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Sex Education Groups in a Psychiatric Day Hospital: Clinical Observations a

a

b

Tonje J. Persson , Kate M. Drury , Elizabeth Gluch & Gerald c

Wiviott a

Department of Psychology, Concordia University, Montreal, Quebec, Canada b

English Montreal School Board, Montreal, Quebec, Canada

c

McGill University Health Centre, Montreal, Quebec, Canada Accepted author version posted online: 23 Dec 2014.Published online: 26 Jan 2015.

Click for updates To cite this article: Tonje J. Persson, Kate M. Drury, Elizabeth Gluch & Gerald Wiviott (2014): Sex Education Groups in a Psychiatric Day Hospital: Clinical Observations, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2014.999395 To link to this article: http://dx.doi.org/10.1080/0092623X.2014.999395

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JOURNAL OF SEX & MARITAL THERAPY, 0(0), 1–9, 2015 C Taylor & Francis Group, LLC Copyright  ISSN: 0092-623X print / 1521-0715 online DOI: 10.1080/0092623X.2014.999395

Sex Education Groups in a Psychiatric Day Hospital: Clinical Observations Tonje J. Persson and Kate M. Drury Downloaded by [University of Iowa Libraries] at 11:37 20 April 2015

Department of Psychology, Concordia University, Montreal, Quebec, Canada

Elizabeth Gluch English Montreal School Board, Montreal, Quebec, Canada

Gerald Wiviott McGill University Health Centre, Montreal, Quebec, Canada

Although the prevalence of sexual dysfunction is high among individuals diagnosed with severe and chronic mental illness, the topic of sexuality is often not part of standard psychiatric assessment. Discussions about sexuality could improve patients’ quality of life. This article outlines the development and implementation of a sex education group for patients admitted to a psychiatric day hospital in Montreal, Quebec, Canada, along with clinical observations. The series was well received by patients who felt that attending the group helped normalize their sexual concerns by providing a safe place in which to learn and to talk about sexuality.

“When I talk about sex, it’s assumed I’m becoming manic.” —Psychiatric day hospital patient

The sexuality of individuals diagnosed with severe and chronic mental illness has not only been relatively neglected as a topic of research, it is also typically omitted from standard psychiatric consultation (Maurice, 2003; Maurice & Yule, 2010). Ignoring sexuality may potentially be harmful to patients’ mental health. First, inadequately evaluating a sexual dysfunction could mean that patients may be unable to fulfill their sexual needs, which could lead to frustration and further distress (Perlman et al., 2007). In addition, sexual dysfunction has been linked to medication noncompliance (Hellewell, Kalali, Langham, McKellar, & Awad, 1999; Kelly & Conley, 2004; Perkins, 2002). For example, one study found that 74% of patients reported having discontinued antipsychotics at one point in time because of sexual side effects (Hellewell et al., 1999). Psychiatric patients often have limited knowledge of sexuality; the illness may have prevented them from experiencing sexuality in an intimate relationship, absence of sexual partners may Address correspondence to Tonje J. Persson, Concordia University, Department of Psychology, 7141 Sherbrooke Street West, Room SP 244, Montreal, Quebec, Canada H4B 1R6. E-mail: tj [email protected]

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translate into a lack of basic knowledge regarding sexual physiology, and poor judgment may put them at high risk of sexually transmitted infections (Kelly & Conley, 2004; Maurice, 2003; Maurice & Yule, 2010). For example, research has documented increased prevalence of HIV infection in individuals with schizophrenia (Gray, Brewin, Noak, Wyke-Joseph, & Sonik, 2002) which may be the result of unsafe sexual practices such as lack of condom use (Cournos et al., 1994). Two studies on people with schizophrenia identified intimate relationships and sexual expression as unmet treatment needs (Bengtsson-Tops & Hansson, 1999; Burns, Fioritti, Holloway, Malm, & R¨ossler, 2001). Furthermore, although the majority of psychiatrists do not inquire about sexuality, it has been found that close to 90% of them believe that good sexual functioning is important to patients’ well-being (Nnaji & Friedman, 2008). Patients and practitioners agree sexuality is an important topic of discussion, and there has been a call for researchers and clinicians to address patients’ sexual health (Assalian, Fraser, Tempier, & Cohen, 2000; Gray et al., 2002; Kelly & Conley, 2004; Kheng Yee, Muhd Ramli, & Che Ismail, 2014; Maurice, 2003; Maurice & Yule, 2010; Raja & Azzoni, 2003). Nevertheless, the topic of sexuality is rarely on the agenda. In light of the identified need to include sexuality as part of psychiatric consultation and treatment, we developed a sex education group for patients admitted to a psychiatric day hospital in Montreal, Quebec, Canada. We subsequently review the development and implementation of this program, as well as our clinical observations regarding patient satisfaction. We also review and discuss patient feedback on the program.

