Everything Is an Occupation. Not Everything Is Occupational Therapy.
Last month I wrote about an article examining drag as an occupation. My objection was not that drag could not be studied as an occupation. Occupational science can study almost anything people do, including activities that are unfamiliar, controversial, highly personal, culturally specific, or socially contested. That descriptive work can help us understand meaning, identity, habits, routines, context, and participation. That is not occupational therapy, per se, but it might sometimes be additive.
The additional leap into occupational therapy practice remains my persistent concern. Once an occupation has been described, authors sometimes attach a few sentences explaining its supposed clinical relevance. The occupational therapist is then asked to acknowledge it, assess it, support it, or incorporate it into practice, even when no particular patient population, health condition, intervention, competency, or outcome has been established.
I now intentionally call this phenomenon "occupational science with a progress note attached." It is a real problem in the professional literature.
A recent American Journal of Occupational Therapy column, “Pornography: What Occupational Therapy Practitioners Need to Know for Clinical Practice,” provides another opportunity to examine the problem. The authors argue that pornography use may be adaptive, neutral, or maladaptive depending on how it affects patients. They conclude that all occupational therapy practitioners should be prepared to evaluate how pornography use may support or interfere with daily life (Rothman & Ellis, 2026).
To be accurate, the authors do not explicitly recommend that occupational therapists ask every patient whether they use pornography. Their suggested questions are presented for situations in which the therapist has already learned that a patient uses it. This is not a proposal to add a pornography checkbox to every occupational profile - that is a good thing.
So the qualification matters, but it does not resolve the larger issue. In almost 40 years of occupational therapy practice, it never occurred to me to ask a patient whether pornography was disrupting sleep. I have asked about pain, positioning, toileting, medication schedules, caffeine, alcohol, nighttime caregiving, work schedules, environmental conditions, anxiety, television, phones, computers, and bedtime routines. Pornography never made the list. Makes me wonder - have I been doing this all wrong for 40 years?
That personal observation does not establish that pornography could never become relevant in an individual case. A patient might report that pornography use is affecting them. A person with a disability might identify concerns involving positioning, privacy, access, adaptive equipment, or sexual expression. A therapist working in behavioral health or with adolescents might encounter a genuine safety, developmental, or legal concern - that HAS happened to me, and I even blogged about it here.
Those circumstances are plausible. Plausibility, however, is not the same thing as a profession-wide clinical obligation. Before accepting pornography as something occupational therapists broadly need to know for clinical practice, there is a more basic question that deserves attention: What qualifies occupational therapists to evaluate it?
Occupational reasoning is not topic expertise
The article suggests that an occupational therapist might explore whether pornography supports or interferes with a range of behavior from sleep and stress regulation to sexual identity. The authors also suggest that therapists can work with patients on these concerns through activity analysis and modification of occupation, even when the therapist has only a limited understanding of pornography (Rothman & Ellis, 2026).
I do not think activity analysis carries that much weight.
Activity analysis is a professional method that helps occupational therapists examine components of a given task. It does not automatically confer substantive expertise in whatever activity happens to be under discussion.
For example, an occupational therapist can identify that online gambling is disrupting sleep and finances without becoming a gambling counselor. Or, an occupational therapist can recognize that political doomscrolling is interfering with mood and sleep without possessing expertise in political psychology, media studies, or misinformation.
General occupational reasoning may help us recognize that any disclosed behavior is affecting daily function. It does not necessarily qualify us to evaluate the psychological, relational, developmental, ethical, and legal dimensions of that behavior.
This distinction becomes especially important when the discussion moves from ordinary clinical responsiveness to questions involving compulsivity, adolescent sexual behavior, exploitation, criminal law, partnered sexuality, and ethically produced pornography. Those are not merely additional boxes on an activity-analysis form. They involve bodies of knowledge that occupational therapists may not necessarily possess.
So I looked at the documents that should tell us what occupational therapists are actually educated and expected to know.
What do the educational standards require?
The current Accreditation Council for Occupational Therapy Education standards establish the competencies that accredited programs must provide to prepare entry-level occupational therapists (Accreditation Council for Occupational Therapy Education [ACOTE], 2023).
