Cognitive Dissonance

Cognitive dissonance arises when two opposing beliefs exist at the same time. For example, nurses grow up learning what society, family, and friends believe about sexual issues. If a nurse is raised in an environment that teaches “it is impolite to talk about sex; it is too personal a subject,” the nurse will carry those beliefs into nursing practice. When a patient wants to discuss a sexual concern, the nurse may feel two opposing reactions: “I should not ask questions about a subject as personal as sex, but as a professional, I should be able to discuss any problem, including sexual problems, with my patient.”

These opposing thoughts, based on different role expectations, make the nurse uncomfortable. However, the discomfort can be positive because it forces the nurse to examine feelings about the issue. The nurse resolves the cognitive dissonance in one of two ways: by continuing to believe that sexual concerns are too personal to discuss with patients or by examining the fact that sexuality is an integral part of being human.

Both beliefs have consequences that involve how the nurse relates to patients who express sexual concerns. If the nurse continues to believe that sex is too personal to discuss with the patient, the nurse may become uncomfortable and choose not to follow up on sexual issues. This discomfort may be projected onto the patient, with the nurse stating, “The patient seemed too upset to talk about that right now.” In this case, the nurse should explore personal values and beliefs about sexuality and ask, “Do I believe these ideas about discussing sexual concerns because I have researched the facts and have accurate, current information?”

Only when the nurse has examined the available information and made an informed choice on values will clarification of those values occur. If the nurse examines personal and professional values and believes that sexuality is an integral part of being human, a second phase of growth will occur.

Anxiety

Most people think that anxiety is a negative emotion. However, a mild level of anxiety can be positive because it can promote an awareness of danger, give extra energy, or stimulate professional growth by creating enough discomfort to initiate some type of action.

In this second phase, the nurse realizes that uncertainty, insecurity, questions, and problems regarding sexuality are normal. The nurse begins to understand that everyone is capable of a variety of sexual feelings and behaviors and that anyone can have a sexual dysfunction or question sexual identity.

The nurse experiencing anxiety may exhibit behaviors that hinder the discussion of sexual issues, such as talking too much (not allowing patients to express their feelings), failing to listen (not picking up on patients’ cues and messages), and diagnosing and analyzing (becoming preoccupied with facts rather than feelings). As the anxiety level rises, the nurse becomes more uncomfortable and tries to reduce that feeling. Learning about sexuality and facing conflicting values bring the nurse to the third phase of growth.

Anger

Anger usually arises after anxiety, fear, and shock. It can be self-directed or directed toward the patient or society. The nurse begins to recognize that issues associated with sex or sexuality can be highly emotional.

Rape, abortion, birth control, equal rights, child abuse, pornography, and religious issues are related to sexuality and give rise to controversy and debate. This realization often leads to anger in the nurse. For example, the nurse may become angry with a colleague or a friend who makes judgmental remarks about pro-life or pro-choice activists.

During this phase of anger, the nurse tends to choose words and actions that may be as judgmental as the attitudes the nurse is fighting against. The nurse may lecture other nurses about the need for sex education or critically judge a teenager who does not fear the consequences of having unprotected sex with someone known to be positive for human immunodeficiency virus (HIV) infection.

The nurse also may be angry with society for perpetuating ignorance about sexuality. Near the end of this phase, the nurse begins to understand that blaming self or society for lack of awareness does not help patients with sexual concerns. This realization helps defuse the anger, and the nurse is then ready for the final phase.

Action

The final step in the growth experience is the action phase. Several behaviors emerge during this final phase of the growth experience: data inquiry, choosing values, and prizing values.

The next clinical example shows the growth health professionals experience while increasing their awareness about sexuality. Chapter 2 has additional content on developing self-awareness and the nurse’s therapeutic use of self.

Heterosexuality

Heterosexuality is sexual attraction to members of the opposite gender. It is the predominant sexual orientation among people in U.S. society. The coupling of a man and a woman in a sexual partnership has legal and religious sanctions, and it influences the culture, values, and norms of contemporary life.

Homosexuality

Homosexuality is sexual attraction to members of the same gender. The term gay is used to refer to male and female homosexuals; however, some use the term to refer only to male homosexuals and use the term lesbian to refer to female homosexuals.

An individual’s attraction to people of the same gender, opposite gender, or both genders is called sexual orientation or sexual preference. Some prefer the term sexual orientation to sexual preference because preference implies that homosexuals choose to be homosexual. Although sexual behaviors do involve choice, research has indicated that sexual orientation is affected by genetics and biochemical events (Blanchard, 2008; Francis, 2008; Hall and Schaeff, 2008; Miller et al, 2008; Bogaert, 2010).

It is difficult to estimate the actual incidence of homosexuality in the United States. The estimates have ranged from 2% to 6% of the population (McCabe, 2009). However, many people have had a sexual experience with a member of the same gender at one time in their lives, and this is typically not identified when surveys are taken. One of the reasons that it is difficult to obtain an accurate incidence of homosexuality is that social stigma is still attached to labeling oneself as homosexual, and it is possible that many individuals do not report their true sexual identity.

