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International Journal of Mental Health Nursing (2015) 24, 121–129

doi: 10.1111/inm.12112

Feature Article

Consumer sexual relationships in a Forensic mental health hospital: Perceptions of nurses and consumers Chris Quinn1 and Brenda Happell2 1

Victorian Institute for Forensic Mental Health and 2Research Centre for Nursing and Midwifery Practice, University of Canberra, Faculty of Health and ACT Health, Woden, Australian Capital Territory, Australia

ABSTRACT: The management of consumer-related risk is paramount in a secure forensic mental health facility. However, the consequent risk aversion presents a major barrier to consumers forming sexual relationships in a manner that is open and accepted. Investigation of the views of nurses working in forensic mental health settings on this topic is limited, and even more so for consumers of services. This qualitative exploratory study was undertaken to elicit the views of consumers and nurses about forming sexual relationships within this long-term and secure setting. Individual in-depth interviews were conducted with 12 nurses and 10 consumers. The benefits of, and barriers to, sexual relationships was identified as a major theme, and these findings are the focus of this paper. Nurse responses included the subthemes ‘supportive factors’ and ‘potential dangers’, reflecting their qualified support. Consumer responses included the subthemes ‘therapeutic’, ‘feeling normal’, ‘restrictions and barriers’, and ‘lack of support and secrecy’. The importance of sexual relationships was clearly articulated, as was the difficulties in forming and maintaining them within the forensic setting. More open discussion about this commonly-avoided issue and the education of nurses and other health professionals is required. KEY WORDS: consumer, forensic, mental health, nurse, sexual issue.

INTRODUCTION Sexual relationships between consumers in inpatient settings are frequently viewed as a risk requiring management (Pacitti & Thornicroft 2009), without considering the importance they hold for the consumer. Providing a safe environment for consumers is essential; however, policy and practices can result in barriers to the formation of sexual relationships (Dobal & Torkelson 2004; Ruane & Hayter 2008).

Correspondence: Brenda Happell, Research Centre for Nursing and Midwifery Practice, University of Canberra, Faculty of Health, and ACT Health, Woden, ACT 2606, Australia. Email: Brenda.Happell@ canberra.edu.au Chris Quinn, RN, DAS (Nurs), Cert PN, Grad Dip (MHN), PhD. Brenda Happell, RN, RPN, BA (Hons), Dip Ed, BEd, MEd, PhD. Accepted July 2014.

© 2014 Australian College of Mental Health Nurses Inc.

Resistance to consumers forming these relationships are generally explained through concerns of possible adverse outcomes, such as sexually transmissible infections (STI), unplanned pregnancies, sexual coercion, and protection of vulnerable people (Dyer & McGuinness 2008; Hales et al. 2006). This is of particular concern for those deemed unable to provide consent (Dickerson et al. 2004; Dixon-Mueller et al. 2009). Forensic hospitals typically provide mental health care and treatment in a secure environment for persons who have involvement with the criminal justice system. Frequently-offending behaviours involve violence, and they are considered a threat to public safety (Carroll et al. 2004). Therefore, their treatment and care needs to be accommodated outside the scope of the mainstream mental health services (Timmons 2010). Admission lengths are also significantly longer, typically between 5