Not surprising to me, those standards do not identify pornography, sexuality, sexual activity, intimacy, masturbation, or sexual health as specific required curricular competencies. Nor do they establish required entry-level knowledge of sexology, compulsive sexual behavior, pornography ethics, sexual counseling, pornography research, sexting law, or the effects of sexually explicit media. The standards provide a broad occupational therapy reasoning structure, but they do not establish subject-matter competence in this area.
Now I suppose that individual occupational therapy programs may teach some of this content. Faculty members may choose to include sexuality within courses on activities of daily living, mental health, rehabilitation, disability, or therapeutic use of self. Practitioners might even obtain continuing education, and specialty therapists may develop genuine competence through advanced training and supervised experience. All of that is possible.
But none of that establishes a profession-wide entry-level competency. If all occupational therapists are supposed to be prepared to evaluate pornography use, the educational foundation for that expectation is not apparent in the standards governing entry-level preparation. That also leads to problems when it comes to professional licensing and scope of practice claims. Those battles that are played out in state legislatures almost always circle back to educational training. In fact, that is the exact argument that is used to shut occupational therapists out of QMHP designations - the educational foundation in the curriculum does not meet the standard in many jurisdictions.
What has been validated as entry-level practice?
This is another important issue. The National Board for Certification in Occupational Therapy’s OTR practice analysis provides an even more direct test because its purpose is to identify the tasks performed by entry-level occupational therapists and the knowledge required to perform those tasks safely and competently. The process included expert-panel review and a national validation survey with 2,137 usable responses from recently certified (0-3 years of experience) occupational therapists across practice settings. The resulting examination outline contains 16 tasks and 62 knowledge statements (National Board for Certification in Occupational Therapy [NBCOT], 2023).
Again, not surprising to me, but pornography does not appear in the practice analysis. Neither do sexuality, sexual activity, intimacy, masturbation, or sexual health as specific entry-level task or knowledge areas.
The practice analysis does establish that occupational therapists gather information, analyze activities, consider habits and routines, evaluate contextual influences, identify mental health factors, plan interventions, monitor outcomes, remain within scope, and consult or refer when appropriate. Those are transferable professional processes. They could be applied when a patient identifies a sexuality-related concern, just as they could be applied when almost any activity becomes functionally relevant.
But that distinction is important. Occupational therapists possess a general method that may be useful when pornography emerges as part of a patient’s problem. That does not establish that occupational therapists possess professional knowledge about pornography.
The article seems to move between those claims without adequately separating them.
Then there is the OTPF
I know that someone out there reading this is now preparing to point to the Occupational Therapy Practice Framework. Sexual activity appears in the OTPF as an activity of daily living, and its definition includes sexual expression and experiences with oneself or others (American Occupational Therapy Association [AOTA], 2020).
That raises a question that may be more important than the pornography article itself. Why does sexual activity appear expressly in the OTPF when it does not appear as a specific required competency in the ACOTE standards or as a validated task or knowledge area in NBCOT’s practice analysis? Now we actually do have an answer to that question.
The answer is that these documents have very different purposes and very different levels of evidentiary authority.
ACOTE identifies what accredited programs must teach. NBCOT’s practice analysis uses a national validation process to identify what entry-level practitioners do and what knowledge is considered essential for safe and competent performance. The OTPF does neither.
The OTPF is not a validated practice analysis or a validated instrument for determining actual practitioner competence. It does not demonstrate how frequently occupational therapists address each occupation listed in the framework. It does not establish that practitioners have been educated to address each one, that patients expect occupational therapists to provide the service, or that occupational therapy intervention produces a distinctive outcome.
The OTPF is an association-approved framework produced through authorship, committee work, organizational review, member comment, and governance approval. AOTA describes a process involving feedback from members, scholars, practitioners, authors, and other interested parties.
That description tells us that comments were invited. It does not establish that the final product represents a meaningful professional consensus. I participate in those AOTA OTPF feedback processes every time the document comes up for review, and my experience has been that substantive criticism disappears into an empty abyss. There is little visible accounting of the comments received, the major points of disagreement, the representativeness of respondents, the reasoning used to resolve contested issues, or the extent to which dissent altered the final document. Members are eventually shown the completed product and told that stakeholder feedback was part of its development.
