Critical Reflection
8 SEXUAL HEALTH IN
MENTAL HEALTH PRACTICE JO BATES
Learning outcomes
By the end of this chapter you should be able to:
• Consider the concept of sexual health • Identify some of the most prevalent sexually transmitted infections (STIs),
including signs and symptoms, treatment and prevention • Discuss contraceptive methods, including their advantages and disadvantages • Explore the role of the mental health practitioner in facilitating good sexual
health
INTRODUCTION
This chapter will introduce the concept of sexual health and relate this specifically to the needs of clients with mental health problems. Sexual health is a broad, diverse, multifaceted and challenging area of health care and the term ‘sexual health’ often means different things to different people. Some may immediately think of illness and infections such as sexually transmitted infections (STIs) and human immunodeficiency virus (HIV), whereas others may think of contraception or women’s health, including cervical smears and breast screening. Indeed, sexual health does include these topics, but it also includes much more than that.
Sexual health is holistic, involving the whole person in both body and mind and affecting each and every one of us throughout our lifespan, whether we are ill or not.
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Good sexual health is essential to good general health and to our sense of wellbe- ing and quality of life, whether we choose to be sexually active or not. There are many definitions of sexual health and the one below is offered by the Department of Health (DH) (2001: 7):
Sexual health is an important part of physical and mental health. It is a key part of our identity as human beings together with the fundamental human rights to privacy, a family life and living free from discrimination. Essential elements of good sexual health are equitable relationships and sexual fulfilment with access to information and services to avoid the risk of unintended pregnancy, illness or disease.
While this definition shows the importance of sexual health to our identity, it is focused largely on the prevention of illness, infections and unintended pregnancy. A further definition from the World Health Organization (WHO) (2012) takes a more holistic view in that it sees sexual health as:
a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coer- cion, discrimination and violence.
Essentially, as stated by Quinn and Browne (2009), sexuality and sexual health are vital components of our life, playing a key role in the overall quality of life and in our general wellbeing. World Association for Sexual Health (1999) go on to advocate that sexual health involves sexual rights that are a basic human given and these are as follows:
• The right to sexual freedom • The right to sexual autonomy, sexual integrity and safety of the sexual body • The right to sexual privacy • The right to sexual equality • The right to sexual pleasure • The right to emotional sexual expression • The right to sexually associate freely • The right to make free and responsible reproductive choices • The right to sexual information based on scientific inquiry • The right to comprehensive sexuality education • The right to sexual health care
While sexual health is an important aspect of life, it is an issue that is often over- looked in health care practice. Several studies have shown that nurses do not discuss sexual matters with their clients for a variety of reasons, most commonly a lack of knowledge, conservative attitudes, fear of offending clients and embarrassment (McCann 2003; Brown et al. 2008; Matevosyan 2009; Quinn and Browne 2009). Other factors, such as lack of time, fear of being perceived as encouraging sex and
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the perceived risk of creating emotional turmoil, have also been found to hinder some nurses discussing sexual matters with their clients (Brown et al. 2008). Johnson et al. (2002) add that wider health professionals are also reluctant to dis- cuss sexual issues, largely due to a belief that such matters are personal, thus rein- forcing that sexual health is a neglected area of health care.
To compound this, Wakley et al. (2003) report that clients are also reluctant to discuss sexual matters, stating similar reasons to that of health care profession- als, such as being embarrassed and feeling ill at ease. In addition, clients state that they feel humiliated, ashamed, are worried about being judged and of having their partner present, unease about their sexuality and concerns about confidentiality. Furthermore, McCann (2003) and Higgins et al. (2006) found that clients are often unaware that their illness or treatment may have consequences in relation to their sexual health, thus suggesting a lack of knowledge that appears currently to be shared with the health professional.