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and 7 years (Davison 2004; Dickens et al. 2011; Ong et al. 2009). However, most consumers in a forensic hospital will eventually be discharged to the community (Ong et al. 2009). The ability to engage in relationships is important preparation for their future life (Bartlett et al. 2010). The incidence of sexual assault is reportedly higher for consumers (Goodman et al. 2001) than in the general population (Elliott et al. 2004). Of further concern are the reports to sexual assaults occurring during times of admission (Frueh et al. 2005). Sexual relationships might, therefore, be considered a greater concern in forensic hospitals, where consumers pose unique risks and sexual safety concerns associated with their offending behaviours (Mercer 2013). Limited evidence from these environments suggests a lack of support from nurses for consumers forming sexual relationships (Bartlett et al. 2010; Tennille & Wright 2013). The influence of the beliefs and attitudes of nurses that define specific sexual behaviours as normal or not normal (DeLamater & Friedrich 2002; Earle 2001) can result in the regulation of sexual behaviour in hospitals (Earle 2001), illustrated as a barrier for the development of future relationships (McCann 2010). The notion that consumers might want to form sexual relationships has often been met with disapproval (Earle 2001), resulting in the stigmatizing of these behaviours (Berer 2004), and in avoidance of including sexuality as a component of care by mental health nurses (Quinn et al. 2011). A further barrier to the formation of a sexual relationship could be attributed to the consumer’s experience of stigma. Link and Phelan (2001) report that stigma can result in status loss. Nevertheless, consumers perceive themselves as sexual beings, despite their diagnosis (Volman & Landeen 2007), and view sexual relationships in a positive manner, valuing the importance of having someone close, who cares for and understands them (Hales et al. 2006; Kidd et al. 2011). Dein and Williams (2008) argue that these relationships might well provide consumers with a sense of hope. Thus, support in developing and maintaining relationships (Eklund & Östman 2010), improving their quality of life, and preparing them to better manage sexual and relationship needs when discharged back to the community have been advocated (Dein & Williams 2008). Furthermore, consumers want nurses to work alongside them to help them understand life situations and challenge them to examine current behaviours and move forward with their life (Gildberg et al. 2010; Schafer & Peternelj-Taylor 2003). Despite the importance of sexuality as a component of holistic health care, limited research is available describing attitudes of consumers and nurses from forensic set-

C. QUINN AND B. HAPPELL

tings about consumers’ involvement in sexual relationships. The aim of the current project is to explore the benefits and barriers from the perspective of consumers and nurses from a forensic hospital.

METHODS Design The research utilized an exploratory qualitative approach (Stebbins 2001), providing an opportunity for participants to describe in detail their experiences beliefs and opinions regarding the topic of investigation (Polit & Beck 2010; Stebbins 2001). This approach is particularly useful in exploring topics where little research has previously been undertaken.

Setting The setting is a 116-bed secure forensic hospital servicing the state of Victoria, Australia. The hospital provides both acute and continuing care wards. All participants were nurses working in, or consumers admitted to, the continuing care wards. The policy about sexual relations in these wards is to actively discourage them and inform consumers that this behaviour is not permitted in the setting.

Participants and recruitment Two participant groups were recruited for this research. These were registered nurses working in continuing care wards of the hospital, and consumers currently receiving care and treatment in these wards. Sample size was determined by theoretical saturation; that is, data collection ceased when no new themes were emerging from data collection (Polit & Beck 2010). A separate recruitment process was employed for the two groups. An email was sent to all registered nurses, seeking their interest and inviting participation. Potential participants were provided with a verbal and written explanation of the research. Twelve responded and agreed to participate in the study, all having a post-basic qualification in mental health nursing. Demographic details are provided in Table 1. Nurse unit managers and consultant psychiatrists were asked to provide names of consumers they felt would be able to consent and would not be adversely affected by participation. A list of potential consumer participants was then forwarded to the principal researcher, who approached each consumer to describe the intended research and to invite them to participate. From a list of 18, 10 agreed to participate. Nurse unit managers and consultant psychiatrists were not told of which consumers chose to participate. Consumer participants were forensic © 2014 Australian College of Mental Health Nurses Inc.

CONSUMER SEXUAL RELATIONSHIPS IN FORENSICS TABLE 1:

Nurse alias Alice Ben Craig Danni Eli Fiona Greg Hannah Irene Jo Ken Larry

TABLE 2:

Demographic characteristics of participants (nurses) Age (years) 59 42 36 51 26 45 45 52 52 35 60 53

Sex

Mental health nurse (years)

Forensic mental health nursing (years)

Current employment (years)

Female Male Male Female Female Female Male Female Female Female Male Male

25 13 9 31 4 13 20 28 32 12 43 22

7 8 8 14 4 1 13 13 11 12 8 14

7 2 8 14 4 1 13 13 11 12 8 14

Demographic characteristics of participants (patients)

Consumer alias

Age (years)

Sex

Current employment (years)

29 26 34 47 25 29 32 48 47 33

Female Female Male Female Male Male Male Male Male Female

8 3 10 5 5 3 10 15 25 8

Andrea Bel Chad Di Ethan Fred Gaz Harry Ian Jane

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patients admitted on custodial supervision orders. The term ‘forensic patient’ is used when a person is found not guilty due to mental impairment at the time of their offence. Demographic details are provided in Table 2.

