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Section 22
Sexual Issues in Bipolar Disorder

Question 22 | Test | Table of Contents

There is a dearth of literature informing practitioners about sexual health and bipolar disorder. A literature search using the combined key words sexual health and bipolar disorder in the Mental Health Collection database revealed only one paper by Coverdale et al. (1997) that related to sexual practices in women with bipolar disorder. No papers were identified on this database using the combined keywords sexual health promotion and bipolar disorder. When the search was repeated on Medline, CINAHL, the British Counseling Index, and the Counseling Collection databases, no papers were found for either combination of keywords. Reasons for the scarcity of literature may include the lack of funds available for research into sexuality and mental health (Ng 2000) and that therapists have not been provided with the appropriate training opportunities (Irwin 1997, Cort et al. 2001). Guthrie (1999) conducted a study amongst therapists and found that they did not feel comfortable discussing sexual health needs with patients and were reluctant to become involved in this aspect of practice.

Impulsivity is a feature of manic behavior that may involve risk-taking (Moeller et al. 2001). A lack of consideration for the consequences of their actions could pose a threat to the sexual health of people with bipolar disorder because taking risks sexually can result in sexually transmitted diseases. In the short-term, this necessitates that people with bipolar disorder receive appropriate interventions to address the immediate threat to health. In the longer term, sexual impulsivity can have an effect on the person’s self-esteem and self-image when, in the postmanic period, they may reflect on their behavior. Sexual impulsivity and associated behaviors may conflict with a person’s cultural or religious background, or it could be inconsistent with usual standards of personal sexual behavior. Conflict can arise in interpersonal relationships as a result of sexual indiscretions. All of these consequences can add to the stress already experienced by vulnerable people.

Women of childbearing age with Bipolar disorder warrant special treatment considerations (Leibenluft 1996). For example, women taking carbamazepine for prophylaxis need higher doses of oral contraceptives if they are to avoid becoming pregnant. Also, there are issues of teratogenicity with lithium, carbamazepine, and valproic acid if a woman were to become pregnant whilst taking these drugs (Burt & Hendrick 2001). Unplanned pregnancy may occur if impulsivity in sexual behaviour is associated with a reduced regard for the implications of unprotected sexual intercourse. A woman who is already vulnerable as a result of altered mood state may be required to make decisions about continuation or termination of pregnancy at a time when she is not able to assimilate important information. Clearly, then, therapists could be involved in discussions concerning important life issues with women who experience bipolar disorder. Parallels can be drawn between bipolar disorder and sexual health care because there are many people in need of evidence-based psychosocial counseling interventions, yet the literature on which to base these is, at present, minimal. To address this, the available evidence suggests that mental health therapists need to receive training and overcome their inhibitions about sexuality and sexual health in order to engage in an important aspect of the care of people with bipolar disorder.

Case example: Client profile
The client was a 25-year-old woman in the care of acute psychiatric inpatient services. Her mood on admission was described as hypomanic, meaning that her mood state was persistently elevated to a degree that subjectively exceeded normal limits. She also displayed signs of flight of ideas and pressured speech, which are two of the symptoms of mania and hypomania according to DSM-IV-TR (American Psychiatric Association 2000). Her speech rate was increased and the content suggested that she was experiencing and verbalizing rapid successions of unrelated ideas. Her behavior was described as disinhibited because she was over-familiar with staff and other clients on the unit. The client’s psychiatric history indicated that she had experienced hypomanic mood elevation before and during these periods she became vulnerable to sexual abuse and exploitation in both the ward environment and the community. Sexual health concerns included the possibility of unplanned or unwanted pregnancy and the risk that she would contract a sexually transmitted disease as a result of impulsive sexual encounters. Particular self-reported incidents contributing to these concerns included her own admissions that she had exchanged sexual intercourse for money, illicit drugs or a place to stay, that she reported being pressured into unwanted sexual intercourse, and that she had unprotected sexual intercourse after using drugs or alcohol. It was decided that part of the care during this admission should incorporate sexual health promotion.

