Perception of nursing professionals on sexuality in people with mental disorders

Abstracts

OBJETIVO: Conhecer como trabalhadores de enfermagem percebem a sexualidade do portador de transtorno mental. MÉTODOS: Pesquisa qualitativa, fundamentada na teoria das Representações Sociais, realizada por meio de entrevistas com sete enfermeiras e 11 auxiliares de enfermagem, utilizando questionário semiestruturado e duas análises de situações diárias. RESULTADOS: Os depoimentos obtidos revelaram que trabalhadores de enfermagem percebiam a sexualidade enquanto orientação sexual, papel sexual ou manifestação do transtorno. Notamos a disciplina e vigilância como formas de controle de sexualidade manifestada em ambiente hospitalar. CONCLUSÃO: Verificou-se que trabalhadores de enfermagem perceberam a sexualidade do portador de transtorno mental de acordo com seus valores, tabus e preconceitos, configurando despreparo dos profissionais frente à sexualidade do sujeito a ser cuidado.

Enfermagem; Enfermagem prática; Cuidados de enfermagem; Sexualidade; Saúde mental

ORIGINAL ARTICLE

Perception of nursing professionals on sexuality in people with mental disorders

Gisela Cardoso Ziliotto; João Fernando Marcolan

Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Correspondence

ABSTRACT

OBJECTIVE: To identify how nursing professionals perceive sexuality in people with mental disorders.

METHODS: This is a quality research study based on the social representation theory. Data were collected through interviews with 7 nurses and 11 nursing assistants using a semistructured questionnaire and two analyses of daily situations.

RESULTS: Testimonials revealed that nursing professionals perceived sexuality as sexual orientation, sexual role, or a manifestation disorder. Discipline and surveillance were the techniques used to control sexual behavior in the hospital environment.

CONCLUSION: Nursing professionals perceived the sexuality of people with mental disorders according to their own values, taboos, and prejudices, which indicated unpreparedness of nursing professionals concerning the sexuality of individuals receiving care for mental illnesses.

Keywords: Nursing; Nursing, practical; Nursing care; Sexuality; Mental health

Introduction

This study approached nursing professionals' perceptions concerning sexuality in people with mental disorders. The origin of this research was based on our experience in nursing practice. Although nursing professionals have familiarity with the subject, sometimes their management is not appropriate. This fact became evident when nursing participants classified sexuality as a conduct or mental disorder, which sometimes is the object of nontherapeutic intervention.

We believe that human sexuality has not been adequately approached in nursing education. This could be seen in nursing education related only as a technical and mechanical model.⁽¹⁾ The nursing undergraduate program curriculum often includes disciplines of technical activities and care management.⁽²⁾ Specific disciplines approaching human sexuality is not common in undergraduate courses in the field. Some disciplines cover limited aspects regarding this subject; however, they do not offer enough background for nursing daily activities, and as a result, several nursing professionals graduate without knowing such information and have some prejudices. Even in nursing practice, studies, discussions, and academic reflections regarding the sociocultural aspects of human sexuality are scarce, and the only time that this topic is discussed is when it is considered a taboo.⁽³⁾

The unpreparedness of nursing professionals in dealing with human sexuality was observed. They are prepared only to act in the biological model, particularly because sexuality is approached as a social, cultural, and subjective phenomenon.

In our daily practice so far, many nursing professional feel uncomfortable discussing issues concerning this topic; they also avoid becoming involved with these aspects during care practice. Perhaps their own feelings and behaviors that involve sexuality could act as barriers to exploring any aspect related to sexuality in their patients.

This research attempted to present the view of nursing professionals concerning sexuality in people with mental disorders and also tried to create a critical and reflexive position of nursing care regarding sexual expression in such patients.

Our findings stimulated reflections about myths, taboos, and prejudices of professionals. In addition, we were able to observe the size and presence of censure in our daily practice about the topic and also promoted changes in behavior concerning sexuality in people living with mental disorders.

The goal of this study was to identify by social representation how nursing professionals perceive sexuality in people with mental disorders.

Methods

This exploratory descriptive study of a qualitative approach was based on the social representations theory. The study population was composed of nursing professionals from emergency departments, inpatient units, day clinics, psychogeriatric services, and alcohol and drug services. These nurses delivered care to individuals of both genders at the Center for Integrated Care for Mental Health, which is based in the city of São Paulo and is managed by a social health organization associated with the State Health Secretary.

