Forthcoming in the International Journal of Law and

Mental Health

Examining professionals’ perspectives on sexuality for

service users of a forensic psychiatry unit.

Kalpana Elizabeth Dein (a), Paul Simon Williams (b),

Irina Volkonskaia (c), Ava Kanyeredzi (d) , Paula Reavey

(e) & Gerard Leavey (f).

a) St Andrew’s Healthcare

Clare House

Pound Lane

North Benfleet

Essex SS12 9JP

b) North London Forensic Service,

Chase Farm Hospital

The Ridgeway

Enfield, Middlesex

EN2 8JL

c) Brockfield Regional Secure Unit

Basildon

Essex SS11 7XX

d) Child and Woman Abuse Studies Unit

London Metropolitan University

Ladbroke House

62-66 Highbury Grove

London

N5 2AD

T: 020 7133 5036

E: a.kanyeredzi@londonmet.ac.uk

e) Department of Psychology

London South Bank University

103 Borough Road

London

SE1 OAA

f) Compass Centre for Mental Health Research & Policy

Northern Ireland Association for Mental Health

80 University Street

Belfast BT7 1HE

Further contact: Professor Paula Reavey:

reaveyp@lsbu.ac.uk

_________________________________________________________

______

Abstract

Very little is known about the sexual activities of

psychiatric patients during their stay in hospital and

beyond. In this article, we have explored how mental

health professionals working within a forensic

psychiatric unit construct the issue of patient sexuality

in order to ascertain the range of sexual possibilities

open to patients. Drawing on interviews with twenty four

participants - psychiatrists and clinical psychologists

(clinical staff), we examined how participants made sense

of patient sexuality and their clinical judgements in

relation to them. Using a thematic analysis, we were

able to identify a number of relevant themes emerging,

including a) what the limits of acceptable sexual

behaviour were judged to be b) discrimination against

transgender and same sex relationships c) vulnerability

among female patients and therapeutic efficacy and d) an

abject fear of patient pregnancy. Furthermore, a general

concern throughout was the putative professional conflict

between the clinical and ward staff. Further discussion

regarding the potential for clearer policy on patient

sexuality and further training for professionals is

developed in the final section.

KEY WORDS – sexuality,, inpatient, mental health,

restrictions, risk.

INTRODUCTION

Patient sexuality and Staff angst

Despite increasingly liberal views about sexuality and

sexual freedom in western societies (Akhtar et al, 1977;

Giddens, 1992; Weeks, 2003), sexual behaviour among

psychiatric inpatients is rarely addressed and provokes

anxiety amongst mental health professionals when it is,

(Mossman et al, 1997) in policy and research. The

restrictions on sexual expression may be especially

problematic within forensic inpatient settings where

individuals may be detained for significant periods of

their adult lives.

Health professionals working with psychiatric patients

may have legitimate concerns about their patients’

sexuality (Dein and Williams, 2008). These include

concerns about the lack of capacity for certain patients

to consent to sex (for instance a manic patient who is

sexually disinhibited may engage in sexual activity with

another patient), the exploitation of vulnerable patients

(Windle, 1997), allegations of sexual assault or rape,

the spread of HIV and sexually transmitted infections

(Meade and Sikkema, 2005) (Lagios and, 2007); and

unplanned pregnancies. Furthermore inpatient sexuality

may meet with disapproval from families and, the general

public. Additionally, this may result in prurient and

damaging media coverage, and litigation against health

organisations. Previous studies, for example, have

highlighted the problem of unwanted sexual advances

against psychiatric patients within inpatient units

(Keitner et al, 1986; Nibert et al, 1989; Batcup, 1994).

Gordon (2007) reported three incidents of homicide in

Broadmoor hospital (a high secure forensic psychiatric

hospital in England) within the context of homosexual

relationships. These took place several decades ago.

However, patients are not the sole cause of sexually

inappropriate behaviour and sexual violence within

hospitals. In the UK, the National Patient Safety Agency

(NPSA, 2006) reported nineteen incidents of alleged rapes

in mental health settings run by the National Health

Service (NHS). Of these eleven (over 50%) were allegedly

committed by professionals. Of the nineteen rapes

reported by the NPSA (NPSA, 2006), eight were allegedly

carried out by a patient and eleven by a member of staff.

In this NPSA report, out of a total of 44,000 incidents

harmful to patients within psychiatric hospitals 122

(less than 0.3%) were “sexual incidents”, which included

thirteen cases of exposure, eighteen of sexual advance,

twenty-six of sexual touching; as well as 20 reports of

consensual sex. Recent studies have found little

evidence of sexual intercourse within psychiatric

hospitals (Warner et al, 2004) or of sexual coercion,

although ongoing work is needed (Hales et al, 2006).

A number of studies have observed risky sexual behaviour

involving psychiatric patients (see Meade and Sikkema,

2005 for a systematic review); and one study (Cournos et

al, 1994) noted HIV sero-prevalence amongst 5.2% male and

5.3% female psychiatric inpatients in New York City.

However, few of these studies (for example, Ramrakha et

al, 2000) used controlled samples. In the USA Cates et

al (1994), and McDermott et al (1994) found no

differences in condom use between people with a diagnosis

of severe mental illness when compared to controls;

however one Italian study (Grassi et al, 1999) found that

people without a mental health diagnosis (60%) were more

likely to use condoms on a regular basis when compared to

psychiatric patients (35%). It is also difficult to

generalise the results of the predominantly American

studies, to other parts of the world.

