Sexual and Gender Identity Disorders

Chapter 11. Sexual and Gender Identity Disorders






▪ Sexual identity is the state of being male or female as defined by anatomy and physiology.


▪ Gender identity is the individual’s perception and understanding of self as male or female. The person’s perception of his or her sexual identity is shaped and reinforced through socialization and is usually fixed by 3 years of age.


▪ Gender role is the person’s expression of his or her gender identity by way of behaviors, attitudes, and emotions appropriate for the gender.


▪ Sexual orientation is sexual preference, or feelings and attraction to the male or female gender. Heterosexuality refers to sexual preference, arousal, and activity toward the opposite gender. Homosexuality refers to sexual preference, arousal, and activity toward the same gender. Sexual orientation is thought to be fixed before pubescence. Homosexuality is not listed as a disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision ( DSM-IV-TR). Sexual disorders manifest in physical or mental symptoms, or a combination of the two.


ETIOLOGY



BOX 11-1
Biologic Factors That Contribute to Sexual Disorders*




DISEASES






▪ Cancer


▪ Genital infections


▪ Degenerative diseases


NEUROLOGIC DYSFUNCTION






▪ Spinal cord injury


▪ Cerebrovascular accident


▪ Head injury


ENDOCRINE DYSFUNCTION






▪ Diabetes mellitus


▪ Hormone dysregulation


VASCULAR DISORDERS






▪ Cardiac disease


▪ Peripheral circulatory disorders


MEDICATIONS/SUBSTANCES






▪ Antipsychotics


▪ Antihypertensives


▪ Sedatives


▪ Narcotics


▪ Antidepressants


▪ Alcohol

*Etiology is attributed to a combination of biologic, psychologic, psychosocial, and environmental factors.

Other etiologic factors that relate to sexual disorders are heredity, familial and cultural origins (transmission of paraphiliac disorders or female circumcision and genital mutilation), or psychologic and psychosocial causes. For example, the early exposure of children to sex acts or actual sexual abuse is often emotionally, psychologically, and physically traumatic for a child, and may result in subsequent sexual disorders and/or other mental disorders. Excessively permissive environments that overexpose individuals to sexually explicit material or behaviors may contribute to sexual disorder, as may excessively restrictive or oppressive environments where norms are being established.

Human sexuality is a complex interplay of many factors. Norms for sexual activity are defined and refuted continuously. This chapter uses the widely accepted classification of sexual disorders presented in the DSM-IV-TR (see Appendix L).


EPIDEMIOLOGY


Sex is a popular topic that permeates daily life in newspapers, fiction, and nonfiction books, magazines, textbooks, films, television, on the beach, on the street, in the parks, in neighboring yards, and in the home. However, sexuality remains a subject that has relatively low research activity. Research directed at sexual disorders is influenced by the underreporting of sexual problems, even though they are common.


Some sexual disorders may put the individual or others in danger. For example, the person with pedophilic fantasies may act on them and endanger a child or children and may place himself in jeopardy for incarceration. Sexually masochistic and sadistic disorders may put the seeker or perpetrator in danger for injury and/or incarceration. The highest proportion of sex offenses occur against children, and the majority of sex offenders commit acts in conjunction with pedophilia, voyeurism, or exhibitionism.

Sexual disorders jeopardize social and intimate relationships and frequently cause disrupted relations when not addressed, go untreated, or do not respond to treatment. In addition to formal DSM IV-TR diagnoses, the following dysfunctions may occur:




▪ Disrupted responses to stress and anxiety


▪ Intergenerational sexual abuse


▪ Failure to achieve intimacy


▪ Perpetuation of misguided myths about roles of male and female


▪ Ignorance of anatomy or sexual arousal and behavior patterns that perpetuate or interfere with interest and performance during sexual activity


▪ Compatibility with mate (common sexual activity interests, sex drives, communication about sex, idealized versus real mate)

Paraphilias, except for masochism (see next section) are 20 times more prevalent in males and are seldom seen in females. Approximately half of the individuals treated for paraphilias are married. Usually the disorder occurs in childhood or adolescence and may last a lifetime, becoming more intense under stress. The fantasies and urges may weaken or abate in older age groups.


