The previous chapter described how the ‘veil’, through which participants viewed the clients’ sexuality, was woven. It was through the processes of ‘weaving’,
‘thickening’ and ‘fusing the strands’ that participants learnt how to view, hear and interpret clients’ sexuality. It was also through these processes that participants inherited normative forms of behaviour that enabled them to respond to clients’ sexuality in the practice environment. These normative forms of responding or taken for granted practices were conceptualised as a cycle of behaviour, named the
‘Veiling-Re-veiling Cycle’. This cycle consisted of the following three sub-
categories: ‘Hanging the Veil’, ‘Lifting the Veil’ and ‘Re-Veiling’. This chapter discusses the first two categories that made up the ‘Veiling-Re-veiling Cycle’: ‘Hanging the Veil’ and ‘Lifting the Veil’.
‘Hanging the Veil’
‘Hanging the Veil’ refers to strategies that participants used to hang a metaphorical veil over the client in order to keep the client’s sexuality verbally and behaviourally contained. By ‘hanging a veil’ around the client’s sexuality, participants were also able to hang a veil around their discomfort, thus sustaining their professional identity as competent and caring professionals. In this way, the veil had a dual function.
Although the veil did allow for a shading over or coverage of both the client and self, it was sufficiently translucent to hint at what lay beneath. Consequently, participants could not completely deny or ignore the sexual dimension of the client’s life. Participants hung the veil using a number of verbal and behavioural strategies; conceptualised as ‘limiting verbal information’, ‘cautionary interviewing’, and ‘protective surveillance’. Each of these three strategies will now be explored together with their properties.
Figure 3 Diagrammatic representation of ‘Hanging the Veil’
‘Limiting verbal information’
‘Limiting verbal information’ refers to the way participants avoided verbally
disclosing the side effects of prescribed medication that could impact on the person’s sexual function, thus drawing a veil of silence around drug-induced iatrogenic sexual dysfunction and, at the same time, veiling their own discomfort. Participants’ allegiance to biological approaches to treating mental distress and a desire to avoid personal discomfort strongly influenced their decisions. Participants limited verbal information by working from a ‘hierarchy of disclosure’ and
‘referring to written information’.
‘Hierarchy of disclosure’: As in other studies (Happell et al., 2002; Jordan, 2002), participants espoused the belief that educating clients about adverse effects of medications, and monitoring these effects, was part of their role and in keeping with the rights of clients to make informed decisions. However, in relation to side effects that impacted on sexual function, these positive aspirations were not transferred into practice. In reality, participants limited the information given to clients about
iatrogenic sexual dysfunction by working from what they called a ‘hierarchy of prioritisation’ where ‘they [sexual effect] are down the bottom of the list’ (25 F) or
‘way down the order of priority’ (12 M). For many participants, positioning
iatrogenic sexual dysfunctions at the bottom of the hierarchy reflected the ‘othering’ process previously discussed. As one participant said, ‘It’s like we expect patients to be kind of non-sexual objects or people’ (13F).
The hierarchy of prioritisation constructed by the participants was not based on research evidence, but reflected participants’ perceptions of the relationship between non-compliance and disclosure of iatrogenic sexual dysfunction, the prevalence of side effects, and the participants’ comfort level around talking about a particular side effect.
In constructing the hierarchy of disclosure, participants classified side effects as ‘safe’ and ‘unsafe’. Safety of a side effect did not refer to toxicity but referred to the participant’s perception of the risk of non-compliance associated with disclosure. In calculating this risk, disclosing iatrogenic sexual dysfunction was considered to carry a considerably high risk of non-compliance. Consequently, in an attempt to control clients’ behaviour and ensure compliance, these side effects were relegated to the bottom of the hierarchy and not disclosed. For some participants, the non- disclosure was also motivated by a desire to work in harmony with the medical team, and avoid being blamed for contributing to a client’s decision not to take prescribed medication.
