Managing Sexual Behavior on Adult Acute Care Inpatient Psychiatric by wuyunqing

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									Managing Sexual Behavior on Adult
Acute Care Inpatient Psychiatric Units
Elizabeth Ford, M.D.
Michele Rosenberg, M.D.
Margarita Holsten, M.D.
Tyson Boudreaux, M.D.



Objective: Protecting and safeguarding persons with impaired decision-                         community, ranging from 1.5 to 5
al capacity are among the critical functions of a psychiatric hospital. The                    percent of patients on adult units over
objective of this study was to investigate the elements of these functions                     one to two years (3–6). Nevertheless,
as they relate to sexual behavior on an adult acute care inpatient psy-                        it can be a very cumbersome issue
chiatric unit and to develop a policy to prevent or at least manage such                       when it does occur. Issues of sexually
behavior. Methods: The authors undertook an extensive literature re-                           transmitted disease, pregnancy, con-
view of articles and legal cases. The review was presented at numerous                         sent, trauma, and interference in
meetings of staff and interdisciplinary teams on the adult teaching unit                       treatment are all concerns. The
at Bellevue Hospital in New York City. The findings from the review and                        American Psychiatric Association
the results of staff discussions were used in creating the policy. Results                     considers sexual intercourse on inpa-
and conclusions: In the acute care setting, it may be both reasonable                          tient units to be high-risk behavior,
and prudent to prevent all sexual interactions between patients, espe-                         specifically in the context of potential
cially given the potential risks of such behavior. Concerns include the                        transmission of HIV (7). However,
transmission of sexually transmitted disease, reproductive issues, and                         many organizations and mental
the legal implications of nonconsensual activity. Despite these concerns,                      health professionals, backed by legis-
adult psychiatric inpatients should be granted as many rights as are pos-                      lation such as the Americans With
sible without having an adverse effect on their treatment or recovery.                         Disabilities Act (8), believe that inpa-
There is currently no standard for a sexual behavior policy for psychi-                        tients on adult psychiatric units, re-
atric inpatients. Thus ward staff are left with minimal guidance and po-                       gardless of length of stay, should be
tential confusion in the event that sexual incidents do occur, and there                       allowed as many rights as are possible
is a greater likelihood of arbitrary responses. The policy developed                           without having an adverse effect on
through this study is an example of how individual institutions can en-                        their recovery or treatment. Some be-
force a structured protocol when dealing with an ambiguous and diffi-                          lieve that such rights should extend to
cult issue. (Psychiatric Services 54:346–350, 2003)                                            sexual behavior.
                                                                                                  These issues became immediately
                                                                                               important at Bellevue Hospital after


A
         mong inpatient psychiatric            colleagues (2) showed that 44 percent           an incident of alleged consensual sex-
         units in the United States,           of patients with schizophrenia in fa-           ual intercourse between a female pa-
         there is little consensus on the      cilities ranging from acute to chronic          tient with schizophrenia and a male
management of sexual behavior be-              care and from inpatient to outpatient           patient with schizoaffective disorder
tween patients, even in long-term fa-          settings were sexually active and en-           on the adult acute inpatient psychi-
cilities where the length of stay can be       gaging in high-risk behavior—for ex-            atric unit. We developed an interest
years and there is generally a more le-        ample, multiple partners, unprotect-            in understanding national trends and
nient attitude toward sexual interac-          ed sex, substance use, and sexual ex-           recommendations concerning re-
tion. Contrary to beliefs held in the          change.                                         sponses to and prevention of sexual
1960s (1), patients with mental illness           Sexual behavior on inpatient units           behavior. There is currently no agree-
are not asexual. In fact, Cournos and          is less common than in the outpatient           ment on the “correct” way to permit,
                                                                                               manage, or prohibit sexual activity on
                                                                                               inpatient units, although a few poli-
The authors are affiliated with the department of psychiatry at New York University            cies are available (3,9–11). We thus
School of Medicine. Send correspondence to Dr. Ford in care of Carol A. Bernstein, M.D.,       attempted to create a policy both to
Director, Residency Training in Psychiatry, New York University School of Medicine, De-        handle sexual incidents on our unit
partment of Psychiatry, 550 First Avenue, Room NB 20N11, New York, New York 10016              and to serve as a potential model for
(e-mail, carol.bernstein@med.nyu.edu).                                                         other institutions.
