Policies on sexual expression in forensic psychiatric settings in different European countries

Toward an Integrated Sexual Policy in Forensic Psychiatry: A Mixed Method Pilot Study

Forensic inpatients reside for long periods in restricted environments, which do not support the presence of sexual experiences or the expression of existing needs. However, sexuality and sexual health are important aspects in the overall recovery from mental illness. Given the lack of national policies, management decisions are bestowed upon individual institutions and staff members. This research aims to describe the current sexual policies in 32 forensic psychiatric wards in Flanders (the Dutch-speaking part of Belgium), varying from low to high security, and explore the perspective of forensic inpatients regarding such policies. The research questions were answered using a survey that questioned the different forensic units. Only 56% of the wards had a sexual policy at the hospital level. Results showed no significant differences in the applicable sexual policies between the security levels, but individual differences and inconsistencies exist in the rules and agreements applied among different wards. Subsequently, 15 semi-structured in-depth interviews with inpatients were conducted using a phenomenological approach. Most of the respondents were dissatisfied with their sexuality and experienced various barriers in meeting their sexual wants and needs. The results have an added value for clinical practice and lead to recommendations in the development of an integrated sexual policy.

[Sexuality in Forensic Psychiatry. Results of a Qualitative Study on Professionals' Perspectives and Recommendations for Clinical Practice]

OBJECTIVE

Investigation of employees' perspectives on sexuality and sexual health of inpatients in two gender-separated forensic psychiatries in Bavaria.

METHODS

19 semi-structured interviews were analyzed with qualitative content analysis. The results were discussed with employees and a recommendation for action was developed.

RESULTS

Employees describe insufficient and non-systematic consideration of sexuality in forensic institutions. Regulations on permitted and non-permitted behavior either do not exist, are unknown or remain on an implicit level for many employees and patients.

CONCLUSION

The consideration of sexuality and the sexual needs of patients should be comprehensible and transparent. An attached recommendation for dealing with sexuality can help institutions to give more consideration to sexuality in forensic institutions.

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.

Guidelines, Policies, and Recommendations Regarding the Sexuality of Individuals with Severe Mental Disorders in Psychiatric Units, Institutions, and Supported Housing Across Europe: A Systematic Review

Sexual behavior of psychiatric inpatients is often inadequately addressed within psychiatric institutions. This systematic review aimed to identify existing policies, guidelines, and recommendations regarding inpatient sexual behavior in psychiatric units, institutions, and supported housing across Europe in existing literature. It also aimed to assess the attitudes held by mental health professionals (MHPs) and inpatients toward existing policies, guidelines, and recommendations. Nine databases were searched in seven languages for articles published between 2000 and 2020. Double-blind bias assessment was performed on 10 articles. Five thematic categories emerged from the selected studies: (1) types of policies and guidelines; (2) MHPs' and inpatients' attitudes toward inpatient sexual behavior; (3) impact and strategies related to inpatient sexual behavior; (4) barriers to inpatient sexual behavior; and (5) facilitators to inpatient sexual behavior. Most screened publications reported implicit norms addressing inpatient sexual behavior among the staff. Surveyed MHPs and inpatients typically showed opposing attitudes regarding inpatient sexual behavior, with MHPs generally deeming such behavior unsafe and inpatients emphasizing it as their human right. The aims of this systematic review were partially fulfilled as articles reported little or no policy documents and guidelines and, therefore, did not allow for the assessment of policy impact. MHPs' attitudes toward inpatient sexual behavior were addressed and trends in several countries outside of Europe addressing inpatient sexual behavior were discussed. Finally, capacity to consent with respect to inpatient sexual behavior is discussed in the context of human rights.

Choreographies of sexual safety and liminality: Forensic mental health and the limits of recovery

Medium secure forensic psychiatric units are unique environments within the broader "post asylum" landscape of mental health services. Length of stay is much greater and restrictions on behavior, including sexual behavior, are legally and institutionally legitimated, due to concerns regarding risk. As a result, sexuality is rarely explored experientially with service users and no official policies on sexual conduct and sexual safety have yet been developed.

