The Sexual Partnerships of People with Serious Mental Illness

Article excerpt

The transmission of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) among people with serious mental illness has garnered attention in the public health community over the past 20 years (National Institute of Mental Health, 2002). Seroprevalence rates among people with serious mental illness are typically higher than in the general population and have most recently been estimated at between 1.0% and 5.4% (Essock et al., 2003; Rosenberg et al., 2001).

Because of this elevated risk, clinicians and public health officials recognize an eminent need for research on patterns of sexual behavior in this population (Buckley, Robben, Friedman, & Hyde, 1999; Lukoff, Sullivan, & Goisman, 1992). Existing studies are beset by sampling and methodological constraints and are informed by an individual-focused approach that limits our understanding of the sexuality of people with serious mental illness (Buckley et al., 1999). Our analysis employed a systematic, venue-based, random sample of mental health clients drawn from various treatment settings. Placing emphasis on the role of social context in shaping individuals' sexual behavior within relationships (Laumann, Gagnon, Michael, & Michaels, 1994), we compared the primary partnerships of people with serious mental illness and the general population.

In the past 10 to 20 years, there have been over a dozen studies of client sexual behavior (see Buckley et al., 1999, and McKinnon & Rosner, 2000, for reviews). The prevalence of sexual activity (anal or vaginal intercourse) among people with serious mental illness has been estimated at between 44% and 80% (Buckley et al.; Cournos, Guido, & Coomaraswamy, 1994; Rozensky & Berman, 1984). Importantly, multiple studies have identified an increased tendency to engage in unprotected, high-risk sexual behaviors (Baker & Mossman, 1991; Buckley et al.; Carey et al., 2001, 2004; Chuang & Atkinson, 1996; Cournos, McKinnon, & Meyer-Bahlburg, 1994; DiClemente & Ponton, 1993; Kalichman, Kelly, Johnson, & Buero, 1994; Kelly et al., 1992; Levan & Johnson, 2002; McKinnon & Rosner, 2000; Susser, Valencia, Miller, & Tsai, 1995; Tubman, Gil, Wagner, & Artigues, 2003). In particular, rates of homosexual activity are high, as is the likelihood of having multiple concurrent sexual partners (Carey et al., 2001; Coverdale, Turbott, & Roberts, 1987; Cournos et al., 1993, 1994; DiClemente & Ponton; Kalichman et al., 1994; Kelley et al., 1992; Lavan & Johnson; McDermott, Sautter, Winstead, & Quirk, 1994; Rozensky & Berman; Susser et al.).

Although the risk-avoidance literature has contributed a great deal to our understanding of the levels and types of sexual risk behaviors in which people with serious mental illness engage, cultural and clinical attitudes characteristic of this research are a limitation. Rarely is sex conceptualized as "an act of communication, expression of emotion, or an attempt at interpersonal bonding" (Lilleleht & Leiblum, 1993, p. 252). Rather, many clinicians believe that their clients are asexual, that their sexuality is inappropriate, or that they are incapable of successful romantic relationships (Buckley et al., 1999; Hogan, 1980; Lilleleht & Leiblum; Nesteros, Lehman, & Ban, 1981; Sadow & Corman, 1983; Thomas, 1989; Vandereycken, 1993). In short, sexual behavior is seen as another symptom to be treated or as a possible risk factor for slowing or reversing recovery (Pinderhughes, Barrabee, & Reyna, 1972).

These attitudes likely contribute to the tendency to ignore the relationship context of sexual behavior in research involving people with serious mental illnesses. Instead of examining how social characteristics such as relationship dynamics, social network pressures, and stigmatizing public attitudes influence sexual risk behavior, clinicians frequently assume that their patients act independently of external social pressures and constraints. …