The aim of this research was to develop a substantive theory of how psychiatric nurses respond to issues of sexuality in a clinical practice context. Following the principles of grounded theory, as set out in the previous chapters, ‘Veiling
Sexualities’ emerged as the core category. This chapter begins with a brief
discussion on the concept of the ‘Veil’ as it relates to the core category ‘Veiling Sexualities’. This is followed by an overview of the complete theory, including a diagrammatic representation of the theory. The chapter concludes with a more in- depth description and exploration of the first subcategory of the theory, which was called ‘Weaving the Veil’.
‘Veiling Sexualities’: An overview of the theory
Core category
The core category to emerge from the data was conceptualised as ‘Veiling
Sexualities’, which describes participants’ accounts of how they respond to
sexuality as a dimension of clients’ lives. Emergence, in this context, does not mean that the core category simply appeared; rather it emerged as the result of the rigorous processes of constant comparison, theoretical sampling, theoretical sensitivity and memo writing (Glaser, 1998; 2001). ‘Veiling Sexualities’ met Glaser’s (1998) criteria for a core, in that it constantly recurred in the data, and was the one with the most explanatory power to integrate all other categories.
The concept of ‘veil’ is not new. Since ancient times it has been associated with different religious practice27, and has come to be symbolically associated with modesty in relation to women and female sexuality (Jordanova, 1989). In this study the ‘veil’ is used in a metaphorical sense, as a verb, noun and adjective. As a verb, it is used to describe participants’ reported actions of shading over sexual issues; as a noun, it describes the perceptual filter through which participants viewed sexual
27
The veil is a term for the head dress worn by women, religious sisters and nuns in the Catholic Church and for a shawl worn by Roman Catholic priests at high mass. The veil is also used to describe a variety of Muslim women’s head dress. In some Muslim cultures, the word veil refers to a face-covering known as niqab; in others, to a simple head scarf, known as hijab.
issues and the sexuality of clients; and as an adjective it is used to describe the impact of participants’ behaviours on their perception of clients as sexual beings (blurred, dimmed). There are certain aspects of the ‘veil’ that make it an appropriate metaphor. The first significant feature is that unlike other materials, the ‘veil’ is sufficiently translucent to hint at what lies beneath. In other words, rather that blocking out or completely covering one’s awareness or knowledge, it allows for some vision or some knowledge, albeit an obscured perspective. Secondly, by spacing the distance between warp and weft threads, transparency can be increased or decreased. Thirdly, the use of different colours, mixtures and textures of threads, enables different patterns to be woven, allowing for variation, while holding some commonality.
An overview of the core category and the subcategories
Describing the latent pattern of behaviour that participants used, in the social setting, to resolve their key concern is an intricate process. The participants’ main concerns about sexuality were related to their feelings of personal and professional vulnerability, and the need to protect the clients and themselves. The participants dealt with these feelings through a process conceptualised as ‘Veiling Sexualities’,
which had five subcategories. Three of these subcategories formed a ‘Veiling-Re- veiling Cycle’ and consisted of the following categories: ‘Hanging the Veil’, ‘Lifting the Veil’ and ‘Re-veiling the clients’ sexuality’. The antecedent to the ‘Veiling-Re- Veiling Cycle’ was a pattern of thinking created through a process conceptualised as
‘Weaving the Veil’. The ‘Veiling-Re-veiling Cycle’ of action was sustained and perpetuated, subsequently, by a number of rationalisations and justifications, conceptualised as ‘Maintaining the Veiling-Re-veiling Cycle’.
Figure 1 is a diagrammatic representation of the theory. This representation provides a visual model of the intricate nature of participants’ responses to sexuality in a clinical practice context, and demonstrates the interconnecting relationship between each category. Although presented in the following manner, it is important to note that the relationship between the categories is neither hierarchical nor linear, but iterative and cyclical, as each category shapes and is shaped by the other. In this way, the process is self-perpetuating and self-maintaining.
The participants in this study spoke of sexuality as an aspect of the client’s life that they did not consider proactively when caring for clients. Although participants acknowledged that the sexual self was an important dimension of their own personhood, participants did not think of clients in the same way, nor did they perceive a need to consider sexuality as a life issue in their work with clients. It was as if there was a perceptual ‘veil’ blurring their professional vision of clients as sexual beings. While participants did not completely deny a client’s sexuality, there was a continual interplay between keeping ‘illicit’ sexuality monitored, controlled and concealed from view, while shading over the need to talk openly to clients about sexual concerns. The strands of the ‘veil’ through which participants viewed the client’s sexuality were ‘woven’, first, through the home and school environment, and later through professional nursing education and practice. Participants spoke of experiencing a repressive discourse around sexuality that emphasised silence. However, what participants experienced were carefully crafted, constructed and directed discourses that were framed and delivered within the paradigms of Christian teaching, natural sciences and the biomedical model. Consequently, in the absence of a discourse that explored sexuality in terms of love, desire, sensuality and essence of self, participants came to view sexuality, primarily, as sexual function, a function surrounded by shame and embarrassment. The absence of a broad discussion on sexuality as a dimension of personhood and positive role modeling on how to talk to clients about sexuality resulted in participants developing, at an unconscious level, a number of habitual strategies or normative forms of responding, which veiled the sexual dimension of the client’s personhood, while, concurrently, veiling their own discomfort.
