CASE STUDY 3

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MY SEXUAL HEALTH MATTERS

Information for people with mental health issues

1 This booklet was developed by SHine SA and the Mental Health Coalition of South Australia, and has been adapted with permission by the Mental Health Coordinating Council for use in NSW.

Research and development Gerald Graves, Paul Nestor, Wayne Oldfield, Maxie Ashton, Ralph Brew

Original text by Ralph Brew Edited by Kylie Browne Graphic design by Kylie Browne Cartoons by Simon Kneebone

Special thanks to all the people who contributed to the development of this booklet.

Any part of this document can be cited with the approval and acknowledgement of SHine SA Inc and Mental Health Coalition of SA. Contact: www.shinesa.org.au

This booklet can be downloaded from our website www.mhcc.org.au and printed as needed on your printer. MHCC does not distribute any hard copies of this booklet.

What’s this booklet about? 2

How mental health issues affect sexual health 3

How mental health issues affect relationships 4

How medication affects sexual functioning 5

What can you do? 7

Learning to please yourself 8

Talking with your doctor or health worker 9 Finding the right words 9

Keeping sexually healthy 10 What’s a sexually transmitted infection? 10 Not ready for a baby 10 What’s safer sex? 10 Sexual assault 11 Sex for favours 11 Age of consent 11

Same-sex attraction 12 Transgender 12

Note to mental health workers 13

Acknowledgements 13

Where to go for help 13

Contents

2 This booklet gives you information about how your mental health issues and medications can affect your sexual health. It aims to help you identify ways of finding joy in intimacy and sexual expression through positive and responsible behaviour.

Your sexual health and relationships influence your wellbeing. Developing healthy relationships with yourself and others can help your recovery.

If you’re having difficulties in your sex life it’s not always easy to ask for help. You may be too embarrassed to talk about it. You may feel like you are the only one.

People often notice that their medications seem to cause changes to their sex drive, arousal or physical responses to intimacy. Many drugs do have these kinds of side effects, but choosing not to take your medications can have dangerous consequences. So what are your options?

This booklet encourages you to talk with your partner, friends, doctors and health workers so you can find solutions together.

Many of the suggestions contained in this booklet have come directly from people who have experienced a mental health issue. Most of the cartoons that you see on these pages represent what they had to say. You’re not alone.

What is sexual health? Looking after your sexual health includes the ability to: • make healthy life choices without guilt, fear, shame or false beliefs • enjoy positive and healthy relationships • be treated with respect • choose behaviours that are safe and without risk of infection and unplanned or unwanted pregnancy • celebrate all positive expressions of sexuality

What’s this booklet about?

Golden rule You can enjoy your sexual health.

Many people find it difficult to enjoy positive and healthy relationships, but living with a mental health issue can sometimes make it even harder. You may feel like others are not treating you with respect, or you may have problems with your sexual functioning.

Some forms of mental health issues can also: • stop you thinking clearly about the consequences

of your sexual actions, including hurting yourself or others, or having unprotected sex which can result in unplanned pregnancy or a sexually transmitted infection

• make you more vulnerable to sexual exploitation by other people (wanting love, but just getting sex instead)

• make you hyper-sexual (wanting to have sex much more than what is normal for you)

• make you hypo-sexual (losing the desire to have any sex at all)

• cause you to be mistrustful of the people you love • cause you to be less sensitive to people you care

about • cause you to emotionally withdraw from others • affect your confidence and self-esteem • make you feel like you have no energy • be as a result of, or affected by, past or continuing

physical, emotional or sexual abuse

It can be especially difficult if your mental health issue started in your late teens or early twenties and interrupted you from discovering and building your sexual identity.

The stigma of mental health issues Mental health issues are often feared and misunderstood in our community. This can cause grief, sorrow and feelings of resentment, loneliness and depression. It’s hard to not be hurt by the negative messages you may hear.

The stigma associated with mental health issues can make management and recovery more difficult. It can also affect your sexual health. Many of these messages challenge your right to be treated with respect and experience positive and healthy relationships.

It’s important to take steps to challenge negative messages about mental health issues and sexual health.

Useful tips è Learn as much as you can about your mental health

issue and the things that help you to keep well. è Be aware that your mental health issue can affect

your sexual health and, if you experience any of the above, talk to your partner, doctor or health worker.

