SOCIAL REPRESENTATIONS IN NURSING : THE SEXUALITY OF PATIENTS WITH MENTAL DISORDERS

Objective: to understand how nursing workers perceive the sexuality of patients with mental disorders. Methodology: this was a qualitative, descriptive, and exploratory research with a methodological approach to social representations. Results: a total of 18 nursing workers from a Center for Integral Mental Health Care in São Paulo participated in the study. The data was collected through interviews using a semi-structured questionnaire between March and June of 2009. Most participants perceived sexuality as a form of disease, which was the target of surveillance, control, and punishment. The lack of preparedness in nursing professionals to deal with the sexuality of patients with mental disorders was noticed. Conclusion: myths, taboos, prejudices, and lack of knowledge was observed in nursing workers facing the sexuality of patients with mental disorders. The need to address sexuality as a natural phenomenon, inherent to human beings is reaffirmed.


INTRODUCTION
Human sexuality is considered an increasingly relevant topic to be discussed in the public area because it has been transformed into a culturally inherent event to individuals with a number of meanings throughout a long process of historical changes. 1 The society has a very diverse conception of sexuality based on the systematization of socio-cultural codes that organize the collective life, and thus, there is not a universal sexuality. 1Therefore, there is a consensus about sexuality being at the core of the personal identity stated in the key components of affection, relationships, and intimacy. 2hen referring to sexuality, we are usually referring to a concept that is often difficult to be understood.It branches out into several points, including the understanding of our behavior in life, the sexual act, the attraction we feel for somebody, our wishes of happiness and pleasure, our prejudices and moral values, and our body and the way we see it.These and other concepts are interlinked within us since birth, and acquire valid and unique forms of expression. 3t is still currently perceived that many nursing workers do not feel comfortable discussing issues related to sexuality and are reluctant to become involved with this aspect of their everyday practice. 4Possibly, their own feelings and attitudes, loaded of sexuality, can act as a barrier to explore any aspect involving the sexuality of their clients.
This claim is related to the fact that human sexuality has not been addressed significantly in the training of nursing professionals.This fact is verified in the training of nursing technicians following a technical and mechanized model. 5In nursing courses, the curriculum is almost always linked to activities of a technical nature and assistance management. 6here is no specific course of human sexuality in most undergraduate courses.Some courses approach only some aspects of it, which do not give sufficient basis for the performance of nurses, and produce uninformed and prejudice professionals.There is a lack of studies, discussions, and reflections on the academic level and in the nursing professional practice itself about the socio-cultural sphere of human sexuality, characterizing a sign that it is considered a taboo. 7t is understandable that the way human sexuality is approached in Psychiatric Nursing is also related to the history of Psychiatry because from the moment in which Psychiatry focused on mental disorders there was the consolidation of sexuality as part of a social imagery prevalent in the 13 th and 19 th centuries, and in the repertories of classifications of psychiatric disorders. 8hus, it can be said that Nursing has accompanied and was part of the intervention process in which the doctor´s knowledge shall intervene in diseases through restorative techniques that restores the normal status in the hegemonic and producer discourse of truths about the disease. 9 this process, the nursing staff acted as the agent of monitoring and institutional control, observing the everyday behavior of inpatients, highlighting anomalies and symptoms, registering occurrences, and acting immediately to control, from their own values, taboos and prejudices. 10he lack of preparedness of nursing professionals to deal with human sexuality is noticed, showing that they have been prepared to work with a biological model to the detriment of the approach of sexuality as a social, cultural, and unique phenomenon.
This study aimed to understand, through social representations, how nursing workers perceive the sexuality of patients with mental disorders.To achieve the objective, the guiding question for the study was based on the following: what are the social representations of the sexuality of psychiatric patients that guide the actions of nursing workers?
With the data found, it will be possible to adjust nursing practices to take into consideration the expression of sexuality in Psychiatry.