An opportunity to submit comments is not the same thing as responsive deliberation. It does not demonstrate consensus, and it certainly does not constitute validation.
Professional organizations engage in normative work. They don't merely describe a profession; they help determine what the profession wants to emphasize, recognize, or become. The authors and committees involved bring values, priorities, theoretical commitments, and advocacy interests to that process. That does not mean every decision is illegitimate or every statement in the OTPF is wrong. It does mean the framework should be understood partly as institutional agenda setting rather than treated as an empirical account of actual practice. I personally think it does represent agenda - too often - but that is just my opinion.
The problem develops when inclusion in the OTPF is later used as circular proof of clinical authority. Sexual activity belongs to occupational therapy because it appears in the OTPF, while the OTPF is treated as authoritative because it supposedly describes occupational therapy practice. The original decision to include the activity, however, is the professional judgment that requires examination.
The framework can claim conceptual territory. It cannot establish by itself that the profession actually occupies that territory. That is the discrepancy that is so visible. The OTPF places sexual activity within the conceptual domain of occupational therapy. ACOTE does not require a specific sexuality competency. NBCOT’s validated practice analysis does not identify sexuality as a distinct entry-level task or essential knowledge area. This does not prove that occupational therapists can never address sexuality. It does demonstrate that placement in the OTPF is not sufficient evidence of profession-wide preparation or competence.
Pornography is also another step removed. Even accepting sexual activity as an ADL does not make pornography synonymous with sexual activity. Pornography use involves media consumption and may raise issues related to psychological health, compulsivity, relationships, sexual development, consent, exploitation, criminal law, and ethics. Placing sexual activity inside an occupational category does not give occupational therapists expertise in every behavior, industry, product, or controversy associated with sex.
The article acknowledges the gap and then walks past it
The pornography column acknowledges that occupational therapy practitioners are undereducated about the subject - a good admission. It suggests that additional training is needed, directs readers toward sexuality specialists, and recommends professional education and communities of practice. It nevertheless concludes that all occupational therapists should be prepared to evaluate pornography use (Rothman & Ellis, 2026).
Those claims do not fit together comfortably.
Let's stress test this with some logical analysis. If practitioners are undereducated and need additional training, this is not an established general competency. It is a proposed expansion of competency. That proposal might ultimately be defensible, but it should be presented as a proposal and supported accordingly. It should not be framed as though the profession has discovered a clinical responsibility that ordinary practitioners have somehow been neglecting.
As I age in this profession I find myself more compelled to point out positions that might be more acceptable to swallow. A more modest conclusion might be: When a patient identifies pornography use as relevant to a functional concern or therapeutic goal, an occupational therapist should respond professionally, avoid reflexive judgment, determine whether the concern falls within the therapist’s competence, address relevant occupational patterns when appropriate, and consult or refer when necessary.
That is ordinary clinical responsiveness. It is different from constructing pornography as an area that all occupational therapists need to know for clinical practice.
A brief note about positionality and disclosure
There is also a small but interesting issue involving positionality.
Occupational therapy scholarship increasingly asks authors to explain how their identities, experiences, relationships, and social positions may influence the questions they ask and the conclusions they reach. AJOT’s contributor guidance strongly encourages positionality statements for research involving historically minoritized and marginalized groups (AOTA, 2023). The general principle is reasonable. Authors do not approach research or professional argument from nowhere, and readers benefit from understanding the perspective from which a claim is being made.
That principle should apply consistently.
The author affiliations in this column include leadership of an organization devoted to expanding sexuality-related practice in occupational therapy. The organization publicly states that it seeks to position sexuality interventions as widespread and mainstream in occupational therapy service delivery. It also provides paid education, certification, renewal, directory placement, mentorship, and other resources in the same area of practice that the article argues occupational therapists should become better prepared to address (Institute for Sex & Occupational Therapy, n.d.-a, n.d.-b).
There is nothing inherently improper about that. People commonly develop expertise, advocacy organizations, educational programs, and professional services around subjects they believe are important. The affiliation is identified in the article, so this is not a hidden relationship.