How mental health issues affect sexual health

4 Starting and maintaining healthy relationships is not always easy, but it can be more difficult for people with a mental health issue.

You may experience: • difficulty talking to someone • feelings of inadequacy, jealousy, fear, shame or guilt • judgement by others for having a mental health issue

It’s good to talk to the people that you’re close to about what is going on. If you find speaking to some people hard, first try talking with someone you’re comfortable with, you trust and you know will listen. Then you can sort out what you want to say and practise how you want to say it to others.

If you want or have an intimate relationship with some- one, then you may experience other problems. Some of the most common problems are: • one person wants sex more often than the other • different sexual desires, fantasies or interests • expecting too much physically or emotionally from

each other

The only way forward is to talk about what you both want and don’t like. And if you don’t feel ready for a relationship, remember being by yourself is OK too.

Women say… Women who experience a mental health issue say that they want men to learn more about what sexually pleases a woman. They don’t want pressure to have intercourse. Some medications can make arousal difficult and intercourse painful.

Men say… Men who experience a mental health issue say that they want less pressure to ‘perform’.

Useful tips è If you find talking to your partner difficult, practise

what you want to say with someone you trust first. è Talk about the things that you and your partner

enjoy and make time to do them together. è Giving each other time and space to do things

separately can make your relationship stronger.

I don’t have any money and I feel like crap! Not having enough money to spend on having fun with friends or going on dates can affect your relationships. Also if you can’t afford to spend money on yourself, you may not feel good about how you look. It’s harder to feel confident to get close to others or meet new people.

You can still feel good about yourself if you look after your personal hygiene. It sounds simple, but having a shower regularly, washing your hair and cleaning your teeth every day can help your self-esteem. And for those special occasions, spend a little extra time so you feel your best.

Useful tips è Put a little bit of money aside and save for something

special for yourself like a new pair of shoes. è Dates can be fun without spending money. Be creative.

Golden rule The key to healthy relationships is communication.

How mental health issues affect relationships

5 Different medications affect people in different ways. It depends on your mental health issue and how you respond to the medication you have been prescribed. Every medication comes with a big list of possible side effects. If you’re concerned about the possible side effects of your medication speak to your doctor.

Some common effects relating to sexual functioning include:

• reduced sexual desire is common with anti-depressants or sedatives

• the skin is too ticklish or painful to touch – for some firm touch and massage are better than soft touch, for others it’s better to have no touching at all

• trouble getting physically sexually aroused, even when sexual desire is there

• the ability to get physically, emotionally and sexually aroused, but can’t always reach orgasm

• being passive and unable to make active decisions, making you vulnerable to unwanted sexual attention

• weight loss or gain which can affect body image

• twitching and tongue chewing

• a very dry mouth and lips

• salivating too much, especially at night

• impotence in men (unable to get an erection)

A warning about very long lasting erections Priapism is a very painful erection that lasts for more than four hours and can be caused by some psychiatric drugs. If men get this side effect, this is an emergency and medical attention is urgently needed.

How medication affects sexual functioning

Do not stop taking medication because of the effects on your body or sexual functioning. This can be dangerous.

Talk to your doctor before you make any changes to your medication. They may be able to help you find a solution.

You may feel that your doctor is uncomfortable about discussing your sexual functioning, or they might not consider it important. But you have the right to ask questions about your medication. If you need help ask your health worker. If they can’t help you ask them to refer you to someone else who can.

Often doctors can use alternative drugs or other methods to fix drug-related sexual problems. This can take time. It’s not always easy to work out what’s causing a particular sexual problem.

Useful tips è Talk to your doctor or health worker about any

difficulties you’re having with your medications. è Try to explore other ways to feel pleasure in your

life.

Golden rule Do not stop taking your medications.

The important point to remember is that you or your doctor can’t always predict your reaction to a new medication.

Sometimes there isn’t always a better medication around at the time, but it doesn’t hurt to ask.

How medication affects sexual functioning

7 We asked groups of people with a mental health issue about how they look after their sexual heath and their relationships. This is what they had to say.

Useful tips from women è Learn more about your sexual health.

è Get informed about your mental health issue, the medications you’re taking and their effects.

è Ask mental health services to create more safe meeting places, support groups and other low cost activities.

è Meet with other women and talk about it.

è Use humour – there’s always a funny side.

è Reject erotica which exploits women and ignores their pleasure.

