According to Levine, there are three components to desire: drive, motive, and values (Levine, 2010). He refers to drive as the biologically motivated interest based in the cerebral cortex, the limbic, and the endocrine system that prompts a focus on sexually appealing aspects of another, physiological response, and plotting for connection. Motive is less physiological and more psychological and is based on choices, aspirations, and motives for interpersonal connection. This is the area that clinicians often target for intervention. Values impact sexuality by imparting certain familial, religious, and cultural beliefs and guidelines for our responses and behaviors. It is a significant part of our programming beginning in adolescence; as adults, values are fairly enduring, but they may shift depending on other motivations.

Invariably, there is a difference in sex drive within a relationship, and negotiations are almost always present (Levine, 2010). Low sexual desire may be a source of frustration, both for the one experiencing it and also for partners. It is sometimes associated with psychiatric or medical conditions. Conversely, excessive sexual desire becomes a problem when it creates difficulties for the individual’s partner or when such excessive desire drives the person to demand sexual compliance from or to force it upon unwilling partners.

Testosterone (normally present in the circulation of both males and females but in a much higher level in males) appears to be essential to sexual desire in both men and women. Estrogen does not seem to have a direct effect on sexual desire in women. A secondary effect, however, may be present in the requirement of estrogen for the maintenance of normal vaginal elasticity and lubrication.

CONSIDERING CULTURE

Female Genital Mutilation and Sexual Functioning

Female genital mutilation is the surgical altering of female sexual organs for nonmedical reasons. The World Health Organization (2008) condemns this practice, as does the United Nations. An estimated 100 million to 140 million females currently are living with the consequences of this surgery, which occurs between birth and 15 years of age. It is performed to decrease libido (ensuring chastity and fidelity to spouses), prevent premarital sex, uphold a cultural tradition, or make the girl more feminine and beautiful by removing parts that are considered “male.”

The actual practice varies and may include partial or total removal of the clitoris, the clitoral hood, and labia minora; cutting or fusing of the labia; and narrowing the vaginal opening. The surgery results in severe pain, infection, recurrent urinary tract infections, cysts, infertility, and childbirth complications and may deny women the ability to experience sexual pleasure.

The procedure occurs mainly in Africa, the Middle East, and Asia and is increasingly being protested and restricted by law. Clinicians in the United States are encountering females who have undergone this procedure. Developing a trusting relationship with patients who have been subjected to this custom includes understanding the types of mutilation, as well as the culture in which it occurs.

While research does not demonstrate a difference in desire or pain, there are is an overall decrease in satisfaction between individuals with female genital mutilation and unmutilated women. Additionally, surgically altered women had problems with arousal, lubrication, and orgasm.

Alsibiani, S. A., & Rouzi, A. A. (2010). Sexual function in women with female genital mutilation. Fertility and Sterility, 93(3), 722–724; World Health Organization. (2008). Female genital mutilation. Retrieved from http://www.who.int/mediacentre/factsheets/fs241/en/.

Sexual dysfunction

Sexual dysfunction is an extremely common problem that involves the disturbance in the desire, excitement, or orgasm phases of the sexual response cycle or pain during sexual intercourse. It may prevent or reduce a person’s ability to enjoy sex and can be classified according to the phase of the sexual response cycle in which it occurs. In evaluating a patient with a sexual dysfunction, a physical assessment—including laboratory studies—is performed before exploring psychological factors, such as emotional issues, life situation, and experiences. Sexual dysfunctions can be the result of physiological problems, interpersonal conflicts, or a combination of both. Stress of any kind can adversely affect sexual function.

Clinical picture

Seven major classes of sexual dysfunction include male hypoactive sexual desire disorder, female sexual interest/arousal disorder, erectile disorder, female orgasmic disorder, delayed ejaculation, premature ejaculation, and genito-pelvic pain/penetration disorder. In addition, there are substance/medication-induced sexual disorders and sexual dysfunction that is not classified (American Psychiatric Association, 2013).

