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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Rape happens to men too

  If you’ve used the London underground in recent works you probably can’t help but have noticed the posters for charity Survivors UK. Under a dark, stormy sky, it features a rugby ball, punctured with a nail. The stark slogan above reads ‘Real Men Get Raped’. 

The advert has an underniable shock-factor. Maybe that’s just because it has the word ‘rape’, displayed so boldly and publically. We’re British, we barely even like talking about sex, especially not anything relating to anal sex, and definitely not sexual assault. What if a sweet, middle-class child saw this, tugged his father’s coat and said ‘Daddy, what’s rape?‘. Now, that would be an uncomfortable conversation! But maybe it needs to be had.

Rape is horribly common. Amongst the people you work with, it’s likely that a couple of them have been victims of some kind of sexual assualt. Amongst your friends and family, it’s likely that a couple of them have also been victims. Statistics hide the large number of people who never come forward about what they have experienced, secrets that go undetected and unchallenged. And rape doesn’t just happen to young women. Perpetrators of sexual violence and abuse can be both men and women. Rape happens to women of all ages. It happens to people of all sexualities and appearances. It happens to children. And yes, it does happen to men. Survivors UK quote the statistic that every hour, a man is sexually assaulted in London. And there will be countless other crimes in other cities, and indeed all over the world.

We don’t usually get too worried about men being sexually assaulted. Men typically don’t wear short skirts, low-cut tops or engage in the other ‘provocative’ behaviour that has too-often been blamed for women’s assaults. We worry about women walking home on their own, about their getting their drinks spiked or picked up by unlicensed taxis. What about men? Are they somehow safe, immune? This article, though focused on sexual violence against men as a weapon of war abroad rather than in the UK, highlights some of the horrific realities of male rape. It’s quite graphic and intense, but worth reading. This is another very powerful article  about a police officer’s experience of being raped and the following investigations. It does happen, far more often than we might like to think.

The Survivors UK campaign has attracted some flack for their use of the phrase ‘real men’ as critics says this perpetuates the idea that there is such a thing as a ‘real’ man, or that a certain type of man may be more ‘real’ and ‘manly’ than another. This is unfortunate, but I don’t think it detracts from the impact of the posters. Their aim has been to try and dispel myths that male rape happens to only a certain subset of men, perhaps those who are gay or men who are physically weaker or more effeminate. The reality is that rape can happen to any man, regardless of whether he fits a stereotype of ‘manliness’ or not. Rape happens to ‘macho’, muscular, heterosexual, beer-drinking, sport-playing, hunting, fishing, all-round red-blooded men, as well as any other variety. On the use of the image, Michael May of Survivors UK said: “We’ve chosen to use an alpha male sport in our advertising to challenge assumptions about the type of men who get raped. It’s just as likely to be a rugby player as a librarian, a suited city banker as a hooded gang member. And we hope that by challenging our innate assumptions about the identity of male victims, we can make it even fractionally easier for a male rape victim to ask for help.” This rugby-themed poster deliberately coincides with the Six Nations, so it’s aimed at these men in particular. Maybe it’ll start a conversation. Maybe people will look at it and then awkwardly look away. If all the poster does is make someone think, perhaps for the first time ‘Rape actually happens to men’, the it’ll be a success. There is a great stigma and culture of shame around rape and this can make it even harder for men to come forward to receive support and justice they deserve. Survivors UK quote that only 11% of men ever report the crime they’ve experienced. This is disturbingly low. Would you ever know if a man in your life had been raped? Would anyone? Let’s start a conversation.

More information and support at Survivors UK

Eating Disorder Awareness Week – Can you spot a sufferer?

Yesterday began the UK’s Eating Disorder Awarreness Week, flagged up by charity B-eat. the year is littered with various ‘awareness’ and appreciation days, weeks and months, making them all too easy to meet. Why should we pay attention to this one? Do eating disorders really need more awareness? Arguably they’re one of the most sensationalised mental health problems, providing women’s weeklies and gossip rags an endless supply of material, along with photographs of emaciated beings. There’s an argument that this publicity does more harm than good, teaching young people that throwing up and skipping meals is a viable way of losing weight. When you think of eating disorders, what kind of image comes to mind? Nicole Richie? Mary-Kate Olsen? Red-carpet shots of protruding ribs or an image of a supermodel nibbling on a lettuce leaf?

For the majority, this is not the true face of eating disorders, and this is what needs greater awareness. An eating disorder may exist in a stereotypical teenage girl who aspires to look like a model and goes on a starvation diet, but they could also be a middle-aged single mother, binging after her children are asleep and then overdosing on diet drugs and laxatives. Body-image campaigners Body Gossip have spoken about this far better than I could, so I’ll leave you with a few links to some fantatastic websites and a few stats.

  • The stereotype of eating disorders is a teenager/young woman, white, heterosexual, middle-class, wanting to lose weight. But eating disorders occur in men and women of all ages and backgrounds. Suffers may have no obvious outward signs of their disorder and may be very successful in other areas of their lives, so the problem goes unnoticed. Not all sufferers want to lose weight, be thinner or be more attractive, the disorder can begin for many different reasons. Some sufferers may actively want to make themselves less attractive. 
  • The majority of individuals with eating disorders will be of ‘normal’ weight, or overweight. Many cases of obesity are due to a binge-eating disorder. Services for individuals who are not at a ‘dangerous’ weight can be very limited, adding to the stigma that one must be underweight to have an eating disorder and be ‘worthy’ of help. Ilona Burton’s fantastic article ‘But you don’t LOOK anorexic’ is well-worth reading.
  • Anorexia is probably the best-known eating disorder, but only accounts for about 10% of cases. 40% have bulimia and the remaining 50% are often categorised as ‘Eating disorder not-otherwise specified’. These are disorders that do not meet the AN or BN criteria and may include: all symptoms of anorexia but being a ‘normal’ weight, binging and purging less often, abuse of diet-drugs, eating non-food items, purging without binging, binging without compensatory behaviour, eating a very selective diet such as avoidance or fear of a particular food/group, difficulties relating to swallowing.
  • All eating disorders, regardless of the individual’s weight, are dangerous. Binging, purging, over-exercising, use of laxatives and diet-drugs can have very serious physical effects including electrolyte imbalance, risk of diabetes, fainting, osteoporosis, obesity, tooth damage amongst others. Sufferers of eating disorders are also at high risk of suicide, self-harm and problematic drug and alcohol use.
  • Eating disorders have been seen in children of 6 and adults above pension age. Often these conditions are misdiagnosed or not picked up. Although age of onset is often between 15 and 30, many sufferers may take the disorder with them through their lives.
  • An estimated 10-15% of eating disorder suffers are male, though the real figure may be greater as many do not come forward for treatment due to the stigma attached. Check out the wonderful MGET for more details.
  • There is often overlap with Body Dysmorphic Disorder, where individuals have a distorted view of their body and may go to frantic and obsessive lengths to change or conceal it. Recently more attention is being given to Muscle Dysmorphia, a condition where individuals believe they are weak and ‘puny’ and may abuse steroids and over-exercise in attempts to build up muscle. This condition is seen more frequently in men than women.
  • Eating disorders can be beaten! It often takes a lot of time, support, patience and determination from both the sufferer and the people around them. There will be set-backs and relapses, but recovery is very much possible and worth it.

More facts and figures at B-eat. 

So there’s my bit! Don’t forget, the Re-Capture exhibition (which features one of my photos) launched today in Edinburgh and will be on at Scottish Parliament on the 27th February – 2nd March, in the Garden Lobby. More on the project here. You can also see my article on body image distortions and obsessions in our culture here.