Sexuality and Sexual Disorders
Sexuality is determined by anatomy, physiology, psychology, the culture in which one lives, one’s relationship with others and developmental experiences throughout the life cycle. It includes the perception of being male or female and all those thoughts, feelings, and behaviors connected with sexual gratification and reproduction, including the attraction of one person to another.
The concept of sexual identity involves a sense of masculinity and femininity that is derived not only from biological sex drives but also from the individual’s perception of his or her sexual being. This perception is partially based on experiences and interests and the attitudes of society, the culture, family, and friends.
Learning objectives
After studying this chapter, you should be able to:
Differentiate among the terms sex, sexual acts, and sexuality.
Describe the theories of gender identity development.
Differentiate between the terms gender identity and sexual identity.
Articulate the attitudes and behaviors of sexuality exhibited by individuals at various developmental stages: infancy and childhood, preadolescence and adolescence, and adulthood.
Identify factors that contribute to sexual aggression in children and adolescents.
Describe the phases of the human sexual response cycle.
Relate the dynamics of female and male sexual dysfunctions.
Describe masochistic and sadistic behavior.
Explain the consequences of sexual addiction.
Analyze the barriers to taking a sexual history.
Articulate the importance of addressing transcultural considerations when conducting a sexual history.
Discuss the various pharmacologic approaches used to treat female and male clients with clinical symptoms of a sexual disorder.
Formulate a list of nursing interventions for a female client with clinical symptoms of a sexual disorder.
Key Terms
Ambiguous genitalia
Chromosomes
Gender identity
Hermaphrodism
Homosexuality
Klinefelter’s syndrome
Male pseudohermaphrodites
Masochistic behavior
Paraphilia
Sadistic behavior
Sex
Sexual acts
Sexual addiction
Sexual behavior
Sexual dysfunction disorder
Sexual identity
Sexuality
Sexual orientation
Sexual response
Transgender
Transsexual
Transvestite
Turner’s syndrome
The terms sex, sexual acts, and sexuality are often used interchangeably. Trieschmann (1975), though, believes the terms should be differentiated. Sex is described as one of four primary drives that also include thirst, hunger, and avoidance of pain. Sexual acts occur when behaviors involve the genitalia and erogenous zones. Sexuality is the result of biologic, psychological, social, and experiential factors that mold an individual’s sexual development, self-concept, body image, and behavior. Sexuality depends on four interrelated psychosexual factors. They include:
Sexual identity: Whether one is male or female based on biologic sexual characteristics
Gender identity: How one views one’s gender as masculine or feminine; socially derived from experiences with the family, friends, and society
Sexual orientation: How one views one’s self in terms of being emotionally, romantically, sexually, or affectionately attracted to an individual of a particular gender
Sexual behavior: How one responds to sexual impulses and desires
Sexuality is associated with attractiveness, sensuality, pleasure, intimacy, trust, communication, love and affection, affirmations of one’s gender identity, and reverence for life (Krozy, 1998; Sadock & Sadock, 2003). It partially defines our role in society and influences our feelings. It can be expressed verbally while talking to a significant other; it can be communicated in written forms such as letters, poetry, or songs; and it can be expressed artistically. Behavioral expressions of sexuality include actions such as looking, touching, handholding, and kissing. Sexuality can be expressed in various ways during the development of an intimate interpersonal relationship.
Sexuality can be influenced by cultural or ethnic factors, religious views, health status, physical attributes, age, environment, or personal choice as a result of one’s personality development. The term normal sexual behavior refers to a sexual act that is acceptable in our society, occurs between consenting adults, lacks any type of force, and is performed in a private setting in the absence of unwilling observers. Any act that does not meet the criteria set forth in this definition is referred to as abnormal sexual behavior.
