Review of Sexual Positions in Special Populations and Recommendations for Clinicians

Abstract

Sexual intimacy is a fundamental aspect of human relationships, yet individuals within special populations often face unique challenges that can impact their ability to engage in satisfying sexual experiences. Special populations encompass a broad spectrum of individuals, including those with physical disabilities, chronic illnesses, or physiological conditions such as obesity or pregnancy. These individuals may encounter barriers such as physical limitations, emotional distress, and a lack of resources or education regarding sexual health. Despite the importance of addressing sexual intimacy within these populations, research in this area remains limited, leaving many individuals without evidence-based guidelines to navigate their intimate lives effectively. This article aims to bridge this gap by conducting a review of the literature focusing on sexual positions tailored to individuals within special populations. By compiling insights from diverse research articles, this study offers comprehensive recommendations for enhancing intimacy through suitable sexual positions, tailored to the unique needs of different populations. Clinicians will also find useful information through helpful links for different sexual position illustrations and leaflets for their clients and patients.

Introduction

Sexual intimacy is a cornerstone of human relationships, serving as a means of connection, pleasure, and emotional fulfilment. However, for individuals within special populations, achieving satisfying sexual experiences can present significant challenges. Special populations encompass a diverse range of individuals, including those with physical disabilities, chronic illnesses, or physiological conditions such as obesity or pregnancy. These individuals may face a myriad of obstacles that can impact their sexual health and well-being, ranging from physical limitations and pain to emotional and psychological distress.

Despite the importance of addressing sexual intimacy within these populations, research in this area remains limited, leaving many individuals without evidence-based guidelines or support. The lack of research in this field is compounded by societal taboos surrounding sexuality and disability, which further marginalise individuals within special populations and hinder access to appropriate care and resources.

This article seeks to fill this gap by conducting a comprehensive review of literature focused on sexual positions tailored to individuals within special populations. By synthesising insights from diverse research articles, this study aims to provide practical recommendations for enhancing intimacy through suitable sexual positions, taking into account the unique needs and challenges faced by different populations. By promoting a more inclusive and informed approach to sexual health, this article endeavours to empower individuals within special populations to navigate their intimate lives with confidence and fulfilment.

Method

Literature Search Strategy

To conduct a thorough investigation into sexual positions tailored to individuals within special populations, a systematic approach was employed to search for relevant literature. The search was conducted using medical research databases Embase, PubMed, Google Scholar, and individual journals specifically focused on sexual health and rehabilitation. In addition to this, a general search on the search engine Google was done. The search strategy aimed to identify peer-reviewed research articles, systematic reviews, and clinical guidelines that addressed sexual intimacy within specific populations, including but not limited to obesity, cancer, rheumatoid arthritis (RA), chronic pain conditions, knee and hip injury and pregnancy. These are the common clinical conditions encountered by clinicians.

Keywords and Search Terms

A comprehensive set of keywords and search terms was utilised to optimise the search process and ensure the identification of relevant literature. These included terms such as ‘sexual positions’, ‘sexual intercourse’, ‘sexuality’, combined with specific population descriptors such as ‘obesity’, ‘cancer’, ‘RA’, ‘pregnancy’, and related terms. Boolean operators (AND, OR) were employed to refine the search and broaden the scope of relevant articles.

Inclusion and Exclusion Criteria

Inclusion criteria for selecting relevant studies were established to ensure the focus on sexual positions tailored to individuals within special populations that we have focused on. Studies were included if they addressed sexual intimacy within specific populations, provided recommendations or insights into suitable sexual positions, and were published in peer-reviewed journals or reputable sources. Exclusion criteria included studies not focused on sexual positions, non-English language publications, and studies lacking relevance to the scope of this article.

Data Extraction and Synthesis

Following the initial literature search, retrieved articles were screened based on their titles and abstracts to assess their relevance to the research objectives. Full-text articles meeting the inclusion criteria were then reviewed in detail to extract relevant data, including descriptions of sexual positions recommended for individuals within special populations. Data synthesis involved categorising recommendations according to different population groups (e.g., obesity, cancer, RA, pregnancy) and identifying common themes and variations across the literature.