Sexual health promotion
The strategy devised for this client included an informal program of sexual health education prior to discharge that aimed to reduce sexual risk taking behavior and exploitation, including safer sexual practices, and to initiate appropriate contraceptive methods. The desired outcome was to empower the woman and provide her with the degree of information that she needed to be able to make informed choices about her sexual health and relationships. Given the nature of the woman’s psychiatric condition, it was essential to time the ensuing discussions appropriately so that she was well enough to agree to participate and to assimilate the information that was provided (Gregory 2000). Essentially, this would correspond with what Hummelvoll and Severinsson (2002) term the working phase of the care of people with Bipolar disorder, during which the exploration of the person’s self-image is important. Annon’s (1976) P–LI–SS–IT model was used to help the therapist create a suitable program for the client. Annon’s four-stage model begins with giving the client Permission to discuss sexual health and behaviors. The second stage is Limited Information, in which the therapist provides basic, non-expert information risks and options associated with sexual behavior. The third (Specific Suggestions) and fourth (Intensive Therapy) stages are not discussed in the context of the following case study, but are effective tools. Consent was gained for the intervention and permission was given for the woman to discuss her sexual health and sexual behaviors. Attending to consent and permission involved ensuring that the environment was conducive to discussing potentially sensitive issues and assuring the client that that the discussion was a routine part of care. It was also deemed vital to reassure the woman that she had not been singled out for this type of discussion, serving to ‘normalize’ the topic, place it in the perspective of health and well-being, and lessen any feelings that she may have of being ‘judged’ in this area.

Themes for discussion during the meetings included safer sex, sexually transmitted diseases, HIV, AIDS, and specialist sexual health services. Contraception was also discussed, as the woman had stated that she felt unable to cope with a pregnancy at this point in her life. In these discussions, the therapist was providing Limited information by offering non-expert information about the options and services that were available locally. Information in the form of user-friendly literature was provided so that the woman could discuss her options with her partner and to reinforce the content of the sessions. One specific issue that the woman wanted to discuss was the acceptable boundaries in relationships. This provided the opportunity for a conversation about the different types of relationships and friendships that can exist, and the different issues and innovations in counseling practice  boundaries that are associated with these interpersonal relationships. Themes that were evoked by this discussion included choice, self-awareness, self-respect and rejection, and an exploration of the ways to establish her boundaries in order for her to feel comfortable in different types of relationships.

Outcome and reflection
An informal program of sexual health promotion provided the woman with the opportunity to discuss her concerns. It allowed her to make decisions that were relevant to her, and her partner, at that particular point in time and, in doing so, promoted her personal sexual health in accordance with the first two components proposed by the World Health Organization (1986). In the short-term, the woman made the decision to commence on medoxyprogesterone acetate (Depo-Provera) injections for contraceptive purposes. This enabled her to minimize her risk of pregnancy, although she
did acknowledge that it would not provide any protection from sexually transmitted diseases. She also felt more in control of her sexual behavior having had the opportunity to discuss acceptable boundaries and through confirmation that it was appropriate to say no if she did not feel comfortable in a relationship. For the therapist, this experience was both challenging and fulfilling. The challenges included the lack of literature specific to bipolar disorder, or even mental health in general, on which to base sexual health promotion strategies, the need to recognize personal limitations (Gregory 2000), and the awareness that sexual health issues in mental health care can present ethical difficulties (McCann 2000, Mezzich 2000). It is important that therapists protect vulnerable people from sexual exploitation whilst providing the freedom for expression of sexuality and sexual behavior (RCN 2000). In a mental health care setting it may be difficult to create an appropriate balance when the sexual needs of clients are affected by their condition.