Nurses come into contact with a variety of client concerns regarding sexual identity or activity (Box 26-1). Sexuality influences how we view ourselves and how we relate to others. It has become an integral part of the nursing process in planning holistic health care. Nurses who are uncomfortable with or confused about their own sexuality may have difficulty discussing sexual issues with clients. Sexual concerns may conflict with the religious beliefs of both clients and staff members. Having respect for the client, examining your own feelings, and maintaining a nonjudgmental attitude are the standards for working with clients in any aspect of human sexuality (Schultz & Videbeck, 2005).
This chapter focuses on theories related to the development of gender identity disorders, the development of sexuality, the human sexual response cycle, and the clinical symptoms and diagnostic characteristics of sexual disorders. Using the nursing process
approach, the chapter describes the care necessary for clients with sexual disorders.
approach, the chapter describes the care necessary for clients with sexual disorders.
Box 26.1: Sexuality: Examples of Clients’ Concerns
A mastectomy client verbalizes that her husband no longer finds her sexually attractive.
A cardiac client expresses fear of resuming sexual activity.
A colostomy client fears rejection due to change in body image and stoma odors.
A teenager discloses that he is gay and expresses fear of contracting AIDS.
A paraplegic client asks his attending practitioner about alternate sexual activity.
A chemotherapy client requests privacy during visits by a significant other.
Elderly clients of the opposite sex ask permission to share a room in the nursing home.
A middle-aged client makes sexual advances while being bathed and attempts to expose his genitals to the nurse.
A young male client asks a nurse for her address and telephone number.
A teenaged client tells a male nurse that she thinks she has a sexually transmitted disease.
Overview of Gender Identity and Sexual Orientation
Identity is the core of human existence. This reality manifests itself in the human as an evolutional focal point. No other species contemplates its very nature. Understanding gender identity encompasses knowledge about sexual development, interpersonal relationships, affection, intimacy, body image, and gender roles. Almost no information is available about the prevalence of gender identity disorders. Most estimates are based on the number of individuals seeking sexual reassignment surgery (sex-change surgery) (Sadock & Sadock, 2003). The following is a discussion of terminology as it relates to gender identity and sexual orientation and a discussion of the etiology of gender identity development.
Terminology
Sexual identity is the pattern of a person’s biologic sexual characteristics including chromosomes, external genitalia, internal genitalia, hormonal composition, gonads, and secondary sex characteristics. Gender identity is a person’s sense of maleness or femaleness (Sadock & Sadock, 2003). Boys with gender identity disorders are at odds with their body image. They rigidly insist that their male sex organs are disgusting or that they will disappear as they grow up. They elicit a variety of social reactions as they reject their own anatomy and demand that others accept their feminine names and female identity (Rekers & Kilgus, 2001). Girls with gender identity disorders have male companions and an avid interest in sports and rough-and-tough play. They show no interest in dolls or playing house (unless they play the male role). They may refuse to urinate in a sitting position, claim that they have or will develop a penis, do not want to develop breasts or experience menses, and state that they will grow up to be a man (Sadock & Sadock, 2003).
Sexual orientation refers to the object of an individual’s sexual impulses. Although normal gender identity may be established at an early age, such as 2 to 3 years, sexual orientation may develop in conflicting or opposite ways as the child progresses through different developmental stages. Sexual orientation may be heterosexual (opposite sex), homosexual (same sex), or bisexual (both sexes). A conflict between gender identity and sexual orientation may precipitate a gender identity disorder in which the individual has a persistent desire to be, or believes that one is, of the opposite sex and experiences extreme discomfort with one’s assigned sex and gender role (Sadock & Sadock, 2003).
Self-Awareness Prompt
Examine your personal feelings about your own sexuality. With which of the clients mentioned in the examples in Box 26-1 would you find it difficult to interact? Could you provide care for all of the clients? What actions could you take to change your attitude or feelings about those clients?
The term transgender is an umbrella term used to describe transsexuals (individuals whose sexual identities are entirely with the opposite sex), transvestites (persons who derive sexual pleasure from dressing or masquerading in the clothing of the opposite sex; commonly called “cross-dressers”), and hermaphrodites. A transgender person is someone whose gender identity doesn’t coincide with birth gender and the individual can be bisexual, homosexual, or heterosexual (WordReference.com English Dictionary, 2006).