METHODOLOGY
The methodological way required by the objective referred to a descriptive and exploratory study, conducted by a qualitative approach of social representations.
Social representations refer to the knowledge produced in common sense, based on shared and articulated knowledge, which constitutes a lay theory regarding certain social objects. 11riginated in the everyday life and in the course of interpersonal communications, the Social Representations Theory is defined as a system of values, ideas, and practices, which has as its functions, the establishment of an order that guides patients in the social and material world to control it and the promotion of communication between members of a community with the goal of providing a code to name and classify the various aspects of their world and of individual and social history, without ambiguity. 12he main function of representations is teaching to classify or conventionalize patients, events, and objects, comparing and explaining the behaviors as part of our social scenario. 13his study was performed in hospitalization sectors for individuals with mental disorders in a Center of Integral Care to Mental Health, located in the municipality of São Paulo, which is an institution managed by a health social organization (OSS) in partnership with the Department of Health from the State of São Paulo in Brazil.
The subjects in the study were seven nurses and 11 nursing assistants, eight males and 11 females, directly involved in the care in all three working shifts.
The interviews were conducted during scheduled visits with the participants according to their availability, in a reserved room at their workplace.Each interview had an average duration of one hour.

ality of the patient appears, but we inhibit sexual intercourse among patients […] (Nurse 2).
So, patients who have some pathology, usually they don't have much sexual libido, except patients who arrive with increased libido, then we have to be very careful because the doctor says he has some risk.The patients of alcohol and drugs, they are very problematic, most problems of sexuality are among them (Nursing Assistant 2).
Depending on the pathology, his sexuality is quite high, for example, in the bipolar affective disorder, when they have mania, which is when we usually say that their sexuality is very high, they have no scruples, they insinuate and say things as if they were on the street, literally they flirt with you.In the case of schizophrenics, they also have high sexuality; however they are more reserved, much more reserved.It's hard for schizophrenic patients to flirt with you.He even comes to talk to you, but it's something duller.In the mania bipolar it is terrible, both men and woman (Nursing Assistant 4).
It is perceived that even the most simple and routine expression of sexuality such as touching, kissing, hugging, looking or the way how to dress were also considered out of the expected context and therefore, seen as psychopathologies.
Thus, the nursing workers understood the expression of sexuality from the perspective of mental disorder and justified the behaviors related to sexuality through psychopathological symptoms and irrationality, and associated erotism, commonly present in cases of bipolar affective disorder in mania phase (increased libido and disinhibition), to schizophrenia (bizarre behavior) and problems with alcohol and drugs (impudence).
There were numerous reports on psychopathological alterations such as change in libido, eroticized behavior, and social and sexual disinhibition.Therefore, most reports were concerning mania in bipolar affective disorder, in which the expression of eroticized sexuality in mental disorder patients was described as acceptable and expected as being part of the psychopathological frame.
Other nursing workers reported perceiving sexuality in patients with mental disorders linked to schizophrenia because these patients often present diminished libido due to the side effect of psychoactive drugs used and their dull affection, both harmful to the socialization of these subjects.
The expression of sexuality or sexual interest in mental disorder patients is seen in a stereotypical way, related to diagnosis or symptom of the illness.
It is worth mentioning that the institutional space disregards the sexuality of mental disorder patients on its uniqueness, stereotyping it as an anomaly, devaluing it to an object of The inclusion criteria were: willingness to participate in the research and have at least one year of experience in the area of Nursing Psychiatric assistance in this institution.
To ensure compliance with ethical issues, the study was approved by the Ethics Committees in Research from the Institution and the Federal University of São Paulo (UNIFESP), authorized under the process numbers 130/08 and 08/1856, respectively, and in accordance with Resolution 196/96 from the National Health Council (CNS).
The interviews were conducted with a semi-structured questionnaire containing guiding questions and situational analyses on two possible daily situations involving the sexuality of patients and professionals.
Thus, the following questions were asked to achieve our objective: what do you mean by human sexuality?How do you perceive sexuality in the psychiatric patient in this institution?Cite some examples that occurred in your professional life related to the sexual behavior of psychiatric patients.Which interventions have you performed before these behaviors?Does the institution in which you work have some standard or routine intervention when facing the sexuality of the psychiatric patient?Which one(s)?What is your opinion about them?
The study proposal was presented to the study subjects, who were clear about the investigation, how the data would be recorded, protected, and used for publication as well as the possible favorable repercussions of the investigative process.Anonymity was guaranteed.Those who agreed to participate signed an informed consent term.
The data collection was interrupted when data saturation occurred.Based on the Social Representations Theory, the data were analyzed and categorized through processes of objectification and anchoring.

RESULTS AND DISCUSSION
There are three categories resulting from social representations of the nursing workers participating in the study.