Quality Assessment

To ensure the reliability and validity of the findings, the quality of included studies was assessed using established criteria appropriate to the study design (e.g., critical appraisal tools for randomised controlled trials, systematic reviews). Studies deemed to be of low quality or with significant methodological limitations were critically evaluated, and their findings were interpreted with caution.

Results

The review of literature encompassed a comprehensive exploration of sexual positions tailored to individuals within special populations, revealing a wealth of insights and recommendations across various conditions and circumstances. We present here an abridged version of the results that we found were clinically relevant for practitioners.

Women with Disabilities

According to research conducted by the Baylor College of Medicine, sexual positions for women with different physical disabilities vary based on each person’s experience of their body. The suggested positions can be performed with a partner, a sex toy, or an adaptive device. Examples include adaptive missionary, modified doggy style, spooning, and sideways 69. The research also highlights the use of positioning aids such as pillows, wedges, and ankle cuffs with leg straps, all of which help alleviate fatigue and provide comfort and stability. ¹

Chronic Pain

According to a study done by Monga et al., ² the most common sex positions described by people who had chronic pain were the top position, Lying on back, Lying on the side position and sitting on a chair. Most of the patients in this study also mentioned that they practised more than one position. Another study done by Fleming & Paice ³ highlights the need for spending time on sexual expression with sufficient foreplay, as the responses to physical touch in patients with chronic pain are much slower. Using sexual positions that require less physical exertion, place little or no weight on painful areas and allow for better control of depth of penetration is important. The suggestions for the same were—Spooning (side-by-side), in which the man is behind the woman, or the L-shape position with both partners lying down and torsos at right angles. They highlight the use of analgesics, muscle relaxants and other pharmacological aids to improve the pain score and comfort levels of persons with chronic pain indulging in sexual intimacy.

Rosenbaum’s review ⁴ focused specifically on research papers for Musculoskeletal Pain and Sexual Function in Women (2010). Based on this review, patients with Fibromyalgia may feel more pain in prone positions as well as supine positions where there is increased pressure from the partner on top. Fibromyalgia patients usually have pelvic and abdominal pain that is aggravated with pressure. Deep penetration may also cause rectal pressure when abdominal symptoms of gas and bloating are present. Even a light touch during fondling may be unbearable when there is hypersensitivity to touch. In patients with RA, there may be associated vaginal dryness that could lead to dyspareunia. For patients with Lower back pain (LBP), it is reported that there is no universally comfortable position; it is based on the aetiology of the back pain, and positions need to be recommended accordingly. Although most women are comfortable with the side-lying position—spooning. The author also highlights the importance of assistive devices, splints, positioning advice, and exercises specifically tailored to improve joint mobility and strength, reduce fatigue and endurance prescribed by physical therapists on an individual basis.

Della Volpe ⁵ in the article titled, ‘Improving the Sex Lives of Patients With Chronic Pain’ suggests that for flexion-motion intolerant individuals, the best position for men was for the man kneeling behind a woman in table top positions while she supports her upper body with her hand. The best position for women would be the side-to-side or the tabletop position, with the woman supporting her upper body with her hands, not her elbows. In extension-motion intolerant individuals, the best position for men was either side-to-side or missionary, with the man supporting his upper body with his elbows, not his hands. For women, missionary while flexing at the hips and knees.

According to a study done by Sidorkewicz & McGill, ⁶ for flexion-intolerant women with low back pain, the recommended position includes the tabletop position with the woman resting her upper body on her hands, not her elbows and side-lying position. For extension-intolerant women with low back pain, the missionary position with legs flexed at the hips and knees, with the man in the prone position resting on their hands, and the missionary position with minimal flexion at the knees, with the man in the prone position resting his upper body on his hands.