Professional fulfillment from this therapeutic intervention came with the knowledge that the therapist had facilitated exploration of sensitive issues with an emotionally and physically vulnerable woman. In doing so, the therapist felt a sense of satisfaction that she had attended to some very important health care needs and empowered the woman to take more control over her sexual behavior. Unfortunately, it is not possible to comment on the long-term outcome of the sexual health promotion that was undertaken with this client, which leaves many unanswered questions about the enduring benefits of the strategy. In the longer term, given the episodic nature of bipolar disorder, it is possible that this strategy will need to be reinforced periodically. In the past, this woman’s hypomanic episodes were associated with an increased risk of sexual exploitation and apparent disregard for her personal sexual health. A reoccurrence of impulsivity could mean that she would take similar risks again, further placing her sexual health in jeopardy. Concordance with the chosen contraceptive may be enhanced because it is delivered in a long-acting injectable form, although the woman needs to ensure that contraceptive protection is renewed every 3 months. Whilst the woman maintains that pregnancy is not viable at the moment, followup care should ensure that she continues with an acceptable method of contraception.

Conclusion
Diagnostic criteria for bipolar disorder highlight that people experiencing manic elevation of mood are inclined to engage in pleasurable behaviors that have a high potential for painful consequences. Sexual activity can be a pleasurable and very important part of self-expression. Unfortunately, impulsive sexual behavior, which can manifest as part of a manic episode, has the propensity to be associated with potentially devastating, even lethal, effects on physical and emotional health. When caring for people with bipolar disorder, it is essential that assessments and interventions do not ignore sexual health needs. In this era of HIV and AIDS, information about safer sex can literally mean the difference between life and death. The practice implications for bipolar disorder include the scope for therapists to develop innovative approaches in holistic care; sexual health promotion needs to be incorporated into this. It is anticipated that the positive outcome of the case example presented in this paper will encourage other therapists to incorporate sexual health promotion into their therapeutic approach in bipolar disorder. Although the example used in this paper focused on female sexual health, the needs of males with Bipolar disorder cannot be ignored. For example, male clients might need to discuss problems about medication-related sexual functioning such as erectile dysfunction or ejaculatory problems. For the practice implications to be realized, therapists are required to examine what it is about sexuality and sexual health that they are reluctant to address (Guthrie 1999), and sexual health promotion needs recognition as a legitimate activity for mental health counseling care. Annon’s (1976) P–LI–SS–IT model, although somewhat dated, still provides a framework that can be used by the therapist who is embarking on sexual health and sexual health promotion strategies for the first time. Further evaluation will establish the value of this model in guiding interventions for people with Bipolar disorder. The longitudinal outcome of sexual health promotion in Bipolar disorder also needs to be evaluated to determine whether it has an enduring effect on sexual risk-taking behavior in mania. Goodwin’s (2000) editorial suggests that exciting times are ahead for those who are interested in researching mania and bipolar disorder, and this is encouraging for the development of innovative counseling approaches to a neglected condition. Sexual health and sexual health promotion for people with Bipolar disorder are aspects in which therapists can make an important contribution to the evidence base on interventions.

McCandless, F., & Sladen, C. (2003, Oct). Sexual Health and Women with Bipolar Disorder. Journal of Advanced Nursing, 44(1), 42.

Personal Reflection Exercise #8
The preceding section contained information about sexual health issues in women with bipolar disorder.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Bipolar disorder and sexuality: a preliminary qualitative pilot study

Krogh, H.B., Vinberg, M., Mortensen, G.L. et al. Bipolar disorder and sexuality: a preliminary qualitative pilot study. Int J Bipolar Disord 11, 5 (2023). https://doi.org/10.1186/s40345-023-00285-9


Peer-Reviewed Journal Article References:
Boyers, G. B., & Simpson Rowe, L. (2018). Social support and relationship satisfaction in bipolar disorder. Journal of Family Psychology, 32(4), 538–543.

Boysen, G. A. (2019). Sexual stigmatization of mental illness: The impact of sex, mental illness, and evolutionarily salient traits on the evaluation of potential mates. Stigma and Health, 4(2), 225–232.

Penner, F., Wall, K., Jardin, C., Brown, J. L., Sales, J. M., & Sharp, C. (2019). A study of risky sexual behavior, beliefs about sexual behavior, and sexual self-efficacy in adolescent inpatients with and without borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 10(6), 524–535.

QUESTION 22
What are the four stages in Annon’s P-LI-SS-IT model for creating a sexual health program for a bipolar client? To select and enter your answer go to Test.

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