Let’s talk about healthy sex – the importance of sexual health care.

By Marije Keulen-de Vos, Kasia Uzieblo & Minne De Boeck (Dutch affiliation of ATSA, NL-ATSA)

According to the World Health Organisation, sexual health refers to a state of physical, emotional, mental and social well-being in relation to sexuality. It encompasses not only certain aspects of reproductive health but also the possibility of having pleasurable and safe sexual experiences. This part of life is often neglected in working with persons with sexual offence histories. Treatment is typically aimed at inhibition, control and suppression of sexual feelings and behavior opposed to identifying healthy sexual behavior and promoting sexual health. Those in the field of providing therapy and education for persons with sexual offence histories are somewhat puzzled by the question of what constitutes healthy sexuality for these individuals. In persons with sexual offence histories, sexual health is not simply a synonym for absence of sexual violence. Instead, it relates to the absence of sexual dysfunction and the presence of sexual pleasure without suffering, without bringing harm to others and having sexual pleasure with mutual consent.

On June 1^st NL-ATSA, the Dutch affiliation of ATSA organized an online symposium on the importance of talking about and facilitating sexual health in persons with sexual offence histories. The symposium started with three plenary sessions which were followed by three parallel sessions. 

The first presenter, Prof. Marieke Dewitte (Maastricht University, the Netherlands), focused on a biopsychosocial model towards sex. Sexuality is complex; it involves our brain system, neuroendocrinological system, and anatomy. For example, a sexual trigger may lead to positive appraisal, subjective arousal, genital arousal, sexual motivation and, ultimately, sexual behavior. Psychological mechanisms such as sexual rewards, thoughts and emotions, and attachment, all linked to the societal and relational context, define our sexual behavior. Hence, psychological theories on these mechanisms help us understand sexual behaviour. For instance, the attachment theory provides an important framework for understanding the dynamics of (sexual) interactions in romantic relationships across the lifespan. Because the attachment system primarily serves an emotion-regulation purpose, the attachment theory can help us explain how individuals cope with stressful or threatening situations within the context of their sexual relationship. For example, feelings of intimacy are a likely result of this sense of security. On the other hand, intimacy might also act as a buffer to prevent the activation of the attachment system when facing relational or sexual challenges. Marieke Dewitte concluded that 10% to 23% of the persons with sexual offence histories experience various problems with sexuality and intimacy. Some exhibit a negative self-image, fear of failure, and problems with intimacy and commitment – often triggered by insecure attachment styles, whereas others have erectile dysfunctions, experience orgasm problems, or an increased sexual drive. However, many treatment providers who work with persons with sexual offence histories lack the knowledge and skills to make informed decisions about improving sexual health care in their forensic clients. Marieke Dewitte thus emphasized the importance of including sexuological insights and methodologies in the treatment of clients who have committed sexual offences.  

