There is a dearth of literature informing practitioners about
sexual health and bipolar disorder. A literature search using the combined
key words sexual health and bipolar disorder in the Mental Health Collection
database revealed only one paper by Coverdale et al. (1997) that related to
sexual practices in women with bipolar disorder. No papers were identified
on this database using the combined keywords sexual health promotion and bipolar
disorder. When the search was repeated on Medline, CINAHL, the British Counseling
Index, and the Counseling Collection databases, no papers were found for either
combination of keywords. Reasons for the scarcity of literature may include
the lack of funds available for research into sexuality and mental health (Ng
2000) and that therapists have not been provided with the appropriate training
opportunities (Irwin 1997, Cort et al. 2001). Guthrie (1999) conducted a study
amongst therapists and found that they did not feel comfortable discussing
sexual health needs with patients and were reluctant to become involved in
this aspect of practice.
Impulsivity is a feature of manic behavior that may involve risk-taking (Moeller
et al. 2001). A lack of consideration for the consequences of their actions
could pose a threat to the sexual health of people with bipolar disorder because
taking risks sexually can result in sexually transmitted diseases. In the short-term,
this necessitates that people with bipolar disorder receive appropriate interventions
to address the immediate threat to health. In the longer term, sexual impulsivity
can have an effect on the person’s self-esteem and self-image when, in
the postmanic period, they may reflect on their behavior. Sexual impulsivity
and associated behaviors may conflict with a person’s cultural or religious
background, or it could be inconsistent with usual standards of personal sexual
behavior. Conflict can arise in interpersonal relationships as a result of
sexual indiscretions. All of these consequences can add to the stress already
experienced by vulnerable people.
Women of childbearing age with Bipolar disorder
warrant special treatment considerations (Leibenluft 1996). For example, women
taking carbamazepine for prophylaxis need higher doses of oral contraceptives
if they are to avoid becoming pregnant. Also, there are issues of teratogenicity
with lithium, carbamazepine, and valproic acid if a woman were to become pregnant
whilst taking these drugs (Burt & Hendrick 2001).
Unplanned pregnancy may occur if impulsivity in sexual behaviour is associated
with a reduced regard for the implications of unprotected sexual intercourse.
A woman who is already vulnerable as a result of altered mood state may be
required to make decisions about continuation or termination of pregnancy at
a time when she is not able to assimilate important information. Clearly, then,
therapists could be involved in discussions concerning important life issues
with women who experience bipolar disorder. Parallels can be drawn between
bipolar disorder and sexual health care because there are many people in need
of evidence-based psychosocial counseling interventions, yet the literature
on which to base these is, at present, minimal. To address this, the available
evidence suggests that mental health therapists need to receive training and
overcome their inhibitions about sexuality and sexual health in order to engage
in an important aspect of the care of people with bipolar disorder.
Case example: Client profile
The client was a 25-year-old woman in the care of acute psychiatric inpatient
services. Her mood on admission was described as hypomanic, meaning that
her mood state was persistently elevated to a degree that subjectively exceeded
normal limits. She also displayed signs of flight of ideas and pressured
speech, which are two of the symptoms of mania and hypomania according to
DSM-IV-TR (American Psychiatric Association 2000). Her speech rate was increased
and the content suggested that she was experiencing and verbalizing rapid
successions of unrelated ideas. Her behavior was described as disinhibited
because she was over-familiar with staff and other clients on the unit. The
client’s psychiatric history indicated that
she had experienced hypomanic mood elevation before and during these periods
she became vulnerable to sexual abuse and exploitation in both the ward environment
and the community. Sexual health concerns included the possibility of unplanned
or unwanted pregnancy and the risk that she would contract a sexually transmitted
disease as a result of impulsive sexual encounters. Particular self-reported
incidents contributing to these concerns included her own admissions that she
had exchanged sexual intercourse for money, illicit drugs or a place to stay,
that she reported being pressured into unwanted sexual intercourse, and that
she had unprotected sexual intercourse after using drugs or alcohol. It was
decided that part of the care during this admission should incorporate sexual
health promotion.
