Getting BETTER: breaking the ice and warming to the inclusion of sexuality in mental health nursing care

Experiences of Sexual and Reproductive Health Care Access for Women and Nonbinary People With Early Psychosis: Towards an Integrated Perspective of Service Users and Clinicians

OBJECTIVE

Individuals with psychosis are at elevated risk of adverse sexual and reproductive health (SRH) outcomes, and not receiving adequate SRH care. SRH is important for youth, yet little is known about SRH care access and experiences among those with early psychosis. This study explored SRH care experiences among women and nonbinary individuals with early psychosis.

METHOD

We conducted semistructured qualitative interviews with 19 service users (cisgender and transgender women, nonbinary individuals) receiving care in 2 early psychosis programs in Ontario, Canada. We also conducted semistructured interviews and focus groups with 36 clinicians providing SRH or mental health care to this population. Participants were asked about SRH care access/provision experiences and the interplay with psychosis. Using a social interactionist orientation, a thematic analysis described and explained service user and clinician perspectives regarding SRH care.

RESULTS

Amongst both service users and clinician groups, common themes developed: (a) diversity of settings: SRH services are accessed in a large range of spaces across the health care system, (b) barriers in nonpsychiatric SRH care settings: psychosis impacts the ability to engage with existing SRH services, (c) invisibility of SRH in psychiatric settings: SRH is rarely addressed in psychiatric care, (d) variability of informal SRH-related conversations and supports, and cutting across all of the above themes, (e) intersecting social and cultural factors impacted SRH services access.

CONCLUSIONS

SRH is important for health and wellbeing; improvements are urgently needed across the healthcare system and within early psychosis programs to meet this population's multifaceted SRH needs.

Sexual knowledge of Queensland forensic mental health patients: A cross-sectional quantitative study

Forensic patients with serious mental illnesses (SMI) encounter significant challenges including active symptomatology, associated social and interpersonal impairments, psychotropic medication side effects and institutionalization, all of which negatively affect sexual functioning and possibly their acquirement of sexual knowledge. Evidence shows an increased prevalence of high-risk sexual behavior by this group however, there is an absence of literature examining the sexual knowledge of forensic patients. This quantitative cross-sectional study enrolled N = 50 patients currently under the treatment requirements of a Forensic Order and utilized the validated General Sexual Knowledge Questionnaire (GSKQ) to quantify the participants' sexual knowledge over the domains of physiology, sexual intercourse, pregnancy, contraception, sexually transmitted diseases, and sexuality. Male forensic patients scored lower than females on all domains of sexual knowledge. All participants had reasonable knowledge of physiology, sexual intercourse and sexuality; of concern were poor scores on pregnancy, contraception and sexually transmitted diseases. Thirty-five (70%) of the respondents indicated that they had some limited sex education, mostly at school. Only six (12%) received any sexual education from a health professional despite extensive contact with the forensic mental health services across many years. There is a need to assess the deficit in sexual knowledge of forensic patients in order to develop sexual health education, intervention and rehabilitative programmes that cater to the specific needs of this group to improve their sexual knowledge, encourage safe and positive sexual experiences, and enhance their quality of life.

Let's talk about sexuality - A web-based survey of self-reported competence in sexual problems among obstetrician-gynecologists in Finland

INTRODUCTION

Sexual health is an important aspect of quality of life, yet both healthcare professionals and patients might hesitate to bring up the topic during appointments. Our study investigated obstetrician-gynecologists' (OB/GYNs') self-reported competences in discussing and treating sexual problems, as well as the barriers to bringing up the subject. An additional aim was to evaluate the need for continuing education in sexual medicine.

MATERIAL AND METHODS

A web-based questionnaire was sent to the members of The Finnish Society of Obstetrics and Gynecology (n = 1212). The survey was completed by 328 respondents (275 specialists and 53 OB/GYN residents). Their background information (gender, age, education, occupational status, daily number of patients, and daily number of patients with sexual health issues) was assessed. The questionnaire included four fields: (A) self-reported competence in discussing and treating patients with sexual problems (three questions), (B) the barriers to bringing up sexual problems with patients (nine questions), (C) the source of education in sexual medicine (two questions), and (D) the need for education in sexual medicine (two questions).