Data collection Data were collected using individual in-depth interviews to provide participants the opportunity to share their views and opinions (Polit & Beck 2010). An interview guide was prepared for each participant group to provide some guidance; however, participants were free to raise other issues relevant to the topic of interest. The interview guides explored personal views towards consumer sexual relationships, benefits and barriers, safety concerns, and how the other participant group or family and carers might view these relationships.

Ethical issues Ethics approval was granted by the Department of Health and Department of Human Services Human © 2014 Australian College of Mental Health Nurses Inc.

Ethics Committee (EC00215). Prior to providing written consent, participants were given full disclosure of the topic and sensitive nature of the research. This discussion provided both researcher and participants an opportunity to gauge the participant’s level of comfort to continue participation. Potential for harm was also reduced by discussing potential participants with the consultant psychiatrist regarding the consumer’s capacity for informed consent. To assist in maintaining confidentiality, pseudonyms replaced participant names, and identifying information has been removed from reported material. The participants were advised of the voluntary nature of participation and their right to withdraw consent at any time, without implications for the ongoing care and treatment for consumers, or employment conditions for nurses (Polit & Beck 2010).

Data analysis Braun and Clarke’s (2006) process for thematic analysis was utilized. The first step involved becoming familiar with the data. The researcher transcribed all interviews, and read and reread the transcripts to become immersed. The next step was to generate initial codes. This is the start of a formal approach to coding, where initial interest areas in the data appear, or repeated patterns become evident. The next stage involved sorting data under initial codes and drawing them together under potential themes. These were revised and arranged in a conceptual map to formulate an understanding of how the themes fit together. Finally, themes were named and described. This process was undertaken independently by two researchers, who subsequently met to discuss the themes and reach consensus.

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FINDINGS Nurses Nurse participants discussed the need for consumers to form relationships with others, acknowledging that consumers, like all people, are sexual beings who need to have someone to love.

C. QUINN AND B. HAPPELL not happening. It’s your illness’. They do support each other. . . . They want to get married. They’re trying to help each other along to facilitate that. (Hannah)

Potential dangers

However, nurse participants were highly aware of the potential risks, such as predatory sexual behaviours by some consumers:

Supportive aspects

Most participants recognized consumers as sexual beings, despite their current circumstances: They are sexual beings and . . . they remain sexual beings, whether they are here for a week, 10 weeks, a year, or 10 years. If anything, I would imagine it to become more depressing over time . . . and more frustrating watching the years go by and not having any outlet. . . . I just can’t imagine that. (Fiona)

Nurse participants discussed benefits to consumer’s selfesteem, and learning about forming relationships through intimate connection with another person, mutual support from the relationship, and as a quality-of-life issue: They may have been in here for a long time, and that may make them feel normal again being in a relationship. . . . I would like to think that if it improved their quality of life and made life just that little bit more tolerable. (Eli)

Nurse participants identified therapeutic benefits by engaging with the couple in a psychodynamic way to improve their mental health outcomes. The long-term environment provides time; consumers do not need to rush decisions and can have support to help them make decisions that are in their best interest within a safe, protective environment: While a relationship in an institution might cause problems, it might also be very beneficial . . . in the community they would be having the relationship, but it might be complicated by taking drugs. . . . So the fact here is that they have to go slow . . . so we are trying to support them in here and organize leaves together, so we are trying to watch the whole thing develop, support and nurture their relationship. (Alice)