è Spend time on learning to love and pamper yourself.

è Spend quality time with yourself.

Useful tips from men è Get educated – read, take part in groups.

è Create safe spaces for people with mental health issues to meet and develop new relationships.

è If you have a partner, communicate and explore alternatives together.

è Write about what you are experiencing; write your story.

è Talk about it with your health worker and others.

è Keep talking about it.

è Be persistent and be honest.

è Ask what options are available; explore cognitive- behavioural therapy and narrative therapy.

è When seeing health workers, bring another person in with you as support. This could be a friend, a parent or whoever you feel comfortable with.

Useful tip è Talking to other people with a mental health

issue can help you understand what you are experiencing. You’ll find you’re not alone.

What can you do?

8 Simple pleasures of many kinds can have good therapeutic benefits, both physically and emotionally.

Giving yourself pleasure can include many things, like going for a walk; exercise; showering with a scented soap; having a bath in a dark room with candles burning and soft music playing; massaging your head or feet; wearing soft, slippery underclothes; or explor- ing yourself sexually in private. It’s about making your- self feel good, so use your imagination!

If you are recovering from an acute mental health issue, exploring your body and learning how to please yourself can help you understand what has changed. Find out what does and doesn’t feel good. Develop a new physical relationship with yourself. If you have a sexual partner, you can then talk about what you have learnt.

Some women have been brought up to believe that they shouldn’t focus on their own sexual pleasure. This can make it difficult for women who have experienced mental health issues to confidently get to know their bodies again, especially through masturbation.

Masturbation is usually thought of as being stimulation of the penis or clitoris, but the whole body can also be involved.

For men, masturbation exercises the prostate and helps keep it healthy. Men can also use masturbation to train themselves to delay orgasm.

Any sexual activity must be in private. If you live in hostel accommodation or live with others you might have less privacy than you’d like. If you feel like sexual activity is always rushed because you might be walked in on, organise some private space and time. It’s okay to ask for help to make arrangements to give you some privacy.

Useful tips è Plan ahead and make private time to be alone. è Cheap water-based lubricants can make masturbation

more comfortable and intense. You can find KY, Ansell Personal Lubricant, WetStuff, Glyde Gel or Surgi-lube in pharmacies or supermarkets.

è Remember hygiene! Make sure you clean and wash up after yourself.

è Think about enjoying the feel of other parts of your own body; ears, skin, nipples, feet or buttocks.

è If you don’t like it, don’t do it!

Golden rule Only do things which feel right for you and don’t cause you or anyone else injury.

Learning to please yourself

9 Sometimes it’s embarrassing talking about sexual matters, but problems probably won’t go away by themselves. It’s important to have a safe place to ask questions, get accurate information and talk about your sexual health. And that’s where your doctor or health worker may be able to help you. If you prefer to talk to a different health worker, for example someone of the same sex, it’s OK to ask.

Don’t worry about embarrassing your doctor or health worker with questions about your sexual health. It’s their job to help you. They should: • treat you with respect • listen to the problems you want to talk about and

be sensitive to your experiences • investigate the possible causes • work with you to find solutions to the problems

If you are experiencing difficulties with your sexual health, finding a solution can involve: • changing or reducing your medication • relationships and sexual health counselling • examining how you could change the way you do

things

Enjoy the things you can do and accept the things you can’t change. Talking with your doctor and health worker can help you understand your choices. They are likely to want to help. You might be pleasantly surprised about how understanding they are.

Golden rule Talk about it. Your doctor or health worker need to know what the problems are so they can help.

Finding the right words Sometimes you might feel like you are struggling to find the right words to say what you want. Women’s sexual organs are less visible and can be particularly difficult to discuss in a comfortable way.

You may feel pressured to use the correct medical terms. You might find it difficult to describe how you’re feeling or what’s going on with your body.

That’s OK. Just do the best you can. Your confidence will increase the more you talk about your sexual health and it won’t seem as embarrassing.

Useful tips è Use whatever words you need to get your point

across. è Use a few slang words if it helps. è Be creative. Don’t be scared.

Useful tips è Try writing down the main issues on a piece of

paper and ask your doctor or health worker to read it. You might even like to show them this booklet. Both can be good starting points for discussion.

è If you find it’s too embarrassing to talk about with your doctor or health worker, get someone you trust to talk to them with you.