‘You’re certainly not going to turn around and say, “you’ll have a problem with expressing your sexuality”; I feel that is the one thing that will put them off taking it, absolutely. It [telling] would be a definite no no, I’ve seen it…if there’s any problem at all in that area and they made the connection between the medication and their sexual functioning the medication is gone, absolutely, out the window’ (2 F).
‘I think the hesitancy is about nurses overstepping the mark,…you don’t activate practice that is going to interfere with the medical practice…I am not saying it is the only thing but it is a factor in that it prevents you …you don’t do something that is going to interfere with compliance’ (22 M).
Participants did not appear to consider evidence which suggested the provision of information simply increased clients’ understanding of treatments and did not have
any significant impact on compliance (Gray et al., 2002b; Fernandez et al., 2006). Instead, they worked from the assumption, which had assumed mythical status, that there was an inverse relationship between education about iatrogenic sexual dysfunction and compliance – a view shared by some community mental health nurses in the UK (Cort et al., 2001). Similarly, despite evidence suggesting that drug-induced iatrogenic sexual dysfunction is prevalent and can have a significant negative impact on the person’s life and self esteem (National Schizophrenia Foundation UK, 2000; Rothschild, 2000; Montejo et al., 2001; Wallace, 2001; Smith et al., 2002), participants did not recognise the implications of their non- disclosure. This lack of awareness was possibly reinforced by the lack of education on this topic, and the infrequency of role modelling of discussions with clients in practice. Consequently, emphasis was placed on what participants considered, from visual observations of clients, to be the most common side effects. The following are indicative of comments:
‘You tell them the common ones…like you see patients sedated and falling, I see people drooling but you don’t really think about the ones you don’t see’ (13 F). ‘I would list the common side effects - you tell about dizziness, blurred vision, dry mouth, constipation, stomach upset…I list side effects I would come across very often, the ones I learnt’ (11 F).
Talking about iatrogenic sexual function was considered a subject that had the potential to engender a high degree of personal discomfort and embarrassment. Therefore, to maintain personal comfort, participants also avoided telling clients.
‘I don’t tell to be honest, again it is one of those things, I’ve said my views would be liberal, but still to be talking to someone about the [sexual side effects], it does make you feel slightly uncomfortable, so you try and avoid the subject’ (8 M).
‘We are comfortable talking about dry mouth, we are not comfortable when we are talking about dry vaginas. Let’s face it, we are not comfortable, so we are not going to talk to them’ (24 F).
‘Referring to written information’: Some participants did give clients written
information about the side effects of drugs and invited them to disclose if they experienced any of the side effects identified. Providing written information is to be welcomed, given that 65.8% (310) of service users with enduring mental illness in an Irish survey (n=471) reported receiving no written information on the drugs
prescribed (Schizophrenia Ireland, 2002). However, referring clients to written information mirrored some participants’ experiences of their own sexual education, when they were given a book to read, without follow up discussion. The tactic of referring to written information projected an illusion of information-giving and education, while at the same time ‘veiling’ the participants’ personal discomfort. By placing the onus on the client to make the connection between sexual dysfunction and prescribed medication and voluntarily disclose difficulties, participants were able to avoid having to engage proactively in direct discussion about what they considered an uncomfortable subject.
‘The booklet is there and you don’t have to bring it up (laughs) and they know that they can come to you then, if they have one [iatrogenic sexual dysfunction]’ (26 F). ‘I would give them the leaflet…but to be honest I think a lot of the patients here don’t understand the leaflet, their level [of literacy] wouldn’t be very good’ (11 F). ‘You go, “Read this leaflet and if you have any problems come back to me”…I suppose that presumes that they still have the courage to come to you and openly talk to you about it’ (18 M).