Etiology of Gender Identity Development
The etiology of gender identity is likely biologically determined and secondarily affected by environment. Maintaining skepticism of assumptions and proclamations of etiology is important even while indulging our scientific faith. Look to the longitudinal outcomes of gender identity studies. Gender is anatomic, physiologic, psychosocial, and psychosexual (Reiner, 1997).
Genetic and Biologic Theories
Chromosomes are the carriers of genetic programming information. The male’s sperm cell determines the sex of the embryo at conception by adding either an X or a Y chromosome to the X chromosome of the ovum. An X and Y chromosome combination (XY) results in a male fetus; two X chromosomes (XX) result in a female
fetus. Klinefelter’s syndrome, seen in males, occurs as the result of an XXY chromosome grouping (an extra X chromosome). The male appears normal until adolescence, when low levels of testosterone result in small testes, infertility, and a low level of sexual interest. Turner’s syndrome, seen in females, occurs as the result of a missing sex chromosome (XO grouping instead of XX combination). The female appears short in stature and lacks functioning gonads. During puberty, breasts do not develop and menstruation does not occur. XYY syndrome, seen in males, contributes to a slightly taller stature, low sperm count, and abnormalities of the seminiferous tubules.
fetus. Klinefelter’s syndrome, seen in males, occurs as the result of an XXY chromosome grouping (an extra X chromosome). The male appears normal until adolescence, when low levels of testosterone result in small testes, infertility, and a low level of sexual interest. Turner’s syndrome, seen in females, occurs as the result of a missing sex chromosome (XO grouping instead of XX combination). The female appears short in stature and lacks functioning gonads. During puberty, breasts do not develop and menstruation does not occur. XYY syndrome, seen in males, contributes to a slightly taller stature, low sperm count, and abnormalities of the seminiferous tubules.
The search for a gene related to male homosexuality, defined as a primary erotic attraction to others of the same sex, has focused on a genetic link between an unknown gene on the human X chromosome and male homosexual behavior (Xq28 marker). Initially, it was thought that this gene or its mutation appeared to influence development of homosexual traits. However, findings revealed a confusing picture as it became evident that more data are needed from much larger samples before any conclusions can be drawn (Medina, 1999).
The work of Imperato-McGinley proposed that gender identity continually evolves under the influence of androgens despite contrary social forces (Baker, 1999). Individuals with an inherited deficiency of the enzyme 5 x-reductase are born with male genes and male internal organs but lack external male genitalia. Referred to as male pseudohermaphrodites, such individuals are declared female at birth and raised as girls. During puberty, they experience a surge in testosterone and gender confusion as they develop emotions and physical signs of masculinization.
Hormonal imbalances may result in a genetic girl or boy developing ambiguous genitalia (a penis and a small vaginal opening). True hermaphrodism or hermaphroditism is a rare occurrence characterized by the presence of testicular tissue containing seminiferous tubules and spermatozoa, and ovarian tissue containing follicles, in the same person (Sadock & Sadock, 2003). Attempts to explain other abnormalities that can occur biologically or genetically have been made. It is believed that subtle chemical imbalances affecting the central nervous system are also involved in forming one’s gender identity (Rippel, 2003).
Psychosocial Theories
Sigmund Freud (1960) theorized that gender identity problems result within the oedipal triangle when conflict is fueled by both real family events and fantasies. Whatever interferes with a child loving a parent of the opposite sex and identifying with the same-sex parent interferes with normal gender identity. For example, the quality of mother–child relationship in the first years of life affects the development of gender identity because mothers normally facilitate their children’s awareness of and pride in their gender. Devaluing, hostile mothering can result in gender identity problems. The father’s role is equally important during the early years, because his presence generally helps the separation–individuation process. Without a father, the mother and child may remain overly close, and the child may not have the opportunity to develop a sense of maleness or femaleness, or distinguish between the roles of males and females. The father represents future love objects for girls and a model of male identification for boys (Sadock & Sadock, 2003).