Cancer: According to the article, titled ‘The Sexual Rehabilitation of Persons with Cancer’, Gallo-Silver ⁷ supports the side-lying position (spooning) for women with an ostomy or a history of breast cancer, where the man is lying behind the woman and cannot rub or press on the sensitive areas of the body. The side-lying and female superior positions also give the female partner greater control over the amount of vaginal penetration, with rubbing against the thighs, buttocks, or abdomen. For men with an ostomy, the female superior positions can be modified so that the woman is not resting on the upper torso. For men who have partial erections, the female superior position can help the erectile ability of the man.

According to the American Cancer Society guidebook on ‘Sex and the Adult Female with Cancer’, ⁸ the ‘build-on’ is to discuss with the partner what works best for each individual because there is no one position that is right for everyone. Using pillows for support and furniture for positioning might be some helpful tools.

Multiple Sclerosis (MS)

According to a booklet by the MS society, ⁹ there are a lot of considerations that come into the picture for an individual living with MS that are directly and indirectly caused by the disease itself. Sexual dysfunction due to nerve damage causes a lapse in the arousal, response and orgasm cycle. Lubrication issues, spasticity, muscle weakness, sensory issues, pains, bowel and bladder concerns, cognitive difficulties, mood disturbances and fatigue are some other issues that come into play. While looking into recommending sexual positions, the recommendations point towards exploring and understanding the bodily responses to oneself and with the help of a partner. Techniques like body mapping, masturbation, and the use of sex toys to avoid repetitive movement, as well as for arousal and positioning, are mentioned. There is also evidence to promote self-pleasuring and mutual masturbation for intimacy, as it helps to find what is more pleasurable for oneself when dealing with the physical and sensory changes as a result of MS. The authors suggest positions that encourage support, comfort and accessibility, like side-lying positions (spooning, leg-over-leg positions) to avoid fatigue.

Knee Injury

Harmsen et al. ¹⁰ in their mixed-method study of patients, partners, and surgeons noted that sexual activity is a common yet often overlooked concern for patients following total knee arthroplasty (TKA). While most patients and their partners adapt over time and typically resume sexual activity within a few months, many express a need for clear guidance from their doctors. Discomfort during deep knee flexion or kneeling is not uncommon, making certain positions challenging. Although 95% of surveyed TKA surgeons reported no formal restrictions, advice tends to vary widely. They conclude that clinicians should recommend positions that minimise knee strain, such as side-lying or supine, and caution against those requiring deep flexion. Proactively addressing this topic during post-operative visits can reduce anxiety and improve patient satisfaction. Using illustrated guides or printed handouts may also help normalise the conversation. Incorporating sexual activity counselling as a standard part of TKA recovery can foster trust and holistic care. Overall, consistent, empathetic communication is key to supporting patients in regaining intimacy safely.

Hip Injury

We were able to come across a few papers focusing on safe positions for intercourse after a hip replacement. According to Laffosse et al., ¹¹ the patient’s significant risk of dislocation is the only reason why resuming sexual activity after a hip replacement should be avoided. The supine (missionary) posture is the suggested coital position for preventing hip dislocation. Similarly, Stern et al. ¹² noted that the greatest defence against a posterior hip dislocation was to adopt a more passive stance in the supine position a few weeks following a total hip arthroplasty (THA).

As part of a study by Dahm et al., ¹³ surgeons were asked to evaluate 12 coital positions to determine which were safest in preventing posterior hip dislocations. The findings revealed that women who had undergone THA could safely engage in only three positions, whereas men could safely use five. The study also included illustrations of the surveyed positions. According to 90% of the surgeons, the safest position for both partners involved the woman standing with her waist slightly bent forward while the male partner approached from behind. For men, the five safe positions included two where the man is prone on top of a supine woman, two where he is supine, and one where both partners are standing. For women, the three safe positions included one where both partners are standing, another where both are in the prone position, and one where the man is kneeling while the woman lies supine at his waist level.

Laffosse et al., ¹¹ conclude that the considerable danger of hip adduction and internal rotation makes the lateral decubitus positions unsuitable. The patient is more likely to experience hip dislocation if they engage in sexual activity when their hip is adducted and internally rotated.

