Professionals' Attitudes towards Sex between Institutionalized Patients
MICHAEL L. COMMONS, Ph.D.*
JUDI T. BOHN, BA., Ed. M.* *
LISA T. GODON, B.A.* * *
MARK J. HAUSER, M.D.+
THOMAS G. GUTHEIL, M.D.+
Decisions about institutionalized patients' sexual activity were not
influenced by professional norms of (1) competence of a patient to engage
in sexual activity) (2) degree of consent but were influenced by
conventional norms of (3) nature of sexual activity, (4) location of sexual
activity, (5) the sex of the initiating patient (6) sex of the other patient.
"Sexual intercourse is for normal people!"
Interviewer to patient with
Sexual activity among institutionalized patients has always been an issue
of concern to institutions (sexual relations between staff and patients
will not be discussed in this component of the research). Patients
inevitably engage in mutual sexual activity.1 Mental health professionals
seem to have some insights into the effects of patient sexual relations2
but little consensus. These insights, moreover, have generally not been
translated into institutional policy, nor have they been empirically
tested. Not surprisingly, institutional policies about such activity vary
widely3; they may be realistic, unrealistic, rational, irrational,
sensible, or nonsensical, or often out of synchrony with what actually
happens.4'5 Staff may be instructed, or may independently decide, to "look
the other way" or may exercise "overzealous prohibition." Administrators
and clinicians may be able to exercise considerable reporting discretion
or may be required to report all incidents for a mandated full investigation.
For many reasons, even in those institutions that allow some form of
sexuality, no written policy may exist condoning such activity.3 One reason
may be clinicians' fears of being held liable for the harm that can arise
from sexual contact. Some institutions have strong prohibitions against any
form of sexual activity between patients, but most report extensive sexual
activity.6 Morgan and Rogers find that although a restrictive written
policy may lead to lower rates of sexual activity between inmates, no
institution controls patient interaction to the extent that some sexual
contact does not take place.1
Three forces may change this status quo. Patient advocacy groups represent
two such forces by, on the one hand, advocating the right of patients to
engage in sexual activity when they are competent and consenting,
6 and, on the other hand, advocating that patients should be protected from sexual
assault, abuse, exploitation, unwanted pregnancy, and now AIDS. The third
and most important force is the increasing threat of AIDS itself. All of
these factors heighten clinicians' uncertainty and fear of liability.
Guidelines concerning sexual activity among hospitalized mental patients
that take these issues into consideration seem to be badly needed. Most
institutions have policies relevant to many aspects of patient social
behavior, but both clarity and consistency of guidelines are entirely
lacking.3'5 This component of our research presents an example of how the
institutional context of decision making about patients' sexual activity
may be assessed by studying professional responses to such activity.
We examined the following six factors that we thought might influence staff
We reasoned that a number of staff characteristics might also influence the
decision-making process since mental health professionals themselves may
carry prejudices shared with the general population about the effects of
sexual activity on patients. This study explores both their prejudices and
their insights. By understanding these perceptions we hope to provide an
empirical basis for developing guidelines that will promote a balance of
many competing claims, rights, and interests. In addition, educational
material could be developed for staff members that would promote patient
responsibility with regard to sex, particularly as it involves complex
issues such as contraception2 and AIDS.
- Competence of patient to engage in the activity
- Degree of consent in or consensual nature of sexual relationship
- Nature of sexual activity (e.g., hugging vs. genital relations)
- Location of sexual activity (e.g., in bedroom vs. on grounds)
- Sex of the initiating patient
- Sex of the other patient
We hypothesized that mental health professionals, both as members of the
community at large and as professionals, would have conventional moral
views towards sexual activity. Kohlberg defines three stages of social
reasoning that are termed conventional.7 This conventional period (Moral
Stages 3, 3/4, and 4) begins at the onset of postelementary school
education and extends across the life-span of all but a small portion of
the population. This period generates the conventional norms of adulthood.
Reasoning at each stage of this period incorporates enough logic to find
its most elaborate expression in some current adult philosophy. The vast
majority of the population performs at these conventional stages. Among
mental health professionals, however, professional norms could compete with
other social norms.