Given the reluctance of both health professionals and clients to discuss sexual health, it is unsurprising that this is a commonly neglected area of practice, but with poten- tially long-term consequences to both physical and mental health the situation needs to change. It is imperative, therefore, that all health professionals who work with peo- ple with mental health disorders feel confident to at least bring up the topic of sexual health with their clients and that they also have a basic knowledge of this sensitive and important area of health care. Being an expert is not a requirement of addressing this topic; indeed, taking that first step of initiating a discussion could well make all the dif- ference. Before going further, consider the issues raised in Action Learning Point 8.1.
Action Learning Point 8.1
Consider the following;
• Do you talk to clients/patients about sexual health issues? • If not what stops you? • What level of knowledge do you have in relation to sexual health? • Do you need to develop this knowledge further?
SEXUAL HEALTH AND INDIVIDUALS WITH MENTAL HEALTH PROBLEMS
There is evidence to suggest that individuals with mental health problems are at an increased risk of poorer sexual health when compared with the general population. In particular, the risk of contracting STIs and HIV is higher than in the general popula- tion, as is the possibility of having an unintended pregnancy (Rosenberg et al. 2001; Brown et al. 2006; Carey et al. 2007; Brown et al. 2008; and Matevosyan 2009).
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According to Farr et al. (2010), 20% of women with mental distress do not use contraception, or when they do, they use contraception that is less effective. An unfortunate consequence of unintended pregnancy in a woman with a mental health disorder is a potential worsening of their condition, resulting in adverse out- comes for both mother and baby (Farr et al. 2010). In relation to STIs, research by Matevosyan (2009) showed that 34% of patients with an STI also had a co-morbid mental health disorder. While both of these studies were conducted in the USA, and may not therefore be generalised to other countries or populations, it certainly pre- sents food for thought.
Chronic illnesses, which include many of the mental health disorders, can also have a significant impact on an individual’s (and consequently their partner’s) sexual health as these affect libido, self-image and general physical and psychological wellbeing. This in turn can influence decision-making and choice (Warner et al. 1999). An exam- ple is the documented assertion that people with a mental health disorder are more likely to engage in risk-taking behaviour such as having sex at a young age, having unprotected sex, engaging multiple partners who may themselves be in a high-risk group, injecting drug use and sex trading (Rosenberg et al. 2001; Brown et al. 2008; Quinn and Brown 2009).
There are also further considerations in relation to the vulnerability of individuals with a mental health problem, starting with the proposal that they are at increased risk of experiencing periods of homelessness, social disadvantage and poverty, all lifestyle issues that can add to their potential for vulnerability to sexual health prob- lems (Drake et al. 1991; Berkman and Kawachi 2000; Carey et al. 2007). Treatment for mental health disorders can also cause side-effects linked to sexual dysfunction and, conversely, the condition itself may cause an array of sexual problems, all of which impact on general health and wellbeing, but more specifically on sexual health and wellbeing.
SEXUALLY TRANSMITTED INFECTIONS (STIs) STIs are infections contracted via sexual contact with another person and are caused by bacteria, viruses or protozoa. The long-term consequences of undiagnosed and untreated STIs are serious and sometimes fatal, and they present a major public health problem in the world today (Adler 2004). STIs have been known about for centuries, with some well-known individuals from history acquiring STIs. Today STIs are still often associated with stigma and shame because of the nature of how they are contracted and this stigma can present a huge barrier to individuals access- ing treatment (Bannerman and Proom 2009). Additionally, the risk of contracting an STI or HIV is linked with the type of sexual activity and number of partners, and the risk increases the more sexual partners a person has (Wakley et al. 2003). How- ever, it is important to recognise that an individual may only have sexual contact with one person but if that person has an STI or HIV then there is the potential for cross-infection. Remember that not everyone with an STI has had sexual contact with multiple partners.