It is important to note that some individuals do not have a desire for sexual relations, termed asexuality, and some persons believe that this may be a distinct form of sexual orientation. Asexuality is differentiated from celibacy. Whereas celibacy is a conscious choice to abstain from sex even though the desire is there, asexuality is having no sexual attraction (Brotto, Knudson et al., 2010). Proponents of formalizing this as a sexual orientation maintain that if heterosexuality is attraction to the opposite sex and homosexuality is the attraction to the same sex, then there should be another category that legitimizes the preference for no sexual attraction. Asexual people may have an interest in cuddling and physical contact but no interest in sex, and asexuals may be married and negotiate for sex or simply do without.

Sexual desire disorders

The male version of low interest in sex is characterized by a deficiency or absence of sexual fantasies or desire for sexual activity and is called male hypoactive sexual desire disorder. It is only considered a disorder if it bothers the person. This problem is determined based on factors such as age and concepts within the culture of the individual where the norm may be to have reduced sexual desire or the reverse. This lack of sexual desire in men can be a lifelong or long-standing problem or may be more acute in nature. The latter, the acquired version, may be situational (the man is not interested in sexual relations with his partner but continues to have interest in another person, others, and/or in masturbation) or generalized (the man has no interest in sexual activity with someone else or solitarily).

The source of this disorder may be physiological, psychological, or a combination of both. Hormonal imbalance, particularly testosterone deficiency, may be an issue. Depression is often implicated in a lack of desire for sexual intimacy in men.

The female version of low sexual desire uses the word “interest” rather than desire and also includes the term “arousal.” Brotto (2010) recommended that the two terms be combined in this disorder since it is extremely difficult to separate one from the other. This combination places the disorder across both the “desire” category and also the “excitement” category (below). Female sexual interest/arousal disorder is characterized by emotional distress caused by absent or reduced interest in sexual fantasies, sexual activity, pleasure, and arousal. Some women experience these symptoms their whole lives while others may gradually become less interested in sexual activities.

Reasons for the disorder may be clear, such as having an abusive mate, while in other cases it is a baffling problem to both the woman and her partner. Researchers believe that it is caused by a combination of neurobiological, hormonal, and psychosocial factors (Clayton, 2010). Dopamine, progesterone, estrogen, and testosterone exert an excitatory role while serotonin, prolactin, and opioids inhibit sexual desire. Female sexual interest/arousal disorder is fairly common and is thought to occur in 1 in 10 women (Clayton, 2010).

Sexual excitement disorders

Erectile disorder (also called erectile dysfunction and impotence) refers to failure to obtain and maintain an erection sufficient for sexual activity or decreased erectile turgidity on 75% of sexual occasions and lasting for at least 6 months (Segraves, 2010). This problem may be a rare, lifelong condition in which a man has never been able to obtain an erection sufficient for intercourse. It may also be an acquired condition in which a man has previously been able to have sexual intercourse but has lost the ability.

Orgasm disorders

Female orgasmic disorder

Study of the female orgasm is more complicated than the male orgasm, which results in a noticeable ejaculation. Additionally, there is no reproduction associated with the female analog. Comparing female and male responses to orgasm, men are more focused on performance while women tend to be focused on the subjective quality of having sex (Graham, 2009). Some women are uncertain if orgasm has even occurred. Up to 22% of women experience an orgasmic disorder while only 6% report this problem as distressing.

Female orgasmic disorder is sometimes referred to as inhibited female orgasm or anorgasmia and is defined as the recurrent or persistent inhibition of female orgasm, as manifested by the recurrent delay in, or absence of, orgasm after a normal sexual excitement phase (achieved by masturbation or coitus). For the recognition of a clinically significant problem, it must happen for at least 6 months and must occur during three fourths of sexual encounters (Graham, 2009).