346                                         PSYCHIATRIC SERVICES   o http://psychservices.psychiatryonline.org o March 2003 Vol. 54 No. 3
Methods                                                                                            Legal cases, precedents, and
In May 2001 we reviewed the litera-                                                             laws. Johnson v. United States (13)
ture by searching MEDLINE,                          Editor’s note: This paper is                found that there should be a “least re-
PsycINFO, and MENTAL HEALTH                         part of a series of papers by,              strictive” policy on inpatient psychi-
COLLECTION and by cross-refer-                      about, and for residents edit-              atric units, with “no more restrictions
encing from collected articles and ex-              ed by Avram H. Mack, M.D.                   than good medical practice requires.”
amining legal cases. Articles were ini-             Prospective authors—cur-                    Although this was not directed specif-
tially limited to those published in                rent residents, fellows, and                ically at sexual behavior, it has be-
1990 or more recently, but because of               faculty members—should                      come a widely applied standard. For
the paucity of relevant data, the                   contact Dr. Mack at the De-                 example, the case of Farago v. Sacred
search was extended to include arti-                partment of Child and Ado-                  Heart General Hospital (14) involved
cles published since 1975.                          lescent Psychiatry, New York                a woman with schizophrenia who was
   In the review, an effort was made to             State Psychiatric Institute,                raped and who subsequently sued the
identify common issues and problems                 Unit 74, New York, New York                 Pennsylvania hospital where she had
related to sexual behavior that arose               10032; e-mail, avram_mack@                  been admitted. She lost her case be-
on psychiatric inpatient units. This in-            hotmail. com.                               cause she was not deemed to have
formation was then presented to an                                                              needed “special observation” on ad-
interdisciplinary team of staff mem-                                                            mission, and the judge found that the
bers and physicians on the acute care                                                           staff had appropriately followed “least
teaching service at Bellevue Hospital.                                                          restrictive” guidelines.
During the course of multiple discus-          tients on a short-term inpatient unit               However, these guidelines do not
sions, nursing staff, attending physi-         who engaged in “relationships” were              imply that hospitals cannot be found
cians and residents, activity thera-           more likely to have an eating disorder,          negligent or responsible in the event
pists, and administrative staff high-          bipolar disorder, or a personality dis-          of sexual indiscretions or assault. In
lighted their concerns about and sug-          order. Sixty-nine percent of the pa-             Knoll v. Ohio Department of Mental
gestions for appropriately and safely          tients were single, were aged 15 to 29           Health (ODMH) (15), a woman sued
handling incidents such as the one             years, and engaged primarily in het-             ODMH for an exacerbation of her
described above. A sample policy was           erosexual encounters; 75 percent of              “mental condition” after being raped
then created to provide a framework            the relationships were reported to be            by a patient who was known to be “ex-
for a comprehensive and feasible plan          consensual. Among the relationships              citable and violent.” Although the al-
to prevent or at least manage sexual           that were not consensual, the “initia-           leged rapist was indicted, the staff of
incidents. It should be noted that this        tor” was more likely to have a person-           the hospital were also found to be
policy was designed with our acute             ality disorder or a substance use dis-           negligent in providing care.
care population in mind—primarily              order, and the “recipient” was more                 The Wyatt standards (16), essen-
young men and women with severe                likely to have a diagnosis of an eating          tially the precursor to the “patient’s
illness, a concomitant substance use           disorder or schizophrenia. Patients              bill of rights,” broadly describe the
disorder, varying degrees of capacity,         who were seen to be “dependent”                  civil rights to which patients are enti-
and an average length of stay of two to        were more likely to be linked sexually           tled. These standards have been en-
three weeks.                                   with someone seen as “angry”; some-              acted, in part, by almost all states and
                                               one “passive” was more likely to be              Congress, but only four states have
Results                                        linked with someone “impulsive.”                 included the standard of granting pa-
Literature review                                 High-risk patients may also be rec-           tients “suitable opportunities for . . .