According to Zucker, head of the Child and Adolescent Gender Identity Clinic at Clarke Institute of Psychiatry in Toronto, Canada, research in the 1950s showed that among children with physical intersex conditions (ie, both male and female sexual characteristics), sexual assignment and rearing was a better predictor of gender identity than chromosomal, gonadal, and other physical variables (Baker, 1999). Little evidence exists that frank parent-initiated cross-gender rearing attitudes caused gender identity disorder (eg, dressing a girl in boy’s clothing or enrolling a girl in sports with boys). Most often, parents just tolerate signs of cross-gender behavior.
Recent theories explore the impact of gender, race, and ethnicity on gender identity. Gender identity, considered to evolve over time, is thought to be shaped by attitudes, values, beliefs, sex roles, religious values, family and ethnic communities, and degree of acculturation. Ryan, Futterman, and Stine (1998) discuss the psychosocial aspects of gender identity development, including the average age of “coming out” (self-identification as lesbian, gay, or same sex and sharing one’s sexual identity with others). They reported that this age has dropped from the early twenties to age 16 years.
Clinical Symptoms and Diagnostic Characteristics of Gender Identity Disorders
The features of gender identity disorders are twofold. The Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition, Text Revision (DSM-IV-TR) states that there must be evidence of a strong and persistent cross-gender identification in which one expresses the desire to be, or the insistence to be, of the opposite sex (American Psychiatric Association, 2000). The individual also experiences persistent discomfort about his or her assigned sex or feels inappropriate in the role of the assigned sex. Impairment occurs in social, occupational, or other important areas of functioning. For example, boys, who outnumber girls more than six to one in diagnosed cases of gender identity disorder, identify with girls or women and are preoccupied with traditionally feminine activities (Zucker, Bradley, & Sanikhani, 1997).
Disorders, 4th Edition, Text Revision (DSM-IV-TR) states that there must be evidence of a strong and persistent cross-gender identification in which one expresses the desire to be, or the insistence to be, of the opposite sex (American Psychiatric Association, 2000). The individual also experiences persistent discomfort about his or her assigned sex or feels inappropriate in the role of the assigned sex. Impairment occurs in social, occupational, or other important areas of functioning. For example, boys, who outnumber girls more than six to one in diagnosed cases of gender identity disorder, identify with girls or women and are preoccupied with traditionally feminine activities (Zucker, Bradley, & Sanikhani, 1997).
Girls with gender identity disorders display intense negative reactions when parents attempt to feminize them. They polarize to male attire and activities and prefer to associate with boy playmates. Adult men and women who are preoccupied with their wish to live as the opposite sex may act on their desires by adopting behavior, dress, and mannerisms of the opposite sex. Cross-dressing, hormonal treatments, or sex reassignment in the presence of genital ambiguity may be attempted to pass convincingly as the other sex. European statistics cited in the DSM-IV-TR indicate that approximately 1 per 30,000 adult men and 1 per 100,000 adult women seek sex-reassignment surgery. No statistics are available for the United States.
Overview of Sexual Disorders
Sexuality is an important aspect of intimate relationships. The presence or absence of sexual intimacy is a powerful indicator of the health of a couple’s relationship. For many individuals, sexuality is an important part of self-esteem. Men and women both may pride themselves on their fertility, their capacity for sexual activity, or their attractiveness to sexual partners. Sexual problems and incompatibilities have a negative impact on how partners feel about themselves and each other. The impairment of sexual function or presence of sexual disorders can make it difficult for partners to enjoy satisfying sex.
Sexual disorders are generally classified as sexual dysfunctions, paraphilias, and sexual addiction. Few systematic epidemiologic data are available regarding the prevalence of various sexual disorders. The most recent comprehensive survey to date focused on a representative sample of the U.S. population between the ages of 18 and 59 years (Gender Identity Research and Education Society, 2003). Table 26-1 compares the frequency of various sexual dysfunctions between men and women.