RESULTS

Most of the OB/GYNs self-reported their competence to be good in discussing sexual problems, but poor in treating patients' sexual problems. The male OB/GYNs reported better competence than did the females. Several barriers were identified-most frequently, "shortness of the appointment time" (76%), "lack of knowledge about sexual medicine" (75%), and "lack of experience with sexual medicine" (74%). Older OB/GYNs and male OB/GYNs reported fewer barriers. The majority of the respondents considered their previous education in sexual medicine to be insufficient, especially in medical school (95%), but also in residency (83%), and they reported a need for additional education.

CONCLUSIONS

Our study indicated several barriers that hindered OB/GYNs from assessing sexual problems during appointments. Although OB/GYNs reported a good competence in discussing sexual problems, they reported a poor competence in treating them. Their previous education in sexual medicine was rated as insufficient, and continuing education was desired. The information provided by our study can be used for improving and organizing education in sexual medicine, which is crucial for diminishing the barriers to discussing and treating sexual problems.

Sex education for patients with severe mental illness in Iran: A qualitative study

Objective

Patients with severe mental illness may experience cognitive deficits, impaired judgment or loss of skills. Therefore, they are prone to sexual health complications. Sex education can promote sexual health, and in many countries, it is integrated into other domains of education. The educational contents taught in western countries are not necessarily appropriate for developing countries.This study aims to address sex educational content for these patients in Iran.

Methods

We have conducted twenty-three face-to-face, deep and semi-structured interviews with patients, family members, psychiatrists, general practitioners, nurses and psychologists. We used the strategy of maximum diversity in selecting the participants.

Results

"Improving basic knowledge," "decreasing the risk of unsafe sex", "empowerment" and "persuading to ask for help" should be covered in the education.

Conclusions

Sexuality is not considered a priority for these patients. It is necessary to develop a training program with simple educational content for this high-risk group.

Innovation

Raising awareness and knowledge about the possible risks of social media on high-risk behaviours, developing social and behavioural skills, and encouraging patients to talk about their new challenges in sexual life is recommended. Cultural, spiritual and personal beliefs should be considered in designing the educational program.

Behavioral Health Provider Attitudes and Beliefs about Sexuality and Intimacy: Findings from a Mixed Method Design

Recovery-oriented services overlook a crucial health domain for persons with severe mental illnesses (SMI): sexuality and intimacy. Though this aspect of social recovery correlates with improved life quality and treatment outcomes, behavioral health (BH) providers avoid such topics. The study's purpose was to obtain an updated snapshot of their attitudes and beliefs about sexuality and intimacy communication. Utilizing a community advisory board, we adapted the Sexual Attitudes and Beliefs Survey (SABS) and distributed it via survey link to a national listserv. We used independent samples t-tests to examine differences on SABS mean scores by gender, age group, educational attainment, and previous training on sexuality and intimacy. We asked open-ended questions and coded responses using content analysis. Participants with more education and previous exposure to training on sexuality and intimacy were more likely to hold open views on communication. Findings offer directions for addressing this neglected aspect of recovery.

'It's Not Really a Part of Standard Practice': Institutional Silencing of Sexuality Within Australian Mental Health Settings

Research seeking to understand and improve sexuality-related practice in mental health settings has paid little attention to the institutional context in which clinicians' practice is embedded. Through a social constructionist lens, we used thematic analysis to examine how 22 Australian mental health clinicians implicated the wider institutional context when discussing and making sense of sexuality-related silence within their work. Interviews were part of a study exploring participants' perceptions of sexuality and sexual health in their work more generally. Broader silences that shaped and reinforced participants' perceptions and practice choices were situated in professional education; workplace cultures; and the tools, procedures and policies that directed clinical practice. We argue that sexuality-related silence in mental health settings is located in the institutional context in which clinicians learn and work, and discuss how orienting to this broader context will benefit research and interventions to improve sexuality-related practice across health settings.

