Sexual Responses and Sexual Disorders



Sexual Responses and Sexual Disorders


Susan G. Poorman





Sexuality refers to all aspects of being sexual and is one dimension of personality. It includes more than the act of intercourse and is an integral part of life. It is evident in the person’s appearance and in beliefs, behaviors, and relationships with others. Four aspects of sexuality are as follows:



Accepting a broad concept of sexuality allows nurses to explore ways in which people are sexual beings and understand more fully their feelings, beliefs, and actions. Nurses



LEARNING FROM A CLINICAL CASE


This case can help you understand some of the issues you will be reading about. Read the case background and then, as you read the chapter, think about your answers to the Case Critical Reasoning Questions. Case outcomes are presented at the end of the chapter.



Case Background


He came to the family practice office saying that he was depressed and confused and that he had thoughts of hurting himself. You observe that he is young, fit, alert, and energetic. He did not appear to be depressed in his affect or body language. While completing your assessment, you ask him about his sexual orientation. He looks straight at you and says he is gay. When you ask him if he is “out” to his family, he looks down and shrugs “no.” When you ask him if his visit is related to being gay, he says he is having a difficult time in his relationship with his boyfriend and that he does not have anyone to talk to.


He comes from a religious family and is active in his church. He is a dispatcher locally for 911 and works weekend shifts. He has been involved with the same man for several years, but it is a secret, and no one knows. Lately, he has seen his partner with another man, and he feels betrayed. He is in love and thinks people who love each other should be faithful. His boyfriend thinks that idea is simplistic and does not hold the same beliefs.


He is very concerned about being “outed” because he wants to be a highway patrolman in the future. He believes that if his sexual orientation becomes public, he will not be recommended for the job, which has been his dream since he can remember. He has never considered any other career for himself. His brother is already a highway patrolman, and he wants to follow in his footsteps. He denies any real plan for hurting himself. He said just getting the appointment and coming to talk made him feel hopeful.



are often called on to intervene in the sexual concerns of patients when providing holistic patient care. It is important to develop skills and competence in addressing sexual issues by increasing awareness through education.


As nurses become educated in the basic principles of sexuality, they can better understand sexual needs and problems. If nurses are comfortable with sexual issues, they will convey this to the patient, who will feel more comfortable in discussing these issues. Patients are often experiencing pain and change as a result of threats to health or even as a part of normal growth and development. It is important that the nurse-patient relationship allows for honest discussions about sexuality.


Nurses need the following in relation to sexuality:



Becoming educated about sexuality allows nurses to develop confidence in their ability to discuss sexual issues with patients, learn interviewing skills for sexual assessment, and counsel or refer patients to appropriate resources.



Continuum of Sexual Responses


Adaptive and Maladaptive Sexual Responses


Experts in sexuality do not agree on what is normal sexual behavior. For years, many people believed that only sexual relations between married heterosexual partners for procreation were normal. Today, people view sexual behavior with a wider range of attitudes.


On a continuum, sexuality ranges from adaptive to maladaptive (Figure 25-1). Adaptive responses meet the following criteria:




Sexual behavior sometimes can meet the criteria for adaptive responses but be altered by what society considers to be acceptable or unacceptable. Unfortunately, society often decides this based on fear, prejudice, and lack of information rather than on data and facts. For example, the homosexual person may have the potential for healthy responses but be impaired by anxiety concerning societal disapproval.


Maladaptive sexual responses are behaviors that do not meet one or more of the criteria for adaptive responses. The degree to which these behaviors are maladaptive varies. Some sexual behaviors may not meet any of the criteria. For example, incest may include force and be psychologically harmful. However, other sexual responses may meet four of the five criteria for adaptive responses but still be maladaptive.


Caution must be used when attempting to label sexual behaviors as adaptive or maladaptive. Disagreements and exceptions to the rule will always exist. The continuum shown in Figure 25-1 is free of moral judgment and was constructed to help the nurse develop self-awareness and understand the range of sexual responses.




Self-Awareness of the Nurse


The first step in developing self-awareness involves clarification of values regarding human sexuality. Figure 25-2 illustrates four phases of the nurse’s growth: cognitive dissonance, anxiety, anger, and action (Foley and Davies, 1983).




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.



CLINICAL EXAMPLE


Carol was a new staff nurse at a rehabilitation hospital. At the monthly staff meeting, the nursing supervisor asked whether there were any concerns the staff would like to discuss. Carol offered, “I wonder if any of you could help me with a suggestion. Over the past several weeks, I’ve seen a number of patients masturbating. One patient was in the lounge, and another was in his room when I came in to give him his meds. I was so embarrassed that I didn’t know what to do. I ignored it both times, but part of me wanted to say ‘stop that—that’s not appropriate for a hospital!’ I guess I could use some help with this one.”


Another staff nurse followed up and said, “That’s what I feel like saying when I see that kind of behavior.” Several other staff members in the room began to snicker. The nursing supervisor interrupted and asked, “Can anyone give Carol some suggestions on how to handle this therapeutically?” After several moments of silence, other staff members admitted that they also were uncomfortable dealing with patients who were masturbating.


With the help of the supervisor, the staff began to brainstorm about how to handle this situation. Staff agreed that dealing with patients who are masturbating is a difficult issue for many nurses and that the problem is most often the nurses’ rather than the patients’ because masturbation is a normal form of sexual expression. They decided that when they observe a patient masturbating in a public area, an appropriate nursing response would be to have the patient return to his or her room for privacy. If a nurse walks in on a patient masturbating in the patient’s room, the nurse should ensure the patient’s privacy by saying, “Excuse me,” and telling the patient that the nurse will return at a later time.