One nurse provided examples of the strong level of support provided by consumers within the context of a current-couple relationship: They’re supporting each other. She has encouraged him about going back on Clozapine, they’re attending groups together, she’s encouraging him to be more social and talks to him about his paranoid thoughts and clarifies things for him if he’s not thinking clearly. I’ve heard her say: ‘What are you on about? Don’t be ridiculous, that’s

I think. . . . there might be some danger of abuse of it or pressure in making a decision about being in a relationship or pressured to consent to sex or activity when they are not ready. I can think of some patients who might target particular vulnerable women or put the hard word on, to get involved in some type of sexual activity that they aren’t consenting to. (Ken)

Concern was expressed about the consequences when relationships break down. Consumers will continue to have contact while they remain inpatients: Most of us, if we had a relationship breakdown, then we would just distance our self from the other. Where they are not in a position to do this, as they are stuck here in this environment . . . it could cause problems for them, when they walk past that same person in the hospital, or at the kiosk, or if they see that person every day in a group. (Ben)

Risks, such as the effect a breakup could have on the consumer’s mental state, particularly due to their forensic history, led to concerns about the possibility of violence: I’d just be concerned for the couple, if something was to happen if they were to have some kind of a disagreement . . . if one of them . . . had a history of assault and takes it out on their partner . . . relationships go through their ups and downs and that is normal, so why wouldn’t this happen here? . . . Putting everybody at risk and taking advantage of other people is what I am really concerned about. (Eli)

Acknowledging possible risks, nurses feel that they have a strong responsibility to monitor these relationships and of their responsibility to intervene and stop the relationship from continuing to protect the positive rehabilitation/ recovery progress of the consumer: For me, a concern is that we are working in a recoverymodel setting where everything is focused on a progression through the rehab process, so how much do we see a relationship retarding a person’s progression? Relationships aren’t always a positive thing . . . this is a realistic concern. If it is a problem, when do we step in to help out? (Greg) © 2014 Australian College of Mental Health Nurses Inc.

CONSUMER SEXUAL RELATIONSHIPS IN FORENSICS

Consumers Consumer participants expressed their view that where consumers are stable in their mental health and able to consent, being involved in a sexual relationship is a positive and healthy experience. Therapeutic

Consumer participants also shared the view that a close, intimate relationship and the feeling of being loved are therapeutic and an aspect of their lives that supports their personal recovery: I reckon it’d be very therapeutic. The sense of feeling loved by another person can help you progress quicker, and supporting each other through stuff that nurses can’t help you with. It helps you with certain emotions, like if you are a male and you’re a bit aggressive, it can help you mellow out . . . having a relationship with a female. (Andrea)

The deep connection of being with someone, and the supportive part of a relationship, was acknowledged by consumers: It’s one thing going out with someone, and another to go out and have sex with them. It’s completely different. It’s more intimate; it’s completely different to holding hands, going out for coffee and kissing and that. Having sex with someone, you get to know them on a deeper level. (Ethan)

Feeling normal

The consumers described having a sexual relationship as normal human behaviour: The staff have got their relationships, people in the community have relationships, the security officers, the policemen, prison officers, they all have relationships. Just because we draw a pension and we’re under the Mental Health Act doesn’t mean that we don’t have needs and wants for a relationship and sex. (Ian)

Restrictions and barriers

While consumers considered having a relationship as normal behaviour, it is occurring in an unusual environment that restricts many of the normal activities that a couple might engage in: You’re very limited as to what you can do here. It’s not like you can go to the movies or go and see a band or anything like that. . . . Most people in a relationship get to have sex in the night time. This can never happen for us. We never as patients get to spend that time with each other, so if you want to have sex, it has to be during the day time and try and do it without getting caught. (Chad) © 2014 Australian College of Mental Health Nurses Inc.