It may be a lifelong disorder (never having achieved orgasm) or acquired (having had at least one orgasm and then having difficulties). Most cases are lifelong rather than acquired, and once a woman learns how to achieve orgasm it is unusual to lose this capacity (Graham, 2009). Acquired anorgasmia in women tends to be associated with painful intercourse during or after menopause. The prevalence of either type of this disorder is estimated at 30% (Sadock & Sadock, 2008). Psychological factors (including fears of pregnancy, rejection, or loss of control), hostility toward or from men, and cultural/societal restrictions may be causative. There is some evidence to suggest that female orgasmic disorder may be inherited.

Delayed ejaculation

In delayed ejaculation, formerly referred to as male orgasmic disorder, inhibited orgasm, or retarded ejaculation, a man achieves ejaculation during coitus only with great difficulty. A man with a lifelong delayed ejaculation has never been able to ejaculate during coitus; this uncommon condition may result from a rigid background in which sex is believed to be a sin.

Acquired delayed ejaculation develops after previously normal functioning and is fairly common. Interpersonal problems may be the cause. Physical conditions, substance abuse, and prescribed medication may also cause this problem and should be assessed.

Premature ejaculation

In premature ejaculation, a man persistently or recurrently achieves orgasm and ejaculation before he wishes to. Diagnosis is made when a man regularly ejaculates before or immediately after the penis enters the vagina. Considerations as to age, newness of the relationship, and how often the man has intercourse should be assessed. About 35% to 40% of men who are treated for sexual disorders complain of premature ejaculation. Physical factors may be involved; some men may be more tactilely sensitive and respond more intensely to stimulation. Psychological factors include fear about performance and stressful relationships where the man feels hurried. There is no disorder in women that corresponds to premature ejaculation.

Genito-pelvic pain/penetration disorder

The group of disorders previously diagnosed in the psychiatric community included a problem called dyspareunia, which referred to pelvic and/or vaginal pain during or after intercourse. It also included vaginismus, which referred to an involuntary constriction response of the muscles that close the vagina. Researchers believe that the distinction between the two disorders is too blurry and decided to combine them into a single disorder (Svoboda, 2010). Genito-pelvic pain/penetration disorder interferes with penile insertion and intercourse and may even be elicited during a normal gynecological examination with a speculum. Individuals experiencing these problems become fearful that pain and spasms will occur during the next encounter (Binik, 2010). This fear compounds the problem by increasing anxiety and muscle tension.

VIGNETTE

Jessica, a computer programmer, had recently had a baby and was looking forward to renewing her love life with her husband. She said, “My husband would barely begin penetration, and the pain would be awful. The whole area just clenched up.” She continued, “I had never had any problems before, and I didn’t think I would because I’d had a caesarean, so I didn’t think that anything would change. ‘Good grief, that hurts,’ I thought. ‘What is wrong with me?’ We were both terribly upset.”

Epidemiology

Overall, sexual dysfunctions are more common in women than men (Shafer, 2010). There is reasonable descriptive data that indicates that nearly half of adult women (40% to 45%) and about a third of adult men (20% to 30%) have at least one sexual dysfunction (Lewis et al., 2010). The prevalence of male orgasmic disorder has been reported at 5% (Sadock & Sadock, 2008). Acquired erectile disorder is the most common sexual disorder in men and may affect approximately one third of all adult men at some time (Heidelbaugh, 2010). In young men, the disorder is uncommon, and the cause is usually psychological. There are estimates that between 12% to 20% of women experience ongoing genital pain during intercourse (Brotto, 2012).

Comorbidity

Sexual functioning may be adversely affected any time there is a disturbance in an individual’s ability to develop and maintain stable relationships. This is especially true for patients with schizophrenia, who show difficulty coping with stress, a decrease in reality-based orientation to the world, and defense mechanisms that lead to withdrawn behavior. Sexual dysfunction is often associated with depression and personality disorders (Becker & Stinson, 2008). A history of sexual trauma is also frequently associated with sexual dysfunction.