Characteristics of high-risk pa-               ognized during an interview by iden-             interactions with members of the op-
tients. Many psychiatric patients can          tifying specific motivating factors for          posite sex” (7). This standard has not
exhibit sexually inappropriate behav-          sexual behavior, such as those de-               been interpreted to mean suitable op-
ior. Hypersexuality is a feature of a          scribed by Modestin (5). He reported             portunity for sexual intercourse, and
number of psychiatric diagnoses,               that factors such as aggression, deep            the Supreme Court has never found
such as bipolar disorder, organic brain        dependency needs, efforts to com-                sexual interaction per se to be a
syndromes, mental retardation (6),             pensate for feelings of inferiority, and         specifically protected right (16).
and borderline personality disorder            response to auditory hallucinations              However, the Court has found that
(2). Persons with schizophrenia may            are particularly important to recog-             individuals have the right to procreate
also have an initial increase in sexual        nize. In addition, Akhtar (12) identi-           (17), the right to privacy concerning
activity, although activity often de-          fied loneliness and boredom as possi-            termination of pregnancy (18), and
creases over the course of their illness       ble motivating factors.                          the right to contraception (19).
(2). Akhtar and colleagues (12) found             Although not mentioned in any of                 A psychiatric inpatient’s capacity to
that patients on acute inpatient units         the articles reviewed, a history of sex-         consent to sexual behavior is an im-
who engaged in sex were more likely            ual assault or inappropriate sexual be-          portant consideration. For example,
to be younger, to be single, and to            havior, especially during previous               engaging in sexual activity with a
have character pathology. According            hospitalizations, would certainly be             “mentally defective” person (defined
to Keitner and colleagues (6), pa-             important to consider as a risk factor.          as one not able to consent to sexual
PSYCHIATRIC SERVICES   o http://psychservices.psychiatryonline.org o March 2003 Vol. 54 No. 3                                       347
activity) has been found to be a felony       ized, a grand jury made recommen-               For example, the University of Cali-
in New York State (20). New York              dations for the hospital to “[complete]         fornia, San Francisco, locked crisis in-
State law requires a hospital director        its development of a policy for all             tervention unit has a no-sex policy (3).
to notify the district attorney and lo-       state hospitals in sexual contact and           The unit attempts to prevent sexual
cal law enforcement if it “appears”           how staff should deal with such con-            contact by including rules about sexu-
that such a crime has been committed          duct. The policy should clearly state           al activity in a handbook that is given
(21). Furthermore, in Ohio, hospital          the criteria to determine competency            to patients at admission. Although
personnel who allow sexual contact            [capacity] to consent to a sexual act,          prevention may not be feasible on a
with “impaired” patients can be in-           who makes that determination, and               chronic unit such as the Rochester
dicted on facilitation of a crime (7).        how it is made” (23). This recommen-            State Psychiatric Center, unit rules
   Despite the legal implications de-         dation was carried out.                         are of utmost importance for safety in
scribed above, state definitions of ca-          The center developed a six-page              an acute unit, where patients are less
pacity to consent to sexual interac-          document (21) outlining a policy to             stable and less familiar.
tion are still vague—some states re-          be implemented if staff found pa-                  Elements of a model policy. Nu-
quire only an understanding of the            tients engaging in sexual intercourse.          merous variables must be considered
nature of the interaction (especially         First, the patients should be asked to          in developing a policy to address sex-
for those with mental retardation),           stop all activity and not to change             ual behavior (22), many of which we
some require an understanding of              their clothes, bathe, or wash, so as            have attempted to include in our
the nature and consequences, and              not to disturb physical evidence.               model policy. Most important, a clear
others require an understanding of                                                            definition of the behavior is needed.
