Attitudes towards sexual expression in professionals in forensic psychiatry in different EU countries

Written by Shaz Majid
Research Assistant, Faculty of Medicine & Health Sciences, University of Nottingham

Sexuality, sexual relationships and sexual functioning are important quality-of-life issues for patients with mental disorders (Assalian, P., Fraser, R., Tempier, R., & Cohen, D., 2000; Dobal & Torkelson 2004). Although sexual interaction is not a specifically protected right, a person’s right to consensual sexual activity, including those persons involuntarily detained under the Mental Health Act 1983 (MHA), is implicitly inferred through Article 8 of the Human Rights Act 1998 (HRA) which upholds one’s right to privacy, personal dignity, autonomy and social interaction. The International Covenant on Economic, Social and Cultural Rights (ICESCR) further supports sexual freedom of mental health patients. Article 12 of ICESCR establishes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. This includes the right to control one’s health and body, including sexual and reproductive freedom.

Patients in secure forensic psychiatric care facilities and hospitals, especially those in long term forensic psychiatric care facilities, in the UK are considerably deprived of sexual expression. In the absence of a clear formal policy regarding sexual behaviour across forensic psychiatric care facilities in the UK, decisions are often left to the discretion of individual practitioners and forensic psychologists. There is an increased likelihood that these mental health care workers will be guided by their personal beliefs and their own moral judgment. Current research indicates that some policies within the UK are the most restrictive in the world, though they do vary within the UK, policies outside of the UK have been found to be less restrictive. For example, in the Netherlands and Germany, sexual interactions between patients, or between a patient and an outside partner may be permitted (Tiwana, 2014). This elicits questions as to why forensic psychiatric care facilities and hospitals in the United Kingdom are implementing different policies and whether blanket prohibition of sexual behaviour is too restrictive.

In our project we analysed the attitudes of mental health care professionals and forensic psychiatrists working in forensic psychiatric settings, including long term forensic care facilities, on issues of sexual expression and compared the beliefs of experts in the UK with other countries. We designed an electronic survey featuring questions on patients rights toward sexual expression, sexual intercourse, other forms of sexual expression, rationale for sexual expression rules, access to resources, consequences on prohibited sexual activity and policies. Participants were recruited anonymously via mailing lists from professional organisations including the forensic section of the European Psychiatric Association (EPA) and Royal College of Psychiatrists (RCP), members of the European Cooperation in Science and Technology (COST) on long-term forensic care, International Association of Law and Mental Health (IALMH), World Psychiatric Association (WPA), the Ghent Group, and book authors of Ethical Issues in Prison Psychiatry.

A total of 310 participants (215 British, 14 German and 81 other) completed the survey (129 female, 141 male). We asked respondents to rate their level of agreement to various statements. Our results suggest that Non-UK respondents believe that denial of sexual expression for inpatients is a breach of human rights: non-UK respondents were significantly more agreeable with this statement compared to UK respondents (p= < .05). Non-UK respondents were also less restrictive in their attitudes towards kissing open-mouthed (p= < .001), hugging (p= < .001) and marriage between inpatients (p= < .001). Consensus was reached in regards to factors important in deciding on sexual expression rules where the capacity of an inpatient to consent to a sexual relationship (82.6%), index offence (66.7%) and the vulnerability of an inpatient (78.6%) were considered to be important factors. When asked about resources, non-UK respondents were more willing to provide contraception on wards (p= .015) and conjugal sites for inpatients to have unsupervised visits with partners (p= < .001). Non-UK respondents were also more open to tranquilisation (p = .015) as a consequence to prohibited sexual activity compared to UK respondents. Finally, non-UK respondents were more in favour of mixed gender forensic wards compared to UK respondents (p= < .001).

Our results clearly indicate that the opinions of UK respondents are generally more restrictive than non-UK respondents on matters of sexual expression in secure forensic psychiatric care facilities and hospitals, including long term psychiatric care facilities. And this is being reflected in their respective policies and practice. However, the uniqueness of patients in forensic psychiatric care, in regards to their mental state; capacity to consent; offending history; and risk was universally accepted. On this basis, we propose that the most reasonable solution to the determination of allowing forensic psychiatric patients the right to consensual sexual activity should be on a case-by-case basis and blanket policies on such matters should be avoided.