PROGRAM DEVELOPMENT Although the earliest sex education program for psychiatric patients was developed more than 30 years ago (Sadow & Corman, 1983), research is lacking regarding sex education for individuals with chronic and severe mental illness. Considering that there is no empirically validated model of sex education for psychiatric patients, our program was based on broad reflections from the literature, namely that psychiatric patients often lack basic knowledge regarding sexuality and that reassurance about sexual difficulties may be beneficial to patients (Higgins, Barker, & Begley, 2006; Maurice, 2003; Maurice & Yule, 2010). There were three major concerns for the lecture series: same-gender groups versus mixed-gender groups, number of lectures and length of each lecture, and the complexity of material to be presented. We ran the sex education groups separately for men and women on the basis of input from staff in the psychiatric day hospital who were concerned that survivors of sexual abuse could feel vulnerable in a mixed-gender group. Although mixed-gender groups may provide positive gender role modeling, they may also make some patients reluctant to attend because of negative past experiences with the opposite gender (Assalian et al., 2000; Higgins et al., 2006). The number, length of, and complexity of the lecture material was based on our previous experience with groups in the psychiatric hospital. G.W., a senior psychiatrist working at the Sex and Couples Therapy Service at the McGill University Health Centre in Montreal, Quebec, Canada, has extensive experience with group therapy in the psychiatric day hospital. In order to maintain the participants’ attention, he suggested that each lecture should be no more than 30 min,

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followed by 15 min of discussion. The complexity of the material presented was similar to that offered in high school sex education programs. This decision was based on G.W.’s familiarity with day hospital patients and Maurice’s (2003) clinical observation that patients with severe mental illness are often lacking in basic knowledge regarding sexuality. From our review of the literature, we identified five major concerns relevant to psychiatric patients: (a) lack of basic sexual knowledge, (b) lack of knowledge relevant to sexual physiology, (c) lack of knowledge about intimate relationships, (d) psychiatric patients may be at risk of contracting sexually transmitted infections because of unsafe sexual practices, and (e) psychiatric patients often complain of sexual side effects from psychiatric medications. These five major concerns were addressed by five separate lectures. We ascertained patient interest for the sex education groups prior to initiating the program. A day hospital nurse gave patients a questionnaire in which they anonymously answered whether they would want to attend; a clear majority answered “yes.” A lecture was presented at the same time and place once per week for 5 weeks in a row. The series was first presented to female patients because the majority of those admitted to the psychiatric day hospital were women when the program was initiated. Attendance at the lectures was voluntary. The patient population in the day hospital changed during the lecture series, which led to varying group size numbers from week to week. On the basis of information gathered after the series was completed, the majority of patients had a primary diagnosis of mood disorder (59% major depressive disorder, 35% bipolar disorder, and 6% schizophrenia). The patients diagnosed with a mood disorder often presented with comorbid personality disorder traits, typically borderline. The groups were coordinated by two clinical psychology interns (T.J.P. and K.M.D.), who, at the time, were working at the Sex and Couples Therapy Service under the supervision of G.W. Neither T.J.P. nor K.M.D. was affiliated with the McGill University Health Centre psychiatric day hospital before leading the sex education groups. Furthermore, they had no knowledge of the patients’ psychiatric diagnoses until after the end of the program. A psychoeducator (E.G.) from the English Montreal School Board, who works daily with the patients in the psychiatric day hospital, was present at each lecture to help facilitate discussion. It was also thought that she could intervene in the case of a crisis and contribute to patients’ sense of security during group. The value of having a person who is familiar to patients during discussions related to sexuality has previously been documented by Maurice and Yule (2010), who have found that the presence of a case manager may help normalize sexual concerns, both for patients and for case managers. The Lectures 1. What Is Sexuality? This lecture included the following topics: defining sexuality, factors involved in sexuality (biological/physiological, emotional, cognitive, personal, interpersonal), examples of positive and negative sexuality (consensual/nonconsensual), social aspects of sexuality (sexuality in the media, relationship types, socially accepted versus stigmatized sexuality), sexuality and gender (gender stereotypes, cultural constructions of gender, gender differences), sexual orientation, sexual fluidity, and sexuality and aging.