Another concern is the likelihood of unplanned

pregnancies. However NPSA (2006) reported only three

claims for compensation following unwanted pregnancies

within NHS mental health settings between 2003 and 2005.

Wignath & Meredith (1968) found that the rate of unwanted

pregnancies in American psychiatric institutions was

lower than that of the general population. There is no

evidence that the prohibition of sexual contact on

psychiatric wards will improve the safety of inpatients.

While much of the anxiety about sexuality and sexual

health described above (unwanted pregnancies, ‘date

rapes’, and the spread of venereal diseases) can be found

in society generally, the sexuality of psychiatric

patients provokes fears unsupported by empirical

evidence. These “irrational fears” may stem from

historical prejudices about ‘insanity’. For instance, in

the 19th and early 20th centuries (when ideas of social

Darwinism and eugenics were at their peak), some

commentators argued that psychiatric patients should not

be allowed to reproduce to prevent the transmission of

their 'defective genes' (Andrau, 1969; Joseph, 2003; Read

et al, 2005).

Autonomy and Rights

The concerns and restrictions surrounding the sexual

behaviour of patients in mental health settings raise a

number of questions about the care-control dichotomy. In

forensic settings such concerns may be heightened in that

detention in such units is predicated on the patients’

commission of and potential for harmful acts, sometimes

of a sexual nature. The sense that they are dangerous and

harmful people, regardless of the cause of this

dangerousness, provokes additional surveillance,

restriction on freedom and a tacit acceptance among the

staff and the general public that punishment rather than

rehabilitation is warranted. This is counterpoised by a

modern view that the pursuit of intimacy and the desire

for sexual expression between consenting adults, albeit

within culturally prescribed parameters, is considered

normal, natural and integral to being a human being

(Giddens, 2001). Moreover, Article 8 of the European

Convention on Human Rights emphasizes the individual’s

‘right to respect for a private life’ , which includes

the right to sexual expression among consenting adults.

The prohibition of sexual expression, during lengthy

psychiatric admissions can impact on the formation of new

relationships, and the maintenance of previously existing

ones. This is particularly relevant in forensic settings

where patients routinely experience lengthy admissions,

and one in five patients in medium secure forensic

services have been an inpatient for an excess of five

years (Jacques et al, 2008).

Longer periods of detention are experienced in high-

security forensic units. Importantly, for a significant

part of that admission, forensic inpatients may be free

of active symptoms and/or undergoing rehabilitative

treatment. Additionally, an increasing number of

patients in the UK are being admitted to secure

facilities for the treatment of a diagnosis of

personality disorder, rather than a severe mental illness

(SMI), such as schizophrenia or psychotic depression.

Patients with a diagnosis of SMI are also required to

remain within these hospitals for a period of

rehabilitation after the symptoms of their illness have

subsided. These inpatients may possess the capacity to

consent to sexual acts in spite of their detention.

Coid (1993) observed that the freedom afforded to

inpatients to express their sexuality, would be

influenced by the attitudes of health professionals

working within particular settings. Previous studies

that have explored such attitudes amongst nursing staff,

to the issue of patient sexuality (Bhui et al, 1994; Cort

et al, 2001; Higgins et al, 2006: Ruane, 2007) suggest

that nurses are generally antipathetic towards inpatient

sexual freedoms. These studies suggest that nurses are

mostly against inpatients having sexual relationships in

a ward environment. Penna and Sheehy (2000) observed

that although occupational therapists viewed patients

having sexual relationships more positively, they felt

constrained by the proscriptive culture of the services

in which they worked. Commons et al (1999) found that

mental health professionals were most condemning of

homosexual acts. Professional norms of consent and

competence were not significant factors in decision-

making. The authors urged professionals to re-examine

their own prejudices (e.g., homophobia) to clarify their

decision-making about institutional policies. In this

study, we sought to explore the views of psychiatrists

and psychologists, working within forensic services.

AIM OF THE STUDY

We sought to examine the attitudes of psychiatrists and

psychologists to inpatient sexual behaviour and their

knowledge about institutional policies, their

willingness, or otherwise, to permit sexual relationships

involving patients, or conjugal visits from external

partners. Additionally, we sought to explore what type

or level of sexual behaviour might be permissible or

denied to patients. We aimed to explore the extent to

which allowance of expression of patient sexuality is

influenced by moral, religious, institutional and

practical considerations.

Ethical approval was obtained from Barnet, Enfield and

Haringey NHS Mental Health Research and Ethics Committee,

in the UK.

METHOD

Study Design

This was a qualitative study. In this study we undertook

semi-structured interviews with psychiatrists and

clinical psychologists using an interview guide that was

developed following a literature review and through group

discussions held. This was then piloted on a small

number of clinical staff and revised in accordance to

feedback.

Interview guide

The definitive topic guide included nine questions which

covered the following areas (a) professionals'

experiences of managing patient sexuality within secure

settings (b) their knowledge of local institutional

policy (and whether one existed) in this regard (c) the

circumstances under which these relationships could be

allowed (d) the impact of resources availability (e)

views about the provision of conjugal facilities within

secure settings and (f) any personal beliefs which were

influential in their thinking. The interview schedule

included one or two vignettes intended to open discussion

on patient sexual freedom. (All the participants were

offered vignettes). The vignettes described difficult

clinical scenarios such as inpatient pregnancy or male

homosexuality, to explore the issues that would arise,

the ensuing team dynamics and feelings of health

professionals. An exploration of each answer was sought,

challenging the view expressed, with the aim of obtaining

as much detail and reasoning for the perspective as

possible.