Comparing the Effectiveness of Sexual Counseling Based on PLISSITand BETTER Models on Sexual Selfdisclosure in Women with Sexual Problems after Childbirth: A Randomized Trial

Background:

Sexual self-disclosure is one of the factors that affect sexual satisfaction. The aim of this study was to assess the efficacy of individual therapy using the Bring up, Explain, Tell, Timing, Educate, and Record (BETTER model) in comparison to individual therapy using the Permission, Limited Information, Specific Suggestions, and Intensive Therapy (PLISSIT model) in terms of increasing sexual self-disclosure in women with sexual problems after childbirth.

Materials and Methods:

This randomized trial was conducted in 2017 in Mashhad, Iran. 80 women with sexual problems within 4 weeks to 6 months after childbirth were randomized into two equal groups and received the interventions in 2 sessions of 60–90 minutes. The research instruments included a demographic questionnaire, the Female Sexual Function Index (FSFI) and Hulbert sexual self-disclosure index. Changes in mean (SD) scores of sexual self-disclosures between groups were assessed before and 4 weeks after the intervention and the results (mean changes) were compared between groups. The data analysis was conducted using independent t-test, paired t-test, Chi-square, analysis of covariance (ANOVA), and Mann-Whitney U test in SPSS (p < 0.05).

Results:

In the PLISSIT group, the mean (SD) sexual self-disclosure score at baseline was 43.80 (9.50) and after 4 weeks was 51.60 (8.30). In the BETTER group, at baseline and after 4 weeks the mean (SD) sexual self-disclosure score was, respectively, 44.10 (10.30) and 55.60 (8.20) (Z = -2.5, p = 0.013).

Conclusions:

The findings confirm the effectiveness of the BETTER counseling model in increasing sexual self-disclosure after childbirth.

Affective and Sexual Needs of Residents in Psychiatric Facilities: A Qualitative Approach

BACKGROUND

The affective and sexual needs of psychiatric patients are often under-considered, although they contribute significantly to their general well-being. Such topics are critical for Residential Psychiatric Facilities Users (RPFUs), whose daily life is paced by therapeutic settings. The aim of this paper is to better understand how sexuality and affectivity are expressed by the RPFUs at the Mental Health Department of Modena, within psychiatric residential settings.

METHODS

Adult RPFUs took part into two audio recorded focus groups. Digital transcripts were analyzed using MAXQDA software in order to perform qualitative narrative analysis, so as to develop a hierarchical code system a posteriori (derived from the data).

RESULTS

Eleven participants (eight RPFUs and three investigators) attended the first focus group, and eight participants (5 RPFUs and 3 investigators) attended the second focus group. 175 interventions were analyzed and coded under seven thematic areas: (a) contraception and sexually transmitted disease prevention (N = 17); (b) affective needs (N = 11); (c) personal experiences (N = 61); (d) regulation of sexual relations (N = 18); (e) Mental Health Professionals' (MHPs) openness towards the topic (N = 17); (f) MHPs' responses to RPFUs' sexual behaviors (N = 33); and (g) RPFUs proposals (N = 18). The highlighted topics suggest that affective and sexual relations commonly occur within residential psychiatric facilities, even if mental health services often fail to recognize and address RPFUs' affective and sexual needs as well as to provide effective solutions to manage them.

CONCLUSIONS

RPFUs expressed a request for support to fulfill their affective and sexual needs and dedicated spaces for sexual activities to relieve their discomfort, while MHPs highlighted a need for awareness, training, and shared problem-solving strategies.