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The importance of finding someone, of establishing a relationship, and falling in love, and to risk losing this relationship due to rules was viewed as being unfair: We’ve been found not guilty due to mental impairment and . . . people have lost their families . . . lost everything over it. They come in here and find a beautiful relationship and wanna keep that, and that’s going to get taken away from them as well? Like you are telling a human being not to fall in love. It’s unhumane (sic). (Andrea)

For some, the restrictions led them to ponder a relationship in the future where they would be free from the hospital rules and restrictions: I’m thinking about getting out and um having a beautiful relationship in the future and having kids. I’m a cool uncle to my sister’s kids, and I’ll be a very good dad. (Gaz)

The difficulties of finding someone, and the support consumers feel they require to make the relationship a success, was discussed: A lot of people from here find it hard to find a partner in the community when they get out, because we are so institutionalized, and you don’t want to tell them about this place because you might scare them off . . . that’s why a lot of relationships . . . eventuate in here because we are planning for . . . when we get out, but we have to do it separately . . . whereas the goal should be we have a couple here, what are the plans for the future, of course they want to live together, of course they want to do this leave together, so how do we go about this leave plan, to get this leave together happening, to go shopping together through the day, or go to their house during the day, you know. (Andrea)

Some consumers supported the need for rules or governance about sexual relationships to ensure safety: I have had sexual relationships with a patient before. I’m not sure if it was the right decision. It created a bit of confusion between us two and our relationship changed as a result. . . . If set up safely, then I think it should be allowed. My biggest concern is that people will abuse it. (Ethan)

Support and secrecy

Participants referred to the lack of support and opportunity rules preventing consumers from being in another consumer’s bedroom. They discussed the difficulties of finding hiding places for sex: People now are having relationships and they have got to hide, and that’s not very good. Perhaps there should be some rule where they could sleep together once a week or something like that in a flat or in a room, or in their room. They shouldn’t have to hide. (Di)

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Consumers discussed that they had tried to solve the problem of having to hide their sexual activity and had asked the hospital through consumer advisory groups (CAG) to assist them: About 2 years ago, I brought it up at CAG . . . that it was undignified to have to have sex behind a tree and what not . . . we should have someplace. (Consumer B)

Consumer participants were well aware of the sexual activity of others, but did not divulge this information to staff: A few patients are having sex, quite a few, and they like it and they don’t worry about getting caught, and if we see it, we don’t tell anyone. . . . We’d never go to the staff and say I just saw them having sex. We don’t ever tell them, cause it causes too many problems for them. I mean it is good for you. If you meet someone here and you like her, you should be able to have fun. (Fred)

Some consumers were concerned that time was running out to achieve the things they wanted from relationships, such as the opportunity to have a family, and beyond that time to a time where one might enjoy their grandchildren. There was a sense of frustration expressed by the consumers of having no control over how long they would be in the hospital impacting on their ability to realistically plan for the future: I want to get out of here and have a family . . . to my partner. I want to get married and have kids with my partner, and have grandkids. The clock’s ticking I’m 33. I’m not getting any younger. I feel that it’s a terrible thing that I can’t have kids, I can’t get pregnant, or have to be on certain medication. (Jane)

Consumers also described their lack of opportunity to have private time with a partner who was not also an inpatient: People coming in to see their partners and they’re not allowed to touch them, or kiss them, or anything, and that’s frustrating. . . . You can’t touch or anything, it’s terrible. It’s terrible. People need affection in their life, and everyone needs some love in their life. . . . It’s not just about me. Husbands, wives, girlfriends, boyfriends. When they visit, they should be allowed to spend some time in their partner’s room. (Jane)

The long-term secure environment was seen to have some advantages. It provided time to consider the pros and cons of their decisions regarding having a sexual relationship with another consumer: I’ve been in relationships on the outside, and there are a million and one things that can go wrong in any relation-

C. QUINN AND B. HAPPELL ship. It’s very hard to find a perfect-matched relationship anywhere. Of course, some relationships require a bit of work, getting to know each other, finding out what works for you, and in here, you have a lot more time to figure all of this out, so you don’t want to jump to the next stage, you can take your time to sus things out. (Chad)

