Most of us have had the opportunity in our lives to tee-hee or snicker as someone demonstrated how to use a condom by deftly rolling it over a banana or some other phallic-shaped fruit or vegetable. But imagine if you saw this and it led you to believe a banana with a condom on it must be present during sex to prevent infection.

It sounds ridiculous I know but this it’s a reality when teaching safe sex practices to someone who is delusional, for example. But an even bigger roadblock to providing sex education to the mentally ill is the general assumption that mentally ill people don’t have sex.

Which is just simply not the case.

In fact, studies in the U.S. and Canada have shown that patients in long-term psychiatric facilities are as sexually active as outpatients, whether they’re having sex with other patients or with partners who visit them. Yet, in most cases, institutions don’t even bother doing regular Pap smears or STI (sexually transmitted infection) testing on patients never mind trying to understand the unique problems that put the mentally ill at greater risk for sexual health problems and HIV infection. As a result, an estimated, 19 per cent of people who are mentally ill are HIV-positive.

Someone with schizophrenia may be more at risk because they have a strong “command force,” that is, their brain makes them to do things most of us would think better of. If someone suffers from Bipolar Disorder, their extreme mood swings can put them at greater risk as well. “The manic are often grandiose, and impervious to potential danger and the results of their actions,” says Jane Reiha, a nurse in London, Ontario, who works with the mentally ill. “The depression phase can also put them at risk as sex is often the only pleasure left to them, she adds. “Often, people with mental illness seek sex with just anyone for a source of warmth, or because sex is cathartic, and a reassurance that you’re still alive -- it may be one final attachment to reality.”

Thanks to funding cutbacks, the trend toward de-institutionalization means more mental health patients are being released into the community, increasing their exposure to risk.

“On the “outside,” there may be increased opportunity for sexual encounters,” says Reiha “And their limited capacity to deal with additional threats to well-being, and their disadvantaged economic and social status -- like cohabitating with others in rest homes – can bring them into contact not only with high risk groups like drug users.” 

Unfortunately, while the mentally ill are at greater risk, says Reiha, there is a persistent belief that talking to the mentally ill about sexual issues will simply encourage promiscuity. Most health professionals would rather hang on to the belief that this group is asexual. The line they usually get from the staff when they ask to come and speak at their homes is: “our clients do not have sex.”

But as far as Reiha is concerned, the human need for intimacy, warmth and sexual expression is universal and people are sexual beings all the time, regardless of health, illness or disability. The mentally ill have a tremendous need to express their feelings, to have their concerns and needs validated, and to be given the information necessary to manage life, she adds. They also have specific needs and considerations when it comes to sexual health.

According to Reiha, women with Schizophrenia often have a history of abuse and usually have chaotic and unsatisfying sex lives as adults. “This is compounded by the fact that they can get pregnant.” In fact, birth control, is another hot topic. “Permanent birth control takes power away from the patient, but we have to think about whether or not the patient is even able to make those decisions,” says Reiha.

Which is why she tends to focus on condom use, especially because condoms also help in STI prevention. But this can be tough when you’re dealing with people who may suffer from delusional thinking, have bizarre ways of communicating and a short attention span (doesn’t sound all that different from trying to teach teenagers if you ask me, but I think I see her point).

To overcome these obstacles, Reiha uses a lot of interactivity, role-playing and visual aids when teaching the mentally ill about sexuality. “There may be a finger dexterity problem, for example,” says Reiha, “so the key is to practice opening the condom package and rolling it on, repeating often.”

And no, they don’t use bananas.