Chapter 12 SEXUALITY
Sexuality is a vital part of being human and therefore promoting sexual health is as important as promoting any other aspect of human functioning. Because of their working practices and relationships with clients, ENs are in an ideal situation to help clients identify sexual concerns and to facilitate them receiving specialised help when it is required.
Each person is born with a basic drive of a sexual nature, the biological purpose of which is the reproduction of the species. Human sexuality, however, encompasses much more than the need to reproduce, as it involves the whole personality, and is influenced by physical, psychological, sociocultural and spiritual factors (Carter DeLaune & Ladner 2002; Varcarolis et al 2006; Videbeck 2007).
The physical component of human sexuality refers to the primary (genital) and secondary (e.g. breast development, hair distribution) characteristics that distinguish male from female. The psychological attributes are those expressed as a person’s gender identity — their sense of knowing to which sex they belong, male or female — and their sexual behaviour. Sexual behaviour is related to biological, spiritual, social and cultural factors that influence the way a person perceives themself as a sexual being (Bristow 1997; Varcarolis et al 2006; Videbeck 2007).
Sexuality is one component of personal identity — an individual’s sense of who they are — and influences the way a person thinks, behaves and interacts with others. It is a powerful component of being human, and humans adapt their sexuality to changes in their life circumstances, including changes resulting from alterations in their health.
A person’s sense of self and self-esteem is linked to expressions of sexuality and the level of comfort a person has with their own sexual orientation. Whereas gender refers to the psychological sense of being either male or female, sexual orientation refers to an enduring, romantic and sexual attraction to another person. It exists along a continuum that ranges from exclusive homosexuality to exclusive heterosexuality and includes various forms of bisexuality.
Heterosexual relationships are those between a male and a female and are the most predominant in adult humans. Homosexual relationships are those between two males or two females and are also common. People with a homosexual orientation are sometimes referred to as gay (men and women) or as lesbian (women only). Bisexual people can experience sexual and emotional attraction to members of both their own and the opposite sex.
Outside this range are transsexuals — people who have a clear and persistent feeling that they are trapped in a body with the wrong genitals. They feel they are, and were always meant to be, the opposite sex. Such a feeling often exists from early childhood and is called gender dysphoria (Videbeck 2007). The cause is not clearly understood but biological and social learning theories have been implicated. As they find partners whom they wish to live with or marry, transsexual people may come to desire sexual reassignment, often referred to as gender reassignment. This is hormonal and surgical treatment that aims to alter functioning and appearance as far as possible to that of the sex they believe themselves to be. Transsexuals do not consider themselves to be homosexual. The biological female who falls in love with a woman, for example, believes herself actually to be a man who loves that woman (Varcarolis et al 2006).
Being homosexual, bisexual or transsexual means that people do not conform to cultural norms for male or female behaviour; they do not fit the accepted social gender role and as a result may experience considerable stigma. Nurses who provide a warm, caring and accepting environment that allows for open and honest communication about sexuality reduce stress for clients of any sexual orientation (Shives 2007; Stein-Parbury 2005).
Experts generally agree that sexual orientation is probably the outcome of complex interactions between biological, cognitive and environmental factors and that it is established at an early age but commonly emerges in adolescence (Perrin 2002). It is accepted that genetic and hormonal factors play a part in shaping a person’s sexuality to the extent that the person has no conscious choice in the matter, but also that there are probably many combining reasons for a person’s sexual orientation, which may be different for different people (Bristow 1997; Makadon 2007; Rathus et al 2007).
Societal prejudice, which sometimes includes that from family and friends, makes it very challenging for non-heterosexual people to be open and frank about their sexual orientation. Sharing such significant aspects of self is important to healthy psychological adjustment and emotional wellbeing. It has been established that the more open people can be about themselves the more likely they are to have a high self-esteem and strong interpersonal relationships (Shives 2007; Varcarolis et al 2006). Nurses have a role in educating and promoting non-judgmental attitudes towards all people in society. To achieve this nurses first need to be aware of their own attitudes, values and beliefs and be able to keep their personal prejudices to themselves when working with clients.
Sexuality can be expressed in the way someone wears their hair or clothes, their adornments and the hobbies and special interests they may have and in the way they walk and talk. Expressions of sexual orientation can be evident in patterns of physical contact and interpersonal interactions. Expression of sexuality is influenced by social and cultural norms and it is the role of nurses to understand, accept and facilitate the expression of sexuality in all clients.
Social and cultural rules influence what is perceived as normal within every cultural group. For example, female circumcision is a cultural and religious tradition in some African and Middle Eastern countries (Jones 2000; Hampson 2002) (Clinical Interest Box 12.1). Cultural rules, religious beliefs and other influences become an integral part of personality within members of each cultural group and have a powerful influence on the way they conduct themselves.
