CHAPTER 18
SEXUAL DYSFUNCTIONS, PARAPHILIC DISORDERS, AND GENDER DYSPHORIA
Jeffrey S. Jones
CHAPTER CONTENTS
Applying the Nursing Process From an Interpersonal Perspective
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Define sexuality
2. Differentiate between a sexual dysfunction and paraphilic disorder
3. Discuss the history and epidemiology of sexual dysfunctions
4. Identify diagnoses that constitute a sexual dysfunction
5. Discuss possible theories related to the etiology of sexual disorders and dysfunction
6. Explain the various treatment options available for persons experiencing sexual disorders and dysfunctions
7. Discuss the common assessment strategies for individuals with sexual dysfunctions, identifying the importance of assessing sexual functioning as part of the nursing assessment
8. Describe the role of the nurse in promoting sexual health for patients
9. Apply the nursing process from an interpersonal perspective to the care of patients with sexual disorders and dysfunctions, with an emphasis on boundary management when dealing with sexual health promotion of patients
KEY TERMS
Human sexuality
Paraphilic disorders
Sexual dysfunctions
Sexual functioning
Sexual health promotion
HUMAN SEXUALITY (how people experience themselves as sexual beings) and SEXUAL FUNCTIONING (the actual act of expressing yourself sexually either for pleasure or for reproductive purposes with others) are woven into the fabric of human life throughout the life cycle. Sexuality and sexual functioning play a major role in everything from basic reproduction to childhood development, maturation, adult lifestyle, and sexual satisfaction (Fogel & Lauver, 1990). Sexual feelings, functioning, and behaviors comprise an important part of each person, no matter age or situation, and should not be neglected or ignored by health care providers. Nurses provide care for the young as well as the old and need to be comfortable in incorporating sexual health assessments and development of a treatment plan regarding SEXUAL HEALTH PROMOTION (the integration of the somatic, emotional, intellectual, and social aspects of sexual beings, in ways that are positively ensuring) for clients.
SEXUAL DYSFUNCTIONS are conditions characterized by a disturbance in the sexual response cycle (desire, excitement, orgasm, or resolution) or pain associated sexual intercourse. PARAPHILIC DISORDERS are more characterized by recurrent, intense sexual urges, fantasies, or behaviors involving certain activities or situations. Sexual preoccupation involving objects is termed as fetish disorder. Gender dysphoria specifically relates to an individual experiencing incongruence between his or her expressed gender and his or her assigned gender (American Psychiatric Association [APA], 2013).
This chapter addresses the historical perspectives and epidemiology of sexual disorders and dysfunctions. Scientific theories focusing on psychodynamic and neurobiological influences are described along with a summary of common treatment options. Application of the nursing process from an interpersonal perspective is presented, including a plan of care for a patient with a sexual dysfunction. Assessment of sexual functioning and the role of the nurse in promoting sexual health through therapeutic use of self skills, such as listening, and through psychoeducation are emphasized.
Difficulties with sexual functioning typically are classified as sexual dysfunctions.
HISTORICAL PERSPECTIVES
The origin of modern understanding of sexual functioning from a mental health perspective can be traced to Freud (Fogel & Lauver, 1990). Freud was one of the first psychiatrists to try to understand how sexual drives and urges manifest and are expressed. In particular, his understanding of the role of the unconscious in dealing with repressed feelings continues to play a fairly prominent role in psychoanalysis. Freud’s theory on psychosexual development and the oral, genital, and anal phases of development were some of the first efforts at describing the transition from infancy to childhood. More recently, scientists such as William Masters, Virginia Johnson, and Alfred Kinsey studied the human sexual response cycle, women’s sexuality, and sexuality and orientation as viewed on a continuum.
Sexual orientation can be viewed on a continuum from exclusively heterosexual to exclusively homosexual.
As theories are refined and knowledge is gained from further research into human sexuality, some topics that were previously referred to as disorders are now understood to be degrees of variance on a continuum. Homosexuality is such an example. Until the 1950s in the United States, homosexuality was considered by many to be a sexual (deviant) disorder. After years of research with psychologists and psychiatrists working in the field of sex therapy, it was concluded that homosexuality is not a disorder because it does not meet the necessary criteria in terms of impairment. Additionally, the particular work of zoologist and taxonomist Alfred C. Kinsey furthered this conclusion. Kinsey, in his groundbreaking empirical studies of sexual behavior among American adults, revealed that a number of his research participants reported having engaged in homosexual behavior to the point of orgasm after age 16 years (Kinsey, Pomeroy, & Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953). Furthermore, Kinsey and his colleagues reported that 10% of the males in their sample and 2% to 6% of the females (depending on marital status) had been more or less exclusively homosexual in their behaviors for at least 3 years between the ages of 16 and 55 years. This research prompted the view of sexuality as occurring on a continuum (Figure 18-1). In 1973, the weight of empirical data, coupled with changing social norms and the development of a politically active gay community in the United States, led the Board of Directors of the American Psychiatric Association to remove homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM). It is also worth noting that current studies involving sexual orientation are finding that there appears to be a much greater fluidity in both male and female orientation than was previously thought (Kort, 2014).
In discussing sexual disorders and sexual dysfunction from a historical perspective, progress on this topic has always been influenced by political, cultural, and theological aspects. The concept of monogamy or sexual fidelity within a relationship or marriage is such an example.
Figure 18-1 Degrees of sexual orientation as viewed on a continuum.
Source: Kinsey Sca le as conceptualized by J. Jones.