According to the study by Charbonnier et al., ¹⁴ the positions to be avoided by individuals who have undergone THAT are Rear penetration, woman on top and leaning forward, face-to-face side-lying and the ‘T–square’ (woman lies supine with knees flexed and legs apart, man lies on a side perpendicular to the woman, with the man’s hips under the arch formed by woman’s legs) for the women; and face-to-face side-lying for men.

Pregnant Women

Uwapusitanon et al. ¹⁵ surveyed pregnant women for sexual activity in a study and found that during pregnancy, there was a dramatic shift in the positions employed for sexual activity. Prior to becoming pregnant, couples would typically assume the male-superior posture (man on top); but, as the pregnancy went on, the female on top and non-weight-bearing positions– particularly the side-by-side position–were preferred. Similar results were found in another study by Staruch et al. ¹⁶ in pregnant women in Poland, which showed that they mostly preferred positions where they are lying on their side with the man behind them (79.5%), and the second most preferred position was one where the woman is sitting on the man who is lying down (51.5%). A study among pregnant women in Istanbul by Gökyıldız & Beji ¹⁷ discovered that the incidence of the male-superior posture declined with the progression of pregnancy. When the postures used during sexual intercourse were evaluated, it was found that the most common positions were male superior, female superior, and side-by-side for 45.3%, 47.3%, and 40.7% of the women throughout the first, second, and third trimesters, respectively.

However, Lee et al., ¹⁸ in a study among Taiwanese women found results contradictory to the ones mentioned above. Here, they found that pregnant women still preferred men in the top position, and the other position commonly preferred was face-to-face. Though women who reported more sexual satisfaction comparatively used women on top, face-to-face and abdominal supportive sexual positions more.

In the context of pregnancy, the majority of couples can typically engage in sexual intercourse without significant risk. Nevertheless, there exist particular circumstances and conditions wherein it is prudent to refrain from such activity to mitigate potential complications. Healthcare providers may recommend abstaining from sexual intercourse in the following scenarios:

First, in cases of placenta previa, where the placenta partially or fully covers the cervix, engaging in sexual intercourse can provoke bleeding. According to the National Health Service (NHS) leaflet, ¹⁹ for pregnant women, placenta previa carries implications for pregnancy, potentially influencing recommendations regarding sexual activity. Similarly, if there are indications of preterm labour or a history thereof, sexual activity may be curtailed due to the potential of orgasms or physical activity inducing contractions. Additionally, cervical insufficiency, characterised by a weakened cervix prone to premature opening during pregnancy, poses a risk of preterm birth or miscarriage, potentially exacerbated by sexual activity. The American College of Obstetricians and Gynaecologists (ACOG) ²⁰ offers guidelines on managing complications like preeclampsia, which may influence recommendations regarding sexual activity.

Discussion

The discussion section provides an analysis of the identified sexual positions tailored to specific populations, exploring their implications, challenges, and potential benefits in depth.

For most people, engaging in sexual behaviour is a normal aspect of life. Sex is rated as moderately significant when weighed against necessities like food and sleep. Despite this, sometimes individuals have experiences that limit their sexual activity due to concerns like pregnancy, knee or hip injury. This article covers that gap by helping educate on the safe position for individuals with special needs.

Women with Disabilities

The studies focused on women with disabilities commonly recommended positions like adaptive missionary (Appendix Figure A1), modified doggy style (Appendix Figure A2), spooning (Appendix Figure A3) and sideways 69. They have recommended these positions for solo play or for partner play, along with the use of positioning items like pillows, wedges, ankle cuffs with leg straps and so on. This is with the intention of reducing fatigability and providing comfort and stability for the woman.

Chronic Pain

The commonly recommended position across studies was spooning (Appendix Figure A3). This allows for less physical exertion, places little or no weight on painful areas and allows for better control of depth of penetration.

Other positions include top positions (cowgirl/boy), lying on back (missionary) (Appendix Figure A1), and sideways 69. For LBP, positions are based on the aetiology of back pain—most are comfortable with side-lying positions (Appendix Figure A3). For flexion-motion intolerant—Doggy style with upper body supported by hands (Appendix Figure A4), Spooning (Appendix Figure A3). For extension-intolerant individuals—Spooning (Appendix Figure A3), missionary with upper body of man supported by elbows (Appendix Figure A1i and A1ii), women with flexion at hips and knees (Appendix Figure A1ii).

