to answer the question: are we doing the right thing? And, are we doing the right thing right?

4. First, you must have a specific objective. For example, "To critically assess the effects of abstinence-only programs on:
a. incidence of pregnancies among adolescents aged 10-19 years
b. initiation of sexual intercourse among adolescents aged 10-19 years.
c. STD rates among adolescents aged 10-19 years.
d. abortions rates among adolescents aged 10-19 years".

In the above example, unintended pregnancies would be your primary outcome, and the others (b-d) would be your secondary measures of effectiveness.

Note how specific this objective is. The key here is that when you identify a good quality study that assessed the effects of an abstinence-only program, you would ideally go the results section of that paper, and check the extent to which the program reduced any of the above outcomes in the intervention as compared to the control group.

5. Second, you must have a hypothesis or hypotheses. In the above example, your hypothesis could be that: abstinence-only programs to reduce unintended pregnancies among adolescents aged 10-19 years have no significant effects on pregnancy rates, initiation of sexual intercourse, STD rates, and abortion rates.

6. To conduct a systematic review of the effects of abstinence-only programs using the Cochrane methodology/CDC Guide, you first want to see if people who had been implementing these programs have been evaluating their work and reporting the results of their evaluation.

7. We do this by searching various literature databases (e.g., MEDLINE, PsychInfo, OVID, EMBASE, ERIC, The Cochrane Register of Randomized Controlled Trials), where such works are indexed. You hand-search relevant journals, and even contact experts and organizations working on the subject to request information on published/unpublished reports.

8. Next, you want to know if the studies you have identified through your search used rigorous and credible designs (this is what we mean by assessment of study quality, and there are guidelines for assessing study quality).

9. Then to conduct your analysis, you select only those studies with rigorous designs and go through their results. You want to see for example, out of 20 good quality studies that evaluated abstinence-only programs, how many showed that abstinence-only programs were effective in reducing sexual risks among adolescents. You then want to know how significant these results were and whether they are consistent in diverse settings.

10. In summary, if you have more studies (published or unpublished) reporting that abstinence-only programs are effective and these results are consistent in all settings, then your conclusion would be that abstinence-only programs are effective.

11. However, if in the course of your review you find that people have been implementing abstinence-only programs without rigorously evaluating their programs, your recommendation should be that there is currently little evidence to support its implementation, and that future programs should include evaluation components.

The concept of evidence-based reviews is growing in popularity. It is the idea behind DHSS's new "best practices" approach. Best practices are identified through evidence-based reviews that show which interventions are effective and which are not.

Lastly, since this is evidence-based research protocol the length would vary, for my purpose the paper should be about 12 double-spaced pages, using APA format. Note that Cochrane Review example above is what I need for this project. Though for my instructor the guidelines are per APA and at a minimum the final paper must be double spaced, use either Times Roman or Courier 12 point font, and a four level header. A title page, abstract, and a reference list are also required.

Some references to use for this evidence-based project are below others are welcomed-Thanks Much:

Crosby RA; DiClemente RJ; Wingood GM; Salazar LF; Harrington K; Davies SL; Oh MK. (2003)Identification of strategies for promoting condom use: a prospective analysis of high-risk African American female teens. Prevention Science: The Official Journal of The Society For Prevention Research; Vol. 4 (4), pp. 263-70.

Emans SJ; Brown RT; Davis A; Felice M; Hein K. (1991) Society for Adolescent Medicine Position Paper on Reproductive Health Care for Adolescents. The Journal of Adolescent Health: Official Publication of The Society For Adolescent Medicine; Vol. 12 (8), pp. 649-61.

Kirby D. (1993) Sexuality education: it can reduce unprotected intercourse. SIECUS Report ; Vol. 21 (2), pp. 19-25.

Harvey B; Stuart J; Swan T. (2000) Evaluation of a drama-in-education programme to increase AIDS awareness in South African high schools: a randomized community intervention trial. International Journal of STD & AIDS; Vol. 11 (2), pp. 105-11.

Munodawafa D; Marty PJ; Gwede C. (1995) Effectiveness of health instruction provided by student nurses in rural secondary schools of Zimbabwe: a feasibility study. International Journal of Nursing Studies; Vol. 32 (1), pp. 27-38.

Robin L; Dittus P; Whitaker D; Crosby R; Ethier K; Mezoff J; Miller K; Pappas-Deluca K. (2004) Behavioral interventions to reduce incidence of HIV, STD, and pregnancy among adolescents: a decade in review. The Journal off Adolescent Health: Official Publication of The Society For Adolescent Medicine; Vol. 34 (1), pp. 3-26.