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2. Sexuality and the Body This lecture included the following topics: Sexual attraction, sexual arousal, sexual desire, labeling/recognizing sexual feelings, the sexual response cycle, and masturbation.

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3. Sexuality and Psychiatric Medications This lecture included the following topics: Benefits of psychiatric medications to recovery, common sexual side effects of psychiatric medications, why psychiatric medications may have sexual side effects, what can be done to help (talk to your mental health practitioner about your concerns, talk about it in therapy (individual and our couples therapy), and how to be creative in your sexuality (for example, sexuality can be more than intercourse). 4. Sharing Sexuality With Others This lecture included the following topics: Talking about sexuality, how sexuality is often not a topic between patients and mental health practitioners, why it may be difficult to talk about sexuality with others, how to talk about sex with your mental health practitioner, how to talk about sex with your partner, defining sexual consent, dating, one-night stands, being in love, and sexuality in long-term relationships. 5. Safe Sex This lecture included the following topics: What is safe sex, what are sexually transmitted infections, symptoms of common sexually transmitted infections in men and in women (chlamydia, gonorrhea, genital herpes, hepatitis B, syphilis, HIV), human papillomavirus, safe sex practices, condom use, and getting regularly tested for sexually transmitted infections. CLINICAL OBSERVATIONS General Observations “The lectures provided a safe space to talk about sexuality.” —Patient attending the sex education groups

Most of the patients in the psychiatric day hospital attended the sex education groups. Although attendance was voluntary, all female patients (except for one) and all male patients (except for one) attended the program. For the women, group size ranged from 7 to 10, whereas for men, group size ranged from 3 to 6. On the basis of our observations from the groups, there is a definite need for sex education in the psychiatric day hospital. The fact that the majority of patients attended every group reflects their desire to learn and talk more about sexuality. During lectures, patients were willing to ask questions and were keen to share their sexual concerns. At the end of the lecture series, many patients said that the groups provided a safe place to talk about sexuality. Furthermore, several patients reported that what they learned from the lectures made them feel more comfortable with their own sexuality. Overall, the groups appeared to normalize sexuality

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and the experience thereof. One patient said, “The lectures were very useful. I feel better about myself and I am more comfortable with my sexuality. I feel like I am more normal.” Many expressed the sentiment that sexuality is not adequately addressed by their mental health practitioners. For example, one male patient said: “The doctors are too busy dealing with our mental health problems to think about sexuality.” Furthermore, several patients said that they often feel that their sexuality is pathologized and seen as a symptom of their illness (e.g., hypersexuality in individuals with bipolar disorder, promiscuity in individuals with borderline personality disorder) rather than as a healthy part of themselves. One female patient expressed, “I only get asked [by my doctor]—’Are you promiscuous?”’ As previously pointed out, one concern before initiating the program was whether to run samegender groups versus mixed-gender groups. We subsequently report on observations specific to the female group, then provide observations specific to the male group. The Female Group “I have gone on dating sites but I feel that I am not worthy as a sexual partner anymore because I am over 40 and I have a few extra kilos.” —Female patient attending the sex education groups