Talking with your doctor or health worker

10 It’s important for you to have the knowledge, skills and confidence to make informed decisions about your sexual health. This will help you avoid the risks and keep you sexually healthy.

What’s a sexually transmitted infection? Anytime you have close body contact with another person you can exchange a range of germs. Most germs aren’t harmful, but there are some that are transmitted sexually, called sexually transmitted infections (STIs). The most common STIs are chlamydia, herpes and genital warts. A less common STI is HIV/AIDS.

STIs can cause serious infections, with pain, infertility and other problems if they are untreated by a doctor. Often there aren’t signs or symptoms. That’s why it’s important to protect yourself. If you’re sexually active always practise safer sex. A condom will reduce the risk of STIs if used correctly and it covers the infected area.

If you are sexually active you should have a sexual health check every six months. See your doctor about it or visit a sexual health clinic. Testing is simple. Often all you need is a urine test. And most STIs are easily treated. So look after your health and have regular check-ups.

Not ready for a baby If you’re not ready for a baby there are many ways you can prevent a pregnancy. Men can wear condoms. Women have many options, including taking the Pill or having a contraceptive implant or injection. Speak to a doctor or health worker to get advice on what method might be best for you or your sexual partner.

Emergency contraception (EC) is now available from pharmacies to reduce the risk of pregnancy. It can be taken up to 5 days after unprotected sex, but it’s more effective the sooner it’s taken. EC shouldn’t be used as the regular method of contraception.

What’s safer sex? Safer sex is about reducing the risk of STIs and unplanned pregnancy. It also includes choosing sexual behaviours that protect you and your partner from violence, harm and exploitation.

It’s important to talk to your partner about what you want and expect. In return, you should listen to what they want and how far they’re prepared to go. Don’t pressure anyone to do things they don’t want to do.

Not everyone wants sexual intercourse. That’s OK. It’s your right to say no at any point. Explore other ways to express your feelings. Many people enjoy kissing, cuddling, stroking, mutual masturbation or sensual massage.

If you’re going to go all the way, then make sure you’re prepared. Using condoms can reduce the risk of STIs and unplanned pregnancy at the same time. They’re easy to buy from supermarkets, pharmacies, sexual health centres, petrol stations and vending machines. Don’t forget to use water-based lube.

Useful tips è Find out more about contraception. Refer to the

contacts at the end of this booklet. è See a doctor to

discuss your options. è If you think you might be pregnant talk over

your choices with someone you trust.

è Not all STIs have visible symptoms. So if you’re having sex, practise safer sex and get

tested for STIs regularly.

Keeping sexually healthy

11 Golden rule No ALWAYS means no.

Sexual assault You have the right to be safe from sexual abuse of any kind. If someone threatens to hurt you, touches you in a sexual way without consent, or forces you to take part in any type of sexual activity against your will, it is a criminal offence and you can make a complaint with the police.

Unfortunately people who experience mental health issues can be more vulnerable to sexual exploitation and assault. The experience of being sexually assaulted is damaging to someone emotionally and mentally, as well as physically. It happens to both women and men.

Most sexual assault victims know the person who assaulted them. It may even be their partner. If you’re in a relationship you still have the right to say no.

No-one asks to be sexually assaulted or raped. A person who sexually assaults someone else is 100% responsible for their actions.

For some people a mental health issue is associated with a history of childhood sexual abuse. It is never OK for an adult to be sexual with a child.

Any sexual activity must be with consent. Never assume you know what another person wants.

Useful tips è If you are sexually assaulted, report it as soon as

you can to someone you trust and get help to prevent it happening again.

è Break the silence. If you have a history of sexual abuse as a child, speak to a professional who can give you counselling and support.

è Stop the violence. If you have a history of sexually assaulting others, you can stop. It’s OK to ask for help.

Sex for favours Some people with a mental health issue get offered money, food, cigarettes or shelter in exchange for sex. This can be with someone they don’t know or don’t like. Sex in this situation is not always safe and sometimes it can leave you feeling bad about yourself.

If you find that you are under pressure to have sex for favours or money, please speak to a worker you trust. They might be able to help you find ways of saying ‘no’ or at least ways of staying safe.

Age of consent In NSW the age of consent is 16 for heterosexual people and 18 for homosexual people.