The interviews were conducted by three members of the

study group, (KD, PSW, IV – all psychiatrists), working

in pairs. The interviews took place on site (the

forensic mental health unit), were audio recorded and

transcribed verbatim.

Participant Characteristics

In a total sample of twenty four mental health

professionals working within a single inpatient forensic

service, sixteen psychiatrists and 8 psychologists were

interviewed for the study. Amongst the psychiatrists

there were 9 consultants, 4 specialist registrars (senior

trainee consultants) and three staff grade doctors

(psychiatrists in non-training posts). All eight

psychologists were of senior grade.

ANALYSIS

The authors assumed that the meanings participants

brought to bear on their experiences and attitudes are to

some extent influenced by the social structures within

which they live and work (Willig, 1999) in our thematic

analysis (Patton, 1990; Braun and Clarke, 2006) of the

data. Further to this we assumed that participants’ use

of language to describe their experiences form a rich

picture of how they actively chose to present themselves

(Potter and Wetherell, 1987). This might mean that views

expressed by participants reflect wider discourses

(Edwards and Potter, 1992) of power, stigma and fear

existing within the wider society in regards to people

who are inpatients and are suffering from illness..

Each transcript was read and re-read by each of the

researchers (KD, PSW, IV, AK, PR, GL) who then

highlighted issues of interest. After having read all the

transcripts each researcher drew out themes from

recurring patterns of meaning (Braun and Clarke, 2006)

using extracts from the data that illustrated those

themes. There then followed a series of group discussions

to compare our readings of the data and the themes each

researcher had drawn out. Analytical corroboration was

achieved using the team of six researchers, over a series

of stages. The selection of themes was based on

prevalence and salience in addressing the research

question. This was an iterative process where researchers

referred back to the data until a clear picture of the

themes could be illustrated.

Normalised Absence and Pathologised Presence

Overview

While agreeing with the notion that everyone deserves a

right to a sexual life and that not every patient in

hospital has committed a sexual offence, almost all

participants acknowledged that there was a normalised

absence of discourse on patient sexuality. Patient

sexuality was rarely discussed and when it was, it was

seen to be problematic. Thus, in staff discourse on

patient sexuality, the pathological was highlighted over

the normal desire for sex. Sexual behaviour among

patients in the ward environment was described in anti-

therapeutic terms and a challenge to control and order.

The key themes that emerge from the current study were:

(1) The limits of acceptable sexual behaviour: in this thematic

section we outline how the ward is viewed by clinicians

as a shared public space which needs to be governed for

the sake of everybody. Just as in the ‘external’ public

arena, specific, anodyne, behaviours are permissible

while others provoke disgust.

(2) Risks to management and therapy: in this section we show

how clinicians organise and balance their views on

patient sexuality around the perceived threats to order

and to patient wellbeing; and

(3) Liberal and conservative perspectives: in this section we

examine the putative cultural conflict between clinical

staff and the ward staff. Highlighted is the absence or

ignorance of any formal policy which may permit

authoritarian perspectives to prevail while maintaining

the semblance of liberal attitudes among clinicians.

|

The limits of acceptable behaviour

Most participants cited the hypothetical dilemma that

would arise if a male patient, convicted of a sex offence

wanted to date a female patient with a history of abuse.

Some talked about the risk to others; if a patient wanted

to date a person in the community who did not have a

forensic history or a diagnosis of mental illness and the

issue of disclosure and safety of that spouse.

“…[O]one of the nurses reporting back on the ward round that they believed

that a sexual relationship between one of the female patient and two of the

male patients had occurred and this was discussed during the ward round.

There was an attempt to find out the nuts and bolts of the situation: who was

the relationship between exactly? How many times have they had sex? Was it

an on-going thing and initial concern was about whether there was any

exploitation going on? But then beyond that there was quite normal

response…And then the discussion went more seriously about trying to think

about sexual exploitation issues and protect all parties involved in that. And

what we should or could be doing differently to insure that people knew their

rights and knew about consent and were able to have relationships

consensually. At the same time being reminded of the fact that it is against

policy to facilitate it.”

A further emergent concern was the perceived failure of

clinicians to perform their duty of care by adequately

acknowledging and attending to the risks arising from

patients’ sexuality, largely through ignorance and

neglect:

“…because society is not just single sex and…in particular forensic patients …

[with history of] sex offending…then its important to test that out at some

level within the rehab setting.”

Additionally most admitted that they were unaware of a

sexual behavioural policy in the hospital and assumed

that such a policy did not exist, further painting a

picture of a much neglected issue:

“…You know people aren’t allowed to have sexual contact on the ward, no-one

is supposed to have…”

“… I would feel somewhat uncomfortable about (being) dictated to … by a

policy about how I should feel about people’s sexual behaviour and about

their sexuality…”

“…there aren’t guidelines or protocols…I think it’s a grey area, and I think its

kind of trial and error really.”

As a result of there being no clear policy on the matter

of patient sexuality, it was apparent that many

professionals used their personal judgement to reach

decisions on whether to allow patients to engage in

sexual activity,

Sexual expressions: what is acceptable?

Predominantly, participants felt that the hospital ward

environment was not an appropriate place to have sex

often because they were concerned about other patients

and staff and most remained uncertain about whether the

boundaries of sexual expression were ever made clear to

patients.