Rotheram-Borus, M.J., Lee, M.B., Murphy, D.A., Futterman, D., Duan, N., Birnbaum, J.,Teens Linked to Care Consortium. (2001). Efficacy of a preventive intervention for youth living with HIV. American Journal of Public Health, 91, 400-405.

Thomas, Elizabeth Abimbola Sexuality and HIV/AIDS Education Curricula. (2002) Georgetown Journal of Gender & the Law; Vol. 3 Issue 2, p547, 11p

Many Thanks in advance for your help!

Excerpt From Essay:

Title: sex history assesment and evaluation

Total Pages: 4 Words: 1222 Sources: 0 Citation Style: APA Document Type: Essay


The format needs to be as a narrative not questions and answers

This should be a sexual history and assessment of an 30 years old white female who has an alcohol dependency problem who came to you with the concern of sexual dissatisfaction with her partner and wanted to know what her problem is. Make (or pretend) that you have that woman as a patient and do or pretend doing approximately 2hr of sexual history intake , you would find some guideline about that history intake style , that is not enough time for a comprehensive history and assessment how ever you can do a practical one suitable for working with that individual. After that interview the information that you gathered submit a written sexual history and assessment of that individual, it should take 4-5 pages and for the last page of the paper include your over-all professional impressions and assessments and any areas that you might pursue should you have the opportunity. Use pseudonyms or initials and guard for complete confidentiality and anonymity.

Core sexual history components
Reasons for attendance
Symptom review
Last sexual intercourse (LSI) - date, patient gender, sites of exposure, condom use
Previous sexual partners - as for LSI
Previous STIs
For women - LMP, contraceptive and cytology history
HIV, Hepatitis B & C risk assessment
Establish mode of giving results

Presenting complaint
Symptom Review
History of the presenting complaint

In women:
Change in vaginal discharge
Vulval skin problems
Lower abdominal pain
Changes in menstrual cycle or irregular bleeding


Are they sexually active?
Sexual history should cover all partners within the last 3 months.
If no partners are reported during this time, then the last time the patient was sexually active should be noted.
If the patient is symptomatic, the sexual history should cover all partners during the incubation period of STIs that may cause current symptoms.
Where no unprotected penetrative oral, vaginal or anal sex is reported during this period, ask the last time that this took place.5
Check the relationship of symptoms to LSI or to intercourse with a particular partner.
Condom use - always, sometimes or never.
Type of sex - e.g. oral, vaginal, anal.
Symptoms or diagnosis of partner(s).
Sex with same or opposite sex partners - check directly "Have you ever had sex with another man?"
Sex work - "Have you ever been paid for sex?"
Partners from overseas in the last year.
Menstrual history and contraception

Check if contraception used and if so what method.
Check correct usage.
LMP/LSI in relation to cycle/possibility of pregnancy.
Menstrual abnormalities (intermenstrual or postcoital bleeding).
Previous STIs

Previous diagnoses (and dates)
Treatment of partner (consider risk of reinfection)

Where a sexual 'problem' or dysfunction has been identified, ask:6

How the patient sees the problem and what they consider the cause.
The duration of the problem and whether it is related to the time, place or partner.
Loss of sex drive or dislike of sexual contact.
Sources of stress, anxiety, guilt or anger.
Any physical problems e.g. pain.
Carefully exclude illnesses that may affect sexual performance (e.g. CVD, testosterone or thyroid deficiency, pelvic or spinal trauma/surgery, arthritis).
In addition:

Past medical and surgical history
Current medication, including over-the-counter and recreational drugs
Smoking and alcohol use
IV drug use with needle sharing (ever) and last use

Excerpt From Essay:

Title: Reforming Rape Laws wk5

Total Pages: 2 Words: 669 References: 2 Citation Style: MLA Document Type: Research Paper

Essay Instructions: Reforming Rape Laws

According to common law, it was not a crime for a man to rape his wife. Men could not rape their wives since wives were considered property and sexual intercourse at any time (whether forced or not) was part of the marital duty. Now under modern rape laws, a man can be convicted of raping his wife. This is just one of the many areas where rape laws have been modified to keep up with the changing times. To many people, these changes were long overdue.

Research the rape law in Illinois. Be sure to share which state you researched, and answer the following questions:
Can a man be convicted of rape in the state where you currently live?
Must the spouse prove additional requirements above and beyond what a traditional rape victim would have to prove?
What year was the law in your state changed?
Explain Russell's four-part typology of men who rape their wives in your own words. Compare this typology to the other typologies of rapists and explain any similarities and differences you see between the groups.
What additional reforms, if any, do you feel are necessary in the area of rape law? Have the reforms that are currently in place gone too far? Explain your answer.

Excerpt From Essay:

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