Obesity and a sedentary lifestyle contribute to sexual dysfunction from both a psychological and a physiological perspective. Psychologically, an obese person may feel undesirable or may have a partner who is no longer attracted. Physiologically, inactivity results in less vitality overall, including sexual ability and responsiveness.

Etiology

Biological factors

Aging appears to be a factor in the prevalence of all sexual dysfunction for both men and women. In addition, a variety of physical conditions are related to sexual dysfunction and are presented in Table 20-1.

TABLE 20-1

MEDICAL CONDITIONS AND SURGICAL PROCEDURES THAT CAUSE SEXUAL DYSFUNCTION

SYSTEM/STATE	ORGANIC DISORDERS	SEXUAL IMPAIRMENT
Endocrine	Hypothyroidism, adrenal dysfunction, hypogonadism, diabetes mellitus	Low libido, impotence, decreased vaginal lubrication, early impotence
Vascular	Hypertension, atherosclerosis, stroke, venous insufficiency, sickle cell disorder	Impotence, but ejaculation and libido intact
Neurological	Spinal cord damage, diabetic neuropathy, herniated disk, alcoholic neuropathy, multiple sclerosis, temporal lobe epilepsy	Sexual disorder—early signs: low or high libido, impotence, impaired orgasm
Genital	Male—Priapism, Peyronie’s disease, urethritis, prostatitis, hydrocele Female—Imperforate hymen, vaginitis, pelvic inflammatory disease, endometriosis	Low libido, impotence Vaginismus, dyspareunia, low libido, decreased arousal
Systemic	Renal, pulmonary, hepatic, advanced malignancies, infections	Low libido, impotence, decreased arousal
Psychiatric	Depression Bipolar disorder (manic phase) Generalized anxiety disorder, panic disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) Schizophrenia Personality disorders (passive-aggressive, obsessive-compulsive, histrionic)	Low libido, erectile dysfunction Increased libido Low libido, erectile dysfunction, reduced vaginal lubrication, anorgasmia, “anti-fantasies” focusing on partner’s negative qualities (OCD only) Low desire, bizarre sexual fantasies Low libido, erectile dysfunction, premature ejaculation, anorgasmia
Surgical-postoperative	Male—Prostatectomy, abdominal-perineal bowel resection Female—Episiotomy, vaginal prolapse repair, oophorectomy Male and female—Leg amputation, colostomy, ileostomy	Impotence, no loss of libido, ejaculatory impairment Dyspareunia, vaginismus, decreased lubrication Mechanical difficulties in sex, low self-image, fear of odor

Data from Shafer, L. C. (2010). Sexual disorders and sexual dysfunction. In T. A. Stern, G. L. Fricchione, N. H. Cassem, M. S. Jellinek, & J. F. Rosenbaum (Eds.), Massachusetts General Hospital handbook of general hospital psychiatry (6th ed., pp. 323-335). Philadelphia, PA: Saunders.

Psychological factors

Pioneers in the study of human sexuality include Helen Singer Kaplan (1929-1995). According to Kaplan (1974), sexual dysfunctions are the result of a combination of factors, including the following:

• Misinformation or ignorance regarding sexual and social interaction

• Unconscious guilt and anxiety regarding sex

• Poor communication between partners about feelings and what they desire sexually

Additional factors have been identified to explain sexual dysfunction. Unacknowledged or unidentified sexual orientation may lead to poor performance with the opposite sex, or the presence of one sexual problem may lead to another. For example, difficulty maintaining an erection may lead to hypoactive sexual desire (Becker & Stinson, 2008). Education seems to have a buffering effect, and people who have more education have fewer sexual problems and are less anxious about issues pertaining to sex (Shafer, 2010).

Sexual assessment includes both subjective and objective data. Many psychiatric hospitals use a nursing history tool that is biologically oriented but typically has few questions on sexual functioning. Health history questions pertaining to the reproductive system may be limited to menstrual history, parity, history of sexually transmitted diseases, method of contraception, and questions regarding safe sex practices. There may be a few vague questions about sexual functioning or sexual concerns.