Interviews were scheduled according to the nurses' availability and were conducted at participants' workplaces or in a private environment. Testimonials were recorded and were then transcribed.

To be included, nurses must be willing to participate and have at least one year of experience working in the psychiatric unit at the institution where this study was conducted.

Data were collected using interviews and a semistructured questionnaire that included individual social identification, six specific questions, and two situational analyses regarding sexuality in individuals with mental disorders, and in professionals. We designed questionnaires and situational analyses and, in addition, a pilot study with 8 nursing professionals who were not part of our sample. The study data were collected from March to June 2009.Based on the social representations theory, data were analyzed and categorized using anchoring and objectifying processes.

This study followed the national and international ethical and legal aspects of human subject research.

Results

A total of seven nurses and 11 nursing assistants were interviewed. Participants were of both genders, and all were directly involved in the care of people with mental disorders during three different shifts.

The time that the nursing professionals were working in the psychiatric unit varied from one to 16 years. Almost all participants were women, with a mean age of 27-47 years. All participants declared that they were heterosexual.

Based on analysis of testimonials, results were organized in the following categories:

Human sexuality is a preference, option, or sexual orientation

"What I understand as human sexuality is someone's sexual preference. That is, the person could be heterosexual, homosexual, or bisexual" (Nurse 1).

"I think human sexuality is the sexual option of each person. Aside from being a man or woman, everyone chooses a sexual option. Men like men, and women like women" (Nurse assistant 1).

Human sexuality is a human need

"For me, human sexuality is a human basic need and it is also a need of every animal; everybody needs it in daily life" (Nurse 5).

"Besides being normal, sexuality is a necessity that every human has, physiologically or psychologically speaking" (Nurse assistant 10).

Sexuality is perceived within the institution as a disease

"Psychiatric patients have psychopathological changes that directly affect their libido. In general, they are erotic, disinhibited, and with expanded humor; therefore, a stronger and less tolerable approach is required in order to establish limits for such dysfunctional behaviors (Nurse 1).

"Sexuality becomes more evident when the patient is in a manic state; in other words, their sexuality is more intense" (Nurse assistant 6).

Sexuality of individuals is perceived by behaviors, clothes, and physical appearance

"They become very disinhibited, and sometimes they show their private parts. In general, women start showing the breast and men the penis" (Nurse 7).

"The way that patients interact with each other. We note how they start to communicate and approach each other, even their clothing style changes" (Nurse assistant 8).

Lack of therapeutic intervention when sexuality in people with mental disorders is perceived

"There is no private or group intervention for patients with such alterations. Intervention depends on each patient or nurse who is delivering care [...]" (Nurse 7).

"There is no intervention. Sometimes when patients have greater libido, his/her physician asks to keep an eye on them to avoid them walking into others' rooms. But a formal intervention is lacking" (Nurse assistant 2).

Hospital as an inappropriate environment for sexual expression

"[...] We try to explain to patients that we understand their sexual desire, but the moment that he/she chosen is not appropriate to express the desire. It's not the right moment and not the right place, right? We respect that people can have a sexual relationship outside but not inside the hospital [...]"(Nurse 2).

"We are not discriminating against them, but their sexual option must be expressed outside the hospital. Here is the place to be treated, not to [get into] emotional involvements" (Nurse assistant 3).

Surveillance, control, and punishment

"If I were the responsible nurse, I would punish that employee who saw patients having sexual intercourse and closed the door as if that act were normal in this environment. To me, that employee should be punished and oriented on how to act in such situation" (Nurse 2).

"[...] During the night shift, a patient was caught in other room performing oral sex. The nursing team approached them, and then both patients were administratively discharged" (Nurse assistant 2).

Nursing team lacks the authority to act

"[...] I would report the case to the physician to check if medicines are influencing patient behavior" (Nurse 7).

"I would ask the responsible nurse what to do after explaining that the patient was [exhibiting] disinhibited behavior and was saying inappropriate words. Once, I approached my boss reporting such a situation, and she advised me to postpone that patient care at that moment..." (Nurse assistant 1).

Care delivery by a professional with the same gender as the patient

"I would ask a woman caregiver to approach a female patient who was erotized" (Nurse 2).

"I did not get into the room. I asked two partners working that day with me to approach the patient" (Nurse assistant 6).

Unpreparedness of professionals concerning the sexuality of people with mental disorders

"He was out of his mind and let the patient keep masturbating and called her "perverted." Anyway, he was placing his own judgments upon the patient's behavior, but it is important to remember that in psychiatry we must be impartial" (Nurse 2).