The sexuality and sexual experiences of forensic mental health patients: An integrative review of the literature

Introduction

Sexuality is an integral aspect of the human experience that defines an individual. Robust research, substantiated by the World Health Organization, demonstrates that healthy sexuality improves mental health and quality of life. Despite this level of global advocacy and clinical evidence, sexuality and sexual health as determinants of health have been largely overlooked in the mental healthcare of patients being treated under the requirements of a forensic order (forensic patients). In this review, the authors have evaluated the literature related to the sexual development, sexual health, sexual knowledge and risks, sexual experiences, sexual behavior and sexual desires of forensic patients to inform policy and clinical practice. Furthermore, the review explored how forensic patients' sexual healthcare needs are managed within a forensic mental healthcare framework. The paper concludes with recommendations for service providers to ensure that sexual health and sexuality are components of mental health policy frameworks and clinical care.

Methods

An integrative review was utilized to summarize empirical and theoretical literature to provide a greater comprehensive understanding of the sexuality and sexual experiences of forensic patients. This included identifying original qualitative, quantitative, or mixed-method research, case reports, case series and published doctoral thesis pertaining to the research topic.

Results

Twenty-one articles were selected for review. We grouped the review findings into three main themes: 1) Forensic patient themes, 2) Forensic mental health staff themes and 3) Forensic mental health organization themes. The review demonstrated scant information on the sexual healthcare needs of forensic patients or how health services manage these needs while the patient is in a hospital or reintegrating into the community.

Conclusion

There is a dearth of evidence-based, individualized or group approaches which clinicians can utilize to assist forensic patients to achieve a healthy sexual life and it is recommended that such services be developed. Before that however, it is essential to have a clear understanding of the sexual healthcare needs of forensic patients to identify areas where this vulnerable population can be supported in achieving optimal sexual health. Urgent changes to clinical assessment are required to incorporate sexual healthcare as a component of routine mental healthcare.

The value of occupational therapy intervention for the worker roles of forensic mental healthcare users in Cape Town, South Africa

BACKGROUND

There is a void in research that focuses on how OT programs facilitate self-esteem in forensic mental healthcare users' return-to-work in the open labor market, particularly in South Africa.

OBJECTIVE

To explore the experiences and perceptions of forensic mental healthcare users, transitioning from an OT program to the open labor market.

METHODS

Five individuals, diagnosed with Schizophrenia, and two key informants participated in this study that was positioned in a qualitative paradigm, with an exploratory and descriptive design. Semi-structured interviews were used to collect data.

RESULTS

Theme one reflects on the challenges experienced by forensic mental healthcare users, when returning to work. Theme two describes various OT programs, as well as how they facilitate the reintegration of forensic mental healthcare users into the worker role. Theme three describes the positive support for forensic mental healthcare users, in the mental healthcare setting, workplace, and the greater community. Theme four describes how participation in occupation installs hope in forensic mental healthcare users, reinforcing the value of work, while positively influencing their work identity.

CONCLUSION

The results revealed that stigma, residual symptoms, relapse due to substance abuse/mental health, and the lack of family support, were not be conducive to work skills development. However, the support of family and friends, workplace occupational therapy support, assembly line work, and therapeutic groups in an OT program, ensured positive workplace reintegration.

Sexuality, risk, and organisational misbehaviour in a secure mental healthcare facility in England

Sexuality in secure mental healthcare has been overlooked in both clinical praxis and academic research. In the UK, there exist no formal policies to inform staff approaches to managing inpatient sexuality. The limited research that has been undertaken in this field has found that often, prohibitive approaches are favoured, which may affect how inpatients conceptualise and experience their sexuality in the long-term. The aim of this study was to identify discursive constructions of inpatient sexuality, as articulated in semi-structured group interviews with inpatients and ward staff from a secure mental healthcare facility in England. The analysis identified constructions of inpatient sexuality within two overarching and conflicting discourses: one of the normalcy and legitimacy of sexual expression in human experience; and the other of risk, wherein sexuality needed to be regulated and obstructed. Inpatients' expressions of sexuality could often only be conceptualised in terms of 'organisational misbehaviour', acts that violated the implicit norms and codes of the institution. It is suggested that recoding inpatient sexuality as misbehaviour could have implications for inpatients' long-term recovery.