 Table 26.1 Comparison of Sexual Dysfunctions Between Men and Women | |||||||||||||||||||||
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Two major factors that influence sexual performance are the presence or absence of normal sexuality (ie, feelings of desire and pleasure to engage in the sexual act) and the presence or absence of an adequate sexual response cycle. A discussion of these two factors follows.
Development of Sexuality
Family is the most important first source of learning about issues of sexuality. Parental attitudes and behaviors begin to shape feelings about male and female gender identity. Developmentally appropriate communication about sex should begin at home with young children and continue through adolescence.
Infancy and Childhood
Infants up to 12 months of age explore their genitalia. Toddlers (ages 1–3 years) master bodily functions and develop a solid core of gender identity. For example, a toddler may experience pleasure from touching his or her genitalia and learns to differentiate between sexual and excretory organs. The toddler also is capable of learning proper terminology regarding body parts, decreasing the likelihood of confusion in the future. Between the ages of 3 and 6 years, the preschooler identifies with the same sex, may ask questions about the origin of babies, and may ask about the anatomic differences between sexes. These are considered to be normal behaviors for children in this age group.
As children interact with other children, they may obtain inaccurate information that could affect the development of healthy sexuality. Parents may consider their children to be asexual beings and avoid discussing or clarifying information related to sexuality because they feel their children may become preoccupied with sex. They also may feel threatened by their child’s natural sexual curiosity and respond with hostility or punishment (Finan, 1997; Krozy, 1998). Guidelines are available for parents who wish to deal with sexuality issues from infancy through preschool (Finan, 1997). A sexuality values scale is also available to help clinicians evaluate parental knowledge about sexuality.
Sexual Aggression in Children
One issue associated with sexuality is sexual aggression, which has been linked to general aggression in children between the ages of 5 or 6 years up until puberty (the latency stage). These children describe a history of neglect and physical abuse; a dysfunctional relationship with parents who quarrel or abuse alcohol; physical or sexual aggression against their mother or siblings by their father or another male figure; confrontation with adult sexuality at an early age; or exposure to distorted or deviant sexuality such as pornography. They often name anger, family problems, and boredom as triggers for sexually aggressive behavior, which includes forcing other children to engage in fondling, oral sex, or intercourse. They are unable to handle stress and have poor impulse control, problem-solving abilities, and social skills. They have internalized adults’ reactions to their aggressiveness to the extent that they see themselves as perverts. Approximately two thirds of young abusers see sexuality not as an expression of love and affection, but rather as a way of hurting, humiliating, and punishing others.
Although child and youth offenders generally are male in the cases known to date, more cases of sexual exploitation by girls committing acts of sexualized violence against younger/weaker children and young people are becoming known (Moon, 2001; Theme Paper, Young Offenders and Prevention, 2003).
Preadolescence and Adolescence
During preadolescence and adolescence (ages 12–18 years), children experience sexual feelings, exhibit a level of sexual interest, and undergo sexual body changes as they develop interpersonal relationships. Various issues such as menses, nocturnal emissions, masturbation, sexual activity, and sex education are explored. During this time, peer pressure promotes sexually active behavior, and teens may declare an interest in or experiment with alternative sexual lifestyles.
Sexual Aggression in Adolescents
Professional recognition of adolescent aggression and sex crimes has been hampered by the long-standing myth that adolescents are merely experimenting with their sexuality (Hornor, 2003). The etiology of sexually aggressive, exploitive, or threatening behavior in adolescents is similar to that cited in childhood aggression. This includes the presence of psychological problems, history of a dysfunctional family relationship, social awkwardness, history of violence or sexual abuse, and the development of a paraphilia which generally begins in adolescence (See Clinical Symptoms and Diagnostic Characteristics of Sexual Disorders). Nearly 50% of adult sexual offenders report that they committed their first sexual offense before age 18. The younger the age when aggressive behaviors first occur, the greater the likelihood that such behavior will recur (Hornor, 2003). Chapter 33 addresses the issue of sexual abuse.