Within the practice environment, these normative forms of responding made up a cycle of behaviour conceptualised as the ‘Veiling-Re-veiling Cycle’. The ‘Veiling- Re-veiling Cycle’ consisted of the sub categories ‘Hanging the Veil’, ‘Lifting the Veil’ and ‘Re-veiling the clients’ sexuality’. Participants ‘hung a veil’ around client sexuality using a number of strategies. These strategies had a dual function. Firstly, they enabled the participants to shade over, mentally and verbally, the clients as sexual beings. Secondly, they allowed participants to protect themselves from personal discomfort and professional exposure. In the absence of participants’ willingness to acknowledge the sexual dimension of the client’s life and to engage
proactively in therapeutic conversation with clients on sexual issues, opening up discussion, or ‘Lifting the Veil’ became the role of another. Most frequently it was the client who ‘Lifted the Veil’. When this occurred, the sexual dimension of the client’s personhood was revealed clearly to the participants. Once the veil was lifted, participants could no longer ignore, consciously or unconsciously, the sexual dimension of the client’s personhood. Participants responded by ‘re-veiling’ the client’s sexual expression, thus, ‘re-veiling’ their own discomfort. Participants were not simply passive agents in the process, but played an active part in the reproduction and weaving of both the veil and the veiling actions, and in socialising and cultivating more junior colleagues into this way of working. Consequently, the
‘Veiling-Re-veiling Cycle’ was perpetuated and sustained within practice.
The ‘veiling’ and ‘re-veiling’ strategies were not used with conscious intent, but were the result of the participants’ socialisation into the culture and practice of psychiatric nursing. During the course of the interviews, participants became more conscious that their actions were not congruent with their espoused theories of holistic client centred care. While acknowledging that sexual issues were not adequately addressed, participants justified their action by using a number of
rationalisations, which ‘Maintained the Veiling-Re-veiling Cycle’. These
rationalisations were conceptualised as ‘Mythical Self Talk’. The participant professional socialisation into the culture of psychiatric nursing was where this pattern of talk was woven.
Through ‘Mythical Self Talk’, participants minimised their responsibility for including sexuality as an aspect of nursing practice, and played down the likely negative effect their veiling actions might have on clients. Many of the rationalisations were constructed in a manner that prevented participants from subjecting their premise to public scrutiny, to test the validity of their claims. Thus, the ‘Mythical Self Talk’ was a self maintaining and self reinforcing pattern, which prevented participants from engaging in reflective practice, and from modifying their practice in the light of experience. In this manner, participants’ views of sexuality in relation to clients were kept intact and the ‘Veiling’ and ‘Re-veiling’
To illustrate the theory further and demonstrate how the theory was constructed, each of the sub categories will be explored in the remainder of this and subsequent chapters (the subcategories and their properties are also summarised in appendix fourteen).
The purpose of grounded theory, as previously discussed, is to transcend the data conceptually and develop ideas on a level of generality, higher in conceptual abstraction than the data being analysed (Glaser, 1998). While some data are used to illustrate and support the categories and their properties, emphasis is not on ‘thick’ and repeated descriptions of similar data. All quotes used appear in italics. Where part of a quote is omitted, the omission is illustrated by the ellipsis ‘…’. Where text has been added to clarify meaning of a direct quote, it is enclosed in a square bracket. The gender of the participant appears after the quote, in the form of M = Male or F = Female, together with the interview number. The remainder of this chapter will focus on an in-depth description and exploration of the first of the five categories, conceptualised as ‘Weaving the Veil’.
‘Weaving the Veil’
This category refers to participants’ socio-cultural and professional socialisation in relation to sexuality. The participants’ socialisation provided a particular frame of reference (or perceptual ‘veil’) through which they viewed sexuality in general, and provided a highly particular frame of reference, or ‘veil’, through which they viewed the sexual dimension of the client’s personhood. This ‘Veil’ was woven through three phases, conceptualised as: ‘Beginning the weave’, ‘Thickening the strands’ and ‘Fusing the strands’. There is a temporal ordering to the phases; however, they do not stand in isolation but form an integrated whole, through which messages and rules of communication and action around sexuality were delivered, and the ‘veil’ through which participants subsequently viewed sexuality and enacted their care was woven.
Figure 2 Diagrammatic representation of ‘Weaving the Veil’
Participants reported that their learning related to sexuality was influenced by a number of sources. These included primary, secondary and professional socialisation in the form of family, school, nurse education programmes as well as experience in nursing practice. Participants spoke of experiencing a repressive discourse that emphasised silence. However, what they experienced was not so much a silence that hid or ignored sexuality, but a subtle network of authorised discourses that constructed sexuality as sex, and created difficulty for the participants to talk openly about sexual issues to clients. Paradoxically, these discourses ensured that the participants were aware of the presence of a ‘deviant’ or ‘pathological’ sexuality in the client’s life that needed to be controlled and monitored. These carefully crafted, constructed and directed discourses were delivered first through the home and school environment, and later through professional nursing education and practice.