DISCUSSION The findings from this research highlight the importance sexual relationships hold for consumers, as previously identified in the literature (Crowe 2004; Hales et al. 2006; McCann 2010). The nurse participants acknowledged consumers as sexual beings and recognized therapeutic benefits to them forming sexual relationships. Some nurse participants described the forensic setting as a safe one to develop the relationship slowly without other distractions, such as illicit substance use and the associated risks of this for consumers in community settings, including the identified high risk of infection to HIV, hepatitis B, hepatitis C, and other STI (Dyer & McGuinness 2008). However, they also identified some potential problems, such as sexual coercion or exploitation, STI, and unplanned pregnancies. These views echo the broader literature where impaired autonomy, increased impulsivity, increased susceptibility to coerced sex, poor education, and safe-sex practices have been reported (Cook 2000; Dyer & McGuinness 2008). Interestingly, the nurses did not specifically raise the issue of consent, despite this being a specific issue for people diagnosed with a mental illness (Bartlett et al. 2010; Dixon-Mueller et al. 2009). Consumers provided vivid and often emotional accounts of the importance sexual relationships held for them. They described relationships as positive and healthy experiences that enhanced their sense of normality. Furthermore, they identified these relationships as essential for their personal recovery. Pacitti and Thornicroft (2009) observed that, despite the abundance of literature discussing recovery, little attention has been provided to the importance of sexual relationships, where consumers have opportunity to make decisions and choices about their sexual relationships (Tennille & Wright 2013). Consumer participants described the many constraints that impacted their ability to form and maintain sexual relationships. Lack of privacy and the difficulties engaging in normal couple activities were highlighted. It is evident from these responses that the relationships consumers value and seek go beyond the need for sex, and include other forms of closeness and intimacy. The caring, supportive, and companionship aspects of a relationship © 2014 Australian College of Mental Health Nurses Inc.

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(Hales et al. 2006), and that relationships are considered more meaningful when about more than sex (Volman & Landeen 2007), have been reported as having great importance for consumers. While parallels in the attitudes of nurses and consumers might have been apparent, the nurses did not describe how they offered advice, practical assistance, or support for consumers regarding sexual relationships. Avoidance of addressing sexual issues has been identified in the literature as characteristic of nurses working in mental health settings (Higgins et al. 2008; Magnan et al. 2005; Quinn et al. 2011). In the current study, however, it is particularly interesting that nurses recognized the importance of sexual relationships, particularly in the long-term forensic environment, yet they still appeared not to incorporate this as part of practice. Avoiding these discussions and not supporting consumers with issues of sexual relationships is concerning, particularly as some consumers will spend much of their adult life incarcerated in forensic settings (Dein & Williams 2008). Not only is this a denial of human rights (Dixon-Mueller et al. 2009; Perlin 2008), it has implications for care and treatment. Research suggests that when consumers are involved in relationships, they show a greater interest in other meaningful activities (Eklund & Östman 2010), and as such, providing relationship support should be an important clinical consideration. Reasons behind the apparent inaction of the nurse participants did not appear to reflect discriminatory, stereotyped beliefs. It might be an outcome of risk aversion, characteristic of forensic hospital settings, where consumers tend to be viewed in terms of their level of dangerousness (Perlin 2008). These beliefs provide justification for following rules and practices that actively seek to prevent sexual relationships occurring on the basis of risk and protection of those who are vulnerable (Perlin 2008), and potentially incapable of consenting (Bartlett et al. 2010; Dixon-Mueller et al. 2009). While legal and ethical issues are important considerations, the current approach prevents holistic, individualized (Pacitti & Thornicroft 2009) support that is recovery orientated and person centred (Slade et al. 2014). Consumer participants also referred to the minimal support nurses offered concerning intimate relationships. This identified practice gap of not providing support for consumer sexual relationships could contribute to poorer mental health outcomes for consumers. It has been noted that sexual relationships can result in the promotion of other relationships, improving social integration, improving quality of life, and decreasing the risk of relapse (Perry & Wright 2006; Tennille & Wright 2013).