Still, I could not find a separate conflict-of-interest or positionality statement in the published column explaining the relationship between the argument being advanced and the professional interests represented by that affiliation. I do not know what may have been disclosed during manuscript submission, and I am not suggesting concealment or misconduct. I simply think the relationship would have been useful context for readers.
The irony is difficult to miss. We have become increasingly interested in positionality as part of diversity responsibility, particularly when authors write about identity or marginalized populations. We seem less consistent about applying the same principle when the relevant positionality involves professional advocacy, institutional commitments, intellectual investments, or a possible financial benefit associated with expansion of the practice area being proposed.
Perhaps positionality should mean more than demographic self-description. It might also include a clear account of the professional changes an author is actively promoting, the organizations represented in the argument, and whether those organizations provide services related to the recommendations being made.
That would not invalidate the argument. It would simply allow readers to evaluate it with a little more context. I like to call that transparency.
How professional territory becomes established
The larger concern is not the motivation of any individual author. It is the process by which a proposed area of practice can begin to look established before it has been demonstrated through educational requirements, validated practice analysis, patient demand, intervention research, or outcomes.
An association framework first places sexual activity within the conceptual domain of occupational therapy. That conceptual inclusion is then cited as a basis for bringing related topics into occupational therapy. A flagship journal publishes a column arguing that all practitioners should become prepared to evaluate one of those topics. The column identifies an educational deficit and points readers toward specialty education. Later articles can cite the AJOT column as evidence that the issue has already been recognized as an occupational therapy concern.
Over time, the claim begins to look settled because professional documents repeatedly refer to one another. It may then migrate into curricula, continuing education, conference presentations, specialty credentials, and future versions of professional frameworks.
That does not necessarily mean the practice area is illegitimate, but it does mean that professional territory can become established through repeated assertion before it has been demonstrated through required education, validated workforce activity, patient expectations, intervention research, or outcomes. I call that circular and self-referential logic.
This is why the threshold matters. Otherwise, a framework declares the domain, a journal normalizes the claim, continuing education creates the credential, and the existence of the credential is eventually taken as evidence that the practice area was there all along.
Professional real estate is limited
Our professional dialogue does not have unlimited real estate. Journals have limited pages and reviewer capacity. Conferences have limited presentation slots. Educational programs have limited curricular time. Practitioners have limited continuing-education resources. Professional associations have limited attention, credibility, and political capital.
Publishing choices communicate priorities.
“The Issue Is” is not simply a location for describing interesting human behavior. It is an explicitly argumentative section of the profession’s flagship journal, intended to identify professional issues and encourage change. This pornography column is therefore an agenda-setting piece. That makes it reasonable to ask whether its clinical claim has been adequately established and, more bluntly, whether this is among the best and most important material we have to place before the profession.
I should acknowledge my own positionality in raising the question of professional real estate. Over many years I have submitted essays to both AJOT’s “The Issue Is” and OT Practice’s “Perspectives That Matter” on contested questions involving doctoral education, ethics, professional formation, and scope of practice. None were accepted. I do not offer that fact as proof of editorial bad faith; publications reject submissions for many legitimate reasons. Still, editorial decisions accumulate into a pattern. The issues and perspectives selected for institutional publication have tended to move in a fairly consistent direction, while sustained dissent from that direction has had fewer official outlets. That is one reason I have maintained an independent blog for more than twenty years. And that is why I no longer have interest in submitting rebuttals to the things that get published in the formal channels.
But the bottom line is that all authors have positionality, and so do journals, editorial boards, and professional associations. Their positionality is expressed less through a formal statement than through repeated choices about which questions deserve attention, which arguments are treated as 'professionally constructive,' and which perspectives are left outside the official conversation. A column called “Perspectives That Matter” makes the issue almost impossible to ignore: someone is deciding which perspectives matter enough to print.
From my observation over many years, those choices have not reflected a particularly broad range of disagreement. They have tended to reinforce one direction of professional development.
I would be considerably less concerned if this article appeared in an occupational science journal as an exploration of pornography as a human activity. Researchers might reasonably examine its meaning, cultural context, routines, relationship to loneliness, role in sexual expression, or significance for people with disabilities. That could be legitimate descriptive scholarship. Probably not occupational therapy, of course.