The Western view has been influenced heavily by the variety of religious doctrines in our culture. Most have a negative, intolerant view of affairs. In some cases, those who have or had affairs are labeled as having a compulsive sexual disorder. This view must be compared with the cultural mind-set in other countries. Although not as prevalent in today’s European culture, previously, certain fractions of French culture had a slotted time between the end of the workday and the beginning of evening hours that was set aside and referred to as “le temps d’affaires.” During this time, a man or woman would have approximately 2 hours of private time between work and home in which he or she was allowed to do whatever he or she wanted to do. The partner was not to ask where the other had been. It was assumed that it was “none of their business.” If the man or woman had decided to spend those hours between work and home with a lover, it was part of the accepted culture. This example is a glimpse into subtle, nuanced cultural differences on topics such as affairs that illustrate variations in perspective. However, this is not a generalization of the French culture because many French couples enjoy a monogamous relationship (Ubillos, Paez, & Gonzalez, 2000).
Sexual problems occur in approximately 31% of men and 43% of women.
EPIDEMIOLOGY
Incidence and frequency of sexual disorders and dysfunctions can be difficult to obtain because this area is understudied and underreported. It is estimated that between 10% and 52% of men and 25% and 63% of women experience some sexual problems. The percentages that meet the diagnostic criteria for a sexual dysfunction are probably lower and less established (Heiman, 2002). Box 18-1 provides some statistical information about sexual disorders and dysfunctions.
BOX 18-1: STATISTICS ON SEXUAL DISORDERS AND DYSFUNCTIONS
• Sexual problems occur in 43% of American women.
• Sexual problems occur in 31% of American men.
• About 10% of women have never had an orgasm.
• Painful intercourse has been experienced by almost two out of three women at some time in their lives.
• It is common for breastfeeding women to have inadequate vaginal lubrication.
• About 15% of postmenopausal women experience a decrease in their sexual desire.
• The success rate for women’s orgasmic dysfunction treatment by sex therapists tends to range from 65% to 85%.
• About 22% of women experience low sexual desire (compared with 5% of men).
• Some 21% of men experience premature ejaculation.
• A woman’s level of androgen (a hormone that develops and maintains masculine characteristics) typically falls 50% during and after menopause (but it is unclear whether the drop translates into decreased sex drive in a large percentage of women).
Source: From National Library of Medicine; National Women’s Health Resource Center; Journal of the American Medical Association, health. www.howstuffworks.com
DIAGNOSTIC CRITERIA
The term dysfunction is used to describe variations in sexual functioning that result in either distress when functioning sexually or inability to function sexually at all. The term disorder is usually diagnosed in the individual who, for either physiological or psychological reasons, cannot engage in sexual activity as desired. Penetration disorder, pain felt during intercourse, is an example. Sometimes the word disorder is used in the title of the diagnosis, such as erectile disorder, but the diagnosis is actually classified as a dysfunction. With that in mind, here are is an overview of common sexual concerns.
Delayed Ejaculation
There is a marked delay in the ability to ejaculate during sexual activity when desired. Sometimes there is a total inability to ejaculate, particularly during vaginal intercourse.
Erectile Disorder
A marked difficulty in achieving or maintaining an erection during sexual activity to the extent of inability to complete the activity. It may be acute or chronic and may be newly acquired or lifelong.
Female Orgasmic Disorder
A significant decrease in frequency of or a total absence of ability to achieve orgasm during sexual activity.
Female Sexual Interest/Arousal Disorder
There is a significant decrease or total absence in psychological thoughts or fantasies involving sexual activity to the extent that there is little to no desire to engage in sexual activity. When sexual activity is attempted there is little to no physiological arousal or excitement with little to no genital sensation.
Genitopelvic Pain/Penetration Disorder
Significant experience of pain during vaginal intercourse or attempts at vaginal intercourse. Severe anxiety around thoughts of or attempts at genital contact leading to any type of vaginal penetration.
Male Hypoactive Sexual Desire Disorder
A pattern of persistent decreased sexual thoughts or fantasies leading to noninterest in sexual activity, causing distress in relational functioning.
Premature Ejaculation
Frequent ejaculation when with a partner earlier than desired, usually within 60 seconds of activity such as intercourse.
Substance-Induced Sexual Disorder
An occurrence of any of the preceding sexual dysfunctions due to presence of a substance. Opiates, for example, commonly cause decreased desire in both males and females. Serotonin reuptake inhibitor (SSRI) medications frequently cause erectile disorders in men and arousal and orgasmic disorders in both men and women.
Paraphilic Disorders
These are a separate category of disorders that are characterized by sexual urges/fantasies around specific objects (fetish) or behaviors. It is important to note that only those who have acted on the urges in a manner that has caused distress in social or occupational functioning are diagnosed with a disorder. Having the thoughts or fantasies themselves may only constitute having paraphilic tendencies and not necessarily the disorder.
Voyeuristic Disorder
Sexual arousal from watching others (unsuspecting) nude, or engaged in sexual activity.
Exhibitionistic Disorder
Sexual arousal from exposing genitals to an unsuspecting person.
Frotteuristic Disorder
Sexual arousal from rubbing up against an unsuspecting person.
Sexual Masochism Disorder
Intense sexual arousal from being humiliated, bound, beaten, or made to suffer.
Sexual Sadism Disorder
Intense sexual arousal from witnessing or causing the suffering of another person (emotional or physical).
Pedophilic Disorder
Intense sexual arousal or urges involving prepubescent children (under age 13 years).
Fetishistic Disorder
Sexual arousal stemming from a nongenital body part (ears, legs) or a nonliving item (certain article of clothing, etc.).
Transvestic Disorder
Sexual arousal from dressing as the opposite gender (this is not to be confused with gender dysphoria).
Specified Paraphilic Disorder
Sexual arousal from entities other than the previous categories (i.e., urine, corpses, feces, etc.).