CLINICAL INTEREST BOX 12.1 Cultural aspects of care
Many young girls who live in traditional Islamic and east African countries undergo female circumcision, a deeply rooted cultural and religious tradition. It is a coming-of-age ritual that ensures chastity and is seen as enhancing eligibility for marriage. There is strong opposition to female circumcision in Western countries because it is considered to be genital mutilation that reduces sexual response after puberty and is seen as a means of social control of women. There is also opposition because it results in complications such as recurrent infections, pain during intercourse, infertility and birthing difficulties.
Some immigrant families request that the procedure (of which there are different types) be performed under modern surgical conditions. Medical officers and nurses are faced with an ethical decision to participate in surgery that interferes with female sexuality or take the risk that such surgery may be performed by a non-medical person, perhaps a family member, without anaesthetic and in non-sterile conditions. There are, in any case, laws in Australia and New Zealand prohibiting female circumcision as a violation of human rights. Nurses care for affected women in a range of situations and are sometimes required to assist with care after surgical procedures to reverse female circumcision.
(Jones 2000: 262)
All nursing care needs to accommodate cultural diversity; however, dealing with sexual needs presents a special challenge and it is helpful for the nurse to first conduct a cultural assessment. Cultural diversity and nursing practice is the focus of Unit 3.
Growth and personality development occur as a process. Interpersonal relationships and life experiences influence the way a person’s self-concept, of which sexual identity is a part, evolves. The process of sexual development begins in infancy.
Sexual development is the process by which a child moves through the stages of growth and development to become a mature adult sexual being, physically and psychologically. (Physical development across the lifespan is explained in Unit 5.) A sense of sexual identity is shaped by what is seen, heard and experienced. For example, gender roles and functions within the family and society are modelled and learned and this learning starts at a very early age. Sexual image begins to develop in the first few months after birth, partly because baby girls are spoken to and played with differently to baby boys, and toys and clothes are often gender specific (Perrin 2002; Sadock & Sadock 2007).
During childhood it is normal for children to experiment with the concepts of sexuality through play and fantasy as a way of expressing growing awareness and interest in their own sexuality. Early concepts of sexuality and the values attached to it are learned from role models, often parents. For example, children learn quickly what is or is not acceptable by the way parents respond to such things as undressing in the presence of others or handling their own genitals. Children who are reprimanded for nakedness or touching their genitals may develop a negative perception of their own bodies and a negative attitude towards expressing sexuality.
By age 10 most children are experiencing some of the changes of puberty. As their bodies begin to change they tend to develop a natural modesty. They are frequently curious about sex and, provided that there is an environment where sex can be spoken about comfortably, they are likely to ask many questions. Sometimes when children are in hospital and curious about their bodies they ask questions of nurses they trust. This may be an indication that information relating to sexuality or sexual matters is wanted. It is advisable for the nurse to find out what knowledge the child already has to avoid giving inappropriate answers (Carpenito-Moyet 2006). If the EN is comfortable to ask them, the questions in Clinical Interest Box 12.2 may be used by the nurse to help determine the child’s knowledge and, if there seems to be anxiety, to talk about matters further.
CLINICAL INTEREST BOX 12.2 Sample questions for exploring sexuality issues with children
The adolescent’s need to develop a personal sense of self is strong and an adolescent will often identify with a peer group that provides an identity. It is a time of acute awareness and sensitivity to emerging sexuality and body image, when appearance, personal and sexual attractiveness and peer acceptance are of crucial importance to self-esteem and a sense of belonging (Perrin 2002; Varcarolis et al 2006; Videbeck 2007).
A positive self-concept and sense of emotional security depends significantly on the support the adolescent receives while coping with the physical and emotional changes experienced during the difficult and sometimes tumultuous transition to adulthood. Support includes allowing for privacy, the freedom to develop personal interests and new relationships, and understanding the frequent changes of mood and behaviour that commonly occur.
Particular sensitivity is needed when nursing the ill or hospitalised adolescent, because changes or threats to appearance or functioning can have a profound impact, resulting in anxiety, feelings of vulnerability and a negative impact on self-image. The nurse can help the adolescent, as any other client, by demonstrating respect, which reinforces self-worth. The nurse can show this in many ways, including by being non-judgmental, reinforcing the belief that the client is doing his best to cope, to adapt or to change and by demonstrating acceptance of the adolescent client’s own perspective and feelings (Stein-Parbury 2005).
