Sexual relations at psychiatric hospitals are implicitly banned to protect patients. However, some institutions in French-speaking Switzerland have begun to use the services of sexual assistants.
Claude has spent more than two-thirds of his life in psychiatric hospitals. He was sentenced in 1975 for murdering his girlfriend’s lover. The Frenchman, now 69 years old, first spent eight years in prison before being committed to a facility for patients with serious mental illnesses.
In 2008, when he was at the Cadillac Hospital in Bordeaux, France, he demanded the right to have sexual relations, “in protest against his unit’s regulations which banned any activity of this sort,” says his lawyer Pierre Burucoa. The case reached the Bordeaux Administrative Appeals Court, which ruled in favour of the patient in January 2013, on the grounds that sexuality was a fundamental right, on the same level as respect for one’s private life established by the European Convention on Human Rights.
This example is exceptional. “It’s a real taboo in France,” says Pierre Burucoa. “Sexual activity between patients is an issue faced by all psychiatric hospitals, but none of them have any clear-cut rules on the subject.”
What is the situation in Switzerland? “At Swiss institutions, there is no explicit ban, but most prohibit it more subtly and implicitly,” says Jean-Louis Korpès, professor at the College of Social Work in Fribourg. “Patients are under constant staff surveillance, from the moment they get up until they go to bed at night, making any form of intimacy impossible.” Until the 1960s, mental patients systematically underwent sexual sterilisation.
“At the Hospital of Cery in the Vaud canton, sexual relations are considered a fundamental right and are not formally banned. But the institution’s handbook asks patients to refrain from sexual activity during their stay,” says Philippe Conus, chief of the General Psychiatry Service at the Lausanne University Hospital. He points out that “psychiatric hospitals are no longer places where patients live. Those who do are experiencing an acute crisis and come for a short stay (20 days on average at Cery).”
Transgressing the taboo for the mentally disabled
Although sexual relations between patients and psychiatric staff remain questionable, sexual activity between the mentally disabled is now quite the norm. “The staff at psychiatric facilities is trained to deal with the emotional and sexual issues in patients’ lives, and residents are allowed to express themselves,” says Catherine Agthe, sex educator and president of the organisation Sexualité et Handicaps Pluriels. “Over the past twenty years, new solutions have been created to address these issues, in the form of evening events, slow dating, double rooms for couples and, since the 2000s, sexual assistants.”
Carmen Wegmann from the organisation Insieme believes that Switzerland’s ratification of the UN’s 2006 Convention on the Rights of Persons with Disabilities stepped up the “standardisation” of all aspects of their lives, including sexual intimacy. Stark differences remain between facilities. “Some allow patients to share rooms and talk very openly about the sexuality of their residents, while others deny it, assuring that that never happens at their facility,” she says. The sexuality of the mentally disabled has also created new challenges. “Supporting them by offering sexual assistance is essential, but they can become too attached or fall in love with the person providing the service,” says Carmen Wegmann. The issue of a potential pregnancy has not yet been solved. “Having a child is a fundamental right, but it remains very complicated in practice,” she says. “These women themselves often need day-to-day support.”
These precautionary guidelines reflect a concern about causing additional suffering. “People admitted to psychiatric facilities are in a situation of intense distress and vulnerability,” says psychiatrist Giuliana Galli Carminati, former senior physician at the Belle-Idée Hospital in Geneva. “They’re incapable of making a well-thought-out decision on their sexuality.” Underpinning this hypothesis is the question of judgement. It is particularly difficult to assess the capacity for good judgement in people with impulsive behavioural disorders or who have hallucinations.
Sexual desire can also impact the choice of medical treatment. “Antipsychotic drugs can cause sexual dysfunction,” says Philippe Conus. “Some patients stop taking them to avoid this unpleasant side effect. That’s one of the reasons why we talk to them regularly about all side effects, to try to find alternatives and help them live a normal life.” Another danger is that sexual desire is sometimes actually one of the patient’s symptoms. “Mania in bipolar patients can be associated with a tendency towards promiscuity, disinhibition or even exhibitionism,” says Philippe Conus.
Some disorders are believed to cause unpredictable behaviour. “People with sexual perversions can become violent or dangerous,” says Catherine Agthe, sex educator and president of the organisation Sexualité et Handicaps Pluriels (SEHP). “Others have a tendency towards paedophilia or fetishes that they want to impose on others.”
The issue of the sexuality of psychiatric patients raises another taboo. “Behind the ban lies the fear that sexual relations will result in a pregnancy, a child who cannot be cared for,” says Jean-Louis Korpès. “The point is not to forbid a patient from getting pregnant. But before she makes that decision, we will discuss it with her, to see if it’s the right time in her life and how she could care for the child,” says Philippe Conus. “This way, we can offer close support during the pregnancy and after the child’s birth.” He adds that the risk of post-partum depression is higher in women with mental disorders. Some medication is incompatible with a pregnancy, and treatment needs to be adjusted.
Despite all these obstacles, many experts wonder if prohibiting sexual relations is really the right choice. “Some patients will break the rules regardless,” says Catherine Agthe. And when patients secretly engage in sexual activity, they sometimes resort to deviant behaviour that is far worse than the act itself. “They can even get obscene, with sexual acts being performed in toilets or gardens,” says Jean-Louis Korpès. “Due to the lack of information provided and absence of contraception, there is a risk of sexually transmitted diseases or unwanted pregnancies.”
Behind the ban of sexual relations between patients lies the fear that they will result in pregnancies that cannot be taken care of.
Banning sexual relations becomes less and less arguable as the age of psychiatric patients lowers. “Early intervention and prevention methods deployed over the past few years and the use of mobile teams reaching out
to the mentally ill have reduced the average age of patients,” says Philippe Conus. “At Cery, the average age is 35.” It is even less acceptable if their stay
is extended. “The average hospitalisation time is supposed to be quite short, but some residents have been and are committed for years,” says Catherine Agthe.
In some cases, sexual assistants can offer a solution. These people receive specialised training to offer disabled people sexual assistance. These sexual “surrogates” have been operating in French-speaking Switzerland since 2009 and in German-speaking Switzerland since the early 2000s. “In Geneva, psychiatric services already work with
us occasionally,” says Catherine Agthe, whose organisation trains both male and female sexual assistants in French-speaking Switzerland. “In Lausanne, they are beginning to look into the option.” Some 20% of the requests handled by SEHP come from the mentally ill.
“If one of our patients is aggressive or tense, and it seems to stem from some form of sexual frustration, we have been known to use the services of a sexual assistant,” confirms Giuliana Galli Carminati, referring to the practices
at the Belle-Idée Hospital in Geneva. However, each case had to be carefully reviewed. “This solution is only an option for patients with a sufficient level of self-control and some degree of emotional maturity,” she says. And it must remain an outpatient service, which takes place outside the hospital. “Mixing settings is out of the question,” she insists. “Medical care and sexual relations must not take place in the same environment.”
People admitted to psychiatric facilities are in a situation of intense distress and vulnerability. They’re incapable of making a well-thought-out decision on their sexuality.
If one of our patients is aggressive or tense, and it seems to stem from some form of sexual frustration, we have been known to use the services of a sexual assistant. However, each case had to be carefully reviewed. This solution is only an option for patients with a sufficient level of self-control and some degree of emotional maturity. And it must remain an outpatient service, which takes place outside the hospital.
Giuliana Galli Carminati