the nature, consequences, and moral                                                           Other variables that must be consid-
or social significance (7). The direc-                                                        ered include legal and moral con-
tive on patient sexual activity of the                                                        cerns (affected by age and marital sta-
New York State Office of Mental                                   Many                        tus), issues of capacity to consent (in-
Health makes numerous references                                                              fluenced by cognitive impairment
to the ability of a patient to consent                      variables                         and other variations in mental status),
and instructs that the treatment team                                                         and general health concerns (such as
leader “shall ensure that an assess-                 must be considered                       sexually transmitted disease and
ment of the patient’s ability to con-                                                         pregnancy).
sent is completed” (10). However,                in developing a policy to                       It is also important to consider staff
the policy does not specify how that                                                          variables. In a study of 131 mental
should be accomplished.                          address sexual behavior.                     health professionals aged 25 to 79
   Documented policies and ap-                                                                years, more people approved of con-
proaches. In 1981, Keitner and Grof               Most important, a clear                     sensual, heterosexual interactions in a
(22) surveyed 70 psychiatric facilities                                                       private place than any other scenario;
in Canada (43 general, 21 provincial,                  definition of the                      more approved of the female’s being
three geriatric, and three private                                                            the initiator; and consent did not ap-
units) and did not find any with an of-                    behavior is                        pear to play a significant role in the
ficial policy. Ten years later, a task                                                        respondent’s interpretation of an in-
force in British Columbia polled 38                          needed.                          teraction as positive or negative (24).
Canadian hospitals to find existing                                                           Other variables include, but are not
policies and again found none (11).                                                           limited to, the education of the team,
However, in 1997 Buckley and Hyde                                                             the proficiency of their assessment
(4) found that of 57 state facilities in                                                      skills, and the chief psychiatrist’s lead-
the United States, 83 percent had a           Second, a physical examination, in-             ership style.
policy. (The details of those policies        cluding checks for tears, bleeding,
were not requested as part of the             and trauma, was to be conducted im-             Model policy
study.) In 1999 another study found           mediately on all parties involved.              A copy of the policy presented as a
that 25 percent of acute care facilities      Third, a collection of blood samples            protocol—that is, in outline format—
in Ohio had a documented policy (1).          as well as nasal, throat, and possibly          is available from the authors.
Notably, only 4 percent of those              vaginal or rectal swabs were to be                 Defining zero tolerance. On
acute care units cited sexual behavior        collected. Finally, the entire chain of         short-stay wards where acutely ill vol-
as a problem, compared with 26 per-           command for the hospital was to be              untary or involuntary patients are hos-
cent in the 1997 survey of long-term          notified immediately.                           pitalized for a matter of weeks at
facilities (4).                                  It should again be emphasized that           most, this policy will standardize the
   Rochester State Psychiatric Center         long- and short-term units often have           prevention of sexual interactions and
is a good example of the impetus to           differing views on sexual interaction           appropriate reactions to incidents and
create a policy for sexual behavior. In       among their patients, and thus poli-            assaults on the unit. In recognition of
response to a suit filed against the          cies will likely address such interac-          the difficulty in defining “sexual inter-
hospital after a patient was sodom-           tion with varying levels of tolerance.          action,” no physical interactions of any
348                                        PSYCHIATRIC SERVICES   o http://psychservices.psychiatryonline.org o March 2003 Vol. 54 No. 3
kind will be tolerated by this policy, in-     to follow it, he or she should be                for signs of sexual activity, potential
cluding handholding and hugging.               placed on 15-minute checks (or an                assault, and sexually transmitted dis-
   As patients are assessed for danger-        equivalent monitoring standard); spe-            ease. Fifth, a pregnancy test should
ousness to self or others upon admis-          cial attention should be paid to the             be offered at the earliest reliable
sion, they should also be evaluated for        patient’s interactions with peers and            time. Sixth, if possible, all medica-
propensity to engage in sexual behav-          any potential for sexual behavior.               tions that are potentially harmful to a
ior during hospitalization. This evalu-        Such potential—for example, making               fetus should be stopped until a reli-
ation may include a questionnaire of           plans with another patient to meet               able pregnancy test can be obtained.