Medical and Health Care Professionals' Sexuality Education: State of the Art and Recommendations

Sexuality is considered an important aspect of holistic care, but research has shown that it is often not considered, as it should be, in health services. Addressing clients' sexuality requires a multidisciplinary approach and is not the responsibility of a single professional. The literature underlines that university students or those working in hospitals and other health care facilities are not adequately prepared to meet patients' needs regarding sexuality. The objective of this study was, therefore, to review the scientific literature addressing training courses for health professionals in sexuality between 2000 and 2020. Several studies have shown enhancement in health care professionals' ability to deal with patients' sexuality issues after participating in sexuality education programs, regardless of the course load and modality, even if the long-term effects have still to be proved. Health care professionals therefore require education in the area of sexuality, regardless of their discipline. According to the articles reviewed, in order to improve the performance and comfort level of health care professionals to deal with patients' sexuality, investments in training are necessary. Further evaluations of interdisciplinary sexuality education programmes should use larger samples and explore the differences across disciplines.

'It's just a peripheral issue': A qualitative analysis of mental health clinicians' accounts of (not) addressing sexuality in their work

Sexuality, relationships, and intimacy are integral parts of many peoples' lives, not negated by mental distress and illness. Yet typically, these needs are not addressed adequately in mental health settings. In-depth interviews were conducted with mental health clinicians with an aim of exploring their perceptions and understandings of sexuality and sexual concerns within mental health settings. Participants were 22 mental health nurses, psychologists, and psychiatrists working with people across a range of settings in four Australian cities. Sexuality or aspects of this were often not addressed in clinical practice, and this was common across participants' accounts. A critical thematic analysis was conducted to explore how participants made sense of or explained this silence in relation to sexuality. Two key themes were 'Sexuality is hard to talk about' and 'Sexuality is a "peripheral issue"'. In positioning sexuality as a peripheral issue, participants drew on three key explanations (sub-themes): that sexuality rarely 'comes up', that it is not pragmatic to address sexuality, and that addressing sexuality is not part of participants' roles or skill sets. A third theme captured the contrasting perception that 'Sexuality could be better addressed' in mental health settings. This analysis indicates that, beyond anticipated embarrassment, mental health clinicians from three disciplines account for omissions of sexuality from clinical practice in similar ways. Moreover, these accounts serve to peripheralize sexuality in mental health settings. We consider these results within the context of espoused holistic and recovery-oriented principles in mental health settings.

Sexual violence and mental health services: a call to action

People who experience sexual violence are highly likely to experience psychological and/or mental health (MH) problems as a result. People who use MH services often have a history of sexual assault and are also likely to be revictimised as an adult. Yet despite there being a very clear association, MH services are not yet performing routine enquiry, and even if they do, are not confident about how to record and manage disclosures. There is some emerging evidence that people with MH problems are exposed to sexual violence in inpatient MH settings, perpetrated by both other patients or members of staff. In this editorial, we explore the evidence to support a wider focus on sexual violence as a part of routine care, as well as some recommendations about how staff can more effectively discuss sexual issues including that of sexual victimisation.

Sexual Counseling in Women With Primary Infertility and Sexual Dysfunction: Use of the BETTER Model

The aim of the study was to determine the effect of sexual counseling based on the BETTER model of female sexual health in infertile women with sexual dysfunction. This is an experimental, prospective study carried out in an infertility clinic. The study included 70 women with primary infertility, of whom 35 were in the experimental group and 35 were in the control group. The Female Sexual Function Scale and the Golombok-Rust Sexual Satisfaction Scale were administered at the initial assessment and the final assessment. Two sessions of sexual counseling were given to the experimental group based on the BETTER model. A routine follow-up of the control group was performed. After the counseling, there was a statistically significant improvement in the mean scores for Female Sexual Function Scale and the total scores for the Golombok-Rust Sexual Satisfaction Scale and its subscales in the experimental group compared to the control group. The women who had been infertile for six years and more had less improvement in sexual dysfunction and sexual dissatisfaction. The sexual counseling given in accordance with the BETTER model was found to be effective in improvement of sexual function and sexual satisfaction in the women with one to two years of infertility.