The latter two comments also highlighted the degree to which participants continued consistently with the practice of referring to written information, even though they doubted in their own minds the clients’ ability to interpret such information, and their confidence to disclose sexual difficulties voluntarily. Similarly, this unreflective and unquestioning approach to clients’ sexuality was evident in the manner that participants, although aware that sexual effects could be distressing for clients and would not like to suffer the side effects personally, were willing to allow it to happen to clients. As one participant said:
‘It can be a great problem for some, very distressing… but it [telling clients] would be just way down the order of priority, they wouldn’t take the drug, not that I blame them, I wouldn’t take it’ (12 M).
In summary, by ‘limiting verbal information’ through the use of a ‘hierarchy of disclosure’ and ‘referring to written information’ participants drew a veil of silence around drug-induced iatrogenic sexual dysfunction and, at the same time, veiled their own discomfort.
‘Cautionary interviewing’
A holistic assessment of the client is a central task for psychiatric nurses and is important for individual care planning and service provision (Simons and Petch, 2002). According to McCann (2000) if mental health nurses want to be truly responsive to people with mental health problems and their carers, they need to include sexuality as a dimension of that holistic assessment, and need to ask about sexual and relationship issues. Although participants talked about holistic care, they avoided proactively initiating or engaging in a discussion with clients around sexuality by speaking through a metaphorical ‘veil’ in assessment discussions. The
metaphorical veil that participants spoke through was named ‘cautionary
interviewing’. ‘Cautionary interviewing’ has the following properties: ‘routine questioning’, ‘avoiding taboo questions’, ‘vague questioning’, ‘passive waiting for disclosure’ and ‘skipping over’.
‘Routine questioning’: Through professional comparing and socialisation into the professional discourse of psychiatry, participants learnt a routine set of questions to ask clients during assessment interviews. As one participant said:
‘There is a practiced line of questioning that you develop an expertise in, you feel comfortable with, you know you are going to be able to deal with the consequence of the answer, and you stay with that…safe questions’ (22 M).
Although participants talked of using a nursing model or conceptual framework to guide their assessment, the questioning process described tended to be significantly infused with the belief system of the biomedical model. Emphasis within this model was on viewing mental distress as ‘illness’ and identifying symptoms as opposed to creating a context for clients to tell their story, in whatever way they choose. In keeping with the biomedical model, questions were limited to the classical questions around symptoms such as thought process, content, mood, behaviour, and what participants considered was the presenting problem. The following are reflective of the comments made that highlight the routine type of questions asked:
‘I ask people about their appetite, I ask them about their energy levels, I ask them about their sleep, I ask them about all the stuff, the delusion or all that kind of stuff, if they’re psychotic thinking, cognitively impaired…it’s just it’s [sexuality] not
something you ask and I mean I was never trained to ask it I suppose, and I don’t’ (5 F).
‘A lot of it is around how people are presenting, their mood, their behaviour, the focus is on that…the presenting problem…it’s [sexuality] not something I think about’ (25 F).
Questions or statements relating to the sexual dimension of the person in terms of developing intimate and sexual relationships or their experience of intimate and sexual relationships was not proactively included in either the initial nursing assessment or subsequent nursing assessments or discussions with clients.
The ‘routine questions’ asked were perceived as necessary to help participants
perform their role, which was to treat ‘illness’. Questions relating to sexuality did not have the same degree of legitimacy. As one participant said:
‘… the questions [routine] are necessary, so you can care for the person…I mean they [questions about sexual relationships, sexual experiences or sexual health] are not necessary. Okay, yes, it is an activity of daily living, but it is not necessary, you can care for people without addressing it’ (22 M).
The emphasis on accessing information in order to treat ‘illness’ is also evident in the following comment:
‘I think peoples’ sleep is so important… it tells you whether people are depressed, whether they are elated, whether they are psychotic, whereas I suppose it doesn’t occur to me that their sex life, relationships tells me so much about them (said with a sense of shock)’ (5 F).
By confining themselves to a routine questioning technique, participants were able to control the interaction, and control the possible outcomes, in terms of what clients told them. In this way, participants minimised the likely consequences to self in terms of exposure of personal discomfort or competency deficits.
