Sexuality and mental health
Written by Sarah Fairbank on February 1, 2009 . Posted in Clinical Psychology Bite-Size
Issue 11 – February 2009
Author: Sarah Fairbank (sarah.fairbank@nottshc.nhs.uk)
Historically sexuality and mental health has been viewed negatively, and service users are often pathologised as either asexual or deviant.
Sexuality is not routinely addressed with service users, despite the focus on holistic care and research suggesting that sexuality is an important part of self.
Implications for practice
Research has demonstrated that service users want to talk about issues of sexuality.
By not addressing the issue of sexuality we are also ignoring issues of sexual health.
Relationships can play a vital part in an individual's recovery.
Historical and Current Context
It is well documented that service users with severe and enduring mental health difficulties can experience a number of losses in their life, including the loss of their sexual identity. Historically, mental health services have ignored or misrepresented sexuality. If sexuality is considered at all, it has normally been in a negative and polarized way resulting in labelling service users as either asexual or deviant 1,2. Sexuality is often pathologised through the lens of diagnosis rather than seen as a natural human need. Consequently, services have responded to issues of sexuality in a controlling, risk management and paternalistic approach through segregation, medication, avoidance and in extreme cases sterilisation1. Sexuality and mental health remains a relatively unexplored area in research and clinical practice. This is despite the recognition that people are sexual beings whether they are healthy, ill or disabled 4. People who are given a diagnostic label of "schizophrenia"[1] report that they view their sexual self as an essential aspect of their core self 3. The consequence of a limited evidence base or professional guidelines is that professionals are forced to use their own judgements, life histories, beliefs and values to inform their clinical practice, which can lead to conflict. The limited amount of research conducted has tended to focus on the impact of medication on sexual functioning or the risks of engaging in sexual activities (sexually transmitted diseases and unwanted pregnancy) 2, 5. Several studies have reported sexual problems caused by medication 2, 5 and side effects such as weight gain, delayed ejaculation and decreased libido which all impact on the individual's self perception of masculinity and femininity3. Sexual functioning has been implicated as one of the major factors contributing to whether service users wish to take medication 5, and yet the impact of sexual dysfunction on the individual's sense of self is rarely explored, instead the focus is on the importance of "drug concordance1.
Talking about Sexuality
Research suggests a number of reasons why professionals are reluctant to talk about sexuality. Sexuality is seen as dangerous and something to be controlled, therefore the primary motivation for staff is to protect themselves from allegations of professional misconduct1. Other themes from research with staff include: feeling embarrassed to talk about the topic; assuming service users will raise the issue; not wanting to upset or embarrass the service user; a lack of resources or time; fear that discussions may be used as a source of sexual stimulation; staff assuming there was nothing to address; and not feeling trained or confident to open a discussion about these issues 1, 2, 3. Higgins et al (2008) highlights that services are often focussed on protecting service users from embarrassment, distress or poor decision making, but if we solely do this we are in danger of infringing their rights to information and freedom 1. For example, many service users have experienced professionals and families advising against marriage and worries about its negative impact, with-out highlighting the many potential positive effects of a relationship2. Such examples and research demonstrate how services can "perpetuate practices that marginalize, discriminate and socially exclude service users as 'sexual citizens'" (p.315)1. Research with service users show that they are not opposed to talking to staff about issues of sexuality and believe that these discussions would be helpful. More recently, service users stated that they not only wanted to be asked about these issues, but expected staff to initiate the conversation and provide support, advice and education1, 2, 3, 4. When service user's felt heard and understood, they reported feeling supported and empowered3 and benefited from attending sexual health education programmes that were facilitated in a sensitive and supportive approach6.
By not asking about sexuality we are inadvertently conveying the message that this is not an important part of life and therefore we neglect the whole person. If we are not asking about sexuality, we are also at risk of neglecting sexual health issues. In addition, if we are failing to address heterosexual needs it is likely that we are also ignoring diversity needs regarding culture and sexual orientation. This is particularly important as research suggests that experiences of discrimination can result in mental health difficulties amongst gay, lesbian and bi-sexual people7. Further, if services are to be holistic and take seriously a person's sexuality, it seems vital for sexual problems resulting from medication to be identified and addressed. In conclusion, as professionals we need to reflect on our own beliefs, values and attitudes towards sexuality and mental health, and consider how this impacts on our interactions with service users to ensure we do not impose our own beliefs and values on service users.
Higgins, A., Barker, P & Begley, C.M. (2008). Veiling sexualities: A grounded theory of mental health nurses responses to issues of sexuality. Journal of Advanced Nursing 62 (3), 307 – 317.
McCann, E. (2003). Exploring sexual and relationship possibilities for people with psychosis: A review of the literature. Journal of Psychiatric Mental health Nursing, 10, 640 – 649.
Volman, L & Landeen, J. (2007). Uncovering the sexual self in people with schizophrenia. Journal of Psychiatric Mental health Nursing, 14, 411 – 417.
McCann, E (2000). The expression of sexuality in people with psychosis: Breaking the taboos. Journal of Advanced nursing, 32 (1), 132 – 138.
Kelly, D, L. & Conley, R. (2004). Sexuality and Schizophrenia: A Review. Schizophrenia Bulletin, 30 (4), 767 – 779.
Higgins, A., Barker, P & Begley, C.M. (2006). Sexual health education for people with mental health problems: What can we learn from the literature? Journal of Psychiatric and mental Health nursing, 13, 687 – 697.
Scott, S. D., Pringle, A. & Lumsdaine, C. (2004). Sexual exclusion: Homophobia and health inequality. UK: Gay Men's Health Network.
[1] For a critical perspective on the concept of schizophrenia see 'Bentall, R.P. (Ed.) (1990). Reconstructing schizophrenia. London: Routledge'.