Unmentionables: Talking about sex in the healthcare setting

'The Sessions', in which a disabled man sees a sex worker, draws attention to the desire for individuals with disabilities to enjoy a sex-life

‘The Sessions’, in which a disabled man sees a sex worker, draws attention to the desire for individuals with disabilities to enjoy a sex-life just as much as the able-bodied.

Doctors, psychologists and other healthcare professionals, both in mental and physical health, are used to talking about difficult subjects. Bowel movements, terminal diagnoses, suicide and self-harm, tricky topics are a standard part of the job. Yet somehow when it comes to sex, many struggle to find the words or avoid the topic all together.

Sex, whether defined by sexual acts, more generally as intimacy or in many other ways, is an important human need. It contributes highly to individuals’ quality of life. On Maslow’s famous Hierarchy of Needs it comes only after physiological and safety needs in terms of importance. I think I can go as far as to say that changes or difficulties relating to sex are common to the majority both physical and mental health problems, whether they relate directly to the symptoms (e.g. impact of pain and limb weakness on sex positions, hypersexuality in mania) or are secondary to medication used to treat the problem or further consequences (such as impact of taking on a sick/carer role, self-consciousness relating to skin conditions). Anti-depressants are very widely prescribed, yet often information on the (common) sexual side-effects is left to be read in the small print. I’m reminded of a quote from Ben Goldacre on SSRIs,

“ I’m trying to phrase this as neutrally as possible, I really enjoy the sensation of orgasm. It’s important to me, and everything I experience in the world tells me that this sensation is important to other people too. Wars have been fought, essentially, for the sensation of orgasm.”

Stroke for example, is a condition where sexual dysfunction has been well documented. Yet in research speaking to rehab staff, they rarely brought the topic up with clients and on the occasion when it was brought up, staff often felt embarrassed and uninformed (McLaughlin & Cregan, 2005). Reasons given for staff not approaching the topic also included fear of upsetting clients and there has been other research suggesting that (often unconscious) stereotypes relating to sex, relationships, illness and disability, play a role in this silence. Although sex problems have been particularly highlighted in stroke, there is evidence that these staff attitudes and difficulties exist in a variety of settings and in relation to many other conditions. Whilst working in a clinic for Chronic Fatigue, I approached staff about the possibility of including sex and relationships as a topic to include in a psycho-education group, and was met with quite a dismissive response. It was too sensitive, and time was needed for other important areas. However, a friend with the condition informed me that on a service-user forum, the sections relating to questions and advice about sex were by far the most used. Service-users often have to go and seek out their own information because professionals fail to provide it.

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Knowing you, perhaps

Rules of Attraction: “What does that mean know me, know me, nobody ever knows anybody else, ever! You will never know me. ”

Rules of Attraction – “What does that mean know me, know me, nobody ever knows anybody else, ever! You will never know me. ”

The woman in front of me frowns, frustrated. “It makes me really angry, I feel like they’re not listening to me, they just don’t understand how things are for me.” We talk about the different ways she can make herself heard, express her perspective in a way that others could be receptive to. Finding a common language to share her experience, that others can translate.

But I wonder if what we’re chasing after is actually something of a myth. This idea that if we found the right words, the right time, and said it in just the other way, others would get it. They’d be able to step into our shoes, inside our skin and really see the world as we see it. The truth is that another person can’t ever truly know what it is to be you. We don’t even know if we’re all staring at the same colour ‘blue’. The same words spoken will be heard and interpreted very different by different people, depending on their own experience and stored knowledge, or how they happen to be feeling at that moment. No matter how clearly you put it, you can’t be sure of what others will take away. And someone can spend a lot of time with you, learn all your history, your interests, your little quirks and mannerisms. And then they will know an awful lot about you, but they won’t know what it’s really like, your own private, subjective experience, what it is to be you.

Like Nagel says, despite everything we know about mammal anatomy, physiology and infra-red, we don’t really know what it’s like to be a bat.

But we want to be understood. We want to be known. The imagined intimacy that comes from someone really knowing you so entirely. Total understanding. But there will always be a limit to this (or at least until we find a way of plugging in to each other’s brains). How can we tolerate this? That total understanding is a fantasy and reality others will always get it just that bit wrong? That no matter how well you know someone, there will always be a mystery there that can’t be solved.