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The long-term consequences of untreated STIs can be devastating. Chlamydia, for example, may be asymptomatic but can result in symptoms such inter-menstrual bleeding and pelvic inflammatory disease in women, which in turn can cause ectopic pregnancies and infertility. In men, the infection may result in urethral discharge, proctitis, conjunctivitis and reactive arthritis (Richens 2004). The World Health Organization (2000) describe STIs as falling into one of four groups:
• Viral infections (including HIV, acquired immune deficiency syndrome (AIDS), herpes sim- plex 1 and 2, human papilloma virus (HPV), hepatitis B and others)
• Bacterial infections (including chlamydia, syphilis, gonorrhoea, trichomonas, garde- nerella and others)
• Yeast infections (including candidiasis and others) • Infestations (including pubic crabs, scabies and others).
An understanding of the common STIs, routes of transmission and signs and symp- toms is invaluable for health care professionals.
• Chlamydia – The most commonly diagnosed STI in young men (age 20–24) and women (age 16–19) in England, Wales and Northern Ireland. It can be transmitted from one mucous membrane to another, e.g. throat, eyes and anus, by close physical contact. Chlamydia can also be transmitted from mother to baby during labour.
Signs and symptoms: Asymptomatic in up to 80% of women and 50% of men; women may also experience post-coital bleeding, inter-menstrual bleeding, vaginal discharge, pelvic inflammatory disease; both genders may experience genital inflammation and swelling, sore throat, pain on urination and lower abdominal pain.
Treatment: Oral antibiotics
• Gonorrhoea – Transmitted by close physical contact from one mucous membrane to another. Easily transmitted via vaginal, oral and anal sex. Can be transmitted from mother to baby.
Signs and symptoms: Up to 50% of cases in women and 10% in men will be asymptomatic; symptoms include genital discharge, lower abdominal pain and pain on urination.
Treatment: Oral antibiotics
• Syphilis – The primary route of transmission is via sexual contact but syphilis can also be transmitted from mother to child. If untreated, it leads to a systemic disease with a vari- ety of clinical complications which over time may be fatal.
Signs and symptoms: Painless ulcer (chancre) at site of exposure (usually genitals, perianal area or mouth), skin rash and systemic illness.
Treatment: Treated with antibiotics via intramuscular (IM) injection preferably, but can be treated with oral antibiotics.
• HIV – Viral infection transmitted via sexual contact, blood to blood (e.g. needlestick injury or infected blood products being transfused), mother to baby. It can take up to three
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months for antibodies to appear in the blood following infection with the virus. This is called the ‘window period’. Testing for HIV antibodies should therefore take place at time of exposure and then be repeated three months later.
Signs and symptoms: Upon initial infection the following signs and symptoms may occur (although they often go unnoticed or are put down to having a cold or feeling ‘off colour’ as most people will recover within 2–4 weeks): high temperature, fatigue, skin rash, myalgia, headaches, sore throat, mouth ulcers, swollen lymph glands, nausea, diarrhoea, weight loss, night sweats, oral thrush, cough (not an exhaustive list). If the virus remains undetected (many people will be asymptomatic), it will over a period of time start to damage the immune system of the infected person. They will then become susceptible to infections such as oral thrush, vaginal thrush, gastro-intestinal infections resulting in diarrhoea, pulmonary infections, herpes simplex infections, skin cancer and pneumonia (not an exhaustive list).
Treatment: At this point in time there is no cure for HIV or AIDS, although modern drug treatments have greatly improved both the quality and length of life for those infected with the virus.
• Genital warts – Many types of warts have been detected (over 100) and they are caused by the human papilloma virus (HPV). Certain strains cause genital and perianal warts, and some strains have been associated with cervical cancer.
Signs and symptoms: Single or multiple fleshy growths which are painless and may or may not be itchy; can cause psychological distress as they may reoccur.
Treatment: Various treatments available.
• Genital herpes (herpes simplex virus HSV) – HSV 1 usually affects the lips and mouth area. HSV 2 usually affects the ano-genital area. It is, however, possible to transfer both types so that HSV 1 is found in the genital area and HSV 2 is found in the mouth and lips. Transmitted by skin-to-skin contact with a herpes lesion (blister), such as during kissing, oral sex or other sexual contact. Mother to baby transmission can occur.