ASSESSMENT AND DIAGNOSTIC CRITERIA




Sexual Dysfunctions


Defining characteristics for sexual dysfunctions are disturbance of sexual desire and the psychophysiologic changes that occur during the sexual response cycle (see below). Regardless of type, the dysfunction causes disturbed interpersonal relationships and marked distress for the individual, the partner, or both.

The human sexual response cycle refers to a neurobiologic process first described by the researchers Masters and Johnson in the 1960s. Subsequent research on the response cycle supports the findings of Masters and Johnson, stating that women and men have different response patterns that may interfere with sexual activity when differences are not known or not considered by two partners of the opposite gender. The human sexual response cycle includes the following four phases:




1. Sexual desire is described as increased interest, intention, and willingness to move forward into intimate sexual interaction. It may be stimulated by characteristics of the other person, environmental cues, or the individual’s own neurophysiologic stimulus.








2. Excitement, or the arousal phase, results in dramatic neurologic and vascular changes in both men and women, in addition to cognitive and emotional changes that further stimulate the partners to continue engagement. The male penis becomes and remains erect and elongated as it fills with blood. Female changes include pelvic congestion; vaginal lubrication; enlargement of the clitoris, labia, and breasts; and other internal vaginal and uterine changes.


3. Orgasm occurs at the height of the arousal phase and is manifested by strong rhythmic contractions in the pelvis that may affect the entire body, release of sexual tension that occurred in the first two phases, and a peak sensation of pleasurable release. Semen is emitted by the male penis, and many internal changes occur in both partners.




DSM-IV-TR
American Psychiatric Association
Sexual Dysfunctions



All Primary Sexual Dysfunctions






Lifelong type/acquired type


Generalized type/situational type


Due to psychologic factors/combined factors


Sexual Desire Disorders






Hypoactive sexual desire disorder


Sexual aversion disorder






4. Resolution is a sense of general relaxation, well-being, and muscle relaxation. The male is physiologically refractory to further erection and orgasm for a variable time. The female may be able to respond immediately to additional stimulation.

Inhibitions may occur at one or more of these phases in the response cycle, although inhibition in the resolution phase rarely indicates clinical pathology. In most cases of sexual dysfunction, there is a disturbance in both the subjective sense of pleasure or desire and the objective performance.


Sexual Desire Disorders



Hypoactive Sexual Desire Disorder.


Persistent or recurrent absent or deficient sexual fantasies and desire for sexual activity, taking into account age, sex, and the context of the person’s life.


Sexual Aversion Disorder.


Persistent or recurrent extreme aversion to and avoidance of all or nearly all genital sexual contact with a sexual partner.


Sexual Arousal Disorders



Female Sexual Arousal Disorder.


Persistent or recurrent partial or complete failure to attain or maintain lubrication or swelling response of sexual excitement until completion of sexual activity, or persistent or recurrent lack of subjective sense of sexual excitement and pleasure during sexual activity.


Male Erectile Disorder.


Persistent or recurrent partial or complete failure to attain or maintain erection until completion of sexual activity, or persistent or recurrent lack of subjective sense of sexual excitement and pleasure during sexual activity.


Orgasmic Disorders



Female Orgasmic Disorder.


Persistent or recurrent delay in or absence of orgasm following a normal sexual excitement phase. Some females may experience orgasms during noncoital clitoral stimulation but are unable to experience it during coitus in the absence of manual clitoral stimulation. The judgment of whether this condition justifies this diagnosis is made by thorough sexual evaluation and trial of treatment by a qualified expert. Age, experience, and adequacy of stimulation are considered.


Male Orgasmic Disorder.


Persistent or recurrent delay in or absence of orgasm following a normal sexual excitement phase, considering the person’s age and other factors. Failure to achieve orgasm is generally restricted to an inability to reach orgasm in the vagina, with orgasm possible with other types of stimulation such as masturbation.


Premature Ejaculation.


Persistent or recurrent ejaculation with minimal sexual stimulation, or before, on, or shortly after penetration, and before the person desires it, considering the person’s age, newness of the sex partner or situation, and frequency of the sexual activity.


Sexual Pain Disorders



Dyspareunia.


Persistent or recurrent genital pain in either a male or female before, during, or after sexual intercourse, not caused solely by lack of lubrication or vaginismus.