Gender Dysphoria
This has its own subcategory due to its unique nature. This disorder is usually characterized by individuals identifying themselves as the opposite gender and experiencing an incongruence between their expressed gender and their assigned gender. Gender dysphoria is more prevalent in childhood than in adulthood, but can be experienced by children, adolescents, or adults (Leiblum, 2007).
ETIOLOGY
Various theories have been proposed to explain the etiology of sexual dysfunctions. It is usually a blend of cultural, biological, relational, and belief system conflict.
Psychodynamic Influences
Professional sex therapists report that the work required with patients in sex therapy frequently has to do with the resolution of a psychodynamic conflict. For example, erectile disorder has received much attention lately with the advent of medications aimed at resolving the problem from a physiological perspective. Often the problem is not one of physical dysfunction but of an emotional stressor such as anxiety or depression. Evidence-Based Practice 18-1 summarizes an important study related to anxiety and sexual functioning.
Anxiety has both emotional and physical consequences that can affect erectile function. It is among the most frequently cited contributor to psychological impotence. Excessive concern about sexual performance is often referred to as performance or honeymoon anxiety and may provoke an intense fear of failure and self-doubt. It can sometimes set off a cycle of chronic impotence. In response to anxiety, the brain releases chemicals that constrict the smooth muscles of the penis and its arteries. This constriction reduces the blood flow into and out of the penis. Even simple stress may promote the release of brain chemicals that disrupt potency in a similar way. Men in predominantly Western cultures fear two things when it comes to their sexual functioning: The first one has to do with the penis size; the second with the ability to maintain an erection. Add to this cultural mind-set the psychodynamic influences of issues such as guilt and shame and it is not difficult to see how mounting anxiety interrupts the sexual response cycle for men.
There may be further underlying forces interfering with the sexual process for men. Some men report that they end up marrying women who have traits similar to their mother. Depending on the nature of the relationship and the strength of the attachment between the man and his mother, the relationship between the man and his wife may begin to take on characteristics of the relationship he has with his mother. He may begin to develop what is termed a “Madonna complex.” According to Freudian psychology, this complex often develops when the sufferer is raised by a cold and distant mother (Freud & Gay, 1989). This man will often date women with qualities of his mother, hoping to fulfill a need for intimacy unmet in childhood. Often, the wife begins to be seen as mother to the husband—a “Madonna” figure—and thus not a possible object of sexual attraction. For this reason, in the mind of the sufferer, love and sex cannot be mixed. The man is reluctant to have sexual relations with his wife because he thinks unconsciously that it would be incest. He will reserve sexuality for “bad” or “dirty” women, and will not develop “normal” feelings of love in these sexual relationships (Freud & Gay, 1989).
These types of psychodynamic forces influencing sexual intimacy are not exclusive to men. A disorder more frequent in woman than men is hypoactive sexual desire disorder (Leiblum, 2007). This disorder is associated with a relative deficiency or absence of sexual fantasies and/or desire to engage in sexual activity. New understanding around female sexual arousal has shed light on this phenomenon.
Previously, it was thought that females followed the same arousal patterns as men; that is, they felt desire, became aroused, experienced orgasm, then went through a resolution phase. It is now understood that the desire and arousal pattern for woman is much more complex and key elements such as emotional intimacy and emotional and physical satisfaction in the relationship need to exist before desire and arousal are triggered (Basson, 2001). Figure 18-2 depicts the interplay of these elements. The belief is that females view sexual activity as an extension of these elements of the interpersonal relationship. Thus, if key relationship components of emotional intimacy, safety, or trust are absent, the female partner may find interest in sexual activity diminished.
EVIDENCE-BASED PRACTICE 18-1:
DEPRESSION TREATMENT AND SEXUAL DYSFUNCTION
STUDY
Baldwin, D. S., Palazzo, M. C., & Masdrakis, V. G. (2013). Reduced treatment-emergent sexual dysfunction as a potential target in the development of new antidepressants. Depression Research and Treatment, 2013, 256841. doi:10.1155/2013/256841
SUMMARY
Although most people value the sexual part of their life, having to choose between sexual functioning and relief of depressive symptoms is now an all too common dilemma for individuals receiving treatment for depression and anxiety. Although the illness of depression by itself can cause decreased sexual functioning, most, if not all, of the current antidepressant medications have potentially serious sexual side effects. The SSRI category appears to be the most assaultive, causing decreased libido, decreased arousal, and difficulty with erection, lubrication, and orgasm. The serotonin and norepinephrine reuptake inhibitors (SNRIs) may be overall less problematic in this regard but many individuals still experience problems with this class as well. Wellbutrin appears to be best tolerated for low incidence of sexual side effects and Remeron and Trazodone may have fewer side effects than their SSRI/SNRI counterparts. This puts forth the question of why aren’t developers of antidepressants engineering new drugs to better reduce sexual side effects? The authors pose this question to researchers and urge providers to consider a drug’s sexual side effect profile before prescribing so as not to put the client in the catch-22 dilemma of taking a medication that may offer relief of depressive symptoms yet compromise his or her sexual functioning.
APPLICATION TO PRACTICE
Psychiatric-mental health nurses need to be cognizant of the influence that psychiatric medications have on numerous areas of functioning. The results from this study illustrate the many difficulties that psychiatric medications can play in causing sexual disorders and dysfunctions. Thus, psychiatric-mental health nurses need to integrate information from this study when obtaining a sexual history from a patient. However, nurses also need to ensure that they do not attribute depression or anxiety as the sole reason for the patient’s complaints, but also consider potential medication-induced sexual dysfunction.
QUESTIONS TO PONDER
1. In working with a patient who has depression, would it be important to assess sexual functioning to see if the depression is impairing this part of the patient’s life?
2. If a patient reports during an assessment that he or she has “no desire” for sexual activity, how would you further assess this area?