No conclusive evidence supports any one specific cause of homosexuality; however, most researchers agree that biological and social factors influence the development of sexual orientation. Some sexuality experts question the need to find a cause for homosexuality rather than simply accepting the fact that it exists. If current estimates of homosexuality are accurate, nurses come into contact with homosexuals daily but often know little about homosexuality and often assume that all patients are heterosexual.

Bisexuality

Bisexuality is sexual orientation or attraction to both men and women. Many studies on bisexuality include homosexuals in their research samples, and this has made the understanding of bisexuality more difficult. Some people believe that bisexuality is a distinct sexual orientation, some view bisexuality as a transition from one sexual orientation to another, and some contend that bisexuality can be an individual’s attempt to deny a true homosexual identity.

Interest in the behavior and characteristics of bisexual men has increased in light of the acquired immunodeficiency syndrome (AIDS) and the need to design effective preventive interventions for HIV infection. The degree of sexual risk behaviors of bisexual men is quite high, but their lack of identification with and participation in the homosexual community makes them unlikely to be reached by the gay community’s safe sex and AIDS prevention programs.

Transvestism

Transvestism is cross-dressing, or dressing in the clothes of the opposite gender. The transvestite who seeks treatment usually is male; very little is known about female transvestism. No reliable statistics concerning the incidence of transvestism are available, but many professionals believe it is more common than usually assumed.

Transvestites tend to be married men who report heterosexual behavior. Although they occasionally or frequently dress in female clothes, they do not want hormonal or surgical gender change. Many transvestites try to find willing partners, and their activities of cross-dressing typically do not prevent sexual relationships with others.

Transsexualism

Transsexualism is the desire to become a member of the opposite gender. It is a condition in which a person has a profound discomfort with his or her own gender and a strong and persistent identification with the opposite gender.

A transsexual is an individual with a gender identity disorder. Transsexuals experience a mismatch between their biological gender and their gender identity. They live as members of the opposite gender part or full time and may seek to change gender through hormone therapy and gender reassignment surgery.

Transsexual patients often describe themselves as “feeling trapped in the wrong body.” Transsexuals genuinely believe that they belong to the other gender. Many experience intense emotional turmoil because of stigma from society. No accurate estimates of the incidence of transsexualism are available; however, postoperative transsexuals in the United States number in the thousands.

Transsexuality is different from homosexuality in that homosexuals are comfortable with their anatomical identity and do not want to change their gender. Many transsexuals are heterosexual and express distaste for homosexual activity. Transsexuals are essentially heterosexual, not homosexual, but they are often mistaken by others or themselves as homosexual, as seen in the next clinical example.

The Sexual Response Cycle

In addition to modes of sexual expression or sexual orientation, the physiological and psychological responses to sexual stimulation can be described. The four stages of the sexual response cycle are desire, excitement, orgasm, and resolution (Box 25-1).

Experts have begun to look at the lack of research regarding female sexual response. It is commonly believed that female sexual functioning is more complicated than and not as linear as male sexual functioning (Kingsburg and Althof, 2009; Sobczak, 2009a; Jordan et al, 2011).

Impairment in sexual response may occur in any one of the phases of the sexual response cycle. For example, both men and women may experience low levels of sexual desire. If the excitement phase is inhibited, it may produce erectile dysfunction in males and problems with arousal in females. If the orgasm stage of the cycle is disrupted, premature, inhibited, or retrograde ejaculation may occur in males, and females may experience vaginismus or pain. Although sexual dysfunction can occur when any phase is disrupted, resolution phase inhibition is rarely responsible for specific sexual dysfunctions.

Men and women experience sexual dysfunctions very differently. Men are more likely to report problems with sexual performance and erectile dysfunction (Diaz and Close, 2010), including difficulty with obtaining or maintaining an erection and premature or delayed ejaculation. Women are motivated to seek help for concerns about sexual feelings, including lack of desire or sexual pleasure (Leiblum, 2007; Jordan et al, 2011).

The causes of sexual dysfunction are varied and complex. Emotional and stress-related problems can increase the risk of sexual dysfunction in all phases of the sexual response cycle for men and women. Sex therapists agree that many sexual dysfunctions are caused by psychological factors ranging from unresolved childhood conflicts to adult problems, such as performance anxiety, lack of knowledge, or failure to communicate with a partner.

Sexual dysfunction also can be caused by physiological factors. Medical problems such as circulatory, endocrine, or neurological disorders and medication side effects can contribute to sexual problems. The interaction between physiological illness and the psychosocial aspects of that illness also can lead to sexual problems.

Behavioral Factors

Behaviorists view sexual behavior as a measurable physiological and psychological response to a learned stimulus or reinforcement event. They specifically are interested in sexual difficulties that result from sexual abuse in childhood. Although men and women are affected differently by childhood sexual abuse, both can experience sexual difficulties in later life.

For both women and men, sexual dysfunction is more likely to be found when the incidence of abusive episodes is high and the types of abuse are many. The care of people who have experienced abuse and violence is described in detail in Chapter 38.