risk factors such as diagnostic history,       privately—should be reported on                  Finally, all patients involved should
age of 15 to 30 years, heterosexuality,        morning rounds and one-on-one ob-                be placed on a one-on-one watch un-
a history of sexual assault, a history of      servation initiated if necessary. If the         til the incident is properly investigat-
inappropriate sexual behavior during           patient is not capable of understand-            ed and the patients show the ability to
previous hospitalizations, and a histo-        ing the hospital policy, he or she               understand the unit’s policy.
ry of violence. A basic sexual history         should be placed on five- to ten-                   All allegations of sexual assault
should be obtained, including HIV              minute checks for sexual behavior                must be immediately reported to the
status and history of other sexually           with continued redirection and, if               treating physician and, if necessary,
transmitted diseases. Patients identi-         necessary, one-on-one observation.               the police. The patient must be kept
fied as high-risk patients should be                                                            safe and segregated from the alleged
managed as described above.                                                                     perpetrator of the assault. A rape kit
   Each patient should be assessed for                                                          and physical and gynecologic exami-
his or her capacity to make decisions                                                           nations should be offered, and a preg-
about sexual behavior. This assess-                              It is                          nancy test should be given at the ear-
ment should include a mental status                                                             liest reliable time. Emergency contra-
examination, including the patient’s                        important                           ception should be considered, and
level of orientation, and an assess-                                                            HIV testing should be conducted if
ment of the patient’s level of under-                      to provide a                         the patient’s HIV status is unknown; a
standing of the rules on the unit, in-                                                          month’s course of antiretroviral thera-
cluding the repercussions of and al-                consistent framework                        py should be considered if appropri-
ternatives to sexual behavior. Patients                                                         ate. The patient should also be of-
should receive a verbal explanation             for all interactions on acute                   fered trauma counseling. Staff meet-
and a written copy of the hospital’s                                                            ings should be held regularly—daily if
policy. Each patient’s chart should             care units, in terms of both                    necessary—to discuss the event and
contain documentation showing that                                                              to assess how the event should be
this information was provided and in-             therapeutic structure for                     managed.
dicating whether the patient ap-                                                                   Staff members should receive
peared to understand the policy. This               patients and minimal                        training in the following areas to en-
documentation may be incorporated                                                               sure that patients’ rights are not vio-
into existing unit orientation forms.                     confusion for                         lated and that the safety of all patients
   Patients should be asked to abstain                                                          is protected: admission and screening
from any physical contact with peers                             staff.                         procedures; sensitivity to patients’
or staff. Patients may also be in-                                                              sexual needs; instruction on sex edu-
formed of alternatives to sexual inter-                                                         cation, contraception counseling, and
course, including masturbation. De-                                                             discussion of safe outlets for sexual
pending on patients’ beliefs and per-                                                           impulses; prevention of sexual assault
sonal dynamic issues, they may be in-            A seven-step procedure can be put              and quick and appropriate reactions
formed that masturbation serves as a           in place for the evaluation of a sexual          to these incidents; restriction of phys-
safe outlet for channeling normal sex-         incident. First, all incidents should be         ical contact and prevention of sexual
ual drives, provided it is done private-       immediately reported to the treating             interactions; and regular meetings to
ly and at an appropriate time and              physician. Second, the patients in-              discuss and debrief after incidents.