Figure 18-2 Desire and arousal pattern in women.
Source: From Basson (2002). Copyright 2002 by Blackwell Publishing Ltd.
Neurobiological Influences
Many sexual dysfunctions, although still containing a psychological component, are biological or neurobiological in their primary cause. Many medical illnesses including cardiovascular disease and diabetes may alter the ability of the individual to function sexually. Additionally, medications that alter brain chemistry have been shown to influence sexual dysfunction. Most antidepressants that increase serotonin such as fluoxetine (Prozac), sertraline hydrochloride (Zoloft), and others potentially lower desire and inhibit or prevent orgasm. Women tend to report lower desire and more orgasmic problems with this class of medication (Heiman, 2002).
The mechanism of action causing dysfunction is thought to arise from the serotonin cell bodies on the brainstem in a raphe nuclei region of the brain. Some of these project into the cortical area of the brain. Sexual dysfunctions of lower desire may result due to inhibition from SSRIs in this region. Serotonergic projections also travel down the spine, and, when stimulated by SSRIs, inhibit aspects of sexual function such as vaginal lubrication and orgasm (Keltner, McAfee, & Taylor, 2002). The result is that intercourse may be painful and orgasm may be delayed or may not occur.
Emotional stressors, such as anxiety or depression, medical illnesses, and medications that alter the brain’s chemistry, have been linked to the development of sexual disorders and dysfunctions.
TREATMENT OPTIONS
Treatment options for patients with sexual disorders range from generalist interventions, such as psychoeducation and medication provided by nurses and other health care providers, to specialized intervention, such as psychotherapy from professionals credentialed as sex therapists.
Therapy
Psychotherapy is the preferred treatment intervention for most sexual disorders. Often the concern can be addressed by a therapist who specialized in sexual disorders and through a variety of strategies such as the use of cognitive behavioral therapy (CBT), or insight-oriented therapy, and so on. For a list of therapists who specialize in this field, the nurse can consult the American Association of Sexuality Educators, Counselors, and Therapists at www.aasect.org to aid in the referral process.
DRUG SUMMARY 18-1:
AGENTS USED FOR SEXUAL DISORDERS
|
DRUG/USE |
IMPLICATIONS FOR NURSING CARE |
|
sildenafil (Viagra)/erectile disorder tadalafil (Cialis)/erectile disorder vardenafil (Levitra)/erectile disorder |
|
|
flibanserin (proposed trade names Girosa and Addyi)/female arousal disorder (pending Food and Drug Administration [FDA] approval) bupropion (Wellbutrin)—off label/SSRI/SNRI-induced sexual side effects |
|
|
Androgen therapy, that is, testosterone, estrogen/low testosterone in men. Estrogen replacement therapy in postmenopausal women |
|
Pharmacological
Medications can sometimes be helpful in treating erectile dysfunction (Drug Summary 18-1). For example, sildenafil citrate (Viagra) helps treat erectile dysfunction by preventing the breakdown of a chemical called phosphodiesterase type 5 (PDE5). Normally, with arousal, nerve signals are sent from the brain to the penis, causing chemicals to be released that relax muscles in the penis. When these muscles relax, large amounts of blood are able to enter the penis, resulting in an erection. The erection is reversed when PDE5 breaks down the other chemicals that caused the muscles to relax. When muscles in the penis constrict again, blood leaves the penis. Thus, when sildenafil prevents the breakdown of PDE5, the erection is achieved and prolonged.
APPLYING THE NURSING PROCESS FROM AN INTERPERSONAL PERSPECTIVE
Although generalist nurses may not find themselves directly treating or caring for patients with sexual disorders, an understanding and awareness of this spectrum of disorders are helpful. More commonly, the nurse generalist will encounter patients with sexual dysfunctions that may be uncovered through skillful questioning. Therefore, nurses need a firm understanding of the nursing process that integrates the interpersonal process when caring for patients who may be experiencing a sexual disorder or dysfunction. Plan of Care 18-1 provides an example for a patient with a sexual dysfunction.
Strategies for Optimal Assessment: Therapeutic Use of Self
Travelbee offered an interpersonal model to guide practice from a human-to-human perspective. The first phase of the relationship according to Travelbee is the original encounter. For many nurses, this is during the patient’s admission when the nurse performs the initial assessment. The original encounter is characterized by first impressions of each other. The nurse and the patient initially perceive each other in stereotypical roles (Travelbee, 1971). The nurse needs to be able to gather data related to sexual function in a competent, coherent, and comfortable manner. This requires that the nurse be very clear and in tune with how he or she feels about sexual functioning. The nurse must understand and acknowledge his or her own sexual feelings, biases, and beliefs. If any are negative or biased, the nurse must temporarily suspend them when working with patients.
When gathering such personal data during an assessment, the patient needs to sense unconditional acceptance by the nurse. Therapeutic Interaction 18-1 provides an example of the therapeutic use of self when performing a sexual assessment. The moment a patient even slightly senses a prejudicial attitude, voice inflection, change of tone, or change in body posture during the interview, the chance that the person will self-disclose important information relative to this area of assessment lessens.
Sexual Health Assessment
Often, the opportunity for sexual health assessment can be performed during the initial assessment. This sometimes is awkwardly presented during the genitourinary or reproductive section of the nursing assessment. When approaching this section of the assessment, it may be helpful to quickly plan ahead and consider some of the following:
Are you alone with the patient?
Is the spouse or significant other with the patient?
Are there family members around?
What is the age of the patient, spouse, or family members?
What are the cultural beliefs?
Have you established if there are any religious beliefs?
What is the overall nature of the illness that has brought the patient for care?
How has the patient answered the questions so far?
Does the patient seem comfortable proceeding with more personal information?
Do you need to ask others to leave the room while you finish the assessment?