We hypothesized that subjects using conventional stages of reasoning with
community norms would be (1) fearful of homosexual activity (homophobic);
(2) would show greater disapproval of homosexual activity, especially male
homosexual encounters, than heterosexual activity; (3) would make decisions
based on the sex of the individuals (sexist); (4) would find male-initiated
heterosexual activity more acceptable than female-initiated heterosexual
activity; and (5) would find activity occurring in a bedroom more
acceptable than open sexual activity on the grounds of the institution.
We also hypothesized that subjects using conventional stages of reasoning
with professional norms might consider the parental-clinical implications
of sexual activity and thus emphasize its nature in decision making. These
norms emphasize professionally designated benefits for the subject. But
because in this situation professional norms are applied without patient
consent, the patient is protected at the cost of being treated like a
child. For example, subjects might be more likely to approve of hugging
between two patients than sexual intercourse due to fears of unwanted
pregnancy, venereal disease, and sexual exploitation. We also reasoned that
professional norms might make the location of sexual activity a factor. We
hypothesized that subjects would be fearful of the negative therapeutic
effects of open sexual activity on other patients. As a result, they would
tend to show greater approval of sexual activity occurring in the privacy
of a bedroom.
The postconventional period (Moral Stages 5 and 6) begins sometime after
adolescence; however, fully postconventional thinking and action appear
after early adulthood.8 Some contemporary philosophies and social theories
use postconventional arguments. These philosophies and theories may embody
social and psychological approaches to medical and legal ethics. In fact,
some researchers have reinterpreted philosophical,9'10 and scientific
debates in terms of conventional versus postconventional arguments. In any
known society, only a small portion of members achieves postconventional
stages of reasoning.
At beginning of Moral Stage 5, the first stage in this period, people
justify actions on the basis of universal abstract principles. Many such
principles can be found in the works of philosophic, political, and
religious thinkers. A number of modern societies also articulate these.12
Moral Stage 5 principles are general in their application, irrespective of
the person affected. The specific content of the principles may be
contingent upon the society in question. People are assumed to have
different interests and expertise. Society is seen first as a creation of
individuals and second as the context in which people develop.
Finally, we hypothesized that subjects using postconventional stages of
reasoning with professional norms might consider the effects of
patient-regulated sexual activity in developing or enhancing patient
autonomy. Consideration of such benefits might compete with
conventional-stage considerations of parental clinical norms. In
postconventional reasoning, competence and consent are the driving forces
behind evaluating the meaning of patient sexual relationships-whether or
not they are part of the patient's rights and evaluating what clinical
costs and benefits they might entail. Competence and consent represent the
factors that professionals would be predicted to consider when devising
treatment plans and institutional policies. Autonomy and competent consent
both require postconventional reasoning to generate them in the first
place. Yet, both concepts can be appreciated and used at the higher
conventional stages when such policies are in force in institutions.
Because such institutional policies generally do not exist, however, we
suspect that subjects using conventional reasoning may ignore competence
and consent, even when applying professional norms. Therefore, we expected
that even competent, consenting individuals would be viewed
(inappropriately) as being incapable of participating in normal adult
The sample consisted of 131 mental health professional subjects, 69 males
and 58 females (4 whose sex was unspecified). The subjects ranged in age
from 25 to 79 years. Most of the subjects, holding positions ranging from
mental health aide to psychiatrist, were employed by state institutions for
the mentally ill. The subjects were drawn from audiences at risk-management
lectures in several states in differing demographic areas.
We designed a series of narrative vignettes to assess how the six factors
earlier noted affected the subjects' perceptions about sexual activity
among patients. Each questionnaire presented two different versions of a
vignette and posed a series of questions about them.
C. C. is a 55-year-old woman [man], who is provocative to the men [women]
clients and frequently sexually teases them. C. C. entices the men by
saying, "I'll give you a dollar if you hug [have sex with] me in the
bedroom [on the grounds]." The clients are able [unable] to refuse C. C. 's
advances effectively. If a client says yes, following what that client
relates as a consensual [nonconsensual] sexual relationship, C. C. reports
being taken advantage of to the staff. If a client says no, C. C. reports
that the client "kicked me in the crotch."
There is a couple, client M. W. and client D. M. M. W. is a woman [man], D.
M. is a man [woman]. They have a consensual [nonconsensual] sexual
relationship. They hug [have sex with] each other in the bedroom [on the
grounds]. Both are able [unable] to refuse the other's advances effectively.
