The politics of sexuality in adolescent psychiatry

The purpose of this paper is to examine and analyze policies towards adolescent sexuality within a total institution. The issues are discussed from the perspective of 4 different domains: clinical, experiential, ethical, and theoretical. Considerations from all 4 domains interact. When the interactions are not made explicit, it is possible that 1 domain may override the others. This, in turn, may produce undesirable side effects such as defensive justifications of policies or distortions of the less favored domains. Included among the issues examined are: policies regarding sexual relationships between patients who are simultaneously engaged in psychotherapeutic relationships; institutional rulings on sexual behaviors; coeducational units for adolescents; and decision making about birth control and abortion for adolescent psychiatric patients. Clinical illustrations from a residential treatment unit for severely disturbed adolescents are provided. Within the context of adolescent sexuality, the 2 diametrically opposed models of psychiatric institutions are contrasted. The 1st is based on ethical concepts of autonomy and antitotalitarianism, while the 2nd model uses a clinical paradigm which recognizes psychodynamic intricacies as well as the restricted autonomy of severely disturbed adolescent patients. When this latter approach is taken to the extreme, it prescribes profound limitations on patients' behaviors, particularly those behaviors with sexual etiologies. In actuality, these 2 models form the poles of a myth. The clinical pole functions entirely within a model that does not allow for individual and ethical considerations while the ethical pole denies psychodynamic complexities. It is obvious that quite different administration decisions will stem from the respective models. A comprehensive framework for discussion of the politics of sexuality in adolescent psychiatry utilizing all 4 domains is proposed. To that effect, the current ethical and clinical myths should be critically analyzed, discussed, and then transcended.