The studies also emphasise the use of analgesics, muscle relaxants and other pharmacological aids to improve pain score and comfort levels of persons with chronic pain; assistive devices, splints, positioning devices, and exercises specifically tailored to improve joint mobility and strength.

Cancer

The commonly recommended positions were spooning (Appendix Figure A3) and female superior positions (Appendix Figure A5) for women, allowing the woman greater control over the amount of vaginal penetration and for men to improve erectile ability and comfort even with an ostomy. They also recommend the use of positional devices like pillows, furniture and so on. There is no one position that is right for everyone; discuss with the partner and build on the same.

Multiple Sclerosis

The general consensus is to experiment and see what works on an individual level, as there are multiple considerations that come into the picture for individuals with MS. Techniques like body mapping, masturbation, using sex toys—with a partner and/or solo were recommended. Avoid positions that require repetitive movement or use toys that help with the same. Recommended positions to start were side-lying positions like spooning, leg-over-leg positions (Appendix Figure A3)—to avoid fatigue.

Knee Injury

Some of the positions that have been recommended for people with knee injury are some face-to-face (Appendix Figure A6), sitting in chair position (Appendix Figure A7), a person with a new joint lying and a partner kneeling (Appendix Figure A8) and spooning (Appendix Figure A3). An important prop is a pillow to support the knees and reduce pressure.

Hip Injury

The fear of hip dislocation is one major reason behind the reduced sexual activity after THA, but there are some positions that have been said to be safe for both genders. One of these is the standing position, where the receiver is bent from the waist and the male is inserting from behind (Appendix Figure A9). The other accepted positions for females is where both the genders are in prone position (Appendix Figure A10) and one where the man is kneeling and the woman is supine (Appendix Figure A8), for males 2 positions one where the man is in supine position with women on top of them (Appendix Figures A5 or A6 with support of pillow) and the other is when the man is prone on top of a supine woman (Appendix Figure A1i and A1ii).

Pregnancy

In pregnancy, it is seen that there is a shift in positions from missionary before pregnancy to side-lying (spooning) (Appendix Figure A11) and woman on top (Appendix Figure A12) during pregnancy. These positions are chosen to avoid pressure on the stomach.

This article could be beneficial for clinicians as it serves as an educational resource and raises awareness about the diversity in sexual experience and needs within special populations. This could be used as a guide for clinicians to provide practical advice that promotes sexual health and satisfaction for their patients. This is essential to improve the overall well-being and quality of life for individuals with disabilities/special needs. Furthermore, knowledge about the sexual positions for special populations empowers clinicians to advocate for inclusive sexual health education and resources. They can actively work towards reducing stigma and barriers to sexual expression for individuals with special needs.

Further research into this topic is essential, as the literature available for this topic is subpar. Clinicians can contribute to this field by sharing their clinical insights and experiences.

In summary, this article can serve as a valuable resource for clinicians, enhancing their knowledge, practice, and ability to provide inclusive and affirming care to all patients.

Limitations

Several limitations were encountered during the literature search and review process. These included the potential for publication bias, wherein studies with positive findings are more likely to be published, leading to an overrepresentation of certain perspectives. Additionally, the heterogeneity of study designs, populations, and outcome measures across included studies posed challenges to data synthesis and interpretation. The readers should also appreciate that research in sexual medicine itself has its challenges, especially so in a subgroup like this. Efforts were made to mitigate these limitations through thorough screening, critical appraisal, and transparent reporting of findings.

The identified sexual positions tailored to specific populations offer practical solutions to address diverse needs, challenges, and preferences in sexual intimacy. By promoting communication, adaptation, and inclusivity, these positions contribute to enhancing pleasure, satisfaction, and overall well-being for individuals within special populations. Further research, advocacy, and education efforts are needed to promote awareness, accessibility, and acceptance of diverse sexual expressions and experiences for all individuals, regardless of physical abilities or health conditions.