Sexual health promotion
The strategy devised for this client included an informal program of sexual
health education prior to discharge that aimed to reduce sexual risk taking
behavior and exploitation, including safer sexual practices, and to initiate
appropriate contraceptive methods. The desired outcome was to empower the
woman and provide her with the degree of information that she needed to be
able to make informed choices about her sexual health and relationships.
Given the nature of the woman’s psychiatric condition, it was essential
to time the ensuing discussions appropriately so that she was well enough
to agree to participate and to assimilate the information that was provided
(Gregory 2000). Essentially, this would correspond with what Hummelvoll and
Severinsson (2002) term the working phase of the care of people with Bipolar
disorder, during which the exploration of the person’s self-image is
important. Annon’s (1976) P–LI–SS–IT model was used
to help the therapist create a suitable program for the client. Annon’s
four-stage model begins with giving the client Permission to discuss sexual
health and behaviors. The second stage is Limited Information, in which the
therapist provides basic, non-expert information risks and options associated
with sexual behavior. The third (Specific Suggestions) and fourth (Intensive
Therapy) stages are not discussed in the context of the following case study,
but are effective tools. Consent was gained for the intervention and permission
was given for the woman to discuss her sexual health and sexual behaviors.
Attending to consent and permission involved ensuring that the environment
was conducive to discussing potentially sensitive issues and assuring the
client that that the discussion was a routine part of care. It was also deemed
vital to reassure the woman that she had not been singled out for this type
of discussion, serving to ‘normalize’ the
topic, place it in the perspective of health and well-being, and lessen any
feelings that she may have of being ‘judged’ in this area.
Themes for discussion during the meetings included
safer sex, sexually transmitted diseases, HIV, AIDS, and specialist sexual
health services. Contraception was also discussed, as the woman had stated
that she felt unable to cope with a pregnancy at this point in her life. In
these discussions, the therapist was providing Limited information by offering
non-expert information about the options and services that were available locally.
Information in the form of user-friendly literature was provided so that the
woman could discuss her options with her partner and to reinforce the content
of the sessions. One specific issue that the woman wanted to discuss was the
acceptable boundaries in relationships. This provided the opportunity for a
conversation about the different types of relationships and friendships that
can exist, and the different issues and innovations in counseling practice boundaries
that are associated with these interpersonal relationships. Themes that were
evoked by this discussion included choice, self-awareness, self-respect and
rejection, and an exploration of the ways to establish her boundaries in order
for her to feel comfortable in different types of relationships.
Outcome and reflection
An informal program of sexual health promotion provided the woman with the
opportunity to discuss her concerns. It allowed her to make decisions that
were relevant to her, and her partner, at that particular point in time and,
in doing so, promoted her personal sexual health in accordance with the first
two components proposed by the World Health Organization (1986). In the short-term,
the woman made the decision to commence on medoxyprogesterone acetate (Depo-Provera)
injections for contraceptive purposes. This enabled her to minimize her risk
of pregnancy, although she
did acknowledge that it would not provide any protection from sexually transmitted
diseases. She also felt more in control of her sexual behavior having had the
opportunity to discuss acceptable boundaries and through confirmation that
it was appropriate to say no if she did not feel comfortable in a relationship.
For the therapist, this experience was both challenging and fulfilling. The
challenges included the lack of literature specific to bipolar disorder, or
even mental health in general, on which to base sexual health promotion strategies,
the need to recognize personal limitations (Gregory 2000), and the awareness
that sexual health issues in mental health care can present ethical difficulties
(McCann 2000, Mezzich 2000). It is important that therapists protect vulnerable
people from sexual exploitation whilst providing the freedom for expression
of sexuality and sexual behavior (RCN 2000). In a mental health care setting
it may be difficult to create an appropriate balance when the sexual needs
of clients are affected by their condition.
Professional fulfillment from this therapeutic intervention came
with the knowledge that the therapist had facilitated exploration of sensitive
issues with an emotionally and physically vulnerable woman. In doing so, the
therapist felt a sense of satisfaction that she had attended to some very important
health care needs and empowered the woman to take more control over her sexual
behavior. Unfortunately, it is not possible to comment on the long-term outcome
of the sexual health promotion that was undertaken with this client, which
leaves many unanswered questions about the enduring benefits of the strategy.