There were 64 variants (cells) of vignette A and 64 variants of vignette B.
Vignette A was very detailed and explicit. Vignette A quoted some of the
hypothetical patient's own language in describing the activity and type of
relationship. This version implied that the provocative and aggressive
"first patient" could be manipulating the victimized "second patient."
Vignette B, in contrast, was a simple, brief, and coolly objective
statement giving the basic facts of the relationship and activity.
Vignette A's richly contextual narrative, then, was contrasted with a very
schematic narrative (Vignette B) to compare the effects of these two forms
Each vignette was constructed by placing one value of each of the six
independent variables (competence, degree of consent, form of sexual
activity, location of sexual activity, sex of initiating client and sex of
other client) into one of the core stories in the vignettes shown on p.575.
Three questions then followed each vignette.
As shown in table I, subjects were asked to rate responses on a scale of 0
to 5, with 0 representing the strongest negative response (e.g.,
disapprove, unhealthy, intolerable) and 5 representing the strongest
positive response (approve, healthy, tolerable). Respondents were also
asked to explain why they gave the particular rating. These responses can
be scored as corresponding to Kohlberg's stages of moral development.8'13
- Do you approve or disapprove of the sexual activity described?
- Would this be therapeutically healthy or unhealthy?
- How would the outside community view this sexual activity, tolerable or
Each subject responded to one of the 64 variants of vignette A and one of
the 64 variants of vignette B. Having 64 variants of each type of vignette
allowed for the analysis of 6 truly independent variables (26 = 64).
Analyses of covariance were performed separately in regard to each of the
three question responses. Covariates were version of vignette (A vs. B) and
heterosexual vs. homosexual activity.
Table I JUDGEMENTS ON SEXUAL ACTIVITY
1. How much do you disapprove or approve of the sexual activity described?
3. Would this be therapeutically unhealthy or healthy?
5. How would you deal with this sexual activity?
6. How would the outside community view this sexual activity?
7. How would the community respond to knowledge of this sexual activity?
This group of professional subjects responded at the conventional stage by
restating societal norms as hypothesized. In response to the first
question, "Do you approve or disapprove of the sexual activity described?"
the respondents rated most highly (indicating approval) consensual,
heterosexual relationships that occurred in a traditional (bedroom)
environment. Indeed, location of the sexual activity was highly significant
(p = 0.0037), with activity located on the grounds of the institution (M =
1.4310) meeting with much greater disapproval than activity in the bedroom
(M = 1.6539). Contrary to our predictions, the respondents approved more
highly of a female patient rather than a male patient initiating sexual
activity with a consenting partner of either sex. There was very strong
disapproval of a male nonconsensual homosexual relationship occurring on
the grounds of the institution (M = 0.8000).
Our protocols elicited a strong current of male homophobia. Conversely, the
female partner as initiator was widely approved. In the mainstream of
society, it is the male who is traditionally accepted as the initiator.
This study then suggests that within an institutional setting, this
behavioral expectation of males and females is reversed. We wonder, given
the conventional view of women needing protection, whether female-initiated
activity decreased respondent anxiety about coercion of women.
In regard to the second question of the activity being therapeutically
healthy or not, respondents reacted strongly to the aggressive tone of
Vignette A and the detailed narrative. Location was highly significant (p =
0.0066), consistently indicating less tolerance for sexual activity that
takes place on the grounds of the institution than in the bedroom. This was
predictable because the bedroom, in addition to being the more traditional
setting, is also considered to be the healthier environment.
Form of sexual activity was significant (p = 0.0115), but little
distinction was made between the therapeutic value of a patient being
involved in simple hugging (M = 1.5009) and having sex (M = 1.5667).
Subjects seemed concerned about any form of sexual activity occurring
Most strikingly, the analysis of therapeutic impact indicates that
consent-hypothesized to be a central and determinative issue-is not a
driving factor. Questionnaires revealed little difference for a patient of
either sex initiating an activity with a consenting or a nonconsenting
"partner" (M = 1.6721 versus M = 1.6715). Perhaps this indicates that staff
do not find either form of activity, whether it be consensual or not, to be
therapeutically beneficial. Again, male-initiated activity with a
consenting "partner" was considered least therapeutic (M = 1.3438).