The perception of sexuality as a manifestation of the disorder
Most nursing workers perceived the sexuality of patients with mental disorders as a manifestation of the disease, with the patient being incapable of expressing sexuality taken as normal, because they cannot restrain their affections and desires.This category can be exemplified from the following speeches: Because we have mixed units, sexuality surfaces and we have several disorders.So what we realize is that some disorders leave patients more hyper-sexualized, the sexu-institutional pedagogy, disabled by representing danger to the hospital order. 14sychiatry appropriated human sexuality from the moment it started looking for the side of extravagance, the etiology of mental diseases, and above all, when it annexed the set of sexual perversions to its exclusive domain trying to separate, protect, and prevent, requesting diagnostics, accumulating reports, organizing therapies. 15he perception of the expression of sexuality as part of the disease meets the biomedical model of health care, whose center points are the disease, the clinic, and the individual and curative assistance. 16hen nursing professionals perceived sexuality of patients with mental disorders as a manifestation of the disease, this representation aimed to make something that is alarming and destabilizing into something familiar and acceptable because it is easier to face it in a sick person.Such a process comforts, reestablishing a sense to the group and society, which accepts the expression of sexuality when linked to the manifestation of a mental disorder. 12hen considering that sexuality is perceived as part of the disorder, such professionals adopt a separation and denial posture regarding the expression of sexuality of the mental disorder patient. 17

Monitor, control, and punish
This category strengthens the concern in the nursing staff with affective and sexual manifestations performed during psychiatric hospitalization, being necessary that nursing workers watch, observe, control, and punish the sexuality of the mental disorder patient.Here there are speeches related to this category:

[…] when the patient arrives, we explain the schedules, what happens in the infirmary and we ask patients to not enter the rooms, men do not come in women's rooms and women do not enter men's rooms and the living room is a common space, so we have to respect this living room environment, no touching, kissing the wife in the living room, or the husband in the living room, because it's a common environment (Nurse 4). […] I've seen one case of a very clever patient, a beautiful girl. There was a man in the room with her, and others outside waiting. She was transferred by us to another psychiatric hospital […] (Nursing Assistant 3). […] I think that we first must prevent when we see these patients with changed sexuality you have to keep controlling one by one (Nursing Assistant 8).
It is noticed that the common attitude in the participants facing the possibility of expression of sexuality was to observe, monitor, stop, and prevent it.
The administrative discharge was a common practice held in the institution as a way to punish mental disorder patients who expressed their sexuality.However, punishment is not only applied to those subjects but also to nursing professionals who did not act as expected on the expression of sexuality by the patient.There are reports of punishment, through sector changes, warning, and suspension by the head of the nursing sector or superiors.
The need for chemical or mechanical contention was reported by the professionals as a measure of control the expression of sexuality by mental disorder patients.
It is perceived that, it is the responsibility of the nursing professional to deal with sexuality through the establishment of order, constant surveillance, control of inappropriate behaviors, and their punishment.
In this study, the attitudes of the professionals dealing with sexuality are related to the history of Psychiatry, which brings the concept of the hospital as an instrument of intervention over the disease and the patient, marked by the practice of systematic observation. 18iming at discipline and order within the hospital space, the observation comes as a starting point for the approach of sexuality in mental disorder patients.Observing the behavior, psychopathological alterations, interpersonal relationships, evolution, and treatment reactions constitute priority objectives. 19uch ideas corroborate the collected data because of the several references to the need for observation, monitoring, and punishment of behaviors in individuals with mental disorders through administrative discharge and chemical or physical contention, or both.
The physical or chemical contention is conducted as a limit to impose order and control the sexuality exposed by psychiatric patients that are not consistent with other control measures.The use of psychopharmacology and physical contention, even if provisional, correspond to the sense of an "incorporeal" penalty, conferring a rocky sense as a control mechanism. 20herefore, it is up to the nursing workers to impose the order and behavior necessary for the hospital organization as established by the institution.Such an attitude reflects the lack of autonomy, making it impossible to adopt the role of a caring agent.

