2017 has a diagnosed mental illness which may

2017
has been a year full of advancements in healthcare, especially in the areas of
sexual health. As reports of rape, sexual assault and harassment continue to
rise – much to the credit of the “Me Too” movement started by Tarana Burke (Zacharek,
Dockterman, & Sweetland Edwards, 2017) – there appears to be a greater
public interest in understanding what qualifies as sexual assault. To put it
simply, sexual assault is a term to refer to any contact or behaviour which is
sexual in nature without the explicit consent of the recipient. (Sex
Information & Education Counsel of Canada (SIECCAN), 2015) Some important
barriers to consent can include anything from age to drug and/or alcohol
intoxication to decreased mental capacity. (Walker-Renshaw, 2012) This
information begs the question: If two or more people consent to sexual activity
but one or more persons has a diagnosed mental illness which may impede with
their ability to consent, is it considered sexual assault? As mental illnesses,
especially dementia, continue to rise (Wong, Gilmour, & Ramage-Morin, 2016),
nurses should act to promote sexual health by developing tools and guidelines
in order to ascertain a better understanding of mentally compromised patients’
capacities to consent to sexual acts, while also protecting their patients’
rights to autonomy and informed decision-making pertaining to their sexual
health. By doing so, nurses have the opportunity to preserve patients’ sexual
autonomy, encourage safer sex practices, and overall improve each patient’s
quality of life – even those who are mentally impaired.

In
Ontario’s Patients’ Bill of Rights, it is clearly stated that citizens of
Ontario are entitled to health care which provides freedom of choice, and
receive treatment from healthcare providers in a way that recognizes client
individuality, privacy, and promotes the autonomy of each individual. (Smith,
2002) A significant part of an individual’s autonomy involves their sexual
autonomy. It is commonly recognized in the 21st century that all
people (including people with disabilities) are entitled to their own sexual
health and rights. (International Women’s Health Coalition, 2015) More
specifically, according to the World Health Organization (WHO), “Reproductive
health, therefore, implies that people are able to have a responsible, satisfying
and safe sex life.” (World Health Organization WHO, 2017, para. 1)

Though
this appears to be a rather simple concept, advocating for people who have been
diagnosed with mental illness (such as schizophrenia, bipolar disorder, or even
dementia) poses some unique challenges. In a brief newsletter published by the
Advocacy Centre for the Elderly, some questions are raised regarding one’s
mental capacity to consent to sexual acts, the responsibility of staff members
to intervene in a situation which may be reasonably considered to be unsafe,
and how to encourage individuals to embrace their sexuality in a safer way. (Wahl, 2009) Additionally, the
Journal of Ethics in Mental Health discusses the limitations to consent in
those afflicted by mental illnesses, but offers some potential guidelines in
order to ascertain a client’s ability to consent to sexual acts. These
guidelines include ensuring that the client has the cognitive ability to: understand
the sexual nature of the act, understand information related to making a
decision to engage in sexual acts (ie. How to reduce risks associated with
sexual activities such as sexually transmitted infections (STIs)), understand
that the individual and their partner may choose to decline to participate at
any point before or during the act and, understand the short term and long term
consequences related to the activities in which they are engaging. (Walker-Renshaw,
2012) In one quantitative research study conducted in Italy, researchers developed
a 32-factor scale to determine one’s ability to consent to sexual behaviour
when afflicted with schizophrenia or bipolar disorder. (Mandarelly, et al.,
2012) Some of these factors included: Understanding peno-vaginal intercourse,
knowing ways to reduce the spread of STIs, demonstrating the ability to say
“no”, and understanding that a sexual partner has the right to withdraw consent
at any point. (Mandarelly, et al., 2012)