The activity viewed as relatively "most therapeutic" involved a patient
(male or female) hugging a nonconsensual female (M = 2.1333) although even
this is still seen as slightly antitherapeutic. Although hugging a female
is predictably viewed as relatively more therapeutic than having sex, one
would have thought hugging a consensual partner would have been preferable
to hugging a nonconsensual female.
The activity viewed as "least therapeutic" was a patient (again, male or
female) having sex with a consenting male (M = 1.1852). From a
professional standpoint, the fact that the person who received the sexual
advance was consenting should make having sex relatively more therapeutic
than if sex were forced. Hence, nonconsensual sex should have been
considered even less therapeutic. This expectation was not fulfilled by the
In the section on community tolerance for activity, staff thought that the
community would find it more tolerable to have a male patient initiating
some form of activity with a female, whether on the grounds or in the
bedroom (M = 1.9206), while the least tolerable was a male-initiated
interaction with another male. This, again, would be the traditional social
view. As noted above, however, females were identified as the more
acceptable initiators within the institution. These data suggest that the
respondents make a distinction between institutional and community
attitudes towards sexual behavior. Significantly, staff classified sex on
the grounds as antitherapeutic. In this case the community view and
institutional view would coincide.
The perceived community view again showed little difference (M = 1.5897 and
M = 1.5756) between a patient of either sex initiating some form of sexual
activity with a consensual or nonconsensual male in the bedroom; again,
consent is, puzzlingly, treated as irrelevant.
A highly significant factor was the community tolerance of a male
initiating some sexual activity with a female either on the grounds or in
the bedroom. The least tolerable was a male initiating some activity with
another male. This finding is consistent across questions, indicating a
strong aversion to male homosexual activity and confirming our "homophobia"
No matter which dependent variable was selected, the most significant
factor was the version (detailed vs. schematic) of the vignette (p =
0.0001). However, we cannot yet discriminate among possible interpretations
of why vignette version mattered so much.
Of the six factors (competence, degree of consent, form of sexual activity,
location of sexual activity, sex of initiating client, and sex of other
client) only location and form proved to be significant. Although we had
hypothesized that consent and competence would be significant factors, they
were not. One possible explanation is that our respondents disbelieved that
the hypothetical inpatients could be competent or consenting. If
respondents viewed patients in the vignettes as incompetent even when the
opposite was stated, and if they disbelieved their consents even though the
vignettes said they occurred, then the usual social norms would not apply.
Under those conditions one would not expect to find competence and consent
making a difference. This last interpretation is somewhat unlikely,
however. The results may be indicative of strong biases, such as those
against sexual activity promoted by an aggressive, manipulative person.
Nevertheless, bias would not alter the fact that staff found it to be
irrelevant whether the participants in the activity were competent and
consenting-the norms used by law and due process. The subjects were more
concerned with the type and location of sexual activity than with the
consensual or nonconsensual nature of the relationship or the patients'
assessed competence to ward off advances.
The core implication of our study is that mental health professionals must
reexamine their own prejudices (e.g., homophobia) to clarify their decision
making about institutional policies. Later components of the research will
further test the parameters of reactions to institutional sexuality.
The findings also suggest the need for more instruction, or at least
consciousness-raising, as to the importance of competence assessment in
regard to decision making by psychiatric patients. Although autonomy and
competence-consent both require postconventional reasoning to generate, an
understanding and consideration of their role in decision making can take
place at the higher conventional stages, provided that the institutional
policies embody such principles and norms. Greater awareness of these
issues should foster authenticity of choices and genuinely informed consent.
Sexual activity among institutionalized patients has always been an issue
of concern to institutions. Despite this fact, there has been little
consensus about how patient sexuality should be dealt with. Nor have
clinical insights with respect to patient sexuality been empirically
tested. Given the diversity of beliefs and policies in this area,
guidelines concerning sexual activity among hospitalized mental patients
seem to be badly needed.
We examined the following six factors that we thought might influence staff
decisions: (1) the competence of a patient to engage in sexual activity,
(2) the degree of consent, (3) the nature of sexual activity (e.g., hugging
vs.genital relations), (4) the location of sexual activity (e.g., in
bedroom vs. on grounds), (5) the sex of the initiating patient (6) the sex
of the other patient. We hypothesized that mental health professionals,
both as members of the community at large and as professionals, would have
conventional moral views (as defined by Kohlberg) towards sexual activity.
