Who decides when people can have sex? Australian mental health clinicians’ perceptions of sexuality and autonomy

Participant selection and recruitment

A total of 22 interviews were conducted with a purposive sample of eight psychologists, six psychiatrists and eight mental health nurses working in four Australian metropolitan cities. A sampling frame was generated to ensure heterogeneity within the sample for each profession across gender, age, sector (public/private) and the socioeconomic status of the areas or individuals that they serviced (higher/lower). A total of 12 participants identified as women and 10 as men. Two of the men openly identified as gay and one woman specifically identified herself as ‘heterosexual’. Most participants were of European decent and all had completed their education and training in Australia or New Zealand. Participants ranged in age from 25 to 75 years old and in relevant professional experience from 2 months to 40 years. Participants were working with a range of individuals and across various settings including private practice, community mental health, emergency departments and inpatient settings (i.e. hospital or forensic settings).

Participants were recruited via advertisements posted on professional websites and circulated through professional networks and via snowballing. In order to participate, clinicians were required to belong to their respective profession and be currently working directly with individuals in a mental health setting in an Australian metropolitan area. The project was approved by the School of Psychology Human Research Ethics Subcommittee at the authors’ university (reference: 15/107). To maintain anonymity, participants were assigned pseudonyms and the interview transcripts were de-identified.

Data collection and analysis

In-depth interviews were conducted by the first author (K.U.) throughout 2016 and lasted an average of 61 minutes (45–90 minutes). A total of 18 interviews were conducted face-to-face and the rest were by telephone, depending on participants’ preference and location. Participants from all three professions were recruited and interviewed concomitantly. Interviews were generally directed by the participant and their experiences, using exhaustive probing to generate rich and detailed data. An interview guide served as an aide-mémoir, however, to always elicit participants’ understanding of sexuality, sexual health, and mental health and illness. Interviews were audio-recorded and transcribed verbatim by K.U., and participants were given the option of receiving a copy of their de-identified transcript to review and approve. K.U. kept an audit trail and noted preliminary codes and patterns generated during data collection. These notes were used to identify when saturation had been reached within each profession group; data collection was ceased when the authors agreed that the data were saturated within and across profession groups.

The project was guided by a social constructionist epistemology and, consistent with this perspective, we applied a form of critical thematic analysis to the data following Braun and Clarke’s (2006, 2013) iterative six-step process. We were most interested in identifying latent aspects of the data in relation to the research question; that is, how and why participants understood and made meaningful their experiences in particular ways. Initial coding and analysis stayed ‘close’ to the data, but development of the final latent themes was necessarily interpretive and theoretical. Coding and analysis was undertaken primarily by K.U. and the final themes were independently reviewed by the second author (A.C.-H.) against the raw data. Further detail about data collection and analysis and a reflexive statement are provided in the supplemental file.

Sex(uality) is dangerous; but ‘people are going to have sex’ (Jeffrey, psychologist)

Despite the varied nature of participants’ conceptualisations of sexual health, most participants agreed that ‘safe sex’ is a central part of a healthy sexual life. Safe sex was about being responsible for the self and for others, where sex(uality) posed a physical or biological risk that needed to be managed. Sexual health was thus something to be achieved by self-regulating individuals who make the right choices to manage sexual risk by ‘protecting themselves and not putting themselves or others at risk’ (Brett, nurse). This responsibility to protect both the self and broader society from sexual risk was reflected in an emphasis on the need for education and knowledge. It was expected that individuals should have ‘sexual health literacy’ (Nick, psychologist) and therefore be able to make ‘sensible choices about things they […] choose to do about the spreading of disease’ and avoiding unplanned pregnancy (Simone, psychiatrist). That sexual expression often takes place in an interpersonal context and that many factors may contribute to the form that the expression takes was rarely emphasised.