Assessment


Any basic health history must include questions about sexual history. A nurse who is comfortable discussing sexuality says that it is normal to talk about sexual health in a health assessment interview. Nurses who are composed and professional can ask questions about patients’ sexual health naturally. The patient can then discuss sexual matters openly and without embarrassment.


Effective interviewing skills are an essential part of a sexual assessment (Magnan and Norris, 2008; Zakhari, 2009; Jaarsma et al, 2010). Nurses sometimes may be uncomfortable addressing sexual issues. However, the principles of effective interviewing are the same even when addressing sexual issues.


Open-ended questions are one of the most effective ways of promoting a discussion on sexual issues, although some nurses report that direct questions also can be helpful in opening up the subject. Regardless, it is important to remember that questions must be asked at the patient’s level of understanding, with sensitivity to the patient’s cultural background because each person is unique.


The time and number of questions needed to discuss a problem vary depending on the patient. Often just a few questions during an interview can obtain the relevant information. Examples of questions nurses may ask related to a patient’s sexual health include the following:




Behaviors


There are many types of sexual expression. In a classic work, Kinsey et al (1953) suggested that most people are not exclusively heterosexual or homosexual. Their studies indicated that a substantial percentage of men and women had experienced both heterosexual and homosexual activity.





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.




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.



Predisposing Factors


Biological Factors


Biological factors are initially responsible for the development of gender—whether a person is genetically male or female. Somatotype includes chromosomes, hormones, internal and external genitalia, and gonads. Sex differentiation is determined by the Y chromosome. Research in humans confirms the general rule that maleness and masculinity depend on fetal and perinatal androgens.


A biological female typically has XX chromosomes, with estrogen as the predominant hormone, appropriate internal and external genitalia, and ovaries. A biological male typically has XY chromosomes, with androgen as the predominant hormone, appropriate internal and external genitalia, and testicles. However, each of these typical configurations may vary.


A person may have triple chromosomes, such as XXX, XXY, or XYY, or a single chromosome, XO. There is no YO chromosomal pattern. The triple pattern XXX and the single pattern XO (Turner syndrome) result in a female body, whereas the triple patterns XXY (Klinefelter syndrome) and XYY result in male bodies. Assuming no variation occurs, the biological factors result in a single, fully developed gender, either male or female.


Based on family studies and DNA samples of homosexual brothers, it has been suggested that a gene may be related to homosexuality. Early work in the field suggested that homosexuality may be inherited from the maternal side of the family through the X chromosome. Before such research is accepted as definitive, however, it needs to be validated by replication, and similar studies of lesbians have not been completed. These findings cannot account for all cases of homosexuality, but they do support a possible biological basis.



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.




Precipitating Stressors


Physical Illness and Injury


Physical illness may alter sexuality. Nurses often care for patients with sexual dysfunctions or altered sexuality patterns; they need to discuss and intervene in patients’ responses to these changes. For example, a person with rheumatoid arthritis may have body disfiguration and a change in body image caused by swollen areas around joints. The same patient may have decreased sexual interest because of joint pain during intercourse.


People who have had a myocardial infarction may have decreased sexual interest because they fear sexual arousal may cause a heart attack. Vascular disease associated with diabetes may affect adequate arousal. Cardiovascular disease may inhibit intercourse because of dyspnea. Urinary incontinence may cause discomfort or embarrassment, leading to dysfunction or decreased sexual activity.


Gynecological conditions also can contribute to sexual difficulties. Hysterectomy, gynecological malignancies, and breast cancer present medical and mortality concerns and may alter perceptions of femininity that may result in decreased sexuality (Hughes, 2008). Normal changes in a woman’s reproductive life related to puberty, pregnancy, postpartum, and menopause can present unique problems.


Puberty may lead to concerns regarding sexual identity. Pregnancy and the postpartum period are often associated with a decrease in sexual activity, desire, and satisfaction, which may be prolonged with lactation. The state of menopause may result in physical changes, alterations in mood, and decreased libido (Woods et al, 2010). As women age, they may also experience a decline in desire and frequency of intercourse.



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).



BOX 25-2   A FAMILY SPEAKS


Our daughter was diagnosed with schizophrenia 5 years ago when she was 17 years old. Since that time, we have received very good care for her. Although we understand that she may never be completely well, she has her illness under control and has even started taking some courses at the local community college. She has also met some people her age and seems to enjoy their company.


However, since she began doing better, we have had the added concern about her sexual needs and activities. As involved parents, we raised this issue with the different health care providers who were managing her care over the years. In each case, almost without exception, we were told, “Don’t worry about such things; be grateful your daughter is as healthy as she is.” Although their intentions may have been good, they didn’t help resolve our questions or fears. Then our daughter was assigned to a nurse who we were told would be her case manager.


The first time they met, the nurse took a detailed history and asked our daughter the unthinkable: What sexual feelings did she have, and how was she managing her sexual needs? It was as if the floodgate had opened for all of us, and that session marked the beginning of an ongoing discussion we would all have about the topic we had been worrying so much about.


For that nurse asking just the right question, we will always be grateful, and if we could share one thought with future nurses in training, it would be to remember that patients are whole people and that sexuality is as important to those with psychiatric illness as it is to people everywhere.


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).

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