Adulthood
Preadolescent and adolescent behaviors may continue during young adulthood (ages 19–40 years) as individuals attempt to establish mature relationships with peers. Decisions are made regarding career, marriage, and lifestyle. Young adults may lack knowledge about relationships with significant others, contraceptive measures, sexual trends, sexually transmitted diseases, and alternative lifestyles (Krozy, 1998).
Sexual patterns established during early adulthood are the best predictors of sexual expression in midlife and beyond. However, expressions of sexuality may vary as the individual continues to work through the developmental stages of middle adulthood (ages 41–64 years) and late adulthood or maturity (65 years to death) (Baxer, 2001). Although physiologic changes occur and chronic illnesses may begin, interest in sexual activity among the elderly may continue, or in some instances, increase rather than decrease. Frequency of sex acts may decline, but the quality need not change. Companionship and physical activities such as touching, hugging, and handholding may replace the individual’s earlier expectations of intimacy. The ability to interact intellectually with people who share similar interests and experiences and the supportive love that grows between human beings (whether romantic or platonic) are equally, and in
some instances, more important than physical intimacy (Youngkin, 2004).
some instances, more important than physical intimacy (Youngkin, 2004).
Krozy (1998) discusses the role of sexuality as a human force throughout life. Individuals generally value intimacy over isolation and express a need for closeness with another person during a terminal illness. Members of the nursing profession or hospice staff often meet this need when individuals are hospitalized, relocated to a long-term care facility, or cared for at home. Family members may be concerned, surprised, or embarrassed as a family member or partner expresses an interest in continuing a sexual relationship with his or her husband, wife, or significant other. Nurses should encourage the client and family to discuss sexual issues and needs.
Human Sexual Response Cycle
Sexual response is a psychophysiologic experience. Psychosexual development, psychological attitudes about sexuality, and attitudes toward one’s sexual partner are directly involved with and affect the physiology of the human sexual response. The human sexual response cycle is commonly divided into four phases: desire, excitement, orgasm, and resolution.
Desire
Sexual desire is described as the ability, interest, or willingness to receive sexual stimulation. This phase involves activation of the inhibitory and excitatory functions of the brain by neurotransmitters in the limbic system. Desire appears to be controlled by the individual’s perception of the environment, personal preferences, attractions to other people, and the absence of inhibitions. Desire may be inhibited by the presence of fear, anxiety, discomfort, other basic needs such as hunger, or an intense emotion such as anger (Byers & Esparza, 1997; Krozy, 1998).
Excitement
Sexual excitement or arousal occurs as the result of psychological stimulation (eg, fantasizing during the desire phase, foreplay involving erogenous zones, or watching sexually explicit movies). Foreplay involves petting and fondling of erogenous zones, areas of the body that are particularly sensitive to erotic stimulation. During this phase, females generally experience vaginal lubrication, pelvic congestion, clitoral swelling, and nipple erection. Males experience stiffening and an increase in the length and width of the glans penis. Testes increase in size and elevate. For both sexes, vital signs increase, motor restlessness occurs, and a fine rash or “sex flush” may appear over the chest and abdomen (Byers & Esparza, 1997; Krozy, 1998).
Orgasm
The third phase of sexual response, orgasm, was formerly termed climax. During this phase, women experience several strong, rhythmic contractions of the vagina, which are followed by spastic contractions. The vagina enlarges, the uterus contracts irregularly, generalized muscle spasm and loss of voluntary muscle control occurs, and vital signs and the sex flush peak. Men experience emission and ejaculation of seminal fluid. Ejaculatory contractions involve the entire length of the penis. They are initially expulsive, followed by several contractions of less intensity. Some women are capable of experiencing multiple orgasms. Men generally experience a refractory period following orgasm and before resolution (Byers & Esparza, 1997; Krozy, 1998).