Sexuality education for health professionals: A literature review

Abstract The objective of this study was to review the scientific literature addressing educational actions related to the training of health professionals in sexuality between 2003 and 2013. The results obtained show that college seniors, recent college graduates, or those working in hospitals and other health care facilities are not adequately prepared to meet patients' needs regarding sexuality. Several studies have shown improvement in the health practitioners' ability to deal with patients' sexuality issues after participating in training programs in sexuality, regardless of the course load. According to the articles reviewed, in order to improve the performance and comfort level of health practitioners to deal with patients' sexuality concerns, investments in educational actions are necessary.

The emancipatory potential of nursing practice in relation to sexuality: a systematic literature review of nursing research 2009-2014

Nurses play a key role in the provision of services in relation to sexuality in both primary and sexual and reproductive health-care. Given the intersection of sexualities with a range of social injustices, this study reviews research on nursing practice concerning sexuality from an emancipatory/social justice perspective. A systematic review of English articles published in nursing journals appearing on the Web of Science database from 2009 to 2014 was conducted. Thirty-eight articles met the inclusion criteria. Analysis consisted of a descriptive phase (types and location of studies, aspects of sexualities focused on, target health users and aspects of nursing practice focused on) and a critical/emancipatory phase. In terms of practice, our analysis revealed that: barriers exist to the integration of issues relating to sexuality in nursing practice; the social location of nurses and their personal feelings regarding sexuality influence their practice; content that addresses gendered norms and media that assist in communication underpin some emancipatory practices. Few studies locate analyses of nursing practice within gendered, cultural and social norms; consider advocacy as part of the practice of nurses; or analyse the promotion of health user participation in health services and structures. The implications for emancipatory practice are drawn out.

Proposed nurse-led initiatives in improving physical health of people with serious mental illness: a survey of nurses in mental health

AIMS AND OBJECTIVES

To identify nurse perceptions on the potential value of general and specific nursing approaches to improving physical health outcomes of people with serious mental illness.

BACKGROUND

People diagnosed with serious mental illnesses experience heightened rates of physical illnesses and can be supported better via healthcare system prevention and management. Nurses working in mental health are a critical part of a system-wide approach to improving physical health care, but there is little known on their views on specific approaches within Australia (e.g. screening for risks, stigma reduction).

DESIGN

A national, cross-sectional and nonrandom survey study delivered online.

METHODS

Members of the Australian College of Mental Health Nurses (n = 643), representing nurses employed in mental healthcare services across Australia (71·6% from public mental health services). Participants were asked to rate the potential of nine nurse-based strategies for improving physical health (options: 'yes', 'no', 'not sure') and the potential value of 10 nursing and general strategies for improving physical health (rating from 'negative value' to 'significant value').

RESULTS

There was a high endorsement of all nine nurse-based strategies for physical health (e.g. lifestyle programmes, screening, linking services), although there was less support for reducing antipsychotics or advocating for fewer side effects. Participants mainly viewed all strategies as of moderate to significant value, with the most promising value attached to colocation of primary and mental care services, lifestyle programmes and improving primary care services (reduce stigma, train GPs).

CONCLUSIONS

Australian nurses working in mental health services view a range of nurse-based strategies for improving physical healthcare services and standards as important.

RELEVANCE TO CLINICAL PRACTICE

Nurses collectively need to work with consumers, health agencies and the general public to further define how to organise and implement physical health integration strategies, towards more comprehensive health care of people with serious mental illness.

Talking about sex as part of our role: making and sustaining practice change

Sexual issues are common for consumers of mental health services and have many adverse consequences for quality of life as well as impacting negatively on the mental illness itself. Nurses in mental health settings are well placed to assess for the presence of and provide interventions for sexual concerns. To date, little research has been undertaken to explore nurses' attitudes and whether sexual issues would be accepted as part of their care. This paper presents findings from the third stage of a qualitative, exploratory research study with mental health nurses working in an Australian mental health service. The findings from the first two stages suggested that the participants had tended to avoid discussion of sexual issues, but a brief education intervention had produced a greater willingness to address sexual issues as part of care. The aim of the third stage was to determine the degree to which changes in practice had continued over time. Two main themes that emerged from this data were: (i) holism, from rhetoric to reality; and (ii) part of what I do. Addressing sexual issues became part of practice, a change sustained 2 years following the intervention, because participants recognized its importance for holistic nursing care.

