How one nurse helped break the taboo of talking about sex in mental healthcare settings

Rachel Luby impresses RCNi Nurse Awards judges with her determination and approach
Rachel Luby

Rachel Luby impresses RCNi Nurse Awards judges with her determination and her broad but methodical approach to improving care

Rachel Luby. Picture: David Gee

A clinical practice nurse lead’s mission to transform the attitudes of forensic staff and service users to sex and sexuality has helped her to win the Mental Health Nursing category of the RCNi Nurse Awards 2019, the profession’s top accolade.

Rachel Luby, who works for East London NHS Foundation Trust (ELFT), drew on external services and developed internal training and staff champions to drive forward her project, ensuring that healthcare teams and service users are talking about sexual health and intimacy.

Explicit material

Ms Luby was rewriting care plans in her new forensic services role when she realised a service user’s plan allowed them access to pornographic DVDs, but this contravened the trust’s policy on sexually explicit material.

‘It struck me that most patients were detained at a crucial period in the development of their adult sexuality, yet it was almost non-existent in discussions throughout their lengthy admissions,’ says Ms Luby.

‘We expected them to defer their sexuality until their illness was managed enough for them to be discharged. Our patients were not offered sexual health checks and any form of sexual expression was seen as problematic.

‘This denies that our patients are sexual beings, who cannot and should not give up on the idea of healthy sexual expression while in hospital. On discharge this makes initiating relationships fraught with difficulties.’

‘By acknowledging service users’ engagement in sex on unescorted leave, we ensure wider population health outcomes’

Rachel Luby, winner of the 2019 RCNi Mental Health Nurse category

Ms Luby joined the trust’s policy committee, and successfully argued for the policy to be changed.

‘Further policy development on access to sex toys was also recommended. This recognised many female patients had requested such access, but without formal guidelines it was left to the individual practitioner’s judgement.’

What the judges say

Chair of the judges and RCN deputy president Yvonne Coghill was inspired by Ms Luby’s innovative approach. ‘Rachel impressed us with her determination to overcome the taboos around sex in mental healthcare and her broad but methodical approach to breaking down those barriers.

‘It is hard to believe she has been qualified only a few years. Her passion for improving care and experience for her patients shone through.’

Realising that wider cultural change was needed, she applied for and was accepted on to her trust’s Improvement Leaders’ Programme.

‘I needed a systematic method to introduce change and measure impact,’ says Ms Luby.

Then she recruited a core quality improvement team, including one service user as equal partner and two more in advisory roles, a doctor, psychologist, occupational therapist, matron, ward manager and two nursing team members.


She asked all service users and healthcare staff to fill in questionnaires. Service users rated their satisfaction with the support they received to meet their needs at just one out of ten.

‘We had a long way to go,’ says Ms Luby. ‘More worryingly, the questionnaire showed a clear reluctance to talk about sex from staff and patients.

‘Simply forcing changes would not improve that confidence so the project now aims to increase and measure patient comfort and satisfaction that these needs are being met.’

Service users are asked to give
feedback using a scale of one to ten

As a result of Ms Luby's reforms, exual health screening is delivered, and service users have access to free condoms in the community. ‘They are empowered to take measures to ensure their own health and well-being,’ says Ms Luby. ‘By acknowledging their engagement in sex on unescorted leave, we ensure wider population health outcomes.’

Care plans now have a section on sexual expression and sexuality, including the service user’s views and actions, and the care team is more aware about post-exposure prophylaxis and sexual health in general.

Service users rate their confidence to talk with staff about sex at six out of ten, up from three out of ten, an improvement that has seen the project adopted throughout the trust’s forensic unit.

‘Patients who have had sexual encounters in the community are able to speak about them,’ says Ms Luby. ''They are invited to explore concerns including legal and ethical issues and informed about the importance of accessing and using barrier protection.'

A weekly psychologist-led group, Let’s Talk about Love, Sex and Intimacy, also offers advice that covers, for example, the sexual side effects of medications.

Why do mental healthcare staff shy away from talking about sex?

Rachel Luby found staff’s reluctance at her trust to talk about sexual health with service users was due to personal views and because they felt they knew too little. Some saw it as a low priority; others were concerned it would lead to sexually disinhibited behaviour and sexual violence. Other reasons focused on the ward’s culture and the fear that any expression of sex would be seen negatively.