“ …[I hope] there would be other ways [than sex]… without perhaps sending a

bit of a mixed message about sexual contact on the ward…”

For some participants certain types of sexual behaviour

would be acceptable on the ward if they were also

considered socially acceptable in other public areas:

“ I think as long as what they do is …acceptable in society, on the streets, as

long as what people do is not offensive to others…[it] is acceptable [in the

hospital].”

However, there was some agreement that the issues,

environment and dynamics on psychiatric wards were

considerably and qualitatively different to those in in

other, open social settings:

“…We know that patients, when they are unwell… can be very influenced and

affected by other [patients] within the confines of the ward.”

Nevertheless, views on what might be considered an

acceptable expression of inpatients’ sexuality, tended to

be polarised. For some, acceptability tended to be skewed

towards ‘mild’ intimacy such as kissing and cuddling:

“I don’t see anything wrong in kissing, cuddling, hugging but I think such a

sexualised intimacy should be discouraged mainly because it’s in a public

place, you know, this visiting business.”

Although, some participants felt that expressions of

sexuality in an environment where patients have different

diagnoses and a complex mix of abuse and illness history

would create a level of toxicity that would not be

therapeutic.

“… [A]ny sort of sexual behaviour that’s being simulated or anything… brings

up so many issues for the patients who may have been raped or any of these

can cause all sorts of distress and knock on effects, … so, you have to be fair

you know, you can’t, I don’t think you can permit that sort of behaviour,

there’s people around…”

A more commonly held view was, if patients were at the

rehabilitation stage of their treatment or were

asymptomatic and had a certain degree of privacy, they

should be allowed to have sex. Some participants felt no

concern about, indeed, appeared to be encouraging of,

patient sexuality, in the context of unescorted leave in

the community as part of rehabilitation. Similarly,

concerns of abuse and vulnerability were less prominent

themes in relation to patients who had progressed to the

rehabilitation stage, had unescorted area leave, or who

had been discharged into the community:

“…patients were thought to be having relationships whilst on leave. That was

dealt with slightly differently because they were …deemed to be better in

terms of their mental health; it was kind of logged but wasn’t really spoken

about again…”

This suggests that patient expression of sexuality per se

is not problematic but rather, the setting and

circumstances of their 'illness' and care created

particular constraints for open sexual expression.

“…As people…stabilised and they [were] more able to think clearly, I wouldn’t

be at all averse to [them] having sexual relationships, and, I think, it’s a

healthy part of recovery.”

“…If that man [coming toward the end of his period] wanted to have sex with

the woman in his bedroom on the ward, or the rehab ward, I don’t have a

particular problem with that.”

Although one participant did not feel that being acutely

unwell necessarily meant being unable to consent to sex

or take part in a sexual relationship and felt instead

that it complicated matters for hospital trusts in

dealing with sexual relationships between patients.

“I am not entirely sure I agree with the idea that simply because somebody is

psychotic that they don’t understand what sex is but having sex and about the

various pros and cons and responsibilities, we know lots and lots of patients

whose psychosis present in very discreet aspects of their functioning. They

are still perfectly aware of various things in the external world and their

internal world so to presume a gross disability, a gross mis-functioning in all

areas, I think it’s an error, that’s just not how it happens psychologically.“

Another participant was also very vocal about there being

institutional investment in disallowing patient sexual

expression whilst on the ward, when there was no

clinical/logical reason to discourage patients.

“Nobody’s worried about it once they’re discharged, it’s fine. It’s for our own

convenience, we don’t tackle problems that are either too challenging for us

to think about or too tricky or too complex so it’s the commission’s need and

peace of mind that has a strong effect over service provision and that never

gets talked about and needs to be because it has a strong influence in my

view.”

Transgender identity and same-sex relationships

The question of staff disagreement was particularly acute

when professionals discussed the issue of minoritised

sexual identities. Although there appears to be a

general lack of confidence in addressing the sexual needs

of patients among service providers, the question of

policies sensitive to minority groups, such as lesbian,

gay, bisexual and transgender groups is even more

unspeakable (Cort, Attenborough et al (2001). As a result

of there being an avoidance of clear policies outlining

anti-discriminatory practices amongst mental health

professionals, many of the professionals here felt that

discrimination nonetheless were manifest in the behaviour

and attitudes of the ward staff. This also highlighted

some key tensions between the clinical staff, who viewed

themselves as 'liberal' and 'progressive' and the ward

staff, who were seen to be prejudiced and at times,

harmful to treatment.

For example, a number of participants commented that

nursing staff appeared to hold some contrasting views

about patients’ sexuality as compared to the rest of the

clinical team.

“… I had a couple of times issues between the team and the nursing staff

(about the provision of contraception), so I suppose the nursing staff are part

of the team but they are, sort of different, in a way a different body as well.”

“... [H]e’s to all sense and purposes a transsexual and has worked for a long

period of time in the sex industry, and been in a very abusive situation in the

sex industry, and one of his tactics or sort of defences is to, is to try to seduce

people around him and to be quite provocative and he disgusts some of the

nurses, its very obviously he disgusts them and that’s something we have had

to work through and its caused a lot of very strong feelings on the ward.

“They had, you know, nursing staff took it for granted for example that we

would not allow him to wear women’s clothes and when that was questioned,

when the rationale was questioned a lot of staff couldn’t cope with that at all,

couldn’t really understand how we could even be having the discussion…”

“I think there would be a big difference [within a multi-disciplinary team],

and a large part of that would be the nursing staff. We have a very

conservative bunch of nursing staff…”

While the participants in this study viewed homosexuality

with as equal yet different from heterosexuality, they

constructed a rather homophobic ward environment.