Physical health care for people with mental illness: training needs for nurses

AIM

People diagnosed with serious mental illness have higher rates of physical morbidity and decreased longevity, yet these people are not adequately served by health care systems. Nurses may provide improved physical health support to consumers with serious mental illness but this is partly dependent on nurses having necessary skills and interest in training opportunities for this component of their work. This survey investigated Australian nurses' interest in training across areas of physical health care including lifestyle factors, cardiovascular disease, and identifying health risks.

METHODS

A nation-wide online survey of nurse members of the Australian College of Mental Health Nurses. The survey included an adapted version of a sub-section of the Physical Health Attitudes Scale. Participants were asked to indicate their interest in various aspects of physical health care training.

RESULTS

Most (91.6%) participants viewed educating nurses in physical health care as of moderate or significant value in improving the physical health of people with serious mental illness. Interest in training in all areas of physical health care was over 60% across the health care settings investigated (e.g. public, private, primary care). Forty-two percent sought training in all nine areas of physical health care, from supporting people with diabetes, to assisting consumers with sexually-related and lifestyle issues.

CONCLUSIONS

The findings suggest that nurses in mental health services in Australia acknowledge the importance of training to improve physical health care of consumers with serious mental illness. Training programs and learning opportunities for nurses are necessary to reduce inequalities in health of people with serious mental illness.

Clinical interventions for women with schizophrenia: pregnancy

OBJECTIVE

A comprehensive treatment program for schizophrenia needs to include services to women of childbearing age that address contraception, pregnancy, and postpartum issues, as well as safe and effective parenting. To update knowledge in these areas, a summary of the recent qualitative and quantitative literature was undertaken.

METHOD

The search terms 'sexuality,''contraception,''pregnancy,''postpartum,''custody,' and 'parenting' were entered into PubMed, PsycINFO, and SOCINDEX along with the terms 'schizophrenia' and 'antipsychotic.' Publications in English for all years subsequent to 2000 were retrieved and their reference lists further searched in an attempt to arrive at a distillation of useful clinical recommendations.

RESULTS

The main recommendations to care providers are as follows: take a sexual history and initiate discussion about intimate relationships and contraception with all women diagnosed with schizophrenia. During pregnancy, adjust antipsychotic dose to clinical status, link the patient with prenatal care services, and help her prepare for childbirth. There are pros and cons to breastfeeding while on medication, and these need thorough discussion. During the postpartum period, mental health home visits should be provided. Parenting support is critical.

CONCLUSION

The comprehensive treatment of schizophrenia in women means remembering that all women of childbearing age are potential new mothers.

The 5-As framework for including sexual concerns in mental health nursing practice

Available evidence informs us that sexual health concerns of consumers are commonly avoided within mental health services. This paper describes the findings of a qualitative exploratory research project. This research was conducted in three stages, all involving in-depth interviews with 14 nurses working in a mental health setting. Stage 1 involved an exploration of participants' views about including sexual concerns in their practice and included an educational intervention designed to encourage sexual inclusivity in practice. Stage 2 involved follow up interviews 4-6 weeks later to discuss the effectiveness of the intervention and whether practice change had resulted. Stage 3 was conducted two years later with the aim of determining the extent to which practice changes had been sustained. The themes emerging throughout the research emphasised five main stages in the nurses' experience: avoidance; awareness; applying; approval; and acknowledgement. Avoidance of the topic was commonly noted in the early stages of the research. The education program led to awareness raising of sexual concerns and approval towards the importance of this area to which lead to applying it to practice. This ultimately resulted in acknowledgement of the need for sexual concerns to become part of mental health nursing practice. These five stages are represented in the Five A's for including sexual concerns in mental health nursing practice, the framework developed by the first author.