Madness, Sex, and Risk in Residential Mental Health Settings

Understanding how sex and sexuality are governed through the discourse of risk in long-stay mental health facilities.


A new article, published in the academic journal Nursing Inquiry, investigates the potential for people diagnosed with ‘severe mental illness’ to have a full sexual life while residing in a long-stay residential mental health facility. The research team, led by Alicia Evans of Australian Catholic University, conducted qualitative interviews with mental health clinicians and analyzed them through the lens of poststructuralism.

The findings reveal that clinicians often problematize the sexual needs and practices of residents. The sexuality of residents is governed and policed under the pretense of reducing risk, but actually acts to safeguard clinicians and staff, leaving residents less safe and more unprotected. The authors explain:

“The clinicians exercised disciplinary power to ensure that the facility was both apparently ordered and safe. This also served to protect them from needing to negotiate with each resident about their sexual needs and how these might still be expressed while living communally. This aspect of ‘rehabilitation’ was silenced, and order was maintained. What happened outside the facility was another matter and one that meant residents bore the risk associated with sexual activity in public spaces.”

The association between risk and what the authors refer to as ‘madness’ has been a concern to mental health clinicians and staff for decades, leading to what is now most commonly referred to as risk assessment. Risk assessment is often used to justify disciplinary power to regulate or control the potential risk. While rooted in concerns for the patients’ safety, critics have felt that the dominant risk being managed is the risk to clinicians and the organization rather than the patient.

The researchers were interested in whether discourses of dangerousness would be present in the data from their study to provide new insights for modern clinicians. They used a case study methodology to explain how residents’ sexuality was governed and to understand if there were restrictions on sexual liberty and how this was organized.

Residents at the facility had “moderate to severe psychiatric conditions with a significant reduction in psychosocial functioning.” Ten clinical staff members were interviewed in a semi-structured format.

The first significant finding was a ‘no sex on-site’ rule.  An extension of this rule was that visitors were not permitted to go into a resident’s bedroom if they were the opposite gender. The clinicians reported that sexual activity was strictly policed and in accordance with the ‘policy’; however, upon clarification about such a policy, it was revealed that no official policy existed. No written document or protocol addressed the policing practice.

None of the clinicians seemed to know where the ‘no sex rule’ came from. Furthermore, this policy assumed that all patients were heterosexual, as the same restrictions did not apply to same-gender visitors.

This led to the second major finding associated with ‘risk.’ While sexual activity was banned on-site, the clinicians approved of sexual activity off-site, such as at their partner’s residence, brothels, or simply having sex somewhere else off-site. Since not all residents have safe places to have sexual relations, this meant that residents who wanted to have a sexual encounter needed to do so in a public space such as a park or public toilet, since most residents did not have the financial means to rent a motel. Although none of the clinicians spoke to the inherent risk involved with this outcome, it was clearly present.

It is worth further consideration as to how the ‘no-sex on-site’ rule introduced an element of risk for the resident at the same time as it secured the clinicians and mental health service against risk,” the authors write. “While these may well be reasonable safeguards to put in place for clinicians and mental health services for protection, it left the residents less safe and more unprotected.”

The author’s situated their understanding of the findings within a poststructural analysis, informed by 20th-century philosopher Michel Foucault’s notions of discipline and governmentality and sociologist Robert Castel’s work on risk.

Foucault refers to ‘discipline’ as an individual’s internalized social norms and also coined the term’ governmentality,’ which was based on his historical research on sexuality. This work concentrated on the relations of power, knowledge, and the body in modern society.

With this in mind, the author’s found that the idea of “allowing” others to have authorized sexual practices was an act of paternalism, which is defined as the “interference of a state or individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off protected from harm.” This introduced a binary division of ‘us’ (staff) and ‘them’ (resident), and by ‘othering’ the resident, it positioned them as different, vulnerable, at-risk, and/or in need of protection.

The power of not allowing residents to have sexual practices operates as a form of policing. Consistent with Foucault’s work on discipline and punishment, mental health nurses had internalized a rule or social norm around the prohibition of sexual activity and then enforced it, even though such a rule did not explicitly exist in the policy.

Robert Castel was a prominent figure to critique the concept of risk. He proposed that the notion of dangerousness was an assessment made on an individual basis. In contrast, the idea of risk is population-driven and then applied to the individual, regardless of their particular circumstances or context.

In relation to Castel’s work, the analysis revealed that the staff had a compartmentalized perception of the resident, with the idea that the resident’s mental state somehow existed as a separate entity to the rest of them. They write:

“In this way, their ‘mental state’ is treated as if it is separate from the dynamic tensions that human beings live with, particularly between one’s desires and their mental/emotional responses to either deprivation or satisfaction of the sexual drive.”