In the longer term, given the episodic nature of bipolar disorder, it is possible
that this strategy will need to be reinforced periodically. In the past, this
woman’s hypomanic episodes were associated
with an increased risk of sexual exploitation and apparent disregard for her
personal sexual health. A reoccurrence of impulsivity could mean that she would
take similar risks again, further placing her sexual health in jeopardy. Concordance
with the chosen contraceptive may be enhanced because it is delivered in a
long-acting injectable form, although the woman needs to ensure that contraceptive
protection is renewed every 3 months. Whilst the woman maintains that pregnancy
is not viable at the moment, followup care should ensure that she continues
with an acceptable method of contraception.
Conclusion
Diagnostic criteria for bipolar disorder highlight that people experiencing
manic elevation of mood are inclined to engage in pleasurable behaviors that
have a high potential for painful consequences. Sexual activity can be a
pleasurable and very important part of self-expression. Unfortunately, impulsive
sexual behavior, which can manifest as part of a manic episode, has the propensity
to be associated with potentially devastating, even lethal, effects on physical
and emotional health. When caring for people with bipolar disorder, it is
essential that assessments and interventions do not ignore sexual health
needs. In this era of HIV and AIDS, information about safer sex can literally
mean the difference between life and death. The practice implications for
bipolar disorder include the scope for therapists to develop innovative approaches
in holistic care; sexual health promotion needs to be incorporated into this.
It is anticipated that the positive outcome of the case example presented
in this paper will encourage other therapists to incorporate sexual health
promotion into their therapeutic approach in bipolar disorder. Although the
example used in this paper focused on female sexual health, the needs of
males with Bipolar disorder cannot be ignored. For example, male clients
might need to discuss problems about medication-related sexual functioning
such as erectile dysfunction or ejaculatory problems. For the practice implications
to be realized, therapists are required to examine what it is about sexuality
and sexual health that they are reluctant to address (Guthrie 1999), and sexual
health promotion needs recognition as a legitimate activity for mental health
counseling care. Annon’s (1976) P–LI–SS–IT model, although
somewhat dated, still provides a framework that can be used by the therapist
who is embarking on sexual health and sexual health promotion strategies for
the first time. Further evaluation will establish the value of this model in
guiding interventions for people with Bipolar disorder. The longitudinal outcome
of sexual health promotion in Bipolar disorder also needs to be evaluated to
determine whether it has an enduring effect on sexual risk-taking behavior
in mania. Goodwin’s (2000) editorial suggests that exciting times are
ahead for those who are interested in researching mania and bipolar disorder,
and this is encouraging for the development of innovative counseling approaches
to a neglected condition. Sexual health and sexual health promotion for people
with Bipolar disorder are aspects in which therapists can make an important
contribution to the evidence base on interventions.
McCandless, F., & Sladen, C. (2003, Oct). Sexual Health and Women with Bipolar
Disorder. Journal of Advanced Nursing, 44(1), 42.
Personal
Reflection Exercise #8
The preceding section contained information
about sexual health issues in women with bipolar disorder. Write
three case study examples regarding how you might use the content of this section
in your practice.
Reviewed 2023
Update Bipolar disorder and sexuality: a preliminary qualitative pilot study
Krogh, H.B., Vinberg, M., Mortensen, G.L. et al. Bipolar disorder and sexuality: a preliminary qualitative pilot study. Int J Bipolar Disord 11, 5 (2023). https://doi.org/10.1186/s40345-023-00285-9
Peer-Reviewed Journal Article References:
Boyers, G. B., & Simpson Rowe, L. (2018). Social support and relationship satisfaction in bipolar disorder. Journal of Family Psychology, 32(4), 538–543.
Boysen, G. A. (2019). Sexual stigmatization of mental illness: The impact of sex, mental illness, and evolutionarily salient traits on the evaluation of potential mates. Stigma and Health, 4(2), 225–232.
Penner, F., Wall, K., Jardin, C., Brown, J. L., Sales, J. M., & Sharp, C. (2019). A study of risky sexual behavior, beliefs about sexual behavior, and sexual self-efficacy in adolescent inpatients with and without borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 10(6), 524–535.
QUESTION 22
What are the four stages in Annon’s P-LI-SS-IT model for creating a sexual health program for a bipolar client? To select and enter your answer go to Test.