Supporting this hypothesis, of the six factors listed above, only location
of the sexual activity and form of the sexual activity affected judgments
on sexual activity significantly. The professionals interviewed appeared to
be most condemning of homosexual acts, and least condemning of hugging.
Although we had hypothesized that profession norms of consent and
competence would be significant factors, they were not. The core
implication of our study is that mental health professionals need training
on competence assessment and its use in decision making and must reexamine
their own prejudices (e.g., homophobia) to clarify their decision making
about institutional policies.
Acknowledgments: The authors appreciate the extensive editorial and
conceptual help of Archie Brodsky and Adam Kearney and the assistance of
Raymond S. Meinert, Jr., in the preparation of this manuscript. Harold
Bursztajn, M.D. and other members of the Program in Psychiatry and the Law
assisted in refining the instrument.
- Morgan, R., & Rogers, J. (1971). Some results of the policy of
integrating men and women patients in a mental hospital. Social Psychiatry
- Shaul, S., & Morrey, L. (1980). Sexuality education in a state mental
hospital. Hospital & Community Psychiatry, 31(3), 175-179.
- Keitner, D., & Grof, P. (1981). Sexual and emotional intimacy between
Formulating a policy. Hospital and Community Psychiatry, 32, 188-193.
- Keitner, D., Baldwin, L. M., & McKendall, M. (1986). Copatient
relationships on a short-term psychiatric unit. Hospital and Community
Psychiatry, 37, 166-170.
- Wignall, C., Meredith, C. (1968). Illegitimate pregnancies in state
institutions. Archives of General Psychiatry, 18, 580-583.
- Akhtar, S., Crocker, E., Dickey, N., Helfrich, J., & Rheuban, W. (1977).
Overt sexual behavior among psychiatric inpatients. Diseases of The Nervous
System, 38, 359-361.
- Kohlberg, L. (1984). Essays on moral development: Vol 2. The psychology
of moral development: Moral stage', their nature and validity. San
Francisco: Harper & Row.
- Colby, A., & Kohlberg, L. (1987). The measurement of moral judgement:
Vol.1. Theoretical foundations and research validation. New York: Cambridge
- Armon, C. (1984a). Ideals of the good life and moral judgment: Ethical
reasoning across the life span. In M. L. Commons, F. A. Richards, & C.
Armon (Eds.), ,em>Beyond formal operations: Vol 1. Late adolescent and adult
cognitive development (pp.357-380). New York: Praeger.
- Armon, C. (1989). Individuality and autonomy in adult ethical
reasoning. In M. L. Commons, J. D. Sinnott, F. A. Richards, & C. Armon
(Eds.), Adult Development, Comparisons and applications of adolescent and
adult developmental models, 1, (pp.179-196) New York: Praeger.
- Commons, M. L., Miller, P. M., & Kuhn, D. (1982). The relation between
formal operational reasoning and academic course selection and performance
among college freshmen and sopho-mores. Journal of Applied Developmental
Psychology, 3, 1-10.
- Reiser, S. J., Bursztajn, H. J., Gutheil, T. G., &Appelbaum, P.S.
(1987). Divided staff:, divided selves: A case approach to mental health ethics.
Cambridge, England: Cambridge University Press.
- Colby, A., & Kohlberg, L. (Eds.) (1987). The measurement of moral
judgment: Vol.2. Standard form scoring manuals. New York: Cambridge
* Lecturer and Research Associate, Program in Psychiatry and the Law,
Massachusetts Mental Health Center, Department of Psychiatry, Harvard
Medical School. Mailing address: Program in Psychiatry and the Law,
Massachusetts Mental Health Center, 74 Fenwood Road, Boston, MA 02115-6196.
* * Research Assistant, Dare Institute, Cambridge.
* * * Assistant to the Legislative Director, Office US Senator Kent Conrad.
+Clinical Instructor, and Research Associate, Program in Psychiatry and the
Law, Massachusetts Mental Health Center, Department of Psychiatry, Harvard
+Co-director, Program in Psychiatry and the Law, Massachusetts Mental
Health Center; Professor of Psychiatry, Harvard Medical School.
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