Some participants drew singularly on this framework when talking about sex(uality) in their work, often positioning themselves as helping autonomous individuals to manage the dangers of sex(uality) through education and co-developing strategies for ‘managing risks [and] regulating activity’ (Jeffrey, psychologist):

So it’s always about advocating safe … Safer sex. […] minimising risks wherever we can and doing it in a way that that is … Not too nannying in the sense of, people are going to have sex you know, and people are not going to use condoms all the time. (Jeffrey, psychologist)

Here, Jeffrey actively constructs individuals as autonomous, sexually active and potentially risk-taking and positions himself as an educator with whom individuals can choose to engage. This kind of construction was more often seen in talk by participants working in private practice with individuals who had never been hospitalised (i.e. psychologists) than by participants working with individuals who were, or had been, in inpatient settings.

Individuals are sexually dangerous; ‘We have to protect these people and help them [to] look after themselves’ (Amy, nurse)

When talking about sexuality in their work, many participants drew simultaneously on the notions that self-regulation is necessary for acceptable or healthy sex(uality) and reduced or absent in mental illness. Within this dual framework, sex(uality) was still considered a risk but the source of sexual danger was now located primarily in the mad individual who was perceived to be lacking autonomy and therefore unable to successfully regulate their sex(uality). This danger was present across multiple settings, including inpatient settings where individuals are ‘inventive’ about having sex in secret (Emily, nurse) and where ‘sexual assaults do occur’ (Eric, psychiatrist), during one-on-one sessions where there might be ‘sexual comments made [by individuals] which will be very uncomfortable’ for the clinician (Ben, psychiatrist), and in the community:

you have to be open to [the fact] that somebody who is disinhibited because of their mental illness and is engaging in risky behaviour … They may be putting themselves at risk of contracting an STI or things like HIV etcetera. (Eric, psychiatrist)

Within the context of mental illness, sexual expression was regularly discussed as a symptom rather than a choice. This was more often seen in talk by participants working in community mental health settings and psychiatric ward settings. Participants discussed concerns regarding individuals’ capacity to make good choices for themselves around sexual expression ‘when they’re not well’ as Yvonne, a nurse working in community mental health, discussed:

[When people] become manic then they become […] very sexually disinhibited and [… they] Make poor choices around that when they’re not well. About having sex with other people that they don’t know and [even] when they’re in committed relationships. (Yvonne, nurse)

This perceived inability of mad individuals to make good choices was not confined to periods of mania or psychosis. Participants also talked about individuals in the community, including those who are ‘really highly anxious or moderately to severely depressed’ (Lucy, nurse), who make choices about reproduction and sexual expression that are ‘[not] that well informed’ (Yvonne, nurse) or potentially unsafe and leading to exploitation. Participants often constructed mad individuals as being a potential sexual danger towards others, themselves or both. Moreover, this sexual danger was often gendered, with men perceived as posing a risk to others through disease transmission, sexual deviancy and predatory behaviour, and women perceived as being at risk of abuse, disease, pregnancy, and distress or shame:

[On the ward] it’s usually male [‘clients’] who will pursue the female clients for sex, trying to get – do the act [sexual intercourse]. And of course if you’ve got someone who’s quite vulnerable [then they’re someone] who’s gonna go and do it. So yeah [we have to] actually protect them. (Emily, nurse)

While men’s perceived hypersexuality caused them to be a danger to others, as in Emily’s extract above, women were more often constructed as simultaneously hypersexual and vulnerable. This perceived vulnerability arose specifically from a ‘loss of […] control of her own sexuality’ (Josh, psychiatrist), situating this sexual danger within the women themselves. In contrast, men were never discussed as being vulnerable to or victims of sexual assault or exploitation because of mental illness. This gendered pattern was identified in the accounts of most participants who constructed individuals as sexually dangerous, regardless of participants’ gender or profession.