Vaginismus.


Persistent or recurrent involuntary spasm of the musculature of the outer third of the vagina, which interferes with coitus.


Substance-Induced Sexual Dysfunction


The defining characteristic of substance-induced sexual dysfunction is significant sexual dysfunction causing distress and interference with interpersonal relationships. Symptoms of dysfunction are substance-specific physiologic effects as a result of intake of drugs of abuse, medications, or toxic exposure. Manifestations of dysfunction include the following:




▪ With impaired desire—absent or deficient sexual desire


▪ With impaired arousal—impaired sexual arousal (impaired lubrication, erectile dysfunction)


▪ With impaired orgasm—orgasmic impairment


▪ With sexual pain—pain associated with intercourse


Sexual Dysfunction Not Otherwise Specified


Sexual dysfunctions that are not otherwise specified do not meet criteria for any of the specific sexual dysfunctions listed previously, such as the following:




▪ No erotic sensation or even complete anesthesia, despite normal physiologic component of orgasm


▪ The female analog of premature ejaculation


▪ Genital pain occurring during masturbation



Treatment


Individuals who experience sexual dysfunctions as described in the DSM-IV-TR may benefit from intervention with a qualified sex therapist. We have elected to construct a care plan based on common problems related to physiologic and psychologic stressors (e.g., effects of prescribed medication, chronicity of the mental or emotional disorder, long-term institutionaliza-tion) that interfere with sexual function, performance, and gratification of the client with a mental or emotional disorder. Thus this chapter’s care plan is based on sexuality problems experienced by psychiatric clients that are best addressed by nurses.


Paraphilias


The defining characteristics for the paraphilias are persistent, intense, and recurrent sexual urges, fantasies, or behaviors that involve nonliving objects, other nonconsenting persons (children or adults), or humiliation or pain and that occur over at least a 6-month period (see DSM-IV-TR box). The disorders interfere with reciprocal intimate sexual relationships. A diagnosis for pedophilia, exhibitionism, frotteurism, or voyeurism is made only if the person has acted on the urges and fantasies or if they cause extreme distress.




Individuals with paraphilias may be driven to be near their fantasy. Therefore they may select work, volunteer, or become involved in hobbies that bring them near to the object of their fantasy (e.g., teacher’s aide, salesperson for ladies underwear). They often collect pictures, films, and artwork that depict the object of their disorder. They may not find or be able to keep partners who share their disorder, so they may use prostitutes to act out the fantasy or urge. Various responses by the individuals are the consequence of these disorders. Some persons with a paraphilia have no remorse, whereas others express guilt, shame, remorse, and depression.

The diagnoses of paraphilia include the following:




▪ Exhibitionism. Exposure of one’s genitals to unsuspecting stranger(s), followed by sexual arousal.


▪ Fetishism. Use of objects (e.g., female underpants, bras, stockings; shoes; feathers; fur) for purpose of sexual arousal and during sexual activity.


▪ Frotteurism. Touching or rubbing against a nonconsenting person, to stimulate sexual arousal.


▪ Pedophilia. Sexual activity with a prepubescent child or children 13 years of age or younger; offender generally is at least 16 years of age and at least 5 years older than the child/children and may be homosexual, heterosexual, or bisexual; may be limited to incest; exclusive type (attracted only to children), or nonexclusive type (also attracted to adults of either gender).


▪ Sexual masochism. The act of being humiliated, beaten, bound, or otherwise made to suffer during sexual activity while alone (masturbating) or with others. One dangerous form of masochism, called hypoxyphilia, involves oxygen deprivation (plastic bags, nooses, chemical substances) in the brain; it may cause death.


▪ Sexual sadism. Acts in which physical (whipping, restraint) or psychologic suffering (humiliation) of the victim is sexually arousing to the perpetrator. The seriousness of sadistic acts usually increases over time, raising the potential for injury or death of partner.


▪ Transvestic fetishism. The act of cross-dressing by a heterosexual male (wears female clothing to achieve sexual arousal) that does not meet the criteria for gender identity disorder, nontranssexual type, or transsexualism.


▪ Voyeurism. The act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity to achieve sexual arousal.


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Mar 17, 2017 | Posted by in NURSING | Comments Off on Sexual and Gender Identity Disorders

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