Unpreparedness of nursing professionals towards the sexuality of patients with mental disorders
This category is related to the unpreparedness of nursing workers to approach the sexuality of mental disorder patients.Concurrently to this fact, some workers perceive themselves as ulum, with a fragmented view of the human sexuality, focused on the biological aspect.
The lack of preparation, lack of qualification, and instrumentalization cancel the professional capacity to reflect on his sexuality, creating the false perception of asexuality in nursing workers.
There is no standard or systematic intervention and institutionalized routine; the intervention is based on the criteria of each nursing worker when faced with the expression of sexuality by mental disorder patients.
In this study, the unpreparedness of nursing professionals facing the sexuality of mental disorder patients is noted; it is identified that in nursing training courses, the un-sexualization process of the patient's body is supported by the technical and hygienic-biological discourse, masking the sexuality because its manifestation is not allowed in the biomedical space. 21urses and other nursing professionals act as asexual beings, ignoring sexual needs of their patients and limiting to cleaning and sanitizing their genital organs and other technical procedures that may be needed. 22here is a lack of content about sexuality in nursing training courses; this fact is related to the ethical and religious foundations that guided the structuring of Modern Nursing, imposing repression and embarrassment when dealing with such thematic. 22videnced by the traditional pedagogical practice, revealed by technical-mechanistic actions, humanist actions, as well as personal relations between professionals and patients, are almost always fragile, making the expression of the singularities of subjects difficult. 6here are strict disciplines that address small aspects of sexuality, not giving enough subsidies for the nurse to act in the context of assistance, producing uninformed professionals and full of prejudices. 23There is a lack of studies, discussions, and reflections on the academic level and professional nursing practice over the socio-cultural sphere of human sexuality characterizing a sign that this is considered a taboo. 7hus, the institution would adopt, through the Continuing Education in Nursing and clinical supervision meetings, critical and contextualized discussions about the human sexuality process, essential to self-understanding, changing attitudes and values, and adopting therapeutic interventions when facing the sexuality of patients with mental disorders. 24Because there is not a collective and institutional debate, the whole approach to the expression of sexuality has been carried out according to internal self-references and social representations of workers when facing the thematic.

CONCLUSION
Although sexuality was present in the everyday life of caring, it is realized that it was surrounded by taboos, prejudices, assexual, they ignore their own sexuality and the sexual needs of the patient receiving their care, being this the fundamental condition of being considered as having a professional attitude.These arguments can be seen in the following speeches: I believe that he's not ready emotionally, nor technically to work with patients who have bipolar affective disorder, because as well as we guide patients that they can contain their sexual emotions, we as professionals have to restrain ourselves and work our sexual emotions (Nurse 4).
[…] but the nursing technician, I thought he did everything wrong, first we cannot be mad in a situation like this.I think that talking, addressing, I also think that in this case of masturbation is not to prohibit, but make sure thatshe's not exposing herself, because then you are exposing the patient to others and that's not right.So be aware of that and do not expose the patient to situations that are not good for her, but never be mad.And so, the technician became excited I've seen it happen in a situation with an employee then there were comments, the employee had gotten excited, I don't remember exactly how it happened.It's complicated, he's got to be a professional at this time and that's fine that he's a human being and he also has needs of sexual expression, but in the professional place he can't present this kind of behavior and never be mad.And respond to calling her a slut, that's absurd, to me it is absurd (Nurse 6).So, if a man professional takes female patient to the shower, that´s wrong.Thus, it is really complicated because we see cases and cases of that kind of attitude, a professional male lead a female patient to the shower.He soon saw that she was masturbating, he sould have left the bathroom.In this case, a female nurse would take the patient to the shower.In fact, he shouldn't have gone.If he saw that something like this would happen, the patient masturbating, he sould have gone out and warned his manager, and request for a female nursing.He was wrong about taking this patient to the shower (Nursing Assistant 1).
[…] the nursing technician was all right until the time he mentored her and gave her the lecture, but from the moment he was excited, he's wrong.So he couldn't have been instigated with the patient's attitude because it's not something intentional from the patient […] (Nursing Assistant 10).
In this category, it is noticed that the unpreparedness to deal with sexuality is related to the professional training of nursing workers as a function of the technical-scientific curric-and judgment.It is recognized how much the prejudice, beliefs, judgments, and stigma from nursing workers negatively interfere with the quality of assistance provided.Each interviewee perceived and understood the sexuality of the individual according to his vision and culturally constructed reference.The only way to deal with sexuality took place through repression.
It is believed that this fact is related to the lack of necessary knowledge received in nursing training courses.Thus, nurses should seek new theoretical and methodological ways that consider the subjective dimension of caring, care, body, sexuality, and subject.
Systematized discussions on the thematic were not recorded in the Continuing Education Programs and Clinical and Institutional Supervision making the updating of knowledge difficult and compromising the quality of care for the individuals´ sexuality.On this evidence, capacitation processes are systematically needed from the problematization of the everyday working process that consider the constant sexuality in the care, allowing the transformation of professional practices, concepts, and values.
The perception and adaptation of the embodiment and sexuality of professionals, as inherent components in the action of taking care, are facilitators of the therapeutic link through the availability of interaction, touch, emotion, and feelings towards their patients, allowing the relationship between affective and experience exchanges, aimed at a qualified practice.