Signs and symptoms: For both men and women the infection may cause tingling, burning or itching sensation; small fluid filled blisters appear at the site of infection which are very painful; in the genital region the blister may make passing urine painful, sometimes resulting in urinary retention which requires catheterisation and hospital admission; can cause pyrexia and myalgia and flu-like symptoms.
Treatment: Various treatments for the symptoms are available and analgesia may also be required during an outbreak.
• Hepatitis B – Can be transmitted by sexual contact, via blood and blood products and from mother to baby.
Signs and symptoms: May be asymptomatic in the acute phase for some people; can cause flu-like symptoms, lethargy, diarrhoea, fever, loss of appetite and weight loss, nausea and vomiting, jaundice of the skin, itchy skin, upper right-sided abdominal pain.
Treatment: Referral to a doctor is required for monitoring of the condition. Immunisation against the infection is available.
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• Hepatitis C – Transmitted via IV drug use, infected blood and blood products, body pierc- ing and tattoos with unclean needles. Transmission via sexual activity and from mother to baby carries a lower risk.
Signs and symptoms: Over 80% of people are asymptomatic but the following may occur: tiredness, nausea.
Treatment: Referral to a doctor is required for monitoring of the condition. No immunisation is currently available (Richens 2004; Peate 2005; Bannerman and Proom 2009).
THE ROLE OF THE MENTAL HEALTH PRACTITIONER
Appropriate awareness and knowledge of sexual health are a prerequisite of quality care for people with mental health problems. Strategies include the incorporation of sexual health within a systematic physical health assessment (discussed further in Chapter 2) and the promotion of effective contraception and safer sex.
SEXUAL HEALTH ASSESSMENT The most important thing that a mental health professional can do to enhance the sexual wellbeing of their clients is to engage them in a discussion regarding their sexual health. It is imperative not to stereotype people according to race, gender, sexual activity, age or illness, but to assess each person’s risk on an indi- vidual basis. While mental health practitioners are well versed in communication and engagement strategies, they are unlikely to feel equipped to discuss sexual health issues as few health professionals receive training in this potentially delicate art. The core skills, however, remain unchanged and so mental health profession- als should feel confident in employing their existing proficiency in relationship development and complement these with some key prompt questions specifically focused on sexual health.
If the discussion is part of a formal assessment, it may feel more comfortable to tell the client that sexual health is part of the holistic approach and that the ques- tions that are about to be asked are standard for everybody. To break the ice, ask- ing whether the client is in a sexual relationship currently can be a good starting point, followed by enquiring whether they, or their partner, are having any sexual difficulties. If the client appears willing to discuss this, then asking whether they are satisfied with their sex life and whether they have any sexual concerns they would like to discuss are good open questions that can elicit information and encourage discussion. Once the client has started to open up, the aim will be to take a fuller sexual history with a question such as ‘Would you mind telling me about your sexual history?’ With an added prompt such as ‘Perhaps your first sexual experience?’ or
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‘Could you tell me how many partners you’ve had?’ This may identify negative and/ or abusive experiences and, while the mental health practitioner should be aware of and sensitive to this, it does not have to negate continuing with the assessment. Instead, clinical judgement will need to be applied.
When taking a sexual history it is important to consider both past and present circumstances and questions should be aimed at identifying sexual behaviours and orientation, sexual difficulties or concerns, sexually transmitted diseases, contracep- tion methods and alcohol and drug use (prescribed and recreational). Whether safe sex has and is still being practised is a key area for exploration and an excellent lead into the promotion of sex education.
Where the discussion of sexual health falls outside a formal assessment, perhaps in a routine visit or a conversation on a ward, the practitioner may want to think about initiating the conversation by asking clients how they are finding their medica- tion and whether they have experienced any disruption to their sexual functioning as a result. Similarly, where clients are using drugs or alcohol, it may be appropriate to ask if these have had any impact on their experience or behaviour in relation to sex. In both situations the fact that sexual ill-health can be a consequence can provide a rationale to the client for initiating the conversation, which will also help normalise anything the client may wish to raise.