In general, the women appeared especially concerned about dating, body image, and sexual self-esteem. In short, their sexual concerns were mostly in the context of interpersonal relationships. For example, one patient asked, “It is normal that it is easier for me to have an orgasm when I am masturbating than when I am with a partner?” At the end of the first lecture (“What Is Sexuality?”), the initial comment was “You have talked about how sexuality and gender may be fluid for some people. Yet, you separated the groups based on biological sex. This seems strange.” This comment was acknowledged by the two group coordinators, who explained that this decision was made out of the concern that individuals who have had negative past experiences with the opposite gender could feel vulnerable in a mixedgender group. Whereas some women said that male and female patients might benefit from being in the group together because they can teach each other about sexuality, others expressed that they would be uncomfortable if men were to be present, especially when talking about topics related to sexual consent and victimization. During this discussion, two patients were on the verge of confrontation. However, this conflict was avoided by the psychoeducator intervening and refocusing onto other topics from the lecture. Considering that the goal of this group was psychoeducational rather than psychotherapeutic, it was important that the focus remained on information giving rather than on patient dynamics. There were no more observed signs of conflicts between the female patients for the remainder of the lecture series. The main discussion topics during the second (“Sexuality and the Body”) and third lectures (“Sexuality and Psychiatric Medications”) were related to body image, sexual self-esteem, and sexual functioning. Several of the women shared details about their sexual lives, especially related to side effects from their psychiatric medications. For example, one woman asked whether it is “normal” that she has difficulties with vaginal lubrication. A general consensus was that the weight gain often linked to taking psychiatric medications is associated with feeling “unsexy” and “ugly.” One patient said, “I masturbate because I feel horny and need to have an orgasm, not because I feel sensual.” This same patient said she has developed strategies to “hide her fat”

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from her boyfriend during sexual activity and joked that she needs “to plan sex now” to hide her stomach. A young woman said that it does not matter to her that her boyfriend says she is pretty and not fat, “I still feel disgusting.” Several of the patients pointed out that they feel their doctors do not care much about how the medications can lead to weight gain: “The only thing that matters is that we are not crazy. Who cares if we are fat?” They said they wish their doctors would give them more information about the possibility of weight gain as a medication side effect. After these discussions, the women gave each other advice about how they can learn to feel more comfortable with their bodies. Several strategies were suggested, such as getting massages, using oils, doing yoga, getting a manicure, and going to the spa. The discussion after the fourth lecture (“Sharing Sexuality With Others”) was less animated in comparison with previous ones. When the women were asked why they had fewer comments and questions, they answered that although the lecture was “good and useful,” the topics (talking about sex, sexual consent, dating, being in love, and sex in long-term relationships) were less emotional to them than were previous ones. Several patients said they were “already familiar with these topics.” One patient suggested that the discussion on sexual consent could have been broadened to include the idea of “enthusiastic consent,” meaning that, for women, consent includes more than just agreeing to sex, it also means “being happy doing it.” In addition, some patients suggested that this lecture should have devoted time to talking about how dating may be different for heterosexual, bisexual, and lesbian women. For example, one patient addressed how people often assume others are heterosexual. She said it can be challenging to come out of the closet (“Do I need to wear a rainbow flag on my chest to let people know?”). She also pointed out how being bisexual is especially difficult because of stigma from gay and heterosexual communities. At the end of the fifth lecture (“Safe Sex”), there was a series of questions, mainly related to safe sex practices and how to talk about sexually transmitted infections, including “Can HIV get transmitted through semen?”, “Which clinics can I go to for tests?”, “What about safe sex practices for lesbians?”, and “How do I talk about STIs with my partner?” At the end of this group, patients gave feedback about the lecture series. As previously pointed out, patients felt that the groups helped normalize their experience of sexuality. Furthermore, they said that the material included was “useful” and “not too simple.” Last, the discussion returned to one of the main topics from the first lecture—namely, whether future groups should be same gender or mixed gender. The opinions were mixed. Some patients said they would have felt equally comfortable to share if men were in the group, whereas others expressed that they might have been less comfortable and therefore less willing to share their concerns. The Male Group “Sometimes [sex] can start coercive and then still be pleasurable.” —Male patient attending the sex education groups

In general, the men appeared especially concerned about sexual side effects from their psychiatric medications, how to treat erectile dysfunction, the meaning of sexual consent, and the meaning of masculine stereotypes. There were several interruptions during the first lecture (“What Is Sexuality?”). For example, when slides depicting different forms of sexuality were shown, one patient asked what was represented in one picture. When it was answered “vaginas,” the men started laughing. In addition, during the lecture, one patient asked, “Which level of sexuality knowledge is expected from us?”