“…There have been incidents on the ward where some staff have explicitly

expressed their homophobic attitudes; people with homosexual orientation

feel very uncomfortable on the wards…”

Some participants felt that displays of homosexuality

were more acceptable among liberal patients from a

European background. Thus, the question of liberalism

became equated by some as a question of differing

'cultural' attitudes among the ward staff.

“[I]f it was a hundred percent western type set up, European patients, I think it

would have been slightly different but when you get people who are a mixture

of different cultures, different religions, values, morals…Both patients and

staffs’ disapproval… You see it day by day on the ward, staff being

discriminating or making comments that are not entirely appropriate and

making judgments but particularly in relation to same sex relationships. You

see patients who are homophobic…Do those views go unchallenged? Yes. One

of my patients, who was gay, became very upset about staff comments about

something which was going on TV, which I found was inappropriate for the

staff member to say any way in front of the patient.”

An example was given of a transgender patient who

provoked strong responses in nursing staff, although the

other patients showed tolerance:

“[H]e… wanted to cross dress whilst on the ward and this provoked very

strong feelings in certain members of the staff…who are religious actually

find this quite offensive and became quite angry at times… actually the other

patients didn’t, it didn’t really particularly seem to disturb or, or trouble the

other patients… I think the strongest, the strongest thing seem to be

engendered in some nursing staff.”

Concerns were expressed that tolerant attitudes towards

patient sexuality would provoke strong feelings and

create a split between the nursing staff and the rest of

the care team.

“[P]eople with different sexuality, lesbian, gay men and how that stir up

feelings in staff, nursing staff how it might impinge on peoples belief system

and they might try and you know, inflict their opinion on other people, and

that, I think that’s a really big issue, which needs grappling.”

It is interesting to note that many of the discriminatory

attitudes perceived to be in operation were located in

the ward staff, and were understood to be a consequence

of a difference of cultural and religious viewpoints.

'European' views were homogenised and conceived of as

more liberal and tolerant, whereas a generic yet oblique

conception of 'non-European' attitudes were posited as

the reason for widespread homophobic and discriminatory

practices among the staff.

Risk, vulnerability and Gender

Most participants were concerned about the potential for

abuse in patient relationships and the vulnerability of

some patients to exploitation within forensic settings.

Many framed their discussions around the need to avoid

risks and ascertaining whether the parties involved

especially the women, had the capacity to consent.

.“…[A]s long as you have some sort of information about the women, and

[are] reasonably confident that it is an informed decision on the part of the

women. If the patient doesn’t have a history of sexual offending of some

sort…that complicates matters further as well. If the offence is against

children, he is having a relationship with women, does this woman have

kids…you need to think about that…is he a sex offender, does he have access

to these children?”

“…Everything in this unit [MSU] is risk based, so… if you are talking about

relationships and sex and leave, then that’s got to be risk based as well…”

Most participants viewed all patients as somewhat

vulnerable to exploitation. However, men and women were

differentiated and presented as predatory and vulnerable

respectively. Thus, a sexual offending history, spousal

homicide, domestic violence and psychopathy were

considered by some participants as key in their

constructions of the risk posed by patient sexuality.

“…I was thinking particularly about acutely psychotic men who were being

sexually inappropriate…who are sexually very violent… men who might be

unpleasant to women because of their current mental state.”

Women who were sexually abused in the past, or had been

sexually disinhibited whilst mentally unwell, and those

diagnosed with a learning difficulty, were considered to

be especially vulnerable. Some participants constructed

women’s vulnerability as the primary reason why they felt

more comfortable on single-sex wards as opposing to mixed

sex wards. Women’s promiscuity was also framed within

this inherent specifically gendered vulnerability where

the woman appeared to have little agency over her own

sexuality.

“…I know some women are not too keen on mixing with men… and then there

are other vulnerable women who are more promiscuous… “

“…I think the women on mixed sex ward, people very unwell, very psychotic,

very power raged, very sexually disinhibited, very unwell…”

Additionally women’s promiscuity was also viewed by some

participants as dangerous and where the female patient

would then assume the predatory role while the men are

seen as more vulnerable.

“..[S]he was very promiscuous and it was really difficult for the men to handle

and to know how to deal with all those feelings.”

This construction of women’s vulnerability stretched to

participants feeling that staff and other patients viewed

lesbian relationships as less threatening.

“I think it’s the whole thing about women being victims and men are seen in a

kind of a different way and for that reason, there’s something about

homosexual relationships probably not seen in as positive a light as lesbian

relationships, yeah.”

“…I suppose, you know lots of things about female patients, vulnerable, past

histories, lots of abuse, maybe they will only feel safe in the context of a same

sex type relationship”.

A few participants indicated that there was an

exaggerated response to any rare occasion when there was

an untoward incident arising as a result of a patient’s

sexual expression:

“... Well it... a female patient under close observation had sex with a male

patient (and this) had a profound effect actually…that and a couple other

issues happened fairly soon afterward led… to the ward being essentially all

male…”

Participants rationalised their concerns about female

patients, by referring back to a duty of care to protect

vulnerable patients, and believed it was preferable to

separate patients into single sex wards at the early

stages of their treatment:

“[Regarding single sex wards]…I think certainly [they are more suitable, when]

…patients are acutely unwell, especially female…”

A few participants also remarked that the risk of sexual

exploitation also applied to patients on single sex

wards:

“…men giving blow jobs to other men on the ward for cigarettes and things

like that…”.