Many STIs have common presenting signs and symptoms which should act as a trigger to indicate that a client should be advised to attend a sexual health screen- ing unit. There is no suggestion that mental health professionals conduct physi- cal examinations; rather, they are encouraged to be attuned to the cues that may indicate a need for referral. These cues could include vaginal discharge and pos- sibly (but not always) vaginal discomfort and irritation, genital ulceration and urethral discharge (Adler 2004). Discharge from the penis in men is abnormal and requires further investigation, whereas in women some vaginal discharge is normal. However, if the vaginal discharge becomes offensive in smell, itchy, more purulent or changes from what is considered normal by the woman, this will require further investigation (Bannerman and Proom 2009). It is helpful to remember that in many cases STIs co-exist together so if a person is infected with one STI, they will need to be fully screened as it may be that they are also infected with another STI as well.
SEXUAL HEALTH PROMOTION AND CONTRACEPTION
Health promotion is an important part of any health professional’s role. Indeed, professionals will be familiar with the Ottawa Charter, which states that ‘Health promotion is the process of enabling people to increase control over and to improve their health’ (World Health Organization 1986: 1).
This is an apt definition when considering the purpose of sexual health promo- tion. Ultimately, the aim is to equip individuals with knowledge and skills to take
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control over the sexual health choices they make. This should be delivered in a non-judgemental and supportive way by health professionals who have at least a basic understanding of sexual health matters, have the ability to communicate effec- tively with others and be self-aware (Ingram-Fogel 1990, cited in Rowe et al. 2009). The latter is particularly important given the wide array of sexual preferences in terms of sexuality and sexual behaviours (promiscuity, fetishes) which you may encounter. In order to enhance your own self-awareness, it is therefore important that you take some time to consider your beliefs and values and Action Learning Point 8.2 will assist with this.
Action Learning Point 8.2
• Do you have any strongly held beliefs and values about sex and sexual behaviour? • If so, what are these and how did you come to hold these beliefs? • Do you make assumptions about a person’s sexual identity and sexual preference?
Most of us tend to assume that most people are heterosexual or ‘straight’ when in fact this may not be the case. Burrows (2011) states that in the UK it is estimated that between 0.3% and 10% of the population report as being lesbian, gay or bisexual (LGB). Indeed, people who are LGB suffer health inequalities due to factors such as social exclusion, inappropriately designed services and lack of awareness among health professionals (Burrows 2011). When considering people with mental health problems this is likely to be compounded even more. A small way in which a difference can be made in relation to becoming more inclusive is to consider the language you use. For example, when dealing with a woman do you refer to her husband? If so, unless you know otherwise, this is making assumptions. First, does the woman have a partner or is she single? Second, if she does have a partner is that person male or female? Try to use words such as ‘your partner’. If assumptions are made about a person’s sexuality and sexual preferences it is very difficult for them to correct that assumption as they may be unsure and even fearful of the reaction and response they may get.
When promoting sexual health with clients it is also extremely important that the mental health practitioner is able to be non-judgemental. To do so you may need to put aside your beliefs and values and focus on maximising the sexual wellbeing of your client. This may not be easy and can cause emotional conflict for some. If this is the case for you, then you should seek help and support yourself in order that you can resolve any personal issues to enable you to work more effectively in your professional role.
Encouraging men and women to use an effective method of contraception, facilitating access to contraception and contraceptive services is an extremely
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important part of sexual health care. This has the dual aim of protecting against STIs and preventing unplanned pregnancies, thus enabling people to choose when and if to reproduce.