Do you need to pull the curtain or otherwise arrange for privacy?
What is your body posture? Are you relaxed/tense? Are you making eye contact? Are your actions establishing clear and healthy boundaries?
PLAN OF CARE 18-1:
THE PATIENT WITH A SEXUAL DYSFUNCTION
|
NURSING DIAGNOSIS: Sexual dysfunction; related to potential side effects of medication and anxiety; manifested by inability to attain or sustain an erection, concerns related to sexual performance, and decreased pleasure with sexual activity. OUTCOME IDENTIFICATION: Patient will verbalize an increase in pleasure and ability to engage in sexual activity with less anxiety. |
|
|
INTERVENTION |
RATIONALE |
|
Establish rapport and provide for privacy. Demonstrate unconditional acceptance, obtain the patient’s permission, and begin assessment with least sensitive topics |
Establishing rapport is essential for developing the nurse–patient relationship, especially in light of the sensitive nature of the topic. Obtaining the patient’s permission is important for developing trust and demonstrates respect for the patient. Providing for privacy and demonstrating unconditional acceptance are important for developing trust. Beginning with the least sensitive topics first promotes the patient’s comfort with the discussion |
|
Review the patient’s history and physical exam for possible underlying contributing factors related to the dysfunction. Assess the patient’s feelings related to sexual functioning and dysfunction |
Reviewing the history and physical exam provides information about possible causes, such as underlying medical conditions or use of medications that can contribute to the dysfunction; assessing the patient’s feelings provides insight into the patient’s view and significance of the condition |
|
Provide the patient with information related to the specific disorder as appropriate. Help clarify any myths or misconceptions the patient may have |
Explaining and clarifying help to provide the patient with an understanding of the condition and dispel myths or misconceptions that may be contributing to feelings |
|
Explain and/or administer prescribed medications such as phosphodiesterase type 5 inhibitors (i.e., sildenafil) |
Using medications may be necessary to address the underlying physiological issue related to the dysfunction |
|
Discuss methods for sexual expression other than sexual intercourse; include the patient’s partner in the discussion and encourage the patient and partner to communicate openly |
Discussing other methods of sexual expression can help the patient and partner attain and/or maintain intimacy. Including the partner in the discussion promotes sharing and enhances feelings of intimacy |
|
Obtain referral for counseling or sex therapy if appropriate |
Referring the patient and partner to a sex therapist may be necessary to promote sexual functioning |
|
NURSING DIAGNOSIS: Disturbed body image; related to recent mastectomy; manifested by feelings of inadequacy, shame or guilt, and sexual relationship difficulties. OUTCOME IDENTIFICATION: Patient will verbalize positive statements about sexual self. |
|
|
INTERVENTION |
RATIONALE |
|
Assess the patient’s view of self and influence of dysfunction on this view; include the patient’s partner in assessment |
Assessing the patient’s and partner’s views provides information from which to individualize interventions |
|
Assist the patient in looking at himself or herself realistically; help the patient acknowledge the link between feelings, self-esteem, and sexual functioning |
Assisting the patient in looking at self realistically and acknowledging the link help the patient to correct misconceptions and promote feelings of self-esteem |
|
Work with the patient to refocus thinking; assist the patient in identifying strengths and resources; emphasize the patient’s strengths and positive aspects of self |
Assisting the patient in identifying strengths promotes feelings of self-worth and self-esteem |
|
Help patient and partner discuss feelings related to body image and self-esteem and how these influence sexual activity; assist them in separating feelings from behaviors |
Identifying feelings and influence on sexual activity can promote understanding of the connection and insight into behaviors |
|
Work with the patient and partner on ways to alleviate feelings that can interfere with sexual activity; encourage open, honest communication |
Encouraging ways to alleviate feelings related to sexual dysfunction and open honest communication can facilitate self-esteem and self-confidence |
|
Assist the patient and partner in appropriate problem solving and provide positive reinforcement |
Using appropriate problem solving and reinforcing it promote feelings of self-confidence and self-worth |
|
Source: NANDA International Nursing Diagnosis: Definitions and Classifications 2015–2017. Copyright © 2015 by NANDA International. Used by arrangement with Blackwell Publishing Limited, a company of John Wiley & Sons, Inc. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work. |
|
Assuming that the nurse has gone through these questions and feels that it is appropriate to move ahead with a sexual assessment, the following statement may provide an opening: “Mr./Mrs. Smith, I need to ask you some questions about your reproductive health. This is a chance for us to talk about any concerns you may have and a chance for me to assist you in this area. Are you ok with my discussing this with you?” Once permission is granted, proceed while conveying a comfortable, relaxed, yet interested attitude.
The ability to proceed with the discussion may signal the transition to the next phase of Travelbee’s model, emerging identities. The nurse may be aware that he or she and the patient perceive each other as unique individuals. A connection has been established and the bond of a relationship is beginning to form. Now is a good time to take a quick moment to ask “What has allowed me to feel this connection?” Most important, are you ready from a boundary perspective to proceed? If so, the 10 questions included in Box 18-2 can help structure the experience. The flow of the questioning will depend on the facility’s nursing assessment form. Box 18–2 highlights the important elements to include regardless of the structure of the form.
THERAPEUTIC INTERACTION 18-1:
OBTAINING A SEXUAL ASSESSMENT
Ms. Stevens is admitted to the unit with severe depression. The nurse is performing a nursing assessment.
The nurse needs to obtain permission from the patient before proceeding with an assessment of sexual functioning.