While the topic of sex may be uncomfortable to some readers and future nurses, many in our society wonder if we are trying to make everyone fit into a certain mold with our approaches, specifically when interviewing patients about such personal issues. We tend to ask basic questions related to sexual interest and performance, yet one of the most basic questions relates to the congruence of a person’s actual sexual life to one that they would like to have. For example, maybe the problem is not in functioning but in fit of the relationship. Perhaps the question to be asked is if there is a type of behavior, a type of partner, or social context that interests the patient more than his or her current situation (Levine, 2010). Perhaps we are asking a homosexual man about arousal and interest in his female partner when the relationship is mismatched in regard to sexual orientation. Also, when approaching non-heterosexual youth about sexual practices, they may be hesitant to truthfully respond, particularly if they have been ostracized or harmed for their sexual choices in the past.

Patients may cue the nurse into the presence of sexual concerns without explicitly verbalizing them. Box 20-2 presents a discussion of these cues.

BOX 20-2 PATIENT CUES THAT MAY INDICATE CONCERNS ABOUT SEXUALITY

Nonverbal behaviors

• Showing discomfort by blushing, looking away, making tight fists, fidgeting, crying

• Openly engaging in overt sexual behaviors (e.g., touching own body parts, masturbating, exposing genitals, placing nurse’s hand on genitals, making sexually suggestive sounds)

Verbal behaviors

• Telling sexually explicit jokes

• Making sexual comments about the nurse

• Asking inappropriate questions about the nurse’s sexual activity

• Discussing sexual exploits

• Expressing concern about relationship with partner:

• “I don’t feel the same about my partner.”

• “My partner doesn’t feel the same about me.”

• “We’re not as close.”

• “Our relationship has changed.”

• “My personal life has changed.”

• Expressing concern that sexuality has been diminished (e.g., feeling less of a man, less of a woman):

• “I’ve lost my manhood.”

• “I’m not as desirable as I once was.”

• Expressing concern over lack of sexual desire:

• “I’m not interested in sex anymore.”

• “My desire has changed.”

• “I’m not the man/woman I used to be.”

• “We don’t click anymore.”

• Expressing concern over sexual performance:

• “I’ve lost my power.”

• “What will happen to my ability to perform?”

• “I can’t perform like I used to.”

• Expressing concern about one’s love life:

• “My love life has changed.”

• “The spark is gone.”

• Expressing concern over the sexual impact of drugs, surgery, or some other medical treatment:

• “Will this drug interfere with my sex life?”

• “Will I still be able to perform sexually after surgery?”

The nurse may ask the patient if there is concern in the area of sexual functioning. Generally, it is more comfortable for the patient if the nurse firsts asks questions in a general manner and then proceeds to the patient’s experience. For example, the nurse might say, “Some people who are prescribed this medication find it difficult to achieve an erection. Have you had this problem?” This allows the patient to feel that he is not alone in what he is experiencing. Table 20-2 provides facilitative statements for the interviewer conducting a sexual assessment.