There are many factors to consider when advising about contraception for women with a mental health disorder. For example, St Johns’ Wort is a herbal preparation available in many pharmacies, chemists and herbal stores and is used to help alleviate low mood. However, it can interfere with the Combined Oral Contraceptive pill (COC) commonly known as ‘the pill’ and the Progestogen Only Pill (POP), commonly known as the ‘mini pill’, potentially affecting their efficacy (Guillebaud and Macgregor 2009; Glasier and Gebbie 2008; Bekaert and White 2006). Break through bleeding (BTB), or spotting bleeding as it is sometimes called, can be a disadvantage of progestogen-only methods of contraception such as the mini pill and Depo Provera, and this may not be well tolerated in some women with a mental health disorder (Matevosyan 2009). When considering contraception it is important to note that only condoms protect against the transmission of STIs and HIV, and only if they are used correctly each time the person has sex. Therefore health professionals should take the opportunity to discuss the use of condoms even if the person is using a hormonal method of contraception such as the COC. The hormonal method will protect against unintended pregnancy and condoms will protect against STIs and HIV.
There are a range of Medical Eligibility Criteria (MEC) developed by the World Health Organization (2012) to assist and guide health professionals when advising and prescribing methods of contraception (2012). Contraceptive methods are cat- egorised according to the presence of specific illnesses or conditions. Contraception is considered in terms of whether the advantages of using the method outweigh the risks of taking it. Those eligible should not have a condition for which there is a restriction for the use of the contraceptive method, or the theoretical or proven risks usually outweigh the advantages of using the method. The contraceptive method should not be used if this represents an unacceptable health risk or where the advan- tages of using the method generally outweigh the theoretical or proven risks (WHO 2012). In the UK, they have been adopted and adapted by the Faculty of Family Planning and Reproductive Health Care in 2006 and are referred to as the UKMEC (French 2009).
Mental health practitioners cannot be expected to be expert in contraception, but it is helpful to have a basic understanding of the contraceptive methods available and their advantages and disadvantages. It is important that you encourage both men and women to seek expert advice, especially if they are taking any form of medication and/or have any medical conditions. Table 8.1 outlines common contraceptive methods and their advantages and disadvantages. It is also important to reiterate that the majority of contraceptive devices do not protect against STIs and, as such, clients should always be advised to use condoms in addition to their chosen method of contraception.
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Contraceptive method Advantages Disadvantages
Male condom 85–98% effective
Widely and easily available The only contraceptive method that protects against STIs and HIV when used correctly and consistently. Available over the counter or via the internet. Available in various colours, flavours, sizes, etc. There are no medical side effects.
Some people say it interferes with the spontaneity of sex and some men report feelings of reduced sensation. Latex sensitivity can occur – alternative non-latex condoms must be used for people with a latex allergy.
Female condom 79–95% effective
Reduced sensation is less likely for the male. An effective method that is controlled by the woman. Available over the counter or via the internet. Protects against STIs. Made of strong polyurethane so there is reduced risk of splitting when compared with the male condom.
Not suitable for women who dislike touching their genitalia. Unattractive appearance. Can be noisy during sex. Penetration can sometimes occur outside the condom and sometimes the condom may be pushed up into the vagina.
Diaphragm 84–94% effective
Woman controlled. Can be used by women who are breastfeeding. Spermicide use provides additional vaginal lubrication. Gives some protection against pelvic inflammatory disease. Gives protection against pre- malignant disease and carcinoma of the cervix. Reusable. Can be inserted up to several hours before intercourse. No hormonal side-effects.
Latex sensitivity can occur. Risk of toxic shock syndrome if the diaphragm is left in situ over a prolonged period. Not suitable for women who dislike touching their genitalia. Needs to be refitted if the woman gains or loses 7lbs of weight and also following childbirth and pelvic surgery. Requires insertion before intercourse. Spermicide can be messy. Initial fitting must be carried out by a trained doctor or nurse. Does not protect against STIs and HIV. May cause some loss of sensation for the woman and also some discomfort. Increased risk of urinary tract infections. Must be motivated to continue using this method.
Combined Oral Contraceptive pill (COC), commonly
Highly effective if taken correctly and consistently. Regulates menstruation so periods can be predicted.
Not suitable for all women therefore expert advice should be sought Does not protect against STIs and HIV.