Within this dual framework of sexual danger, there was little space for individuals to make decisions about their sexual expression: any expression of sexuality could be perceived as arising from or symptomatic of mental illness and therefore as a danger requiring control. The clinician’s role was therefore to manage risk for individuals in order to protect others or to protect the individuals from themselves. In inpatient settings, sexual danger was managed primarily by prohibiting individuals from having sexual contact with each other or with their visiting partner(s). Such encounters were considered ‘inappropriate and potentially harmful’ (Josh, psychiatrist) because these individuals were ‘not necessarily able to give consent’ (Eric, psychiatrist). There was also a sense that relationships and intimacy did not belong within a context of mental illness:

They may not be detained [on the psychiatric ward], but they are unwell and because of that making some poor judgements […] it’s not … the time for people to be having [or] developing new relationships […] It’s just not a good time in your life to be making those choices … Yeah so, no. It’s [sex is] not allowed. (Eric, psychiatrist)

Despite this, participants often knew that individuals were having sex, both in inpatient and community settings, and so other risk-management strategies were employed. It was desirable for women to be using contraception ‘to protect her from unwanted pregnancy’ because they would be ‘[un]able to actually care for a child’ (Josh, psychiatrist). When women who were perceived as ‘at risk’ of pregnancy did not agree to use contraception then court-orders could be gained to enforce the use of long-term hormonal contraception (Emily, nurse). Conversely, Mia (psychiatrist) discussed the need to ensure that there is ‘sufficient support in place’ for women who become pregnant and have children because ‘we don’t want somebody’s child to be removed’. She emphasised that it is rare for her ‘patients’ to become pregnant and have children, however, because they are ‘people with the more severe mental illnesses and they’re often just not at that stage in their lives’, reflecting Eric’s idea that relationships and intimacy may not belong within the mental illness experience.

Participants focused on protecting women from themselves more often than managing the sexual danger to others posed by men, with the exception of prohibition in inpatient settings. Some participants did talk about managing the sexual danger that men posed to others and this was mostly in the context of ‘excessive’ sexually deviant behaviour that was controlled using sexual suppressants (Josh, psychiatrist). For example, Amy (nurse) had worked in a community setting with a man who was considered to be at risk of acting on paedophilic desires. She insisted that the man was ‘not really a paedophile’ but rather that his deviant desires were a symptom of his chaotic upbringing and subsequent mental illness. This perceived lack of responsibility that exonerated him for the label ‘paedophile’ also justified the use of a sexual suppressant to forcibly control his sexual deviancy. Josh (psychiatrist) also shared experiences of ‘kind of castrating sexual behaviour’ using sexual suppressants. He provided an exceptional case, however, by explicitly emphasising the human rights implications of ‘using chemicals’ to affect an individual’s sexual function and, more broadly, fertility. Although Josh felt that these decisions were the right ones in their clinical and social contexts, he considered them to be serious and requiring careful consideration. Very few participants discussed the human rights implications of managing perceived sexual danger, forcibly or otherwise:

it’s somebody’s personal right to determine what they do with their fertility and their sexuality, and we’re actually imposing in quite a significant way on that so clearly it’s got implications for human rights. (Josh, psychiatrist)

Dangerous liaisons; ‘It’s really tricky’ (Yvonne, nurse)

The category of madness and its associated lack of self-regulation could not always be ‘neatly delineate[d]’ (Simone, psychiatrist). Many participants perceived a ‘continuum between […] what you would call normal mental health and illness’ (Mia, psychiatrist) and therefore did not draw on the dangerousness of madness or sex(uality) in a static way. Rather, there was ambiguity as to when or how individuals might be considered autonomous or not and their sex(uality) dangerous or not, as evidenced by tensions and contradictions both within and across participants’ accounts. Although some participants emphasised the complicated nature of addressing sexuality in their work, judgements regarding individuals’ needs were mostly presented as professional, objective and therefore unproblematic. Yvonne’s comment neatly demonstrates the active judgements made by clinicians regarding individuals’ autonomy and sexual expression:

[The ability to make choices about sex] really depends on the level of psychosis and the person. It’s really tricky to have a blanket answer around that and I think it probably would be on the whole of the spectrum, yes they can make decisions [about sex] to absolutely no way, depending on the assessment of how I saw that person or assessed that person for their psychosis. (Yvonne, nurse)