A few participants were concerned about the potential for

difficulties within an intimate relationship to

destabilise patients’ mental state (if the relationship

broke down), causing them to become distressed or

psychotic. And yet, other participants could recall

instances where patients had coped well with the break-up

of a relationship:

“…[I]f that relationship was to end and…they would be able to have the

resources themselves to be able to cope if that relationship did finish, or could

that potentially destabilise their mental state to the degree that they could

become very unwell again.”

“…[We thought] she was going to destabilise his progress to(wards) discharge,

but she didn’t, and the relationship sort of pitted out after a few months…”

Some participants felt that addressing sexuality during

the course of a patient’s admission through sex education

as well as discussion groups, not just for sex offenders,

but for all patients could reduce the risk of

exploitation. Many of the participants also believed that

young male patients of child-bearing age did not conceive

of celibacy as a viable option.

“…[T]he reality for a lot of our inpatients… is that they have had a very

deprived life. They are very damaged, a lot of sex offenders, their offending

isn’t really sexual offending, it’s kind of sexualised offending.”

“[M]ost patients will [be] discharged from hospital and there does come a

point where you have to manage what they do in the community and you

don’t have all that control. So starting to have a supportive role earlier might

be a better way forward.”

“…[I]t would be far more useful to the individual if you focused more on the

educational aspects of people learning about appropriate relationships, how

you manage relationships and focusing more on social skills of an individual

in forming relationships.

Furthermore a relationship could still work for two

people considered to be risky by professionals as one

participant recounted

“This one long term relationship, the male patient is still here, but they’re still

together, there’s obviously something there. We may kind of look at it from a

distance and say it’s not very healthy and it’s not really good for their long

term mental health, but they’ve been together for a long time, so something is

working for them.”

Pregnancy and professional concern

For the majority of participants, a pregnancy involving

an inpatient would be professionally damaging to their

career. Some felt that such a pregnancy would harm their

professional reputation and saw it as a failure on their

part to avoid such a consequence. Inherent within these

feelings of failure was a paternalistic assumption that

inpatients could be so controlled as to avoid such an

eventuality. As a number of participants remarked:

“It would just make my life considerably more complicated.”

“I think people might feel worried that they hadn’t done their job properly,

especially the nursing staff but maybe other people as well...”

I think the hospital itself has a role in trying to do everything it can to make

sure something like this doesn’t happen in the first place.”

And yet, there were no clear suggestions, apart from

patient abstinence, regarding the avoidance of pregnancy

among patients under their care.

Some participants assumed that the relationship that

brought about the conception could only be a result of a

chaotic, possibly abusive liaison, where the woman’s

capacity to consent, was again brought into question. The

nature of the sexual relationship was framed within a

vulnerable/predatory partnership, with the man viewed as

a possible rapist or sexual bully. The fact that an

inpatient could be come pregnant within a psychiatric

facility was an illustration of this ill-informed,

possibly impulsive action.

“It is a disaster really because it is bound not to be a planned situation.

There is the other physical aspect of how safe is a pregnant woman on a

crazy, you know acute forensic ward. “

“How it happened? You don’t know if it was consensual sex, you don’t know

everything that has happened.”

Other participants did not agree that psychosis could

erode the capacity to such an extent that the woman was

not aware of what was going on when she conceived the

child.

“The patient herself to some degree would have to take some responsibility

for what has happened. Unless they were in such an acutely psychotic state

that they didn’t know what they were doing. But it’s pretty rare….my personal

view is they still do have a responsibility for their actions.”

Some participants even thought that a baby resulting from

such a partnership could somehow in a eugenic sense,

contaminate the gene pool of sane adults.

“I think it’s pretty disastrous actually if a female patient does get pregnant...A

lot of my thoughts are about genetics and I think the genetic aspect of it is

just disastrous. I mean you know, two schizophrenics, you’re going to get a

schizophrenic child..”

One participant felt that a pregnant patient could evoke

feelings of envy and protection in both patients and

staff.

“Its provocative, why is this person gotten pregnant, motherly kind of feelings,

there’s the protective feelings, there’ll be lots of different kinds of feelings.

There may also be feelings that other people would also want a baby, so you

may get people wanting also to get pregnant.”

Others acknowledged patient pregnancy as a potential new

and positive beginning for the patient. What was notably

absent from the discussions about pregnancy was any

notion that inpatients might see themselves as “normal

individuals” who might desire to have a baby as an

expression of a wholesome bond between partners.

DISCUSSION

While sexuality is an important aspect of wellbeing, the

prevailing view among clinicians in general is that

sexual intercourse should not take place on hospital

wards. In what appears to be an issue of double

standards, sexual tolerance does not extend to

psychiatric inpatients (Akhtar et al, 1977; Eiguer et

al., 1974).

Moreover, there is a tendency among the predominantly

western and liberal participants in the current study to

apportion blame for sexual prohibition on the

conservative and religious attitudes and beliefs of the

nursing staff. This is consonant with previous studies

of patient sexuality (Bhui et al, 1994; Cort et al, 2001;

Higgins et al, 2006). Some commentators, notably Cuthbert

(1961) and Ruane (2007) have questioned the role of

ethnicity and religiosity in determining these attitudes.

