Michelle Rydon-Grange: Sex and intimate relationships in secure inpatient forensic settings

Michelle Rydon-Grange_picIt seems that Britain is becoming more liberal in its approach to sex in UK prisons. Last week, the country witnessed its first same sex marriage in prison. And a report published last month by the Howard League for Penal Reform revealed the true scale of consensual sexual activity in UK prisons. While this might indicate a change in attitude to sex in British prisons, are attitudes towards sexuality in inpatients detained in Britain’s secure forensic hospitals changing?

The Royal College of Psychiatrists (Sexual boundary issues in psychiatric settings, 2007) is clear in its recommendations on managing the sexuality of patients in secure settings: each inpatient has the right to expect an individualised, person centred approach to managing their sexual and emotional relationships while in hospital. However, most forensic psychiatric hospitals in the UK either prohibit or actively discourage the sexual expression of inpatients (Bartlett et al, 2010), and sex is typically far down the priority list (if on the list at all) of debates held about forensic mental health services.

Given that there seems to be no clear legal authority or framework for governing the sexual and emotional expression of forensic inpatients (unlike prisons, where the Prison Act 1952 provides the legal framework for regulation), it seems pertinent to ask: what are the assumptions underlying the blanket “no sex” rule in UK secure forensic hospitals, and is it time to reconsider the default ban on inpatients’ sexuality and intimate relationships in these settings?

There is scant empirical research on how psychiatric inpatients manage their sexuality while in hospital. However, the existing research highlights that we may not be getting it quite right for patients. In one of the few empirical papers to explore patients’ experiences of sexuality when detained in a medium secure psychiatric hospital, Brown et al (2014) reported that inpatients viewed their sexuality as “amputated” while in hospital. As one patient stated, “this place has amputated my sexuality . . . I just don’t even think about sexuality in here, and I grieve over that.”

It is important to bear in mind that these findings represent only two of several secure facilities in the UK; however, a recent paper exploring current policies and practices on patient sexual relationships in high, medium, and low secure forensic hospitals across England and Wales revealed considerable inconsistencies across and within settings, with most facilities implementing a “No sex” policy. And, perhaps unsurprisingly in a healthcare culture focused on risks, the few policies that did exist were dominated by safety concerns (Bartlett et al, 2010). So, what is it about sex in psychiatric hospitals that causes such unease? Clearly, patients with a history of sexual offending throw up a particular set of questions around safety and risk, and issues of sexuality within this particular subgroup of inpatients may need to be managed differently. However, the remainder of this piece focuses on patients detained in secure facilities whose index offence(s) are non-sexual.

Research provides a few clues about the assumptions that may underlie current practice regarding sex and sexual relationships in secure hospitals. Firstly, as Brown and colleagues (2014) note, the dominant discourse related to forensic inpatient sexuality is centred on “risk, predation, and vulnerability.” Thus, it is perhaps not surprising that any risks associated with sexual activity are currently managed by the prohibition of sexual activity. Clearly, issues of risk—exploitation, re-victimisation of patients with abuse histories, and sexual attacks—need to be managed very carefully. But is forbidding any form of sexual expression the way to go? Does this not carry risks itself, such as moving sexual activity “underground,” and outside all reasonable measures to ensure it is conducted safely and is consensual?

Continuing to view inpatient sexuality dichotomously—as indicting “vulnerability” or “predation”—surely perpetuates the idea that the only way to manage sexuality in inpatients, is to pretend it doesn’t exist? How might things be different in our secure hospitals if patients’ sexuality was viewed as a natural expression of humanness? After all, sexuality is a fundamental part of being human, mental illness or no mental illness.

Secondly, that inpatients are typically viewed as asexual (by mental health professionals (Brown et al, 2014) and wider society (McCann, 2000)), and likely to shun any potential intimate relationships as a consequence of their current mental health disorder, which is a remarkable oversimplification of the often complex interaction between mental health and sexuality. Mental health professionals may have legitimate concerns regarding inpatients’ sexual relationships (for example, the potential for retraumatisation in patients with histories of sexual abuse), but is simply denying all inpatients the freedom to express their sexuality safely heavy handed? Moreover, the fact that most patients are detained in hospitals during a critical period in the development of adult sexuality raises further ethical questions around the denial of sexual activity. By “protecting” inpatients from experiencing fulfilling, safe, and consensual sexual relationships, are we doing more harm than good?

Thirdly, the current prohibition (or discouragement) of sexual relationships in secure hospitals may rest on the assumption that sex and recovery (i.e. the ability to live independently in the community) in mental health inpatients is incompatible. That is, in order to form and maintain a sexual relationship, the patient must have “recovered” from mental illness. However, there is evidence that positive experiences of sex and intimate relationships during the “acute” phase of mental illness can help stabilise mental health and promote family connections (Gilburt et al, 2008). That sex and recovery are currently assumed as incompatible may require reconsideration.

Although the recommendations from the Royal College of Psychiatrists (2007) are clear in stating that a patient’s sexuality, and their wishes in respect of this, should form part of an individualised care plan, there is little guidance on how issues of sexuality and relationships are managed in secure hospitals. Indeed, issues of patients’ sexuality and their management are, in the absence of a legislative framework, at the discretion of the multidisciplinary team. This potentially means that nursing staff, in the absence of clear recommendations, will be guided by their own beliefs and judgments about the acceptability of patients’ sexual activity (Civic et al, 1993). Given that patients’ sexuality is currently viewed within the dichotomy of “victim” or “predator,” leaving this area up to staff’s discretion could be problematic.

Arguably, this piece asks more questions than it answers. It also neglects other important aspects of sex in inpatient settings. For example, how do antipsychotic medications and their side effects affect sexual expression in inpatients? How should secure hospitals manage sexual relationships that develop between two inpatients while detained? How should hospitals respond to issues of capacity to consent in sexual activity, and does the presence of a mental health difficulty (particularly in the context of criminality) inherently preclude capacity to consent?

However, at the very least, the sexual expression of inpatients should be considered in their diagnostic formulation and care plan. While we may be a long way off the provision of conjugal suites in forensic hospitals, a frank discussion about the role of sexuality in relation to inpatients’ general wellbeing, mental health, and recovery is long overdue.

Michelle Rydon-Grange is a third year trainee clinical psychologist at the North Wales clinical psychology programme.

Competing Interests: None declared