Transformations of self and sexuality: Psychologically modified experiences in the context of forensic mental health

Abstract

Forensic mental health inpatients in medium secure settings have a limited capacity for sexual expression during their stay in hospital, due to a number of factors, including a lack of willingness on behalf of staff to engage with sexual issues, as a result of safety fears and ambiguity regarding the ability of the patient to consent. Furthermore, UK forensic medium secure units do not provide conjugal suites for patients to have sexual relations, with their spouse or other patients. To date, there is no empirical research on how forensic psychiatric patients (or service users) manage their sexuality, whilst in hospital and when released into the community. Here, we present an analysis of semistructured interviews with patients at a UK medium forensic unit, in order to explore these issues further. More specifically, we examine how the public exclusion of sexuality from these units results in sexuality being experienced as sectioned off or amputated, such that a new form of sexuality emerges; one that has been cultivated by the psychologically informed practices operating within the unit. This process, we argue produces a Psychologically Modified Experience (PME), a new form of self-relation that continues to modify when released into the broader ecology of the community. IntroductionForensic mental health services in the UK are based around secure hospital units, varying from low to high security, that are embedded in local health services. Persons diagnosed with severe or enduring mental health issues who have entered the criminal justice system after committing a criminal offenceknown as an 'index offence' -may be detained or 'sectioned' under the Mental Health Act (1983) and subsequently transferred to a secure unit for a significant, open-ended period of time. Two-thirds of forensic mental health service users spend over two years on a section, with twenty percent detained between five and ten years and eighteen percent between ten and twenty years (Rutherford & Duggan, 2007). This period of detention can occur at a critical period in the individual's development of adult sexuality and personal relationships, with over half of all patients being within an age range of twenty to forty years of age (Rutherford & Duggan, 2007). Sexuality and personal relationships are therefore significant issues for service users (Lowson, 2005). However, we have found in previous studies 2 ( AUTHORS, 2007) that staff working in secure forensic mental health units express significant concerns around service-user sexuality.When patients engage in sexual activity with one another, this raises a significant number of dilemmas for staff. This includes the impact of such activity on the health and wellbeing of the patients concerned, given their current state and the timing of the events concerned in relation to the duration of the stay on the unit. It also raises a concern for patient's rights and whether sexual activity has been consensual for all who are involved. We found (AUTHORS, 2007) that staff reported extensive...

Ethical issues of long-term forensic psychiatric care

“…Staff attitudes in the settings we visited contrasted with those in other countries, such as Germany and the Netherlands, where sexual activity between patients or with an outside partner is permitted [27]. Doctors explained the need to protect vulnerable patients and highlighted the fact that many patients were sexual offenders, implying that they saw engaging in a sexual relationship as an obstacle to recovery [28]. These responses may reflect the broader social and cultural context in which forensic units are situated, with less liberal views regarding sexual relationships in the UK than the Netherlands, for example [28].…”

A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation

“…156 Doctors explained that there was a need to protect vulnerable patients; they also highlighted the fact that many patients were sexual offenders, implying that they viewed a patient engaging in a sexual relationship as an obstacle to that patient's recovery. 157 These responses may reflect the broader social and cultural context in which forensic units are situated (e.g. less liberal views regarding sexual relationships in the UK than in the Netherlands 156 ) and they imply clear constraints on 'normal' living and quality of life.…”

First-person narratives around sexuality in residential healthcare settings: a meta-ethnographic synthesis

“…Of those described, 48% of participants were male and 52% female. Four studies reported on participants' ethnicity (Brown, Reavey, Kanyeredzi, & Batty, 2014;Jenkins, Walker, Cohen, & Curry, 2010;McCann, 2000;Stein et al, 2010). Due to inconsistent reporting, overall participant demographics could not be summarised.…”

“…Three studies offered an account of participants perceiving staff as unwilling to engage with discussions around sexuality (Brown et al, 2014;Lemieux et al, 2004;Östman, 2008), suggesting that the approach of care staff moderated how sexuality was discussed.…”

“…"…I still can't feel human enough to be a sexual being in this environment" (Brown et al, 2014, p.250) Eight studies (Brown et al, 2014;Frankowski & Clark, 2009;Lemieux et al, 2004;Nay, 1992;Östman, 2008;Stein et al, 2010;Villar et al, 2014) described participants as having experienced an 'adapted' sexuality; their experiences of their sexuality had changed as a result of their ailment and/or the residential healthcare environment. The shift in how sexuality was conceptualised was described more concretely by participants in residential healthcare settings for physical health needs, for example, aging participants described a shift in associations with sexuality, from procreation and marriage, to intimacy, spirituality and beauty, (Nay, 1992).…”