"I think [it] is not right for a professional to get sexually excited in front of a patient, because you are there to be a professional. So you are losing control of your professional side. Because if you get sexually excited after seeing a woman naked, you don't have self-control" (Nurse assistant 3).

Discussion

This study had limitations in that it was carried out at single health service with a restricted population of a few professionals whose performance depended on strict institutional rules that, in our opinion, do not represent the concepts of a current paradigm of psychiatry care on patient sexuality. On the other hand, the results were in accordance with knowledge and contribution of advanced studies on the topic, which are scarce but are relevant to psychiatric nursing.

Our findings contributed to the knowledge of social representations and a value system for nursing professionals to manage sexuality in psychiatric care. These steps are the first to adapt practices concerning beliefs and sexual values of those receiving care or those who will receive care. In addition, this study has application in psychiatry nursing because it gives room for reflections concerning myths, taboos, and prejudices that must be pedagogically transformed to promote changes and to achieve quality in the care delivered.

The category "human sexuality is a preference, option, or sexual orientation" relates to the concept that human sexuality is understood as an attraction that a person feels for someone else, which relates closely to physical attraction or a desire by someone of the same sex, the opposite sex, or both sexes. The main idea of this category is the feeling directed to the person with whom someone desires to be emotionally or sexually involved.

In the category "human sexuality is a human need," some participants stated that sexuality is a natural and basic need of all human beings (physiological and psychological). Respondents also reported that because sexuality is necessary, it is closely related to self-knowledge, personality, feelings, beliefs, and emotional relationships.

According to a previous study, it is possible that nursing professionals have a fragmented vision of human sexuality more related to a biological aspect, which is understood as a need, desire, preference, option, or sexual orientation. ⁽⁴⁾

In the institution as a whole, sexuality was perceived as a disease. Caregivers included it as part of the patients' psychopathology. Another study reported that to perceive sexual expression as part of the disease agrees with a biomedical model of health care focusing mainly on disease, clinical, and individualized care and healing. ⁽⁵⁾ Such a belief is based on a Cartesian discourse of separation and reduction of complexity phenomena contributing to reinforce sexuality as a biological phenomenon. The medical vision of disease characterization for adequate intervention remains strong and is mainly focused on the care of issues that involve human sexuality.⁽⁶⁾

In this study, nursing professionals denied sexuality in people with mental disorders. In the medical literature, this fact is justified by feelings of safety, protection, and comfort when determining sexuality as a disturbance, wrongdoing, disease, or illegitimate act.⁽⁷⁾

Hence, sexuality has been affected by invisibility and hiding. Although sexuality is presented at all times during professional practice with gestures and body movements, it is kept silent and uncovered in care practice. ⁽⁸⁾ In addition, it is treated as part of a mental disorder. Considering this judgment, individuals with mental disorders are not capable of expressing feelings or emotions from a sexual relationship as a normal activity because they are not able to regulate their emotions and passions, which are interpreted as antisocial and abnormal, therefore preventing them from being integrated into society.⁽⁹⁾

We noted that other simple and common behaviors expressing sexuality such as touching, kissing, hugging, making eye contact, or sporting a certain clothing style were considered out of context and were seen as psychopathologic in patients with mental disorders.

In the category "the sexuality of individuals is perceived by behaviors, clothes, and physical appearance," sexual expression influenced each person's behavior by creating an impression on the other person. In this way, effeminate men and masculine women in this study were thought to exhibit nonstandard behaviors in current society; therefore, they endured more prejudices because they did not fit society's standards.

These perceptions are in accordance with a study that considered sexuality as a fundamental factor creating self-identity, which enables us to identify and differentiate each person within the universe of sexual diversity.⁽¹⁰⁾

Based on the subjective view of how sexuality is perceived in daily care practice, we verified that nursing professionals' lack of knowledge of human sexuality could not promote therapeutic interventions on sexuality in people with mental disorders.

Having the biological concept of human sexuality, professors of nursing college programs exclude erotic and sensual aspects, giving room to doubts, prejudices, myths, and taboos. Such attitudes lead nursing professionals to work according to preconcepts; thus, they fail to intervene in other aspects of sexuality in the clinical environment.⁽¹¹⁾

Nursing professionals at the institution in our study did not receive systematic guidelines, education, or supervision about the topic, so intervention criteria depended on each professional's decision when facing a situation concerning sexual expression. The participants in this study identified the need to intervene when facing sexuality expression in people with mental disorders.