My concern is the conversion of descriptive possibility into a broad clinical claim without evidence that ordinary occupational therapists possess the required knowledge, that the issue commonly appears in their caseloads, or that occupational therapy offers a distinctive intervention with measurable benefit.
Meanwhile, the lunch bucket practitioners face ordinary and consequential everyday problems related to evidence and reimbursement that never get space in print. Not every AJOT article (especially in this particular column category) needs to be a clinical trial. A mature profession needs conceptual scholarship, qualitative inquiry, ethical discussion, historical analysis, and disagreement. A flagship clinical journal should still require authors to earn clinical claims rather than simply attach occupational language to an interesting topic.
The missing threshold
So as a bottom line I have to state that the drag article and the pornography column are not identical. The pornography article provides more recognizable examples involving disability, privacy, sexual function, compulsive behavior, adolescent safety, and legal concerns. There are circumstances in which the issue could reasonably enter occupational therapy.
But the recurring disciplinary problem is still the same. An activity is described using the language of habits, routines, roles, identity, context, meaning, participation, and well-being. Because occupational therapists address occupation, the activity is then presented as something the profession should be prepared to evaluate.
That reasoning has no natural stopping point. Almost every human activity can support or interfere with sleep, relationships, identity, emotional regulation, productivity, health, and occupational balance. If possible relevance is enough, everything becomes an occupational therapy concern.
Before a topic becomes something all occupational therapists need to know for clinical practice, we should be able to identify the patient problem, its frequency in occupational therapy caseloads, the knowledge required to address it, where that knowledge is taught, how competence has been validated, what occupational therapy contributes, where the professional boundaries lie, when another discipline should lead, and what outcomes improve. It boils down to a scope of practice and licensing conversation.
Placement in the OTPF is not enough because the OTPF does not reflect validated practice. The ability to perform an activity analysis is not enough because a general method does not create subject-matter expertise. Publication in AJOT is not enough because journals should examine professional claims rather than manufacture them through repetition. The presence of a specialty training program is not enough because the existence of education for a proposed practice area does not prove that the area is an established responsibility of the profession.
These questions do not suppress innovation. They are the work required to distinguish an interesting occupational observation from a legitimate health-professional claim.
Until we establish that threshold, we will continue to confuse the fact that something can be described as occupation with evidence that occupational therapists are qualified, expected, or needed to address it. That remains occupational science with a progress note attached, although in this case the progress note may arrive with a continuing-education certificate.
References
Accreditation Council for Occupational Therapy Education. (2023). 2023 Accreditation Council for Occupational Therapy Education (ACOTE®) standards and interpretive guide. https://acoteonline.org/accreditation-explained/standards/ (ACOTE)
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process—Fourth edition. American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001 (AOTA Research)
American Occupational Therapy Association. (2023). Guidelines for contributors to AJOT. American Journal of Occupational Therapy, 77(Suppl. 3), 7713430010. https://doi.org/10.5014/ajot.2023.77S3005 (PubMed)
Institute for Sex & Occupational Therapy. (n.d.-a). About the Institute for Sex & Occupational Therapy. Retrieved July 16, 2026, from https://www.sexintimacyot.com/the-institute-of-sex-and-occupational-therapy (Institute for Sex & Occupational Therapy)
Institute for Sex & Occupational Therapy. (n.d.-b). Become a Certified Sexuality Occupational Therapy Practitioner. Retrieved July 16, 2026, from https://www.sexintimacyot.com/become-a-certified-sex-ot (Institute for Sex & Occupational Therapy)
National Board for Certification in Occupational Therapy. (2023). Practice analysis of the Occupational Therapist Registered: Executive summary. https://www.nbcot.org/-/media/PDFs/2022_OTR_Practice_Analysis.pdf (NBCOT)
Rothman, E. F., & Ellis, K. M. (2026). Pornography: What occupational therapy practitioners need to know for clinical practice. American Journal of Occupational Therapy, 80, 8004347020. https://doi.org/10.5014/ajot.2026.51409
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