For instance, Ruane (2007) found that nursing staff were

conservative irrespective of their religious or ethnic

backgrounds. The conservative approach of ward staff to

patient sexuality may result from their very close

contact with patients and feelings of helplessness in the

face of complex behaviours. Due to a lack of training,

guidance, and being left to deal with the issue as best

they can, nursing staff may well blur the boundary

between the personal and professional, and may even see

inpatients as an extension of their family (Ruane, 2007).

Interestingly, although our participants were able to

identify the role of culture and religion in influencing

the attitudes of nurses (Lief & Payne, 1979), the

majority stated that their own background was unimportant

in the decision making process. This may be attributable

to the self-confessed ‘liberal’ leanings of the study

participants, with 'tolerance' being an underlying

principle of liberal thinking. This carried the

underlying assumption that the patients were also western

liberals, where in fact immigrants and ethnic minorities

are over-represented within secure settings (Dein et al,

2007). Importantly in spite of the liberal views held by

senior clinicians there was an acceptance that the sexual

culture of psychiatric hospitals was ultra conservative

and prohibitive in its essence. Therefore, whether we

regard ourselves as liberal or conservative in our own

thinking, psychiatric professionals as a microcosm of

society would appear to reflect the conservative values

of society. Indeed, Commons et al (1999) in their study

of the attitudes of mental health professionals found

that mental health professionals as members of the wider

society would express conventional moral views (Kohlberg,

1984). The prohibition and regulation of sexual

behaviour among patients indeed tends to fit into a

protective, conservative and moralistic discourse (Dein

& Williams, 2008).

Although the lack of training and resulting discomfort of

professionals in dealing with patient’s sexual issues can

lead to outright homophobia (Mosher, 1991) as suggested

by the study participants, heterosexual expression was

also viewed with concern because of the risk to

vulnerable women, which was in turn related to the ‘risk

of pregnancy’. For this reason, clinicians were of the

view that female homosexuality would be tolerated more

than heterosexual expression, although male homosexuality

it was believed, would be deplored, because of the

perceived risks of sexually transmitted diseases, and

aggression. In relation to risk, some studies (Nibert et

al, 1989; Batcup, 1994) have found that relationships

within psychiatric hospitals were not always reciprocal.

In contrast a recent (large) study set in psychiatric

hospitals in West London (Warner et al, 2004) did not

find any incidents of non-consensual sexual intercourse.

While professionals may have understandable concerns

about risk issues within these relationships (see Dein &

Williams, in print, for a discussion), one would question

the usefulness of negating patient’s sexuality in order

to manage this risk. If indeed we are concerned about

the risks that patients pose within sexual relationships

we should be addressing this risk pro-actively by

exploring the sexuality of patients, and supporting them

in forming healthy relationships. The tendency to negate

patients' sexuality would suggest that hospitals are more

concerned about their corporate image, public opinion,

media coverage and the risk of litigation, than the

welfare of patients or indeed the risks posed by patients

in relationships.

With regards to public opinion on the subject, according

to a study in US, (Smith & Lipsey, 1976) a substantial

proportion of the public were in support of conjugal

visits for prisoners. Conjugal facilities have existed

in the US since the 19th Century with respect to the

rights of the prisoner’s married partner. These

facilities exist in Spain and Sweden in Europe, Zimbabwe

in Africa, Iran in Asia, Brazil and Mexico in South

America (information obtained from the BBC website).

Prison officials within these institutions assert the

value of conjugal visits in preventing male homosexual

rape within custodial settings (Hensley et al, 2002). In

Europe, test cases in high secure units have established

the right to marry and found a family but not the right

to intimacy (Fitzgerald & Harbour, 1999). Whilst this

might apply to high secure units it may not be

immediately applicable to medium secure units where the

role of treatment is to prepare/rehabilitate patients

towards discharge into the community. Similarly, case

law exists upholding the ban of the use of condoms in

high secure units (R (RH) v Ashworth Hospital Authority,

2001) , may not be immediately applicable to medium

secure units for the same reason.

In England, Fitzgerald and Harbor (1999) observed that a

hospital policy to permit sexual relations between

patients (within psychiatric facilities) would be lawful,

subject to certain exceptions. The authors suggest that

any limitation on sexual relations between detained

patients would have to be justified. Apart from the risk

issues described earlier, the lack of conjugal facilities

threatens the stability of patients’ long-term

relationships, and the formation of new ones. Therefore

restrictions on sexual expression for prolonged periods

(when not justified by security concerns) violate the

patient’s rights to family and privacy (Articles 8 and

10) under the European Convention of Human Rights.

According to a recent study (Jacques et al, 2008) one in

five patients in a large Medium Secure Facility had been

an inpatient for over five years. Restrictions on sexual

expression for such long durations can potentially

destroy existing relationships, prevent the formation of

new relationships, and damage the patient’s identity as a

sexual being. This systematic assault of patient

relationships and sexual identities runs contrary to the

ethical principle of non-maleficence.

The participants in this study reiterated the importance

of sexuality in the patient’s life. Coid (1993) placed

freedom of sexual expression at the third level of

(Maslow’s) hierarchy of needs for detained patients along

with occupation, education, physical exercise, leisure,

companionship, of belonging and religious freedom.