Boundary Maintenance
Working with patients when the focus is on sexual issues can be uncomfortable. The subject matter combined with the expectation of practicing psychiatric-mental health nursing from a relationship-based perspective will challenge the skillful navigation of boundaries. The need to stay within the boundaries of a healthy nurse–patient relationship means that the nurse does not become overinvolved with the patient just because the treatment issue is one of a sexual nature. Conversely, the subject matter may also be awkward for the nurse. Therefore, the nurse must avoid failing to engage the patient, becoming underinvolved, or being neglectful with treatment just because the treatment issue is one of a sexual nature.
Diagnosing and Planning Appropriate Interventions: Meeting the Patient’s Focused Needs
The next phase of the nursing process is planning. After concluding an interview in which assessment data were gleaned implicating a sexual dysfunction, deciding on how to incorporate this into the treatment plan must involve a sense of where the patient feels this need falls. This can be best accomplished by ensuring empathetic practice. As described by Travelbee (1971), the empathy phase is characterized by the ability to share in the other person’s experience. The nurse may begin to imagine how having a sexual dysfunction has affected this patient’s overall well-being. Consumer Perspective 18-1 provides insight into what it is like to experience a sexual dysfunction.
BOX 18-2: 10 ESSENTIAL QUESTIONS FOR A NURSING SEXUAL HEALTH ASSESSMENT
1. Do you consider yourself sexually active?
2. If so, please discuss any concerns related to your sexual functioning; for example, pain, or any difficulty functioning as you would like.
3. If you are not sexually active, please share with me the reason(s) for this? (belief system, illness, etc.)
4. Please discuss any illness (medical or emotional) that may be concerning you regarding your ability to function as desired sexually.
5. How do you maintain your sexual health; that is, breast exams, testicular exams, prostate exams, Pap tests?
6. Please discuss any experience of sexual trauma such as rape, sexual abuse, or anything you felt was sexually abusive or exploitive.
7. Have there been any changes in your level of interest in sexual functioning (either increase or decrease) and if so, has this caused any difficulties?
8. Based on our conversation so far, what would you like to talk about further?
9. Is there anything you would like more information on?
10. I will be developing a nursing treatment plan based on my whole assessment. Would you like me to focus on any area of concern regarding sexual health promotion?
Source: Developed by J. Jones.
The nurse’s desire to address this issue and make it a treatment goal indicates movement into sympathy. This next phase of the therapeutic relationship, sympathy, goes beyond empathy and occurs when the nurse desires to alleviate the cause of the patient’s illness or suffering. This is where the appropriate plan of care is generated. This phase requires a combination of the disciplined intellectual approach combined with the therapeutic use of self-using appropriate boundaries.
Quality and Safety Education for Nurses (QSEN)
In addition to the previous strategies, it is important to remember that you will also be held to these following patient-centered care practice knowledge and skills in accordance with QSEN initiatives.
|
• Explore ethical and legal implications of patient-centered care • Describe the limits and boundaries of therapeutic patient-centered care |
• Recognize the boundaries of therapeutic relationships • Facilitate informed patient consent for care |
Source: Cronenwett et al. (2007).
For example, the nurse discovers during the course of an assessment that a patient is experiencing erectile dysfunction and this problem has never been disclosed before. Thus, the nurse, in collaboration with the patient who believes this to be a significant issue for him and his partner, includes this as part of the treatment plan. This decision is not because the nurse has determined that this is a problem. Rather, it is because the nurse has experienced sympathy and understood the importance of the matter to the patient because they are now in a therapeutic relationship.
Due to the wide range of assessment findings and multiple problems faced by patients with sexual disorders and dysfunctions, numerous nursing diagnoses would apply. Examples of possible nursing diagnoses would include:
Sexual dysfunction related to painful intercourse
Ineffective sexuality patterns related to low desire
CONSUMER PERSPECTIVE 18-1: A COUPLE EXPERIENCING GENITOPELVIC PAIN/PENETRATION DISORDER
Penetration disorder strikes young and old, sexually experienced and inexperienced. In our case, we were young and inexperienced. Marrying right after graduation from college, neither of us had had intercourse before and we really didn’t know a lot about sex. We were basically college sweethearts that loved each other, had plans for a family, and hopes for the “American Dream.” We were both brought up in caring, loving families.
We discovered genitopelvic pain on our honeymoon—the classic primary penetration disorder story about the young couple that couldn’t consummate, no matter how hard they tried. Calls back home to the family physician were met with the standard advice to “Try using more foreplay or more lubricant—and just keep trying. Don’t worry, you’ll figure it out.” We tried again and again using every method we could think of, but it was like “hitting a wall”; penetration was simply impossible. We were confused and felt utterly foolish and embarrassed.
When this happened to us, the Internet was still in its infancy. Endless searches revealed little useful information. With the honeymoon over, we worked hard adjusting to our new careers in a new city. We relocated all our possessions and created a home, all the while carrying on as if everything was perfect. Our family and friends had no idea what we were experiencing. We assumed somehow that we would eventually figure it out and didn’t dream of suffering the embarrassment of letting anyone know about our strange honeymoon problem and ongoing failure.
As is typical for couples going through penetration disorder, the passage of time began to create difficult paradoxes. How do you simply go in to a new doctor and say “By the way, we’ve been married for 7 months and we haven’t had sex yet. Any ideas?” A person feels extreme shame and failure, to the point that it becomes very difficult to be courageous enough to seek help. In our case, we reluctantly got up our courage out of necessity and kept asking more professionals, until finally we were referred to a sex therapist who knew exactly how to begin helping us.
Situational low self-esteem related to erectile dysfunction
Chronic low self-esteem related to changes in body following mastectomy for breast cancer
These nursing diagnoses will also vary based on the acuity of the patient’s illness, developmental stage, comorbidities, current treatment regimen, and sources of support.
Based on the identified nursing diagnoses, the nurse and the patient would collaboratively determine the outcomes to be achieved. For example, possible causes such as medication side effects for the erectile dysfunction will be explored and identified.