Exploring Needs and Quality of Life of Forensic Psychiatric Inpatients in the Reformed Italian System, Implications for Care and Safety

The Italian forensic psychiatric system underwent drastic reforms. The newly developed facilities are inspired by psychiatric community services, embracing a recovery-oriented approach. Needs and quality of life are broader concepts that consider the more rehabilitative and humanitarian aspects of treatment. In one of the new Italian forensic psychiatric services, this cross-sectional study aimed to investigate the needs and quality of life of forensic psychiatric patients. A second aim was to validate the Italian version of the Forensic inpatient Quality of Life questionnaire Short Version (FQL-SV). Overall, 42 forensic psychiatric patients were assessed using the Forensic version of the Camberwell Assessment of Need (CANFOR), the Historical-Clinical-Risk-Management-20 (HCR-20), the FQL-SV, and the World Health Organization Quality of Life (WHOQoL-Bref). Patients reported significantly fewer needs, whether met or unmet, than their treating clinicians. The general level of agreement between patients and clinicians on specific needs was low Kappa values were < .40 for 64% of the total needs and 46% of the unmet needs. Risk factors according to the HCR-20 mean scores were 13.1, 4.6, and 6.4 for the historical, clinical and risk management subscale. Quality of life was moderate to high for 74% of the patients. Our results showed that lower numbers of needs, whether reported by patients or clinicians, were associated with a better quality of life. The Italian FQL-SV had a Cronbach's alpha of 0.86 and correlated as expected with the WHOQoL-Bref. The FQL-SV is a valid and reliable tool, justifying its use for routinely assessing QoL in Italian forensic psychiatric services. This study enhances our understanding of needs and quality of life of forensic psychiatric patients and how their assessment could have an additional value for recovery-oriented treatment in forensic psychiatry. Although the detained status of forensic patients imposes real limits on the capacity for autonomy and choice, incorporating the patient's perspective on decision-making processes, in relation to aspects of treatment, care, and daily life, may have benefits such as a better treatment adherence or therapeutic alliance. Future research should clarify how routinely assessing needs and quality of life can contribute to the recovery of these forensic psychiatric patients.

A Comparison of English and Dutch Long-Stay Patients in Forensic Psychiatric Care

Background: A significant proportion of forensic patients in England are long-stayers. This can be problematic as individuals are kept in restrictive environments at potentially inappropriate levels of security for many years, sometimes decades. Improvements to the current English forensic mental health system to meet the needs of long-stay forensic patients more effectively might be informed by the Dutch service for long-stay forensic patients. Aims: To compare the characteristics of representative samples of long-stay patients in England and in the Netherlands in an attempt to draw conclusions on the degree to which the Dutch service model might be relevant to England. Method: This cross-sectional study explores the relevance of the Dutch service model by comparing the characteristics of representative samples of long-stay patients in England (n = 401) and the Netherlands (n = 102). Descriptive statistics and analyses of differences between groups are presented. The Risk-Need-Responsivity model was used to guide the selection of the study variables and structure the interpretation of the findings. Results: Compared to their English counterparts, the long-stay Dutch patients were less likely to be diagnosed with schizophrenia, but more likely to have personality disorder and have committed sex offences. The English group were younger at first conviction and at first custodial sentence. The total number of offences and the proportion of violent offenders were similar, but the Dutch HCR-20 scores indicated a significantly higher risk of violence. Conclusions: Whilst there may be barriers to adopting the Dutch service model in England, the differences in the characteristics of the two groups studied here do not necessarily preclude this approach.