During adolescence there may be a great deal of experimentation in the expression of sexuality. Heterosexual and homosexual liaisons are common and sexual behaviour usually includes masturbation (Perrin 2002; Makadon 2007). Assurance about what is generally accepted as normal in physical and emotional development is helpful, as is open, honest and accurate information on topics such as body ’changes, sexual orientation, sexual practices, emotional responses within intimate relationships, sexually transmitted infections (STIs) and contraception. (Information about contraception and reproductive health is provided in Chapter 40.)
There are times when an EN may feel it appropriate to explore sexuality issues with an adolescent, for example, when working in sexual health clinics, adolescent mental health units and in drug and alcohol clinics. However, the EN’s role is most commonly concerned with providing basic information. Information about gaining specific expertise in this is provided later in this chapter. For nurses who have the expertise and are comfortable, Clinical Interest Box 12.3 provides some sample questions to aid the exploration of sexuality issues with adolescents.
CLINICAL INTEREST BOX 12.3 Sample questions for exploring sexuality issues with adolescents
During early adulthood people develop physically and emotionally towards sexual maturity. Individuals shape and modify their sexual image and attitudes towards sexuality, sexual relationships and behaviour. It is usual for sexual partnerships to be established and for sexual behaviour to include masturbation and sexual expression with others (Vanzelli & Duck 1996).
Adults have gained physical maturity and this is a time of life when many continue to explore and define emotional boundaries in relationships. It is a time when close intimate relationships are important. However, many people choose to be single and value their privacy and individuality, but this does not mean that intimacy and sexuality are not important issues for them. An adult who is comfortable in an intimate relationship is likely to have a strong sense of personal identity and feel emotionally secure, and this promotes a positive self-concept (Shives 2007; Varcarolis et al 2006; Videbeck 2007).
Middle age is associated with many changes, and people in their middle years may experience doubt or anxiety about their sexual attractiveness or adequacy. The term ‘mid-life crisis’ is sometimes used to describe a time typified by reflection on what has been achieved or not achieved; it may also be a time to contemplate stability in life or significant change (Breslin & Lucas 2003; Orshan 2006).
The major developmental change influencing sexuality for women is the onset of menopause. Some women may perceive this in a negative way and may view it as a time when maternal potential, feminine characteristics and sexual attractiveness are disappearing. Others may perceive it as a time of freedom and new challenges (Breslin & Lucas 2003; Orshan 2006). The term ‘male menopause’ is sometimes used to describe the changes that occur in men during this stage of the life cycle. Some men experience feelings of anxiety and depression that accompany a negative perception that their masculine virtues of strength and vigour are beginning to decline (Gould et al 2000).
In these middle years, self-image is less likely to suffer if the person has previously established a positive self-concept in relation to personal appearance and relationships with other people and is generally satisfied with life achievements (Shives 2007; Varcarolis et al 2006; Videbeck 2007).
The middle-aged person who already has a low self-image is more likely to have that esteem further reduced when the physical changes of middle age begin, such as greying hair, wrinkles, alterations to genitalia. Societal and cultural attitudes that value youth and beauty above age and experience may be a cause for anxiety in people approaching older age. If people perceive a loss of attractiveness during these years it may impact negatively on their ability to express their sexuality.
Although it is commonly believed that sexual desire diminishes with age, many older people enjoy a very healthy and active sex life (Wallace 2000). Old age for many is a time of life when the responsibilities of raising families and employment are over and there is time and freedom to enjoy sex as well as many other pleasures in life, such as hobbies and travel.
The ability to continue to enjoy an active sex life requires adaptation to the normal physical changes of ageing that include alterations to mobility, dexterity, hearing and sight. Normal physical changes also mean that older men remain capable of erection but may attain fewer orgasms, and the incidence of spontaneous erection declines (Gould et al 2000). Some men may find this a relief from unwanted or embarrassing erections during earlier years and adapt without concern to the greater need for manual stimulation from partners.
Older women may experience some discomfort due to the vaginal dryness that can accompany hormonal changes. Commercially available lubricants, pelvic floor exercises and sexual activity can help with this. It is the role of the nurse to provide helpful information that promotes the expression of sexuality (see Clinical Interest Box 12.4).
CLINICAL INTEREST BOX 12.4 Jean’s experience
Some nights, even when he was so sick with the cancer, he still wanted me. I worried it would hurt him and I was so tired caring for him that I seemed to be dry all the time, so we didn’t do it. It was Nancy, the nurse who came to shower him — she made the difference. She organised respite care one afternoon a week so I could have a break. Then she talked to us about safe positions for him and told us about the lubricants I could buy. It was so comforting being able to please him and love him like that almost right until the end and I feel good now because I know it was comforting for him too.