Implementing Effective Interventions: Timing and Pacing
After the patient’s needs have been identified and outcomes and goals have been set, the nurse works with the patient to implement interventions. These interventions will vary depending on the actual diagnosis. Before proceeding, the nurse needs to make sure that he or she has established rapport with the patient. This last phase of Travelbee’s model is characterized by nursing actions that alleviate an ill person’s distress. The nurse and the patient are relating as human being to human being (Travelbee, 1971). The patient exhibits both trust and confidence in the nurse. How Would You Respond? 18-1 provides an example of a patient with a sexual dysfunction requiring intervention.
Consider the example of a patient with erectile dysfunction in which the problem is disrupting his relationship. Possibly, one of the interventions may be to rule out potential side effects of the patient’s current medications. There may be a combination of medications that the patient is taking that could be contributing to this dysfunction, for example, antihypertensives or antidepressants. Several levels of intervention would be appropriate. First, the nurse would share education about potential side effects of medication to establish the patient’s knowledge base and determine what would be the next course of action. The patient may have an awareness of these potential side effects and has raised this concern with the provider on several occasions, but nothing has been changed. This may present an opportunity for the nurse, in treatment team meetings with the provider, to advocate on the patient’s behalf. The timing and pacing of these interventions are key factors. First is the manner in which the nurse approaches the patient with the suspicions about potential side effects. When does the nurse do this? Should it be done when the patient’s partner is visiting? Should the nurse gather some printed information about the medication regimen and discuss it with the patient? How should the nurse begin the conversation? A possible start may go something like this:
HOW WOULD YOU RESPOND? 18-1:
MAJOR DEPRESSION AND LOSS OF INTEREST
Mrs. Rittenour is a 47-year-old Caucasian female homemaker, mother of two teenagers, admitted to the mental health unit with a diagnosis of Major Depressive Disorder Recurrent, Most Recent Episode Severe. She had been on the antidepressant escitalopram (Lexapro) at 20 mg for over the past 3 years with good results. Recently, she reported experiencing depressed mood, sleep disturbance, change of appetite, and vague suicidal ideations. Her primary mental health care provider, a psychiatric clinical nurse specialist, added aripiprazole (Abilify) 5 mg to augment the regimen. Mrs. Rittenour reported almost immediate relief of her symptoms and for approximately 1 month claimed she “felt like her old self.” Unfortunately, the following month her husband announced he wanted a divorce as he had decided to pursue a relationship with someone else. Mrs. Rittenour quickly decompensated and presented to the emergency department with suicidal ideation. She was admitted for observation and possible medication reevaluation.
During the nursing assessment, Mrs. Rittenour reveals that she had lost her interest in sexual activity about 3 years ago and that she and her estranged husband rarely engaged in any form of intimacy. She also reported that he noted her cycles were very irregular and her moodiness seemed to correlate to her cycles. She reported increased sleep disturbance in the past 3 years, trouble focusing and concentrating, and painful intercourse on the few occasions she did engage in sexual activity with her husband. How would you respond?
CRITICAL THINKING QUESTIONS
1. During the sexual health portion of Mrs. Rittenour’s history, what areas would need further exploration?
2. Suppose Mrs. Rittenour asks you what you would do about the marriage if you were in her shoes. How would you respond?
3. When working with this patient, you notice yourself becoming angry and frustrated with her at times. This seems to occur primarily when she discusses her interest in reconciling with her husband, imagining that, when you were young your father frequently left your mother and then would come back. What might you be experiencing?
“Hello, Mr. Smith, I am the nurse on duty today and will be meeting with you periodically throughout the shift. Do you mind if we review your treatment plan during one of those meetings to see how things are going?” Later, when the nurse senses that the timing is right, he or she might bring in the treatment plan and briefly review the problems identified. When the nurse gets to the sexual dysfunction problem, it will have been introduced within the context of his overall health and may be less threatening to discuss. The next conversation may go accordingly:
APPLYING THE CONCEPTS
Several areas need to be addressed during the sexual health portion of the assessment. This, however, would only occur after the patient’s suicidality is assessed and immediate interventions are implemented to ensure the patient’s safety. Once the patient’s condition stabilizes, then the nurse would continue with the assessment. Areas to address would include the patient’s change of sexual function, along with her change in menstrual cycle and medications used for treating her depression. According to her statement, the patient’s loss of interest occurred around the same time that she was prescribed the antidepressant.
When responding to Mrs. Rittenour about what you would do if you were her, it would be important to clarify why she is asking you. Is she doing so because she doesn’t know what to do? It would be best to reflect the question back to her to encourage her to process what her options are. Another area for self-reflection may be your frustration in dealing with the situation as some of the key elements mirror your own life (i.e., your father left your mother periodically). If you do find yourself experiencing some countertransference, it is all the more important that you do not provide your opinion, but focus on the patient as you may have lost some objectivity.
“I see that one of the problems listed is sexual dysfunction related to an inability to engage in intercourse manifested by inability to achieve and/or maintain erection. One of the interventions listed is an opportunity to rule out potential side effects of medications known to cause this problem. Were you aware that some of the medications you are taking may be causing this problem?”
The nurse then assesses the patient’s knowledge base, provides information as appropriate through patient education about medication and potential side effects, and together with the patient plans on the next, if any, intervention. As mentioned, this may involve the nurse advocating on the patient’s behalf with the provider coordinating the medicine regimen. Again, deciding how to approach the person(s) responsible for this and in what forum will be important: approach them privately or at the nursing station? Wait until the treatment team is available or when they are making rounds, joining them in the patient’s room? The nurse’s assessment and judgment of when and how to do this may determine the success or failure of this intervention.
Psychoeducation and acting as a patient advocate are two key nursing interventions for patients with sexual dysfunction.