Sexual rights, mental disorder and intellectual disability: practical implications for policy makers and practitioners

Clear policies regarding sexual expression, sexual behaviour and related decision-making assist in ensuring that the rights of people with mental disorder or intellectual disability are upheld, and that staff know how to react to situations consistently and lawfully without interfering on the basis of their own moral judgements or personal beliefs. Sensitive and holistic planning of care that complies with domestic law, international human rights law and statutory guidance is necessary to complement such policies. Non-intimate physical contact, masturbation, sexual relationships, contraception, sterilisation and vasectomy, pregnancy, termination of pregnancy, sexual dysfunction, parenthood, marriage and civil partnership, divorce, prostitution, pornography, and sex aids and toys are all matters that may properly be part of care planning.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

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

Background

Forensic psychiatric services provide care for those with mental disorders and offending behaviour. Concerns have been expressed that patients may stay for too long in too high levels of security. The economic burden of these services is high, and they are highly restrictive for patients. There is no agreed standard for ‘long stay’; we defined a length of stay exceeding 5 years in medium secure care, 10 years in high secure care or 15 years in a combination of both settings as long stay.

Objectives

To (1) estimate the number of long-stay patients in secure settings; (2) describe patients’ characteristics, needs and care pathways and the reasons for their prolonged stay; (3) identify patients’ perceptions of their treatment and quality of life; and (4) explore stakeholders’ views on long stay.

Design

A mixed-methods approach, including a cross-sectional survey (on 1 April 2013) of all patients in participating units to identify long-stay patients [work package (WP) 1], file reviews and consultant questionnaires for long-stay patients (WP2), interviews with patients (WP3) and focus groups with other stakeholders (WP4).

Setting

All three high secure hospitals and 23 medium secure units (16 NHS and 9 independent providers) in England.

Participants

Information was gathered on all patients in participating units (WP1), from which 401 long-stay patients were identified (WP2), 40 patients (WP3), 17 international and 31 UK experts were interviewed and three focus groups were held (WP4).

Results

Approximately 23.5% of high secure patients and 18% of medium secure patients were long-stay patients. We estimated that there are currently about 730 forensic long-stay patients in England. The source of a patient’s admission and the current section of the Mental Health Act [Great Britain.Mental Health Act 1983 (as Amended by the Mental Health Act 2007). London: The Stationery Office; 2007] under which they were admitted predicted long-stay status. Long-stay patients had complex pathways, moving ‘around’ between settings rather than moving forward. They were most likely to be detained under a hospital order with restrictions (section 37/41) and to have disturbed backgrounds with previous psychiatric admissions, self-harm and significant offending histories. The most common diagnosis was schizophrenia, but 47% had been diagnosed with personality disorder. Only 50% had current formal psychological therapies. The rates of violent incidents within institutions and seclusion were high, and a large proportion had unsuccessful referrals to less secure settings. Most patients had some contact with their families. We identified five classes of patients within the long-stay sample with different characteristics. Patients differed in their attribution of reasons for long stay (internal/external), outlook (positive/negative), approach (active/passive) and readiness for change. Other countries have successfully developed specific long-stay services; however, UK experts were reluctant to accept the reality of long stay and that the medical model of ‘cure’ does not work with this group.

Limitations

We did not conduct file reviews on non-long-stay patients; therefore, we cannot say which factors differentiate between long-stay patients and non-long-stay patients.

Conclusions

The number of long-stay patients in England is high, resulting in high resource use. Significant barriers were identified in developing designated long-stay services. Without a national strategy, these issues are likely to remain.

Future work

To compare long-stay patients and non-long-stay patients. To evaluate new service models specifically designed for long-stay patients.

Study registration

The National Institute for Health Research (NIHR) Clinical Research Network Portfolio 129376.

Funding

The NIHR Health Services and Delivery Research programme.