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Several of the patients appeared to be anxious. For example, rather than listening, some were moving around in their chair, talking to the person next to them, sleeping, or giggling. At the end of the lecture, the majority of the questions were about sexual consent and the meaning thereof. For example, “Sometimes [sex] can start coercive and then still be pleasurable”; “Think about people who like S&M”; and “Some women feel ashamed because they had sexual pleasure while they were raped.” Reflecting on this first group, our impressions were that the men responded with anxiety, that the topic of sexuality may be more difficult for male than for female patients, and that the men may have felt safer if the lecture series had started with a more concrete topic. In light of these observations, we decided to change the lecture sequence for the men. There were no interruptions during the second lecture (“Sexuality and Psychiatric Medications”). In the discussion period, all of the men said that they would appreciate it if their mental health practitioners were to talk about and to ask about sexual side effects of medications. One patient said he thought it would be “a good idea for the doctor to ask the patient if he is comfortable talking about sexuality before bringing up the topic.” In addition, the men agreed that their mental health practitioners do not usually talk about sexual side effects. Echoing comments from the female group, one patient said, “The doctors are too busy dealing with our mental health problems to think about sexuality.” In addition, one patient asked about treatments for erectile dysfunction “except for Viagra.” During the third lecture (“Safe Sex”), most of the men were sleeping. There was only one question: “Isn’t it just better to not have sex at all?” There were more questions and comments after the last two lectures (“Sexuality and the Body” and “Sharing Sexuality With Others”). As during the female group, there were concerns related to sexual orientation. For example, one patient asked, “Am I asexual or do I feel asexual due to my depression, anxiety, and medications?” This individual said he feels alienated by the gay community because there is so much focus on sex there, “I don’t fit in.” Furthermore, several of the men shared their thoughts about the meaning of masculinity. One man said: “Men can also feel invisible [as women can feel invisible], Lamborghinis are sexy, not my Bixi bicycle.” This discussion led to talking about gender stereotypes, such as men are expected to be “strong and powerful,” while women are expected to be “trophies.” In addition, one male patient said, “In the past only men were supposed to like sex and women were not supposed to like it. Now, there is all this talk about female desire.” Furthermore, there was an extended discussion during the topic of sexual consent. For example, one male said that women who have sex with male teenagers are less judged that men who have sex with female teenagers, which lead to a discussion about how the interpretation of sexuality and consent may differ for men and for women. As for the women, the men gave feedback about their experiences of attending the sex education lecture series at the end of the last group. The men said they found the program “helpful and informative” and that it should be done again. One patient said: “Next time, bring in a lot of general practitioners [so that they can learn about our sexual concerns].”

CONCLUSION As discussed, there were three major concerns for the lecture series: same-gender groups versus mixed-gender groups, number of lectures and length of each lecture, and the complexity of material to be presented. Although there were mixed opinions among patients regarding the gender