Exploring Non-Monogamy – Many & More

Big Love’s Polygamist Mormon family

A few years ago I made a friend who told me his was polyamorous and I genuinely had no idea what he meant. I’d come across the idea of polygamy (more than one wife, generally not viewed very favourably in western society) but really as far as I knew it, a relationship was always two people, that was what was normal and that was what worked. For some people, being monogamous isn’t something they’ve ever felt comfortable with and they see this as part of their identity, a form of sexuality. For others, it may be a lifestyle that they choose to be a part of. The rather amazing and comprehensive map below shows some of the various forms non-monogamy (by Franklin Veaux, click to expand).

One of my friends is a poly activist and through a lot of in-depth conversations with him and my own experiences and explorations, I’ve come to a place of questioning how we arrive at ideas of what a relationship ‘should’ be. Some of the ideas he and others have espoused to me have definitely challenged some of my previously held views. In the same way that we might be brought up to think that a relationship should be between a man and a woman, of similar age (perhaps the man can be a little older, but not too much), race and background, but may later go on to reject or adjust these views to include more diversity of experience. Similarly, I wonder if notions of monogamy just something I’ve swallowed from my upbringing and taken on, without ever really considering? (note – I’m not expert on this topic, these are merely my own thoughts and reflections and no doubt they don’t reflect all of the complexity of different forms of non-monogamous relationships)

Love doesn’t run out – This was one of the main ideas I’ve heard people using, and it rings very true for me. Is love a finite resource? And if I love one person, does that mean I don’t have any left for others? Indeed, I have a lot of friends and family members that I love. The presence of others doesn’t seem to impact on how much I care about these individuals or the quality of our relationship (provided others don’t actively interfere). So I do believe it’s possible to love more than one person, and that I’ve often seen that in romantic/sexual love as well as the more platonic  So it seems very possible that you can fall in love with more than one person at the same time, so what happens then? I guess traditionally (and as is often part of the plot of the cheesier of soap operas), you have to (often painfully) pick. But what if you didn’t have to? It feels quite a strange notion to consider that you could love two people (or even more) without it being a conflict, which to me feels quite freeing.

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New guidelines for working therapeutically with Sexual & Gender Minority Clients

It’s already shaping up to be a good year for gender and sexual diversity in mental health. Last month the BPS (British Psychological Society, the organisation that oversees all practising psychologists in the UK) released the document ‘Guidelines and Literature Review for Psychologists Working Therapeutically with Sexual and Gender Minority Clients‘, which can be viewed for free online here. Although aimed particularly at those delivering therapy in sexuality/gender-focused settings, this advice has relevance for health professionals working in all areas. The report states its aims: ‘These guidelines have been developed in recognition of the importance of guiding and supporting applied psychologists around their work with sexual and gender minority clients in order to enable their inclusion in clinical practice at a high standard. They also aspire to engender better understanding of clients who may have suffered social exclusion and stigmatisation in order to reduce the possibility of this in the clinical arena.’ Attention is given to the harm caused in the past by perspectives in mental health about sexuality, which began to be put right the the removal of the diagnosis of homosexuality from the DSM in 1973. However, there is still a long way to go before services truly are inclusive and sensitive to the needs their clients, regardless of their sexual or gender identity. High levels of mental health problems have been reported in this client group, but they often experience difficulty accessing services, and may experience discrimination (unintentional or otherwise) from uninformed professionals.

It’s a large document that I’m still in the process of digesting, but so far I’ve been struck by how inclusive and wide-ranging it is. The report discusses ‘less-visible’ sexualities and identities, such as the spectrum that gender identities can take, forms of bisexuality and more fluid identities. Controversial and often-overlooked topics such as non-monogamous relationships/orientation, BDSM and sex-work are also tackled. It is worded sensitively, with effort to use quotes from service-users and use current phrases and slang, to bring professionals closer to the world inhabited by the clients they may meet.  The report encourages professionals to consider their own understandings of gender and sexuality, the context we live in and how this has shaped our own and others’ perceptions of.There is also a focus on doing away with myths that perpetuate throughout the system about certain identities, and a strong opposition to attempts to ‘cure’ a sexual or gender identity. It seems to be a really positive and well-researched report that would be beneficial to individuals working in a wide range of sectors, to inform and advise on a range of issues with working with this client group. If you’ve seen the document, what were your thoughts?