So
how could this all relate to nursing in Canada? The Canadian Nursing
Association (CNA) has developed a code of ethics (2017) which provides nurses
with regulatory ethical guidelines to assist nurses in making ethical decisions
and to protect the public. (Canadian Nurses Association CNA, 2017) When promoting
sexual health, nurses must remember their ethical duties to promote client
health and well-being, promote and respect informed decision making, maintain privacy
and confidentiality, and promote justice among their clients. (CNA, 2017) In
terms of promoting clients’ health and well-being, nurses must advocate for all
clients – regardless of altered mental status on account of illness – by
allowing them to identify their own sexual needs and providing any and all
resources available to ensure they have the ability to tend to those needs in a
safe and satisfying manner. (CNA, 2017) As for promoting and respecting
informed decision making (CNA, 2017), nurses should assist clients, first by
understanding their ability to consent, and then by educating them, at an
appropriate level, of the risks associated with sex (such as STIs, unintended
pregnancy, and sexual violence (Mandarelly, et al., 2012)) and ways to prevent
these risks, through using condoms, oral contraceptives, and clear
understanding of consent and the importance thereof. (Mandarelly, et al., 2012)
As for the maintenance of privacy and confidentiality, nurses must take extra
special care to prevent the spreading of such information, especially since
disclosing sexual needs is oftentimes challenging for all individuals, let
alone those dealing with a mental illness. (CNA, 2017) Finally, nurses must continue
to promote justice for these clients by protecting their rights to their own sexual
health and refraining from discriminatory behaviour and actions based off of
clients’ health status, lifestyle, mental ability, or any other attribute. (CNA,
2017) In the context of sexual health promotion, nurses have the responsibility
to develop and maintain a judgment-free therapeutic relationship wherein a
client can safely confide in their healthcare providers. By doing this, nurses
can continue to maintain an open and honest relationship with their clients,
ultimately ensuring high quality healthcare.

As
for ethical theories, there are many which could be used in favour of the
recommendation for nurses to develop ways to ascertain clients’ abilities to
consent to sexual activity. In the case of utilitarianism, an ethical theory
which places higher emphasis on the outcomes rather than the actions which
yielded them (Gray & Schein, 2012), nurses can preserve their client’s
sexual autonomy and improve their sexual health by using various tools (such as
the Sexual Consent Assessment Scale (Mandarelly, et al., 2012) to understand
the ability of each client (even those who are mentally ill) to consent to sexual
activity, develop strategies for sexual safety, and therefore improve their
quality of life. As for deontology, an ethical theory which places higher
emphasis on the actions which yielded certain consequences (Gray & Schein,
2012), nurses can use their knowledge and skill to harbour therapeutic
relationships to encourage clients to openly discuss their sexual needs in a
respectful, nonjudgmental context. Nurses can then work in line with the CNA
code of ethics and to develop and identify safe strategies for their clients to
engage in safe sexual activity. However, though the discussion of ethical
models is important in this context, it is also critical to discover and
understand the implications this approach to sexual health will have for
nursing.

 Furthermore, the College of Nurses of Ontario has
developed eight professional standards which include: Accountability,
continuing competence, ethics, knowledge, knowledge application, leadership,
and relationships (both therapeutic nurse-client relationships and professional
relationships). (College of Nurses of Ontario CNO, 2002)  In order to develop the best possible outcome
for their clients, nurses should understand and use these standards to guide
their words, actions and care in a manner which is extremely professional. Nurses
should practice accountably by advocating for their clients’ sexual health,
using their nursing knowledge and expertise to assist the client in determining
and meeting their sexual needs in a safe manner, and ensuring the best possible
care for their clients by developing therapeutic relationships which condone
open and honest communication between the client and nurse. (CNO, 2002) Nurses
should continue working competently by investing time, effort and more
resources in educating their clients and promoting safe sexual behaviour
through the use of contraceptives and understanding of consensual sexual
activity. (CNO, 2002) Nurses should work in an ethical manner by identifying
all ethical issues at play, such as the risks for sexual assault of the
mentally impaired client, and communicating them to the client and health care
team, and developing strategies to minimize or resolve these risks. (CNO, 2002)
Nurses should work knowledgably and apply that knowledge by understanding the
complex needs of the mentally ill client while also promoting safe sexuality
and planning approaches to provide appropriate care for the client in a safe,
satisfying manner. (CNO, 2002) Nurses should demonstrate leadership by
advocating for their clients and developing innovative solutions to ensure that
the client can meet their sexual needs in a healthy manner through the use of
birth control and teaching the importance of consensual sexual activity. (CNO,
2002) Finally, and most importantly, the nurse must work to establish and
maintain a therapeutic relationship by collaborating with clients to recognize
their individual needs, wishes, and knowledge to assess their capacity to
safely engage in sexual activity, while developing safer strategies (such as masturbation)
to meet the client’s sexual needs. (CNO, 2002) 

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