place.                                         volved should be immediately evalu-                 This policy does not address moral
   All patients should have the oppor-         ated for their capacity to consent to            issues concerning sexual behavior
tunity to participate in sex education,        sex and to participate in a manage-              among inpatients, because it is our as-
including open discussions about sex-          ment or treatment protocol. If such              sertion that all sexual interaction on a
uality and sexual preferences, person-         capacity is not established, an alter-           short-term, controlled unit should be
al body awareness, pregnancy and               nate decision maker should be                    prohibited to ensure as safe an envi-
contraception, prevention of sexually          sought. Third, HIV status must be as-            ronment as possible. We are not pro-
transmitted diseases, and any other            sessed and HIV testing and antiretro-            posing that this model be instituted in
issues specific to a given individual.         viral prophylaxis offered. Fourth,               its current state but rather are at-
   If a high-risk patient understands          physical and gynecologic exams and               tempting to provide guidelines to be
the hospital policy but does not agree         rape kits should be offered to assess            used by individual institutions and
PSYCHIATRIC SERVICES   o http://psychservices.psychiatryonline.org o March 2003 Vol. 54 No. 3                                        349
tailored to their specific population                     Available at www.narpa.org/beyond_the_            supp Op 344 F supp 373 (MD Ala 1972)
                                                          last_frontier.htm
and needs.                                                                                               17. Skinner v Oklahoma, 316 US 535 (1942)
                                                      10. Statement Concerning State Office of
                                                          Mental Health Directive on Patient Sexual      18. Roe v Wade, 410 US 113 (1973)
Conclusions                                               Activity. Albany, New York State Office of
Sexual behavior on psychiatric units                      Mental Health, July 27, 1993                   19. Griswold v Connecticut, 381 US 479 (1965)
has long been an important issue but                  11. Welch SJ, Clements GW: Development of a        20. People v McMullen, 414 NE 2d 214, 217
apparently has rarely been specifical-                    policy on sexuality for hospitalized chronic       III App Ct (1980)
ly addressed in terms of protocol and                     psychiatric patients. Canadian Journal of
                                                          Psychiatry 41:273–279, 1996                    21. Holbrook T: Policing sexuality in a modern
policy. It is important to provide as                                                                        state hospital. Hospital and Community
consistent a framework as possible for                12. Akhtar S, Crocker E, Dickey N, et al: Overt        Psychiatry 40:75–79, 1989
                                                          sexual behavior among psychiatric inpa-
all interactions on acute care units, in                  tients. Diseases of the Nervous System 38:     22. Keitner GI, Grof P: Sexual and emotional
terms of both therapeutic structure                       359–361, 1977                                      intimacy between psychiatric inpatients:
for the patients and minimal confu-                                                                          formulating a policy. Hospital and Commu-
                                                      13. Johnson v United States, 409 F Supp 1283,          nity Psychiatry 32:188–193, 1989
sion for staff members. The policy de-                    1292–93 (MD Fla 1976)
scribed here is intended to increase                  14. Farago v Sacred Heart General Hospital,
                                                                                                         23. Additional Grand Jury of Monroe County,
awareness about policy formation and                                                                         New York: Report. Rochester, NY, Monroe
                                                          562 A 2d 300 (Pa 1989)
                                                                                                             Co District Attorney, July 1986
the avoidance of incidents that can                   15. Knoll v Ohio Department of Mental
become medically and legally cata-                        Health, 577 NE 2d 135 (Ohio Ct Cl 1987)        24. Commons ML, Bohn JT, Godon LT, et al:
                                                                                                             Professionals’ attitudes towards sex be-
strophic. The policy should be con-                   16. Wyatt v Stickney, 325 F supp 781 (MD Ala)          tween institutionalized patients. American
sidered a work in progress. In re-                        amended, 334 F supp 1341 (MD Ala 1971),            Journal of Psychotherapy 46:571–580, 1992
sponse to the presentation of this pol-
icy to the psychiatric staff at Bellevue
Hospital, efforts are under way to im-
plement it on appropriate units. Fur-
ther investigation and follow-up of
the efficacy of this implementation
would certainly be helpful in continu-
ing to address this important issue. o                               Submissions Invited for
                                                                     Multimedia Reviews Column
References
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350                                                PSYCHIATRIC SERVICES   o http://psychservices.psychiatryonline.org o March 2003 Vol. 54 No. 3

								
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