Policy makers and mental health services need to take urgent action to ensure that people with serious mental illnesses receive greater guidance about sexual health, including the risk of HIV, especially if they suffer from schizophrenia.
A UK survey of nearly 300 mental health workers, published in the Journal of Clinical Nursing, found that although 80% agreed that promoting sexual health was an important part of their role, only 30% routinely discussed sexual health issues with service users.
It also discovered that up to 39% of respondents didn't routinely wear gloves when performing clinical procedures that could expose them to HIV.
"We were encouraged by the respondents' positive attitudes to sexual health promotion and the fact that the majority (78%) agreed that mental health workers should have mandatory training in the subject" says Dr Elizabeth Hughes, who carried out her research at the Institute of Psychiatry and is now based at the University of Lincoln.
"But we were disappointed that less than a third were actually providing the advice and guidance that people with serious mental illnesses need.
"The fact that 14% felt uncomfortable discussing sexual health issues and 13% were uncomfortable discussing gay and lesbian issues may have some bearing on the low level of sexual health promotion recorded by this survey.
"Lack of awareness of the increased HIV risks faced by service users with schizophrenia was also a particular concern, as studies have shown that they have higher HIV infection rates than the general population. These range from 5% in Europe to up to 19% in North America.
"Despite this, UK sexual health strategies don't mention people with serious mental illness as a high risk group, even though studies from various countries, including Australia, suggest that a fifth engage in risky sexual behaviour."
Dr Hughes feels that this lack of awareness could also be putting mental health professionals at risk of infection. "Four out of ten people who took part in our study admitted they didn't routinely wear gloves when they gave patients injections and glove wearing for other clinical procedures varied."
The survey, carried out in conjunction with Professor Richard Gray from the University of East Anglia, was completed by 283 professionals working in in-patient and community mental health clinical areas.
Most were registered nurses (51%) and other respondents were healthcare and nursing assistants, psychiatrists, clinical psychologists, occupational therapists, social workers and student nurses.
Other findings from the 42-question survey included:
Attitudes to sexual health promotion
- 69% felt that telling people about the risks was sufficient for behaviour change, 82% that discussing sexual issues did not encourage sexual activity and 91% that people with a serious mental illness should not be discouraged from having sex.
- 51% felt there should be condom dispensers on wards, but 28% disagreed.
- 69% recognised that people with serious mental illness could be coerced into sex.
Knowledge about HIV/AIDS among people with schizophrenia
- 92% were unaware that people with schizophrenia were more likely to have HIV than the general population and 72% did not believe they were more likely to engage in high-risk sexual behaviour.
- Knowledge about risk behaviours and risk factors for HIV infection
- Knowledge of risk behaviours averaged 91%, with higher awareness of the dangers of unprotected anal and vaginal sex and drug use than oral sex and sharing razors.
- Risk factor awareness was 59%, with higher awareness of the risks from cuts on hands and bleeding gums than poor physical health and hopelessness.
- The number who always wore gloves when carrying out clinical procedures ranged from 92% for cleaning and dressing wounds down to 61% for giving an injection.
- Staff were more aware of the need to wear gloves if they had received drug and alcohol training.
Reported sexual health promotion
- Only 30% routinely discussed sexual health with clients and even fewer (18%) explored whether medication caused sexual dysfunction.
- 81% encouraged patients to use condoms and 29% had condoms available.
- 57% said education material was available on HIV and AIDS and 39% on sexually transmitted diseases.
- 63% wouldn't stop patients having apparently consensual sex on a ward.
"We are concerned by our findings because it means that people with serious mental illnesses are not routinely receiving sexual health information and intervention" says Dr Hughes. "Lack of awareness of the increased risks of schizophrenia and lower levels of glove wearing for some clinical procedures could also pose an infection risk for staff.
"As a result, we are calling for improved training on the sexual health risks faced by people with serious mental illness and better links between mental health and sexual health services.
"We would also like to see more research into the kinds of sexual risk behaviours that people with serious mental illness engage in and targeted intervention to make them more aware of, and reduce, the risks they expose themselves to.
"Finally we would like to see research to identify the prevalence of HIV, hepatitis B and C in people with serious mental illness, as this would be an important step in understanding how serious the problem is in the UK."
- Hughes et al. HIV prevention for people with serious mental illness: a survey of mental health workers’ attitudes, knowledge and practice. Journal of Clinical Nursing, 2009; 18 (4): 591 DOI: 10.1111/j.1365-2702.2007.02227.x
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