The lack of support identified by consumers might reflect an environment concerned largely about risks (Gildberg et al. 2012; Timmons 2010). Sexual issues are always controversial (Magnan et al. 2005), particularly within mental health services (Perry & Wright 2006; Quinn et al. 2011), and more so in forensic settings (Bartlett et al. 2010; Dein & Williams 2008; Hales et al. 2006). The risks of sexual relationships, particularly the legal and ethical complications, need to be acknowledged and addressed. When viewed from this lens, there would be less need for reliance on control (Dein & Williams 2008), and a greater appreciation of sexual relationships as a quality of life issue (Eklund & Östman 2010), where recovery-orientated care would include support for consumers with their sexual relationship decisions (Tennille & Wright 2013). Dealing with the issue of sexual relationships by adhering to rules or avoiding the issue might feel more comfortable for nurses; however, it is not an effective approach. There is clear evidence that rules do not prevent sexual activity from occurring (Higgins et al. 2008; Welch & Clements 1996). For example, in a sample of 100 consumers in an inpatient setting, it was reported that 30% of consumers were sexually active (Warner et al. 2004), despite the existence of a no-sex policy. Lack of support from nurses and institutional rules that warn of dangers and risks result in the need for consumers to protect their sexual relationships in secrecy to avoid being caught breaking the rules. Hiding sexual relationships provides consumers protection from the belief systems of clinicians who consider sexual relationships as symptoms arising from illness (Tennille & Wright 2013) that require containment and preventative measures, and as a contributing risk factor that can negatively affect consumer recovery (Perlin 2008). A further concern raised by consumers was the lack of consideration to the needs of those who had pre-existing relationships, where visits from the consumer’s partner were strictly supervised with no opportunity for private, intimate time. Dein and Williams (2008) also observed that constraints placed on current and pre-existing sexual relationships challenge the justification for these practices, given that the goal of forensic hospitals are essentially therapeutic (Dein & Williams 2008). The findings suggest further evidence that a no-sex policy does not prevent sexual relationships from developing. It would, therefore, appear timely for these relationships to be acknowledged, and consideration given to how they can be supported within the clinical environment.

© 2014 Australian College of Mental Health Nurses Inc.

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The education of nurses and other professional staff is an important first step in changing attitudes. The 5 A’s framework developed by Quinn et al. (2013), following in-depth interviews with mental health nurses about the inclusion of sexual issues in practice, would appear a useful starting point. Quinn’s research demonstrated the effectiveness of a brief educational programme, which essentially raised awareness of the importance of sexual issues in mental health, and assisted nurses in feeling comfortable to raise them.

LIMITATIONS As a qualitative, exploratory project, the capacity to determine the degree to which similar findings would be obtained from another forensic mental health service cannot be accurately determined, and so caution must be used in interpreting these results. As this research was undertaken with a limited number of participants, all employed in the one service, their opinions might be influenced by elements of the local environment. Furthermore, as participation was voluntary, those who chose to participate might have been those who held strong and possibly positive views about the importance of sexual relationships for consumers of forensic mental health services. There was involvement of the consultant psychiatrist and nurse unit manager during recruitment of consumers. As such, the views of consumers might have been limited, and particular opinions not heard.

CONCLUSIONS These findings suggest that sexual relationships are important to consumers receiving long-term mental health care, and this is also recognized by nurses. Although it appears that nurses are not actively providing support for consumers in this aspect of their care, there is sufficient common ground from which conversations about forming sexual relationships in forensic mental health services can commence. The controversy and potential risks associated with this issue are acknowledged; however, human rights and the need for therapeutic care dictate that this situation should not be ignored. It is intended that the perspectives presented in this paper would contribute to the commencement of discussion, debate, and action towards an effective resolution.

ACKNOWLEDGEMENTS The authors extend their sincere thanks to Victorian Institute for Forensic Mental Health for supporting the study,

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and to the participants for their willingness to devote their time, thoughts, and opinions to make this project possible.

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