Through the lens of Castel’s work, this compartmentalized view of the patients aligns with the shift that occurred within the broader field of psychology in the 20th century, moving away from talking therapies, such as psychoanalysis, toward a more empirical, biologically based approach privileging the brain.

Castel felt that this move had much less regard for the therapeutic relationship that had been so central to the mental health disciplines, and brought with it the abolition of messy dynamic relationships to introduce apparent order, which we see in this study.

In conclusion, it was clear that a discourse of risk was operating through staff interviews. While the organization remained safe, well protected, and avoided fear of future litigation (which is often seen as the gold standard for a treatment facility), it significantly impacted the resident’s recovery and placed them at risk to have their sexual needs met. The authors close with the statement:

Residents could not be empowered in relation to expressing their sexuality when the compartmentalized, applied way of thinking dominated, and the safety of the corporation was privileged.”



Evans, A. M., Holmes, D., & Quinn, C. (2020). Madness, sex, and risk: A poststructural analysis. Nursing Inquiry. (Link)

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Madison Natarajan, PhD candidate
Madison is a doctoral candidate in the Counseling Psychology PhD program at the University of Massachusetts Boston. She is currently completing her pre doctoral internship at the Massachusetts Mental Health Center/Harvard Medical School working in psychosis interventions across the lifespan. Madison primarily considers herself an identity researcher, assessing the ways in which dominant cultural norms shape aspects of racial and gender identity for minoritized individuals, with a specific focus on the intersection of evangelicalism and its relationship to Christian Nationalism. Madison has a family history that has been intertwined with psychiatric care, ranging from family members who were institutionalized to those practicing psychiatry, both in the US and India. Madison greatly values prioritizing the experiences of those with lived experience in her research and clinical work, and through her writing in MIA seeks to challenge the current structure of psychiatric care in the West and disseminate honest and empowering information to the community at large.


  1. My psychiatrist claimed that a wife – who, in the privacy of her own home, wanted to have “a little afternoon delight” with her own husband, once ever – had “hyper-sexual behavior.” Such intrusive malpractice does destroy marriages.

    That same psychiatrist – three years later – when confronted with the fact that medical evidence of the sexual abuse of my three year old child was handed over. He thought the appropriate solution to that sexual CRIME was to neurotoxic poison my child. Goodbye, sick twisted insane lunatic psychiatrist.

    I didn’t know the number one societal function of the “mental health” system was covering up rape of children, and it’s all by DSM design. Now I do.

    And since profiteering off of covering up child abuse is the number one actual societal function of the “mental health” industry, the psychiatric leaders now want to legalize pedophilia. No doubt, because that would be great for business for the systemic child rape covering up systems.

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    • “While the organization remained safe, well protected, and avoided fear of future litigation”

      And of course when you engage in cover ups for colleagues “character flaws” and to remain ‘safe, well protected and litigation free’ we don’t see the outcomes of the abuses that occur for some time (in Aust some 40 years and hundreds of victims later). Wouldn’t it be nice to see these organisations be ‘open, protected by truth, and living in fear of litigation for enabling abuses via negligence, fraud and slander’? Though that wouldn’t suit abusers.

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  2. There is a parallel to be drawn here with the developmentally disabled community. There is a understanding within that community that caretakers have a responsibility to prepare themselves and their charges for the onset of puberty, appropriate sexual relations, and their constitutional right to reproduce and care for their children (with or without substantial supports and supervision, case-depending.)

    I have to wonder why we (at least those of us in the know) understand that sex happens among the developmentally disabled and yet the same desires and behaviors are treated as deviance among the so-called “mad”.

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  3. I wonder if they will consider intake of food a debatable subject. Oh that’s right, there are a few that determine what is allowed. Besides, give people anti-psychotics which result in castration of mind and desire. The chemical lobotomy.

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  4. I find topical psychiatric SEXUAL discussion a bit amusing as for the time I consumed any level of “therepeutic psychiatric chemotherapy” I was incapable of any type of sexual performance. At this time Sexual fulfillment was also probably the least of my problems.

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  5. “…clinicians often problematize the sexual needs and practices of residents.”

    That’s pretty damned euphemistic! Why not say, “Clinicians tried to shut down any opportunites for sexual expression due to their own discomfort, and used their power to deny residents their civil right to meet their sexual needs without interference.” This is a matter of a violation of rights, not some philosophical discussion of “problematization!”

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  6. What isn’t covered here is the issue of consent. And providing appropriate protections that someone experiencing hypersexuality isn’t taken advantage of or taking advantage of another, and whether in certain mind states/altered states someone is well enough to grant consent. A lot to consider and digest here. Thanks for the article!

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