Resolution
Resolution is the final phase of the sexual response cycle. The organs and body systems gradually return to the unaroused state. Vital signs return to normal. The sex flush disappears. Relaxation and satisfaction are felt.
Clinical Symptoms and Diagnostic Characteristics of Sexual Disorders
Sexual disorders are categorized as sexual dysfunction disorders or paraphilias. Sexual dysfunction disorders involve an impairment of the sexual physiologic response. Paraphilias refer to disorders involving recurrent intense sexual urges and sexually arousing fantasies generally involving nonhuman objects. The major sexual dysfunctions and paraphilias are highlighted here.
Sexual Dysfunctions
Sexual dysfunction disorders involve a disturbance in the processes that characterize the sexual response cycle, or the presence of pain during sexual intercourse.
Specific subtypes indicate the underlying etiology and context of the disorder. For example, the dysfunction may be the result of inhibitions, psychological factors such as depression or anxiety, impaired communication between partners, or certain types of stimulation. It may occur at the onset of sexual functioning, or it may develop after a period of normal functioning.
Specific subtypes indicate the underlying etiology and context of the disorder. For example, the dysfunction may be the result of inhibitions, psychological factors such as depression or anxiety, impaired communication between partners, or certain types of stimulation. It may occur at the onset of sexual functioning, or it may develop after a period of normal functioning.
The psychologically induced inability to perform sexually also may result in one of the following DSM-IV-TR subtypes of sexual dysfunctions. For example, a female whose first sexual act caused a vaginal tear may be afraid to engage in sex with her significant other.
Sexual Desire Disorders
Two sexual desire disorders are identified: hypoactive sexual desire disorder and sexual aversion disorder. The diagnosis of hypoactive sexual desire disorder is used only if the lack of desire causes distress to the client or the client’s partner. Factors such as age, health, frequency of sexual desire (diminished libido), and lifestyle are considered when one is interviewing the person seeking help. The diagnosis of sexual aversion disorder is used if anxiety, fear, or disgust occurs when an individual is confronted with a sexual opportunity.
Sexual Arousal Disorders
In female sexual arousal disorder, the woman may experience little or no subjective sense of sexual arousal. Physiologic studies of sexual dysfunctions indicate that a hormonal pattern may contribute to responsiveness in women who have excitement-phase dysfunction. Alterations in testosterone, estrogen, prolactin, and thyroxin levels, as well as medications with antihistaminic or anticholinergic properties, have also been implicated in female sexual arousal disorder (Sadock & Sadock, 2003).
In males, sexual arousal disorder, also termed male erectile disorder or more commonly erectile dysfunction (ED), refers to the inability to attain or maintain an erection adequate for sexual activity. The causes may be organic or psychological, or a combination of both. Risk factors include cardiovascular disease, cigarette smoking, and diabetes mellitus. Neurologic disorders associated with ED include spinal cord injury, multiple sclerosis, cerebral vascular accident, Parkinsonism, and multisystem atrophy (Shy-Drager syndrome). Numerous prescription and over-the-counter medications may contribute to ED, possibly affecting the neurovascular events that lead to an erection directly or indirectly, by reducing libido (Gray, 2001).
Orgasmic Disorders
The diagnoses of female orgasmic disorder and male orgasmic disorder are used to describe recurrent, persistent inhibited orgasm after an adequate phase of sexual excitement in the absence of any organic cause.
Numerous psychological factors are associated with female orgasmic disorder. These factors include fears of rejection, impregnation, or damage to the vagina; hostility toward men; and guilt feelings related to sexual desires and impulses.
Male orgasmic disorders may include premature ejaculation (ie, ejaculation occurring before the person wishes, due to the absence of reasonable voluntary control during the sexual act) and retarded ejaculation or inhibited ejaculation (ie, ejaculation occurring during coitus with great difficulty, if at all) (Sadock & Sadock, 2003).
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