‘Avoiding taboo questions’: Designating a topic as taboo was a product of
perspective. When a topic was appraised as sexually laden with meaning or extremely intimate, participants would not, because of personal discomfort, initiate a conversation on this topic. Questions in relation to sexual activity, sexual orientation, sexual violence and iatrogenic sexual dysfunction fell into this category
and were consciously avoided by participants. Even in situations where participants recognised that clients were experiencing some difficulties around sexual identity and orientation they were reluctant to ask questions or explore issues, as highlighted by this participant.
‘It is something that is difficult to ask like whether they have any issues…I have nursed a couple of young lads who I felt were struggling with their sexual identity and I felt uncomfortable asking them anything; it is something we as nurses are scared of, so you don’t ask’ (15 M).
Participants expressed a high degree of discomfort around the area of sexual violence; consequently, they avoided any questions in relation to sexual experiences, whether positive or negative:
‘I wouldn’t ask, (pause) no, I wouldn’t feel one hundred percent comfortable asking about sexual abuse – again, you are only going to ask questions that you feel comfortable with’ (22 M).
‘People who have been abused who have been sexually abused I would be more cautious as well… just the whole sensitivity around that issue,…being abused can cause such issues for people over their life, you know so that one would be kind of an area that I wouldn’t ask questions about’ (23 F).
There did not appear to be an alert consciousness of the need to break the cycle of silence, fear, stigma and shame, by creating a context that encouraged people to tell of their experiences of sexual violence. Participants were also not conscious of the way their actions could either reinforce a belief that the client’s experience was too bad or too unpleasant to discuss with anyone, or be experienced as a further collusion with society’s denial of the prevalence or impact of sexual abuse.
Participants did ask some direct questions of clients which could be considered related to sexuality. However, these questions were not linked, in the participants’ cognitive schema, with sexuality, sexual expression or the ‘erotic’. Consequently, they did not evoke the same element of discomfort and were not perceived as transgressing social taboos. For example, participants asked female clients about contraceptive medication. The purpose of this question was not to explore sexual relationships or sexual health, but to acquire facts deemed important for medication management. Commenting on asking about contraception, participants said:
‘We have a physical section [on the assessment form] so we get information there, if somebody is on the pill they will bring it in to us, and we will dispense it from the drug trolley so they can continue the contraception while in hospital, but we don’t delve into things beyond that’ (10 F).
‘When we’re doing the initial assessment we would ask people are they on any medication and they almost always think it’s psychiatric medication and I’d say, “Are you on the contraceptive pill”…it is just another question…because they are on other medication that might interact with the pill’ (1 F).
Similarly, participants did enquire if clients were in relationships. However, the focus was not on the significance or meaning of the information to the client’s sexuality and sexual health, but on acquiring facts about next of kin or civic status, in order to complete some administrative duty. Subsequent, follow up, or exploratory questions on the nature of the relationships or the impact of the current crisis on the relationship were not addressed. Inherent in many of these questions about relationship was a heterosexist bias that assumed heterosexuality:
‘You say “are you married Mary or Jack”’ (14 F).
‘We would ask their marital status, but it is just for our knowledge are they married, single, separated’ (12 M).
‘Vague questioning’: In light of the discomfort participants reported around asking direct, focused questions about what they considered to be taboo subjects, they veiled what could not be openly spoken about by using a ‘vague questioning’ style. Vague questioningenabled participants to ‘walk the very fine line between intrusion and what needs to be addressed’ (24 F). Vague questioning consisted of the use of questions that lacked a degree of precision. Given the imprecise nature of the questions, they were open to different interpretations by clients, thus enabling participants to project themselves as unintrusive. However, in the absence of follow up questions, this vague questioning style left clients without a context or permission to discuss sexual or intimacy concerns. The following are reflective of the style of questions participants used to ask about sexual related issues:
‘You might ask, “Are you in a relationship?” and “How is it going?”, but you would never ask if it was sexual’ (13 F).
‘I wouldn’t give specifics. I was saying like “How are you feeling like, is there