Interestingly all the other aspects of this third level

of the hierarchy are being actively addressed in forensic

services across England, and yet the area of sexual

expression has been neglected. Mossman (1997) notes that

the sexuality of psychiatric inpatients has received

little attention in contrast to the extensive analysis

devoted to other issues affecting inpatients' lives, in

sharp contrast to the Western media’s pre-occupation with

sexual themes. Indeed sexuality forms an integral part

of people’s lives, and there is little to suggest that

psychiatric patients are any different. Regarding

relationships involving psychiatric inpatients, Davison

(1999) indicates that where a relationship exists they

are similar to those between 'healthy' individuals. For

inpatients who are interested in pursuing their

sexuality, who are mentally well and able to consent, it

would only be a matter of time before they chose to

express their sexuality. In such circumstances it would

be advisable to take “the minimalist approach”, that the

conditions within the institution should be as near as

possible to those outside (Coid, 1993). In such

instances, a sexual relationship involving a patient can

be used as an opportunity to understand the patient’s

difficulties and work on them in a constructive way

(Modestin, 1991). Within forensic services they would

inform risk assessments and risk management strategies

specifically where vulnerabilities are identified.

Furthermore, inpatients who are in relationships are more

motivated to participate in their rehabilitative process

with a view to being discharged, and starting a new life

outside of hospital. Sexual relationships involving an

inpatient could also give hope to other patients (Dein

and Williams, 2008).

Few UK hospitals have written policies regarding patient

sexuality, although many have unwritten policies banning

all sexual activity (Taylor and Swan, 1999). Where

policies exist in the UK, they have often articulated on

article the unspoken ban which exists elsewhere.

Hospital policies relating to the subject extol the

virtues of Human Rights. And yet paradoxically, the real

focus tends to be on risk, especially that posed by

inpatients with a history of sex offending, and

protection (Welch & Clements, 1996; Ford et al, 2003).

These policies appear to arise from the fears hospital

administrators have of being sued in cases where

inpatients are raped or become pregnant (Perlin, 2000).

It is important to note that a written or unwritten ban

on sexual expression has previously existed where

vulnerable inpatients have been raped or become pregnant,

and it is, therefore, unlikely that a written ban will

assist in protecting patients further. Indeed, Rowe

(2006) suggests that institutions that actively prohibit

sexual expression set the stage for sexual assaults.

Furthermore, Krumm (2004), in a review of the literature

on sexuality states that during the 1970s and 1980s

patients equal rights of sexuality were weighed against

moralistic concerns. It is discussed by participants in

this study against a background of negative consequences

for the individual patient.

Implications of this study

This study identified several clinical strategies to

address the issue of patient sexuality proactively.

These included care planning patient sexual needs as part

of a routine assessment, examining their capacity to form

relationships and monitoring them during their stay in

hospital (Ford et al, 2003), offering sex education and

extending the opportunity to attend healthy relationship

groups to all patients, and not just to sex offenders.

Pfammatter et al (2006) in a meta-analysis found that

social skills training consistently effectuated the

acquisition of social skills for patients with a

diagnosis of schizophrenia. This could be offered to all

patients within forensic facilities along with HIV

prevention programmes (Kalichman et al, 1995). Mental

health professionals should be provided an opportunity to

understand their inherent prejudices about sexuality,

especially in relation to psychiatric patients (Commons

et al, 1992). They should be offered training to address

the discomfort they feel when dealing with this aspect of

patient care. It is considered due diligence for

hospitals to have policies on inpatient sexuality

(Perlin, 2000; Abbasin, 2002). The policy writer should

demonstrate an understanding of the broader issues

involved and have undergone some specific training in

this area. In this study the participants who were

senior, experienced clinicians described discomfort while

addressing the issue of patient sexuality. It should not

be assumed that professionals automatically understand

the issues involved as a result of working in psychiatric

hospitals for several years. In the absence of training

and supervision they are likely to rely on personal or

direct professional experience to inform their

perspectives on patient sexuality.

FINAL CONCLUSIONS

This study adds several new findings to our understanding

of the professional construction and management of

patient sexuality. On the one hand, mental health

professionals believe that psychiatric patients who

engage in sexual relationships pose particular risks, and

yet paradoxically this risk is managed through the denial

or negation of their sexuality (leaving risk matters

completely unaddressed). The findings also expose the

large number of contradictions in the attitudes and

practices of psychiatric professionals in relation to

patient sexuality. While senior clinicians describe

themselves as liberals and suggest that junior ward staff

are conservative in their approach, psychiatric hospitals

behave as conservative institutions. The recent move

within forensic psychiatric settings towards single sex

wards highlights this shift towards greater conservatism

(Mezey et al, 2005), despite evidence suggesting single

sex wards are no safer than mixed wards (Mezey et al,

2005; Leavey et al, 2006; Hensley et al (2003); Hales et

al (2006).

Finally, we ask, are single sex psychiatric wards a

conscious or unconscious drive to prevent inpatient

sexual expression? Participants in our study described

inpatient sexuality as a “complicated issue”, and

described the issue of inpatient pregnancy, in

particular, as a professional “nightmare”. Andrau (1969)

observed that in the 19th Century some authors suggested

that psychiatric patients should not be allowed to

reproduce, so they could not ‘pass on their defective

genes’. While Western societies have taken a more

liberal approach to sexuality in general, attitudes to

patient’s sexuality within psychiatric hospitals could be

likened to that of the Victorian age. Importantly this

raises the question of whether mental health

professionals irrespective of their personal views are

colluding (by commission and omission) to prevent the

spread of ‘defective genes’. It is vital that health

professionals take a step back and seriously consider

whether this is the role of any caring professional,

given both the scientific evidence against such a view of

gene transmission, and the worrying paternalism implied

by any such control over sexual intimacies.

Disclosure of interest

We declare there are no conflicts of interests pertaining

to the work reported in this article.

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