Sexual expressions, behaviours and choices that were not necessarily perceived as healthy or appropriate were often constructed as potentially dangerous. Whether participants perceived individuals as engaging in sex for the wrong reasons or having the wrong kind of sex depended also on how they simultaneously constructed the individual’s level of autonomy. Even participants who drew singularly on the sex(uality) as dangerous framework nevertheless described their concern for individuals who, in the context of psychological distress or illness, might have sex for the wrong reasons:

When peoples’ mental health and wellbeing is good they probably have a greater … Sense of regulation. That is, maybe not … engaging in unsafe sex as much because they don’t need to. They feel okay. They feel supported, they feel loved, they feel valued. (Jeffrey, psychologist)

However, these participants reinforced individuals’ autonomy by giving them the freedom to make choices about their own sex(uality). This included the freedom to decide whether or not their choices might be dangerous or problematic, as Gale (psychologist) discussed in the context of an individual with a diagnosis of bipolar disorder and who had had many sexual partners. Gale acknowledged that her personal judgements or choices about sexual expression may not match the individual’s but that it was the individual’s judgement about her own sexual expression that should direct how or if this was addressed as a concern:

I think it’s [‘promiscuity’ is] a problem when … When it’s serving a need. Like if they’re doing it for … To fill a void then it can be problematic. But again, it’s not for me to say if it is, I think it’s really up to them. (Gale, psychologist)

In contrast, when individuals were constructed as necessarily lacking autonomy, they were not granted this same freedom to determine their sexual expression. Instead, sexual expression could be perceived as a marker of illness rather than a choice or self-expression, and so the wrong kind of sex – according to the clinician rather than the individuals themselves – could be included in the category of sexual danger. For example, for Emily, risky or dangerous sex(uality) was as much about the kind of sex or sexual activity as it was about a lack of safe sex practices. The perceived immorality of sexual expression devoid of intimacy is reflected in her concern for the distress or shame that individuals are expected to experience as consequence:

[We need to] talk [to individuals who experience mania] about how risky it can be because they’ll just go ‘round the pub and whoever’s up for it, they’ll be out the back [having sex] and there’s no connection, there’s no feelings, it’s just an act. And so talking to them about [… how that] could impact on their psychological aspects [of health] for when they do come down and realise what they done and they’re mortified. (Emily, nurse)

This idea that some kinds of sexual expression are immoral and cause individuals to feel shame was used by some participants to justify protecting individuals from this danger. Emma (psychiatrist) described an experience in which two individuals who were involuntarily detained in an acute psychiatric unit were found out to have had a sexual encounter. Emma felt that the man had ‘preyed on this vulnerable woman who definitely didn’t have capacity to consent’ and was therefore very concerned that it ‘could be[come] quite traumatic’ for the woman as she recovered from her mental illness. While Emma’s concerns were based on the expectation that the woman would feel a certain way following the encounter, other participants explained that this was ‘not my opinion’ (Yvonne, nurse) but rather what individuals had told them:

[A client in the dialectical behaviour therapy group] brought up that a lot of her impulsive behaviour was around sexual activity, she had a lot of shame around her sexual activity […] you know, making decisions in the moment that she then wasn’t happy with later. (Fay, psychologist)

Ultimately though, it was always up to the clinician to decide if individuals were sufficiently autonomous to manage risk or were ‘at risk’ from perceived sexual dangers (Emily, nurse) including disease, unplanned pregnancy, assault, exploitation or shame. Importantly, what constituted dangerous or immoral sex(uality) was not agreed upon and could change even within a single interview. Ben’s account neatly demonstrates this ambivalence as to when individuals might be ill or not, autonomous or not, and therefore dangerous or not:

[Some patients] may not have achieved optimum mental health, and so sometimes their decision making may not be the wisest […] an obvious case is when some of our patients who do have severe mental illness [are] well enough to be in the community, but will utilize sex to augment their income. And will do that in a way that is unfortunately associated with significant risk. […] So we would be very very interested and concerned about that with some of our patients. (Ben, psychiatrist)

Interestingly, Ben had previously discussed the economic challenges faced by many individuals with a mental illness diagnosis but when talking about participation in sex work he focused almost entirely on the individual’s perceived (in)capacity to make safe choices. Participation in sex work, which is perceived as a danger, became necessarily indicative of the individual’s mental ill-health and reduced autonomy rather than a reflection of their economic and social circumstances. How or when an individual should be considered autonomous and self-regulating, or lacking autonomy and unable to regulate their sex(uality), was not only ill-defined across the data but within participants’ own talk.