Keeping sexually healthy

12 Being sexually or romantically attracted to the same sex is not a mental illness, but being bisexual, lesbian or gay in an unfriendly world can leave some people feeling confused or like they don’t belong. If this is your experience, you are not alone.

If you’re feeling like you’ve got no-one to talk to, ask your health worker for support. You may like to ask them to refer you to a peer support group. There are also phone numbers attached to this booklet.

People who are attracted to the same sex have as much right to acceptance, love and companionship as anyone else. You have a right to be treated with respect by your house-mates, house-staff, landlord, doctors, health workers, shop-keepers, teachers or employer.

If you believe that you are experiencing discrimination because of your sexuality, speak to a person you trust about this. You might be able to get help from the NSW Anti-Discrimination Board.

Useful tips è Don’t accept being put down by others. è Tell people when their words or actions are hurtful

to you. è If you feel like things are not getting better, ask for

help.

Golden rule You have a right to feel safe.

References Baldwin D & Thomas S 1997 Depression and Sexual Function, Martin Dunitz Cohen A, Stachel L & Sanders B 2002 The Uses of Natural Products in the Treatment of Female Sexual Dysfunction, http://www.priory.co.uk/psych/sexherb.htm Giles, G 2003 ‘Sexual factors and prostate cancer’ BJU International, Vol 92, Blackwell Science Levine, S 2003 Clinical Sexuality for health professionals, Taylor & Francis Inc, United States of America Maurice, W 2003 ‘Sexual Medicine, mental illness, and health professionals’ Sexual and Relationship Therapy, Vol 18, No. 1, British Association for Sexual and Relationship Therapy, Brunner Routledge World Health Organization 2000 Consideration for Formulating Reproductive Health Laws http://www. who.int/reproductive-health/publications

Transgender Transgender people are those who feel like they are the opposite sex to the one they were physically born as. This is listed by medical authorities as a disorder, but there is growing acceptance that transgender people need acceptance and support. The Gender Centre in Sydney provides a wide range of services for people with gender issues, their partners, families, friends and employers. These include counselling, education, support, referrals to medical and other specialists, social and support groups and outings, legal, welfare, housing and other community services.

Same-sex attraction

13 Research shows that only one-third of people having sexual side effects because of medications will mention them to their doctor without being directly asked.

The people with a mental health issue who were consulted when developing this booklet suggested that silence and embarrassment on both sides can prevent sexual issues being raised for discussion. Do you wait for your client to raise sexual health matters?

Some mental health consumers find that their workers are sensitive and responsive. These workers are prepared to discuss sexual difficulties and will do all they can to help. Others have had negative responses. Being told ‘it’s all in your head’, for example, can reinforce existing phobias or the sense of being ‘disembodied’, a common experience for many people with a mental health issue. How do you respond?

This booklet also offers consumers some ideas for thinking about sexual health differently. Many of the suggestions have come directly from consumers’ own experience. How can you help?

Mental health consumers would like their psychiatrists, psychologists and other mental health professionals to be approachable and informed about sexual health, relationships and sexual functioning issues. How can you raise these issues as part of their assessment?

Please don’t wait for mental health consumers to raise the issue first.

The authors hope that this booklet can be used by you to help start the discussion now.

The need for information on sexual health and medications was identified by a group of South Australian mental health consumers. Workers from SHine SA and the Mood Disorders Association had also been having discussions about sexuality and sexual functioning with mental health consumers over several years. The consumer group and the workers joined forces to address this issue and this booklet is the result.

The following medical and mental health professionals were also consulted about the content of this booklet: • Professor Ann Crocker from the Mental Health

Coalition • Ms Robyn Brodie from Southern Yorke Peninsula

Health Service • Mr John Bauer and Ms Maxie Ashton from Port

Adelaide Mental Health Service • Dr James Hundertmark from Queen Elizabeth

Hospital • Dr Katrina Allen from SHine SA

This booklet was developed by SHine SA and the Mental Health Coalition of South Australia, and with their permission has been adapted initially for Northern Sydney Central Coast Area Mental Health by Ms Paula Hanlon and then for NSW by the Mental Health Coordinating Council.

If you would like help with any of the issues discussed in this booklet, please talk to your health professional or mental health worker.

There are a number of specialist services also available for you to talk to. Please consult the special list attached to this booklet or check MHCC’s website: www.mhcc.org.au

Note to mental health workers Acknowledgements

Where to go for help