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organization of the groups, our conclusion is that it was advantageous to host the groups separately for men and women. Many of the female patients shared personal sexual information related to, for example, masturbation, that they might not have shared in the presence of men. The fact that some of the men made comments, especially regarding sexual consent (for example, “No can mean yes,” “Some women like to be forced”) left us with the impression that some male patients’ deficient understanding of boundaries could have made the female patients uncomfortable and less willing to share. This theory should be tested further in formal evaluations of sex education programs for psychiatric patients. For example, future studies can test three major designs: (a) sex education groups run separately and consecutively for men and for women, (b) sex education groups run separately but in parallel for men and women, and (c) mixed-gender sex education groups. On the basis of feedback from the patients, the number, length, and complexity of the lectures were appropriate. The majority of patients participating in the current sex education program were primarily diagnosed with a mood disorder. It is possible that the lecture material may have been received differently if most of the patients had been principally diagnosed with schizophrenia or a personality disorder rather than a mood disorder. In summary, sex education appears to be well received by psychiatric day hospital patients. Presenting the topic of sexuality by lectures in a group context may provide a safe place for patients to learn about and express their concerns regarding sexuality. It is important to note that sex education may be a means of normalizing patients’ experience of sexuality. Although both male and female patients showed interest by regularly attending the lectures, the women asked more questions. In addition, although both men and women said that sexuality is not adequately addressed by their mental health practitioners, the main sexual concerns of male and female patients may be different. Whereas the women were especially concerned about dating, body image, and sexual self-esteem, the men were mostly worried about sexual side effects from their psychiatric medications, how to treat erectile dysfunction, the meaning of sexual consent, and the meaning of masculine stereotypes. ACKNOWLEDGMENTS The authors thank Drs. Irving M. Binik and Allan Fielding for their valuable comments and input throughout the preparation of the manuscript version of this article. REFERENCES Assalian, P., Fraser, R., Tempier, R., & Cohen, D. (2000). Sexuality and quality of life of patients with schizophrenia. International Journal of Psychiatry in Clinical Practice, 4, 29–33. Bengtsson-Tops, A., & Hansson, L. (1999). Clinical and social needs of schizophrenic outpatients living in the community: The relationship between needs and subjective quality of life. Social Psychiatry and Psychiatric Epidemiology, 34, 513–518. Burns, T., Fioritti, A., Holloway, F., Malm, U., & R¨ossler, W. (2001). Case management and assertive community treatment in Europe. Psychiatric Services, 52, 631–636. Cournos, F., Guido, J. R., Coomaraswamy, S., Meyer-Bahlburg, H. F. L., Sugden, R., & Horwath, E. (1994). Sexual activity and risk of HIV infection among patients with schizophrenia. American Journal of Psychiatry, 151, 228–232.

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Gray, R., Brewin, E., Noak, J., Wyke-Joseph, J., & Sonik, B. (2002). A review of the literature of HIV infection and schizophrenia: Implications for research, policy and clinical practice. Journal of Psychiatric and Mental Health Nursing, 9, 405–409. Hellewell, J. S. E., Kalali, A. H., Langham, S. J., McKellar, J., & Awad, A. G. (1999). Patient satisfaction and acceptability of long-term treatment with quetiapine. International Journal of Psychiatry in Clinical Practice, 3, 105–113. Higgins, A., Barker, P., & Begley, C. M. (2006). Sexual health education for people with mental health problems: What can we learn from the literature? Journal of Psychiatric and Mental Health Nursing, 13, 687–697. Kelly, D. L., & Conley, R. R. (2004). Sexuality and schizophrenia: A review. Schizophrenia Bulletin, 30, 767–779. Kheng Yee, O., Muhd Ramli, E. R., & Che Ismail, H. (2014). Remitted male schizophrenia patients with sexual dysfunction. Journal of Sexual Medicine, 11, 956–965. Maurice, W. L. (2003). Sexual medicine, mental illness, and mental health professionals. Sexual and Relationship Therapy, 18, 7–12. Maurice, W. L., & Yule, M. (2010). Sex and chronic and severe mental illness. In S. B. Levine, C. B. Risen, & S. E. Althof (Eds.), Handbook of clinical sexuality for mental health professionals (2nd ed., pp. 469–481). New York, NY: Routledge. Nnaji, R. N., & Friedman, T. (2008). Sexual dysfunction and schizophrenia: Psychiatrists’ attitudes and training needs. Psychiatric Bulletin, 32, 208–210. Perkins, D. O. (2002). Predictors of noncompliance in patients with schizophrenia. Journal of Clinical Psychiatry, 63, 1121–1128. Perlman, C. M., Martin, L., Hirdes, J. P., Curtin-Telegdi, N., P´erez, E., & Rabinowitz, T. (2007). Prevalence and predictors of sexual dysfunction in psychiatric inpatients. Psychosomatics: Journal of Consultation and Liaison Psychiatry, 48, 309–318. Raja, M., & Azzoni, A. (2003). Sexual behavior and sexual problems among patients with severe chronic psychoses. European Psychiatry, 18, 70–76. Sadow, D., & Corman, A. G. (1983). Teaching a human sexuality course to psychiatric patients: The process, pitfalls, and rewards. Sexuality and Disability, 6, 47–63.

Sex Education Groups in a Psychiatric Day Hospital: Clinical Observations.

Although the prevalence of sexual dysfunction is high among individuals diagnosed with severe and chronic mental illness, the topic of sexuality is of...
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