‘Beginning the weave’
‘Beginning the weave’ refers to the process participants experienced during their early years within the family and later through other social institutions such as schools, often referred to as primary and secondary socialisation (Stainton-Rogers and Stainton-Rogers, 2001). Properties of this category are ‘acquiring family values’ and ‘acquiring structured institutional values’. Participants did not enter psychiatric nursing out of a vacuum, but came to nursing with views and attitudes that were socially created from the wider culture of family, primary and secondary education. As participants interacted with others, in these contexts, all involved were affected and to varying degrees acquired and modified ideas, attitudes and values around sexuality. Thus, the process of ‘Weaving the Veil’, which later impacted on the participants’ clinical practice, commenced long before they came to psychiatric nursing.
‘Acquiring family values’: The family as the primary communicator of values and
beliefs strongly influenced the participants’ perception that sexuality was something that should not be openly discussed. For most participants, open discussions around sexuality were absent within the home; consequently, participants read between the lines and developed a construct of sexuality as sex, and issues relating to sexual behaviour as private, personal, delicate and dangerous.
‘When I was brought up, it just wasn’t a thing you discussed really…so I suppose; you see it as a delicate topic. We were always brought up to not talk…it was just a thing that wasn’t discussed’ (4 F).
‘I suppose we see it as a delicate topic…It just wasn’t a thing you discussed really
…there wasn’t really any discussion at home’ (14 F).
On occasions within the home when sexual function was portrayed in an open manner, for example through the media, anxiety, shame and embarrassment were the associated feelings. Consequently, participants learned embarrassment from others, and to feel uncomfortable around overt expressions of sexuality and discussions on sexual issues.
‘When I grew up at home, when the first ads for sanitary towels or something like that came on the telly, my father would be panicking to get at the remote
control…so I think it was the fact that we got a panic reaction… or if there was a love scene on the telly there was a huge panic to get it off the screen…I certainly didn’t come from a family that was very open about sex, the sex education I got was “ there’s a blue book on the mantelpiece, if you want to read it work away”’ (8 M).
As described, sexual education for some participants involved being given or being directed towards a book on sex education, without any follow up discussion. When sexual issues were explicitly spoken about within the family, it appeared that the mother adopted the role of educator. The style of communication was more of a vertical information-giving session, on ‘traditional moral values’, which defined sex as penetrative vaginal sex that occurred within the confines of marriage, as opposed to an open dialogue on desire, gratification, affection and love. To instigate a discussion with a parent around sexual issues was seen as in some way revealing self as a sexual being; thus, it was perceived safer not to raise any issue for discussion. The following extract is taken from an interview with a recently qualified participant in her early twenties.
‘You don’t really talk about it at home…like you would have your conversation with your mother and stuff about girly things, but you wouldn’t be talking to her about intimate things. It was about periods and things like that and meeting the right person, and behaving yourself… To be honest it was about not to have sex until you are married. That was it really …it is just an embarrassing subject…my parents are great, but it is all about upbringing and what you grew up in (pause)… God you don’t talk about that. I have just always been mortified about talking about the whole area, I think that is where it comes from …If I went to my mother she would be very open-minded and everything, but you just didn’t, like you would be afraid, in case she would think, “Oh my God! (said with emphasis), what do you need to know that for?”’ (26 F).
In the absence of education within the home environment, participants accessed information from other sources such as peers, or as one participant described it
‘school yard education’ (16 M).
‘Acquiring structured institutional values’: Beliefs that sexuality was not a topic for open discussion and that sexuality was about sex were reinforced to a greater or lesser extent within both primary and secondary school education. The older participants, especially the female participants and those educated in schools run by religious orders, spoke of experiencing a discourse that portrayed sexuality as a source of sin. As one participant said: ‘basically everything was about sin, dirty, filth, impurity and modesty’ (19 F). This emphasis on purity, self-denial, modesty,
and chastity resulted in the subjugation of a discourse that explored sexuality from the perspective of intimacy, joy, fulfilment or satisfaction. Emphasis was also placed on heterosexual relationships, with no discussion on other forms of sexual expression, such as same sex relationships. If and when sex took place, which was to be within the confines of marriage, sexual obligation for procreation purposes was to take precedence over sexual pleasure. These messages resulted in what many felt was a sexually repressed nation of people who engaged in sexual behaviour, but did not give much consideration to exploring or talking about personal sexual identity, feelings or needs; this gave rise to feelings of shame and guilt around sexual behaviour. These ideas are reflected in the following quotes.
‘The church, I think, influenced sexual education and the messages you got in school…you don’t have sex until you are married, don’t get pregnant and you don’t use contraception,…there was a shame about it or it wasn’t about enjoying it [sex], it had to be contained,…when I say the church, that was through the school, through being at school and the nuns…you weren’t free to speak about it, to talk about your bodies, to talk about what is happening- it was contained. It was very private, so you don’t speak the sexual language, or you don’t say openly about how