The second presenter, Jantien Seeuws (forensic psychologist, Fides Beernem, Belgium) focused on policy in forensic centers regarding stimulating healthy sexual expression in persons with sexual offence histories. Despite the liberal view of sexual freedom in Western Europe, expression of sexuality in individuals in mandated care seems to cause fear and division among forensic health care providers. What complicates matters is the fact that – in these individuals – sexuality is intertwined with sexual violence and all kinds of sexual problems, such as a disrupted psychosexual development, deviant sexual scripts, limited sexual regulation and sexual disfunctions. Therefore, a multidisciplinary approach is important when addressing healthy sexual behaviours. The Good Lives Model suggests that treatment for persons with sexual offence histories must regard participants as whole beings in need of focus in many principal life areas, such as family, employment, leisure, community, and well-being including sexual health. Risk and good lives models are complementary models in forensic care, and by emphasizing the merits of each, management and well-being of patients can be maximized while community safety is increased. Furthermore, sexuality is a basic human right. Professionals should commit to this universal right when supporting sexual health of their patients. Forensic settings that offer long-term mandated care should have a clear policy, consistent with local law, aimed at accepting patients’ sexual needs and helping them to securely manage their privacy, sexuality and relationships. Yet, forensic hospitals or units rarely develop such a policy. Jantien Seeuws argued that there are several challenges in developing a sexuality policy in treatment wards for persons with sexual offence histories. First, perpetrators of sexual violence pose a heterogeneous group; there are distinct differences in psychosexual development, the nature of sexual violent behaviors and sexual deviances, criminal history, and other relevant characteristics among those who have offended. These individual differences call for tailoring treatment to the individual. Second, patients and staff may have different views on healthy relationships and sexuality preventing a unified vision. Also, public opinion typically emphasizes repression and punishment. This may induce the tacit acceptance in professionals that punishment is also justified with regard to intimacy and sexuality.  Finally, the interconnectedness of sexuality and violence means that themes such as masturbation, phantasies and pornography are approached very carefully and evokes various important questions. For example, an interest in playing with power dynamics is common and healthy for consenting adults, but is it healthy for someone convicted for sexual assault? Do these (sexual) behaviors all raise the risk for recidivism? Jantien Seeuws concluded that current policies on sexuality in forensic settings are long overdue. It is important to thoroughly map and discuss sexuality in persons with sexual offence histories as sexuality also influences their physical and psychological health. Treatment providers should also take initiative in providing non-judgmental language with regard to sexuality and sexual dysfunctions in their clients.   

In the final plenary presentations, Bas Frelier (psychiatrist, the Forensic Care Specialistis, the Netherlands) discussed the implementation of a Sexual Health Project in a forensic setting. In forensic settings, sex is often approached in a negative way. Also, even in patients for whom sexuality is not related to risk, treatment providers are cautious about the subject. In 2019, the Forensic Care Specialists instated a department of sexology with the goal to integrate sexology within their treatment program for their forensic patients. The department’s vision on sexuality is that a healthy sex life and healthy relationships are protective factors for all forensic patients, and that everyone has the right to sexual health. To achieve their goal, the department initiated the Sexual Health Project, which started with sexuological education for practitioners as treatment providers regularly feel shy about talking about sexual behavior and interests, and providing sexuological treatment. The sexology department is collaborating with two other forensic hospitals to develop a guideline for integrating sexuality as a vital component of forensic treatment programs. The guideline is anticipated by the end of 2022.

The symposium closed off with three workshops. The first workshop focused on providing sexual services to people with intellectual disabilities. The presenter of this workshop Miek Scheepers (vzw Aditi) explained and demonstrated with case studies that, in addition to supporting their social network, sexual services can offer these clients opportunities for learning and experiencing sexual interactions in which consent, equality and voluntariness are the common thread. The second workshop provided by Tom Platteau and Corinne Herrijgers (Institute of Tropical Medicine Antwerp) focused on drug use in combination with sex (“chem-sex”). A recent study on the needs of 20 chem-sex users led to the development of a health-app (“budd”). This app aims to sensitize and support chemsex users in safe sex participation, as well as to increase awareness and insight into their own (risky) behaviors. The third workshop provided by Zohra Lkasbi (ZNA, UKJA) and Jeroen Dewinter (GGzE, Tranzo & Tilburg University) focused on sexuality in adolescents who displayed sexual violent behaviour. They provided several methods to maintain and discuss healthy sex and relationships in forensic youth care and therefore pointed out the necessity of a good therapeutic relationship. These experts also emphasized the importance of paying attention to and cooperating with parents, counsellors and the social environment in order to enhance healthy sexual behavior.

The fact that this symposium was attended by over 250 practitioners (psychologists, psychiatrists, probation officers to name a few) from the Netherlands and Belgium, as well as the grateful feedback during and after the event, illustrates that many practitioners are struggling with how to deal with sexual health in persons with sexual offense histories, but are also acknowledging the importance of including this necessary topic in their work. Opportunities to share best practices to obtain an in-depth understanding of sexual wellbeing in forensic patients are clearly highly needed.