Tackling sexual risk behaviors in co-educational departments of adolescent psychiatry – challenge for a systemic approach in treatment

Objective: Sexual risk behaviors are common in adolescent populations with devastating consequences especially in clinical subpopulations. The noxious influences of such behaviors not only disturb the somatic and psychological wellbeing but also damage personal development, family system, neighborhood/social context and peer relations. The development of sexuality, when saturated with dynamic cognitive, emotional and behavioral disorders, exposes the child to the risk of sexual abuse, changes his/her mental activity and behaviors as well as parental and social perceptions of the child. Sexual risk behaviors mistakenly separated from a specific disease can lead to the worsening of basic mental condition, primarily affected by a mental disorder or intellectual disability. The therapeutic milieu of a co-educational in-patient ward focalizes and sharpens functions of sexual behavior of adolescence. In order to understand such risk behaviors and their meaning in clinical context as well as to tackle them in peer group interrelations there is a need to identify them.

Methods: Over the last 18 years, hospital observation of a cohort of over 6000 girls and boys (age 12 to 18) affected with mental illnesses (e.g., Bipolar Disorder, Schizophrenia, ADHD, Obsessive-Compulsive Disorder, Conduct Disorder, Intellectual Disability) hospitalized for an average of 3 weeks in a co-educational psychiatric department, the roles of their revealed sexual behaviors were categorized and discussed within their individual family therapies, patients group therapy and staff continuous training meetings. Psychotherapeutic work was aimed at a proper understanding of sexuality of young people, natural ways of psychosexual development and its interference with psychopathological signs and symptoms of basic mental illness. Broadening awareness of different meanings of adolescents’ sexual behaviors was associated with delimiting stable boundaries supported by open discussions. The effectiveness of such a multidimensional approach was assessed periodically every month, evaluating staff meetings and patients’ and parents’ reports.

Results: The roles of the disclosed sexual behaviors were categorized into: 1. preparation of reproduction; 2. confirmation of adulthood; 3. confirmation of masculinity/femininity (in front of the group); 4. establishment of intimacy, close dyadic relationship; 5. enhancement of self-esteem (attractiveness); 6. seeking of pleasure; 7. reducing emotional tension (fear, frustration); 8. risk-taking as sexual excitement and inversely; 9. expressing hostility and/or dominance; 10. governance and domination within the group - peer abuse (sexual bullying); 11. financial benefits as exchange; 12. symbolic/real self-mutilation and self-destruction; 13. rebelliousness against moral standards; 14. opportunistic implementation of desired standards of the group; 15. manifestation of psychopathology. In family meetings exploration of parental attitudes and patterns of their own sexuality were discussed in the context of revealed meanings of the child’s sexual behavior. The role of the social milieu (peer group, hospital setting and environmental influences - religious and mass culture in particular) were always considered. The open and friendly discussion diminished the “grey zone” of undisclosed, harmful sexual relations, improved patients’ subjective cooperation and their acceptance of necessary restrictions.

Conclusion: The multisystemic approach based on family along with work within the therapeutic group seems to tackle objectionable sexual risk behaviors in adolescent psychiatric departments and to enhance family resources in coping with them in future.