‘Without the team on board, patient satisfaction would never increase,’ says Ms Luby. ‘I needed the project to be owned by the ward, not just me. We decided collectively what we would measure.’

Staff filled in sticky notes answering three questions:

  1. What one thing would make you more comfortable to talk about sex?
  2. What are your concerns about the project?
  3. What are your hopes?

‘The most popular response was "extra training",’ says Ms Luby. ‘So I engaged the charity Positive East, which offers a range of support and advice on sexual health, and offered them volunteer time in exchange for staff education.

‘We discussed staff opting out, but it was agreed that our professional obligations should take priority over personal feelings. However, there are staff champions who are comfortable with the subject matter and to whom patients could be directed by less confident staff.’


Tackling a complex issue

Service users have access to free
condoms in the community.
Picture: Alamy  

ELFT consultant forensic psychiatrist and chief quality officer Amar Shah says Ms Luby has been ‘inspirational’ in leading the work to raise awareness and confidence so that service users can talk about sexual health and sexual need.

‘Ms Luby’s work has embraced the use of quality improvement as a systematic way to tackle a complex issue, and is helping to create a more open atmosphere of trust and awareness’ says Dr Shah, who is also national quality improvement lead for the mental health safety improvement programme run by NHS Improvement and the Care Quality Commission.

Ms Luby is also designing relationship and sex education sessions for patients. ‘People with serious mental illness are more likely to experience inter-partner violence and exploitative or coercive sex. There is also a higher prevalence of HIV, hepatitis B and hepatitis C,’ she says.

And she is in discussions with two universities to deliver workshops to mental health and learning disability nursing students around the importance of speaking about sexual health and sexuality, and is helping develop a training package for staff caring for people with learning disabilities.

‘Many students are not taught about sexual health, contraception, lesbian, gay, bisexual, trans, queer and others (LGGTQ+) relationships, masturbation and legal and emotional aspects of sex,’ says Ms Luby. 

‘At the start, patients said things like: “I think about sex, but I can’t talk about it”. We have created an environment in which staff and patients feel comfortable to,’ says Ms Luby. 

‘We haven’t even delivered all our interventions yet. This is just the beginning.’ 

Sex and sexuality – some service users’ perspectives

Service users’ views were used to prioritise interventions and persuade Rachel Luby’s colleagues there was a need to break the taboo around talking about sex.

These views included:

  • ‘We are locked away from our boyfriends or girlfriends and not allowed to engage in normal relationship stuff. Then the relationship breaks down. We have nothing to leave hospital for’
  • ‘I’m still a man. I still think about sex every day. I just can’t talk about it’
  • ‘Porn magazines, porn DVDs are legal. I didn’t do a sex crime. I still have needs’
  • ‘I once had my leave suspended because I told the team I had visited a prostitute. Couldn’t they have just given me, you know, sex advice?’

‘The project has been a success in improving discussions about sex generally,’ says Ms Luby. ‘Previously the emphasis was on stabilising mental state, and sexual side effects were seen as something of little importance.

‘But there is now a greater recognition that this does our patients a disservice and is likely to lead to non-adherence in the community if ignored.’


Cards help mental healthcare staff to DO BETTER

While researching ways to support her colleagues, Rachel Luby came across the BETTER model (Mick et al 2004), which supports cancer healthcare staff to discuss with patients how their sexual identity changes. She gained permission to adapt it and laminated small cards printed with the mnemonic, DO BETTER, that mental healthcare staff can use for reference.

‘This model can be adapted for use by any staff in any setting who require support to start conversations about an uncomfortable or unfamiliar topic,’ says Ms Luby.

The words DO BETTER spell out the following:

Discomfort is normal, but needs to be addressed – do we consider patient sexual health? Do we address it?

Objectivity is key – what are your own views? Assumptions? Judgements? Do these affect interactions?


Be the one to start the conversation

Explain that we know that sexuality does not stop on admission to hospital

Tell the patient that we take their sexuality seriously and will do our best to support their needs

Time – know that some patients will need time before they are ready to discuss the topic – give them it

Educate yourselves and patients about the side effects of medication

Record discussions and interventions in care plans, share with the team or make referrals


Mick J, Hughes M, Cohen M (2004) Using the BETTER Model to Assess Sexuality

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