Evaluating: Objective Critique of Interventions and Self-Reflection
The nurse may have successfully provided education regarding potential medication side effects to the patient, and may have also further successfully advocated for the patient about changes in medications with the treatment team. Evaluation of successful goal attainment may not be identified immediately or ever known to the nurse because the patient may be discharged right after the interventions. The nurse would focus evaluation on the interventions, which in this case would be that the nurse provided appropriate education after identifying a problem, and successfully advocated on the patient’s behalf for change in a medication regimen to try to address the identified sexual dysfunction. The resolution of the actual sexual dysfunction would have to be evaluated as “unknown or partially met.”
The nurse should reflect on his or her own feelings as the scenario unfolded with regard to such intimate issues. When evaluating the treatment plan, the nurse needs to determine if the goals were reflective of the patient’s needs and if healthy boundaries were maintained. The nurse also needs to determine if there were any areas at issue that became uncomfortable and, if so, how the nurse dealt with them. The nurse questions himself or herself about the possibility of self-discomfort interfering with not meeting certain goals. For any goals not met, the nurse needs to self-reflect on anything he or she may have done differently while providing nursing care.
SUMMARY POINTS
Sexual dysfunctions involve a disturbance in the sexual response cycle. Paraphilias involve recurrent intense sexual urges, fantasies, or behaviors.
Freud was one of the first psychiatrists to attempt to understand how sexual drives and urges are manifested and expressed. Political, cultural, and theological issues of the time influence the approach and discussion of sexual disorders and dysfunctions.
Treatment options range from psychoeducation and medication administration to specialized interventions such as sex therapy.
Assessment of a patient with a sexual disorder requires the nurse to understand and acknowledge his or her feelings, beliefs, and biases related to sexual functioning.
Identifying and maintaining appropriate boundaries are priorities when caring for a patient with a sexual disorder or dysfunction.
NCLEX – PREP*
1. When assessing a patient with genitopelvic pain/penetration disorder, which of the following would the nurse expect the patient to report?
a. Inability to attain adequate lubrication in response to sexual excitement
b. Recurrent pain in the genital area with sexual intercourse
c. A deficient lack of desire for sexual activity
d. An avoidance for engaging in sexual activity
2. A nurse is engaged in assessing a male patient and has determined that it is appropriate to move on to assessing the patient’s sexual history. Which of the following would be most important for the nurse to do first?
a. Make sure that the nurse and the patient are alone
b. Ask the patient about whether or not he is sexually active
c. Question the patient about any history of sexual abuse
d. Obtain the patient’s permission to ask him questions about this area
e. All of the above
3. A group of students are reviewing information about the various types of sexual dysfunctions. The students demonstrate understanding of this topic when they identify which of the following as not an example of a sexual dysfunction?
a. Genitopelvic pain/penetration disorder
b. Gender dysphoria
c. Premature ejaculation
d. Erectile disorder
4. A client reports that since being placed on Prozac she notices a decrease in her interest in sexual desire, and difficulty becoming aroused and achieving orgasm when she does engage in sexual activity. You would plan your nursing intervention around the likelihood that she is suffering from:
a. Substance/medication-induced sexual dysfunction
b. Female sexual interest/arousal disorder
c. Genitopelvic pain/penetration disorder
d. Female orgasmic disorder
5. A nurse is preparing an in-service presentation about sexual dysfunction for a group of nurses involved in a continuing education course. As part of the presentation, the nurse is planning to describe the classic male sexual response cycle. Place the phases of the cycle in the order in which the nurse would present the information.
a. Resolution
b. Desire
c. Orgasm
d. Excitement
*Answers to these questions appear in the Answers to NCLEX Prep Questions section at the back of this book.
REFERENCES
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Baldwin, D. S., Palazzo, M. C., & Masdrakis, V. G. (2013). Reduced treatment-emergent sexual dysfunction as a potential target in the development of new antidepressants. Depression Research and Treatment, 2013, 256841. doi: 10.1155/2013/256841
Basson, R. (2001). Female sexual response: The role of drugs in the management of sexual dysfunction. Obstetrics and Gynecology, 98(2), 350–353.
Basson, R. (2002). Rethinking low sexual desire in women. BJOG: An International Journal of Obstetrics and Gynaecology, 109(4), 357–363.
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., … Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131.
Fogel, C. A., & Lauver, D. (1990). Sexual health promotion. Philadelphia, PA: W. B. Saunders Company.
Freud, S. & Gay, P. (1989). The Freud reader. New York, NY: W. W. Norton and Company.
Heiman, J. R. (2002). Sexual dysfunction: Overview of prevalence, etiological factors, and treatments. Journal of Sex Research, 39(1), 73–78.
Keltner, N. L., McAfee, K. M., & Taylor, C. L. (2002). Mechanisms and treatment of SSRI-induced sexual dysfunction. Perspectivesin Psychiatric Care, 38(3), 111–116.
Kinsey, A. C., Pomeroy, W. R., & Martin, C. E. (1948). Sexual behavior in the human male. Philadelphia, PA: W. B. Saunders.
Kinsey, A. C., Pomeroy, W. R., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in the human female. Philadelphia, PA: W. B. Saunders Company.
Kort, J. (2014). Is my husband gay, straight, or bi?: A guide for women concerned about their men. Lanham, MD: Rowman & Littlefield.
Leiblum, S. R. (2007). Principals and practice of sex therapy (4th ed.). New York, NY: Guilford Publications.
Travelbee, J. (1971). Interpersonal aspects of nursing (2nd ed.). Philadelphia, PA: F. A. Davis.
Ubillos, S., Paez, D., & Gonzalez, J. (2000). Culture and sexual behavior. Psicothema, 12, 70–82.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