Table 8.1 Common contraceptive methods
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Contraceptive method Advantages Disadvantages
known as the pill, 92–99% effective
Reduces PMT symptoms, bleeding and menstrual pain. Provides protection against ovarian, endometrial and bowel cancer. Reduces ovarian cysts. Nearly 100% reversible. Does not interfere with sex.
Side-effects can include: break through bleeding (BTB) or ‘spotting’ bleeding, nausea, breast tenderness and mood changes, headaches, migraines, weight gain, depression, reduced libido. Efficacy may be affected by some medicines such as St John’s Wort, some anticonvulsants, some antibiotics and some antiretrovirals. There may be a slight increase in risk of breast cancer, although this is uncertain. There may be an increased risk of thrombosis and stroke for some women – this risk increases if the woman smokes and is over 35 years old. Long-term use of the COC (over 8 years) may slightly increase the risk of cervical cancer.
Progestogen Only Pill (POP) commonly known as ‘the mini pill’ 96–99% efficacy with consistent use
Does not contain oestrogen and may therefore be suitable for women who are unable to take the COC. Effective method of contraception if taken correctly and consistently. Can be used by women who are breastfeeding. Does not interfere with sex.
Although the POP is very safe, there are a few women for whom the POP is not suitable, therefore expert advice should be sought Must be taken within a 3-hour margin every 24 hours (Cerazette 12-hour margin). Ovarian cysts and risk of ectopic pregnancy in conception does occur. Some women report weight gain, acne, breast tenderness, spotting, bleeding and erratic bleeding patterns. Does not protect against STIs and HIV.
Progestogen only injection (Long-Acting Reversible Contraception [LARC]) 99–100% efficacy
Highly effective method of contraception. Does not contain oestrogen and may therefore be suitable for women who are unable to take the COC. Does not interfere with sex. Need to have a repeat injection every 12 weeks so do not have to remember to take a pill daily Protects against pelvic infection and cancer of the uterus. Not affected by other medicines.
Not suitable for all women therefore expert advice should be sought Have to wait at least 12 weeks for the effects of the injection to subside. Need to return to health provider for repeat injection every 12 weeks. Reported side-effects include weight gain, spotting, irregular bleeding, mood changes, breast tenderness and loss of libido. Delay in return of fertility from a few months up to 18 months on stopping the injection.
(Continued)
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Contraceptive method Advantages Disadvantages
Can be used by women who are breastfeeding. Some women will have no bleeding which can be seen as an advantage.
Does not protect against STIs and HIV. There is a possible link between the progestogen injection and an increased risk of osteoporosis.
Intra-Uterine System (IUS) known as the Mirena Coil and Intra-Uterine Device (IUD) commonly known as ‘the coil’) Both methods are LARCs 97–99% efficacy
Both devices are highly effective methods of contraception. Long-lasting between three and five years depending on device used. Does not interfere with sex. Can be used by women who are breastfeeding. Does not contain oestrogen and therefore may be suitable for women who are unable to take the COC. Fully reversible on removal. Mirena coil can be used to treat heavy and painful periods.
Needs insertion by a qualified doctor or nurse. Insertion may be uncomfortable for some women. Small risk of uterine perforation. The IUD may increase menstrual blood loss. There may be some progestogen side- effects with the Mirena coil, such as spotting bleeding. Does not protect against STIs and HIV.
Progestogen implant known as Implanon and Nexplanon Efficacy >99% It is a LARC method
Highly effective method of contraception. Long-acting (three years). Fully reversible on removal Does not contain oestrogen and may therefore be suitable for women who are unable to take the COC. Does not interfere with sex. Can be used by women who are breastfeeding after six weeks following the birth. No evidence that it affects bone mineral density.
Needs insertion and removal by a qualified doctor or nurse. Small risk of complications following insertion, such as infection, bruising, bleeding and scarring. Sometimes may be difficult to remove. Possible side-effects, including weight gain, headaches, breast tenderness, altered bleeding pattern, such as spotting bleeding. Does not protect against STIs and HIV.