Psychiatric Illness

Psychiatric illness affects a person’s sexuality and the sexual behavior and satisfaction of the person’s partner (Box 25-2). In a study of inpatients with a psychiatric illness, 71% reported an impairment in their sexuality. Although sexual dysfunction was found in all diagnostic groups, it was particularly prevalent among those with depression (Cohen et al, 2007).

Depression can be the result or cause of sexual dysfunction. Many depressed patients have decreased sexual desire and decreased frequency of intercourse. Most often, depressed men engage in intercourse less often; depressed women may participate in sex but with less enjoyment.

In contrast, hypersexuality may be the first symptom of a manic episode. People with bipolar illness have decreased sexual inhibitions, often impulsively choose sexual partners or begin extramarital affairs, display inappropriate sexual behavior, or act seductively or flirtatiously.

The sexual expression of patients with psychotic illnesses may be inappropriate and sometimes intrusive. Delusions and hallucinations may present with sexual content. The patient with a psychotic illness may not be able to understand or control sexual thoughts or impulses. For example, a patient may openly masturbate on an inpatient unit or inappropriately touch others. Thinking and judgment also may be impaired, resulting in sexual behavior that may be detrimental to the patient’s health, such as unsafe sexual practices.

Questions also have been raised about the sexual lives of persons with serious and persistent mental illness who live in residential treatment facilities. Each facility and group of staff members caring for residents need to identify ways to acknowledge and respect the normal sexual needs of these individuals and balance this with the need to keep the residents safe from sexually transmitted diseases, unwanted pregnancies, and nonconsensual sexual advances or assaults.

The nurse can help the patient identify and express needs related to sexuality. This includes helping the patient form healthy relationships with others, learn about safe sex practices, engage in healthy sexual expression, and decrease potentially dangerous sexual encounters.

A study examining the sexual needs and relationship experiences of patients with schizophrenia revealed that 83% were currently experiencing sexual feelings and had a need for an intimate relationship. Unfortunately, only 10% of the staff recognized the need for sexual expression in their patients (McCann, 2010). These findings support the need for a discussion of sexuality as an integral part of treatment.

Medications

Some medications contribute to sexual dysfunction, and nurses need to be knowledgeable about the medications they administer. The index of medications that can create sexual side effects continues to grow. These medications, which may include antihypertensives, antihistamines, anticholinergics, chemotherapeutic agents, and antiseizure drugs, can cause diminished sexual desire or orgasmic disorders in women and men. Some medications, especially antihypertensive agents, can cause erectile difficulties in men.

The sexual side effects of psychiatric medications are well documented. In a study of men and women with schizophrenia, 52% reported a sexual dysfunction. No differences were reported for the atypical, conventional, and combination antipsychotics (Ucok et al, 2007).

Sexual dysfunctions are a common side effect of selective serotonin reuptake inhibitors (SSRIs). These antidepressants can cause problems in any phase of the sexual response cycle. Although stopping the drugs for a specified period, sometimes known as drug holidays, has been proposed to treat these problems, drug holidays may lead to decreased efficacy and noncompliance with treatment. Alternatively, other antidepressant agents or additional medications can be used to treat the dysfunction. Psychiatric medications and their side effects are described in Chapter 26.

Nurses should be familiar with the sexual side effects of medications, educate their patients about them, and encourage patients to notify a health care professional when these effects occur. For example, a man may not be aware that his medication can cause impotence, but he may be embarrassed and hesitate to talk with the physician or nurse about the problem. The medication or the dosage often can be changed to correct the problem.

Abuse of alcohol or nontherapeutic drugs also may have a debilitating effect on sexuality. Although many people believe alcohol is a sexual stimulant, prolonged use can cause erectile difficulty and other dysfunctions.

HIV/AIDS

Fear of contracting a sexually transmitted disease (STD) may create a change in sexual behavior. The most frightening STD is AIDS, which is caused by HIV infection. HIV/AIDS is a leading worldwide health problem despite the attempts by health care professionals to educate society about the following safe-sex practices:

In the United States, most of those infected with HIV are males (76%). According to the Centers for Disease Control and Prevention (CDC), between 2006 and 2009 the incidence of HIV among males remained stable, whereas it declined among females. Heterosexual contact is the most common mode of transmission in women. The number of people infected through intravenous drug use has steadily declined.

In contrast, the number of people living with AIDS has increased. From 2006 through 2008, the rate per 100,000 of people living with AIDS was lowest among people younger than age 20 and older than age 65 years, but the number of persons diagnosed with HIV who are middle aged is concerning. In 2008, 41% of people living with AIDS were between the ages of 40 and 49 years (Centers for Disease Control and Prevention, 2011). Although the success of treatment for AIDS is promising, the effects of this illness have a significant impact on all aspects of society.

Many people infected with HIV also may have psychiatric and drug dependence problems and may experience more problems with HIV care (Fremont et al, 2007; Dyer and McGuinness, 2008). Nurses and other health care providers need to actively identify those at risk and work with clinicians and policymakers to ensure the availability of appropriate testing, counseling, and treatment for these individuals. Advanced practice nurses can be particularly effective in delivering community-based care in tailored interventions to improve outcomes of individuals with HIV and co-occurring serious mental illness (Blank et al, 2011).