In the category "hospital as an inappropriate environment for sexual expression," the participants expressed great concern regarding emotional and sexual manifestations in people with mental disorders during psychiatric internships.

Some nursing professionals reported observing and controlling patient sexuality. However, the technical and legal responsibilities that society and family impose on the institution state censure for sexuality in people with mental disorders, which agrees with another study.⁽¹²⁾

Therefore, because the hospital is considered an inappropriate place for sexual expression (as stated in the previous category), such expression is considered psychopathological. This concept appears in nursing professionals' discourse, particularly because they consider a hospital as a place for protection, giving emphasis to medicines and a therapeutic environment.⁽¹³⁾

In the institution of our study, we perceived that professionals understand that sexuality must be surveilled, controlled, and punished. By fearing the sexual expression itself, the professional justifies the use of strength, control, and surveillance. Therefore, sexuality becomes an object of concern and analysis.⁽¹⁴⁾

Basically, the behavior of respondents facing the possibility of witnessing sexual expression in their patients was to observe, surveil, stop, set apart, and prevent sexual expression; and, whenever possible, punish by discharging from the psychiatric unit those who had sexual contact with other.

In the category "surveillance, control, and punishment," some respondents suggested punishment to employees who did not approach the patient or intervene when faced with sexual expression between individuals with mental disorder.

The need for chemical or mechanical restraint was mentioned as a measure to control sexual expression in patients with mental disorders. In addition, almost all of the nursing professionals did not know the strategies to approach and intervene in a sexual situation, which shows that these professionals had limited techniques. In general, professionals facing such situations asked responsible nurses and/or the medical team about management techniques. However, most of the team members, including the nurse, only followed directions and nothing more; hence the category "nursing team lacks the authority to act."

The main idea of the category "care delivery by a professional with the same gender as the patient" was that the professional delivering care is chosen according to the patient's gender. In some testimonials, this strategy was used to protect the nursing team from patients with greater libido or hallucinations; therefore, the gender of the nursing professional was seen as a possible stimulus for sexual expression. Another important concept is that the professional could be "guilty" of the patient's behavior, so care by someone with the same gender as that of the patient was standard. However, such a strategy does not apply to homosexuals; therefore, this approach could suggest prejudice because people tend to take heterosexual orientation for granted.

Although nursing professionals have permission to touch the patient's body in order to deliver health care, nurses, nurse technicians, and nurse assistants perceive themselves as asexual; therefore, they ignore their own sexuality as well as that of the patient.⁽¹⁵⁾ Interestingly, these results agree with our study because we observed that some participants perceived themselves as asexual, which is why they ignored their patients' sexuality. In addition, some professionals consider asexuality a professional behavior in the work environment.

Regarding the category "unpreparedness of professionals concerning sexuality in people with mental disorders," we believe that this lack of knowledge in dealing with patients' sexuality relates to the professionals' education. Therefore, such unpreparedness was evident during situational analyses, which reflected the participants' difficulty in coping with their daily practice when it involved sexuality in people with mental disorders.

By denying their own sexuality and desires, nurse professionals created a perception of purification and asexuality. It is important to highlight the participants' difficulty with perceiving their body as care instruments and assuming their own sexuality. Such difficulties are justified because these professionals' education program does not include human sexuality. In the curriculum, a traditional perspective is used in which assistance of health care delivery is mechanical, technical, and without judgment.

Institutions should include systematic discussions about sexuality in patients with mental disorders in permanent education programs and also at clinical and institutional supervision meetings.

Conclusion

We verified that prejudice, believes, value judgments, and stigma of nursing professionals has had a negative effect on patient care. Each participant understood and interpreted sexuality in people with mental disorders according to their cultural references and views. When facing a sexual situation regarding patients, the professional's main approach was repression.

The difficulty of professionals in dealing with sexuality in individuals with mental disorders was clear in this study. Basically, management was linked to discipline. Although sexuality was the target of surveillance, control, and punishment, these behaviors must be reversed.

Interventions such as systematic training for nursing professionals are required to reduce problems that may arise from the constant presence of sexuality in the care environment. These attitudes could transform professionals' practices, concepts, and values.

Collaborations

Ziliotto GC and Marcolan JF were responsible for the study design and draft. They also analyzed and interpreted data and were solely responsible for final approval of proofs.

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Publication Dates

• Publication in this collection
  08 Apr 2013
• Date of issue
  2013

History

• Received
  31 May 2012
• Accepted
  21 Feb 2013