Emergency contraception ‘the morning after pill’ (pill containing progestogen; only known as Levonelle in the UK)
Safe method for when other methods have not been taken correctly or not used.
Can cause nausea and vomiting. Does not protect against STIs and HIV. May alter bleeding pattern.
Table 8.1 (Continued)
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SEXUAL HEALTH IN MENTAL HEALTH PRACTICE 123
Before moving on to the conclusion, utilise the information from this chapter to consider the following case study.
Clara
Clara is a 34 year-old married lady who works part-time as a clerical worker and has two young children. She was diagnosed with manic depression in her early twenties but despite having had long periods of remission she has also had several short but intense periods of mania, some of which have led to brief hospital admissions. Clara has recently experienced her most severe period of mania yet, and during your visit to her home today she has become very upset. Clara explains that during this period she stayed away from home for five nights with people she had recently met at a party. She is distraught as she recalls that she was highly promiscuous during this time and had sexual encounters with a number of different men. Clara’s primary concern is the potential damage this may do to her marriage and she is struggling to decide what to disclose to her husband. She rebuffs your suggestion that she visit her GP or sexual health centre as she feels embarrassed.
• What are the risks to Clara’s sexual health? • Identify the steps you could take to ensure she receives the optimum care at this time?
Answer guide:
1 Clara is at risk of having contracted an STI. The long-term consequences of undiagnosed and untreated STIs are serious and sometimes fatal, so it is vital that any STI is diagnosed and treated as soon as possible. In addition, Clara is of child- bearing age and there is a risk that she may be pregnant.
2 It is vitally important that you, as her mental health practitioner, are open and willing to discuss this sensitive issue with Clara and every attempt should be made to encourage her to attend a sexual health screening clinic. This may be achieved by highlighting the anonymity of the service, educating her about the importance of early diagnosis and the availability of effective treatments for many infectious conditions, facilitating access and possibly even accompanying her on her visit. However, if this is unsuccessful, then you could assess Clara for the presence of common signs and symptoms of an STI, such as inter-menstrual bleeding, vaginal discharge, genital inflammation and swelling, vaginal ulceration or rash, genital itching, pain on urination and lower abdominal pain. In addition, Clara should be encouraged to take a pregnancy test and may benefit from having the details of a pregnancy advisory service. She should also be strongly encouraged to use a barrier method of contraception until an STI has been ruled out so that she does not risk passing an infection on to her husband. Clara should be made aware of the how to access a sexual health screening service in case she changes her mind at a later date. Lastly, it may be possible to liaise with Clara’s family GP, with her consent, to consider the possibility of Clara taking a course of broad-spectrum antibiotics.
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THE PHYSICAL CARE OF PEOPLE WITH MENTAL HEALTH PROBLEMS124
CONCLUSION
Good sexual health is a basic human given yet so many people fail to experience this. Both body and mind can be affected by sexual ill-health, yet it is an often over- looked aspect of health care practice. While a variety of reasons have been offered for this, reluctance on the part of the health professional is undoubtedly key, with personal discomfort and a lack of knowledge being at the core of the problem. Addressing this reluctance must, however, be a priority for mental health practitioners as the increased risk of sexual ill-health to individuals with mental health problems adds yet another vulnerability to an already disadvantaged group. By promoting sexual wellbeing, mental health practitioners have the opportunity to enhance the overall health of their clients, while being attuned to the signs of sexual ill-health will facilitate access to appropriate sexual health services.
USEFUL RESOURCES
At the time of writing in the UK we recommend the following resources:
World Health Organization – www.who.int/ HIV and Aids information – www.avert.org.uk Marie Stopes International – www.mariestopes.org.uk International Planned Parenthood Federation – www.ippf.org/en
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Collins, E., Drake, M., & Deacon, M. (Eds.). (2013). The physical care of people with mental health problems : A guide for best practice. SAGE Publications. Created from scu on 2022-01-21 03:35:23.
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