Limitations

We did not seek directly the perspectives and experiences of sexuality, intimacy and relationships for individuals experiencing psychological distress and illness. The perspectives of individuals engaged in mental health services have been explored both in Australia (Quinn and Happell, 2015) and elsewhere (Blalock and Wood, 2015; Deegan, 1999; Perry et al., 2017), and the experiences identified in those studies are reflected in our findings with clinicians. That we did not systematically collect information about participants’ sexual orientation or identity may be considered a limitation. The interviewer avoided asking directly about personal experiences regarding sexuality and sexual health, including sexual identity, to maintain participants’ comfort during interviews about an already sensitive topic. Nonetheless, discussions about participants’ personal experiences were welcomed if initiated by the participant themselves. Future research might explore the relationship between clinicians’ personal and professional perceptions and experiences of sexuality, sexual health and intimacy.

Practical implications and conclusion

The analysis presented here identifies a preoccupation with risk and danger regarding sex(uality) in the mental health setting. This reflects the long-standing focus on ‘high-risk behaviours’ and ‘disease prevention’ within sexual and mental health research more generally (McCann, 2003; Perry and Wright, 2006; Rohleder and Flowers, 2018). Identifying and managing (sexual) risk in the context of psychological distress and illness is a pertinent and, as many participants expressed, complex issue. A prevailing focus on risk, however, comes at the expense of developing an improved understanding and practice around broader and positive aspects of sexuality and sexual health including intimacy, relationships and identity. Moreover, orienting specifically to risk at the level of the individual overshadows the social contexts in which sexual expression occurs and tends to ignore the historical, cultural and political context within which broader concepts of sexuality, sexual health and mental illness have been constructed and are continually (re)negotiated.

There is a need to critically engage with and challenge dominant biomedical and neoliberal discourses that facilitate a risk-avoidance perspective and constrain efforts to take a positive, rights-based perspective to sexuality in the context of mental illness (McCann, 2003; Perry et al., 2017; Perry and Wright, 2006). Individual understandings and actions are simultaneously informed by and perpetuating of processes and discourses within health care systems and broader social structures (Kleinman, 1980). Thus, while not sufficient to effect broad institutional and policy level change, individual actions can facilitate a broadening of perspective in both practice and research away from a primary focus on sex(uality) as risk or danger. Clinicians can engage in reflection to interrogate their understandings of, professional practice around and level of comfort with addressing sexuality and sexual health. Researchers can similarly reflect on their own values and assumptions around sexuality, sexual health and mental illness and how these shape their research (for a discussion on taking a reflexive stance when researching stigma topics, see Wigginton and Setchell, 2016).

Clinicians and researchers strive to conceive, develop and deliver best possible care but excluding sexuality and sexual health needs in mental health settings is at odds with this goal. Individuals engaged in mental health care do not forfeit their sexual needs and rights due to psychological distress or a mental illness diagnosis. We do not mean to suggest that individuals are never vulnerable or requiring of help to stay safe, or that sexuality and sexual health needs ought to be prioritised by all mental health clinicians at all times. Indeed, it is a clinician’s role to care for and provide support to individuals experiencing psychological distress and illness, and this includes keeping them safe from perceived physical, emotional and social harms. In order to do this, clinicians must make judgements regarding individuals’ autonomy and their relative safety; however, this study and previous research demonstrates that such judgements and practices regarding individuals’ sex(uality) are not necessarily as objective, static or beneficent as clinicians may believe them to be.