TABLE 20-2

FACILITATIVE STATEMENTS FOR THE INTERVIEWER CONDUCTING A SEXUAL ASSESSMENT

PURPOSE	FACILITATIVE STATEMENT
To provide a rationale for a question	“As a nurse, I’m concerned about all aspects of your health. Many individuals have concern about sexual matters, especially when they are sick or having other health problems.”
To give statements of generality or normality	“Most people are hesitant to discuss ….” “Many people worry about feeling ….” “Many people have concerns about ….”
To identify sexual dysfunction	“Most people have difficulties sometime during their sexual relationships. What have yours been?”
To obtain information	“The degree to which unmarried persons have sexual outlets varies considerably. Some have sexual partners. Some relieve sexual tension through masturbation. Others need no outlet at all. What has been your pattern?”
To identify sexual myths	“While growing up, most of us have heard some sexual myths or half-truths that continue to puzzle us. Are there any that come to mind?”
To determine whether homosexuality is a source of conflict	“What is your attitude toward your homosexual orientation?”
To identify an older person’s concerns about sexual function	“Many people, as they get older, believe or worry that this signals the end of their sex life. Much misinformation continues this myth. What is your understanding about sexuality during the later years? How has the passage of time affected your sexuality (sex life)?”
To obtain and give information (miscellaneous areas)	“Frequently people have questions about ….” “What questions do you have about ….” “What would you like to know about ….”
To close the history	“Is there anything further in the area of sexuality that you would like to bring up now?”

Adapted from Green, R. (1975). Human sexuality: A health practitioner’s text. Baltimore, MD: Williams & Wilkins.

The sexual history includes the patient’s perception of physiological functioning and behavioral, emotional, and spiritual aspects of sexuality. It also includes cultural and religious beliefs with regard to sexual behavior and sexual knowledge base. During the assessment, both the nurse and the patient are free to ask questions and clarify information. It is reasonable to defer lengthy sexual health assessment when acute psychiatric symptoms preclude a calm, thoughtful discussion. As symptoms subside and rapport is developed, the assessment may be resumed. With experience, the nurse is able to identify those patients who are at greater risk for difficulties in sexual functioning. This includes patients with a history of certain medical problems or surgical procedures (see Table 20-1) and patients taking some drugs (Table 20-3).

TABLE 20-3

DRUGS THAT CAN CAUSE SEXUAL DYSFUNCTION

CATEGORY	DRUG	SEXUAL SIDE EFFECTS
Cardiovascular drugs	Methyldopa Thiazides Clonidine Propranolol Digoxin Clofibrate	Low libido, impotence, anorgasmia Low libido, impotence, decreased lubrication Impotence, anorgasmiaLow libido Low libido Gynecomastia, low libido, impotence Low libido, impotence
Gastrointestinal drugs	Cimetidine Methantheline bromide	Low libido, impotence Impotence
Hormones	Estrogen Progesterone	Low libido in men Low libido, impotence
Sedatives	Alcohol Barbiturates	Higher doses cause sexual problems Impotence
Antianxiety drugs	Alprazolam Diazepam	Low libido, delayed ejaculation
Antipsychotics	Thioridazine Haloperidol Risperidone	Retarded or retrograde ejaculation Low libido, impotence, anorgasmia Impotence
Antidepressants	MAOIs (Phenelzine) Tricyclics (imipramine) SSRIs (fluoxetine, sertraline) Atypical (trazodone)	Impotence, retarded ejaculation, anorgasmia Low libido, impotence, retarded ejaculation Low libido, impotence, retarded ejaculation Priapism, retarded or retrograde ejaculation Low libido, impotence, retarded ejaculation Priapism, retarded or retrograde ejaculation
Antimanic drugs	Lithium	Low libido, impotence

MAOIs, Monoamine oxidase inhibitors; SSRIs, selective serotonin reuptake inhibitors.

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Feb 3, 2017 | Posted by admin in NURSING | Comments Off

Sexuality

Phases of the sexual response cycle

Desire

Excitement

Orgasm

Resolution

Clinical picture

Sexual desire disorders

Sexual excitement disorders

Orgasm disorders

Female orgasmic disorder

Delayed ejaculation

Premature ejaculation

Genito-pelvic pain/penetration disorder

Other sexual dysfunctions and problems

Application of the nursing process

Assessment

General assessment

Nurse Key

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Sexual dysfunctions, gender dysphoria, and paraphilias

Sexual dysfunctions, gender dysphoria, and paraphilias

Sexual dysfunction

Epidemiology

Comorbidity

Etiology

Biological factors

Psychological factors

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Sexual dysfunctions, gender dysphoria, and paraphilias

Sexual dysfunctions, gender dysphoria, and paraphilias

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