SEXUAL DYSFUNCTIONS, PARAPHILIC DISORDERS, AND GENDER DYSPHORIA
Jeffrey S. Jones
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
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.
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.
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.
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
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.
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.
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.
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.
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.
Sexual arousal from watching others (unsuspecting) nude, or engaged in sexual activity.
Sexual arousal from exposing genitals to an unsuspecting person.
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).
Intense sexual arousal or urges involving prepubescent children (under age 13 years).
Sexual arousal stemming from a nongenital body part (ears, legs) or a nonliving item (certain article of clothing, etc.).
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.).
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).
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.
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
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
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?
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.