Chapter 21 Sexual Dysfunction and Sexual Disorders

NORMAL SEXUAL FUNCTIONING

- The diagnostic and statistical manual of mental disorders .A four-phase sexual response cycle:
-Phase 1, Desire
-Phase 2, Excitement
-Phase 3, Orgasm
-Phase 4, Resolution
DESIRE
- Many factors may affect interest in sexual activity, including age, physical and emotional
health, availability of sexual partner and the context of an individuals life.
- The luck of sexual desire is not a source of distress either to the person or to his partner thus
absent sexual desire is not viewed as an illness.
- Low sexual desire is a source of frustration.
- Excessive sexual desire becomes a problem when it forces it up on unwilling partners.
EXCITEMENT
- Is that period of time during which sexual tension continues to increase from the preceding
level of sexual desire.
- Traditionally penile erection and vaginal lubrication used indicators of presence of sexual
excitement.
ORGASM
- Is attained only at high levels of sexual tension in both women and men.
- Sexual tension (sexual arousal) is produced by a combination of mental activity including
thoughts, fantasies and dreams and erotic stimulation of erogenous areas more or less specific for
each individual.
- For orgasm to occur for most men require some penile stimulation and most women some
clitoral stimulation.
- Most women experience multiple orgasms tension through continued stimulation.
- Once man ejaculate as a part of orgasm, they go through a refractory period, which required
producing another ejaculation varies primary with age.
- In a young man, refractory period is measured in minutes where as in an older man, it may last
several hours.
RESOLUTION
- Sexual tensions developed in prior phases sub sides to baseline levels, provided sexual
stimulation has ceased.
- A period of psychological vulnerability and experienced as a period of pleasurable after glow
or described as being uncomfortably emotionally exposed.
- Restoration of normal physiological pulse, respiratory rate and blood pressure increased
perspiration.
SEXUAL DYSFUNCTION
- Is a disturbance in the desire, excitement or orgasm phases of the sexual response.

-Cycle or pain during sexual intercourse

-Reduce a persons ability to enjoy sex.
-A patient has to go for physical assessment; including laboratory studies, exploring
psychological factors like emotional issues, life situation and experience.
CLINICAL PICTURE
- Sexual dysfunction can be the result of physiological problems, interpersonal conflicts, or a
combination of both.
- Stress of any kind can adversely affect sexual function.
SEXUAL DESIRE DISORDERS
-based on damage to biological sex drive, self-esteem, acceptance of personal sexuality, sexual
experiences and relationships.
- Divided in to two classes:
1- Hypoactive sexual desire disorder, characterized by a deficiency or absence of sexual
fantasies or desire for sexual activity.
2- Sexual aversion disorder characterized by an aversion to and avoidance of genital sexual
contact with a sexual partner or by masturbation.
- Hypoactive sexual desire related to chronic stress and depression, prolonged suppression of
sexual impulses, and a deteriorating relationship.
- Happens frequency in men and comorbid with panic disorder.
SEXUAL AROUSAL DISORDERS
FEMALE
- Characterized by persistent or recurrent partial or complete failure to attain or maintain the
lubrication and swelling response of sexual excitement until the completion of the sexual act.
- It is distressing to the woman.
- Can be life long problem or it may be acquired.
- Medication such as antihistamines and anticholinergic may result in decreased lubrication.
MALE
- Erectile disorder (erectile dysfunction and impotence)
- is the recurrent and persistent partial or complete failure to attain or maintain an erection to
perform the sexual act.
- It is a rare, lifelong condition in which a man has never been able to obtain an erection
sufficient for intercourse.
- A man has previously been able to have sexual intercourse but has lost the ability.
- In young men, the disorder is uncommon and the cause is usually psychological.
ORGASM DISORDERS
- referred to as inhibited female orgasm or anorgasmia.
- Defined as the recurrent or persistent inhibition of female orgasm, as manifested by the
recurrent delay in, or absence of orgasm after a normal sexual excitement phase (achieved by
masturbation or coitus)
- It may be life long disorder (never having achieved orgasm) or acquired (having had at least
one orgasm and then having difficulties).

- Psychological factors (including fears of pregnancy, rejection, or loss of control), hostility

toward men and cultural/societal restrictions may be causative.
- Female orgasmic disorder may be inherited.
Male Orgasmic Disorder;
- called inhibited orgasm or retarded ejaculation.
- A man achieves ejaculation during coitus only with great difficulty.
- Man with a life long orgasmic disorder has never been able to ejaculate during coitus.
- Result from a rigid background in which sex is seen as a sin.
- Interpersonal problems may be the cause
- Physical conditions, substance abuse
- prescribed medication may also cause this problem.
PREMATURE EJACULATION
- a man persistently or recurrently achieves orgasm and ejaculation before he wishes to.
Diagnosis: when a man regularly ejaculates before or immediately after the penis enters the
vagina.
- Considerations as to age newness of the relationship and how often is the intercourse.
- Psychological factors include fear about performance and stressful relationships where the man
feels hurried.
DYSPAREUNIA
- Recurrent or persistent gentile pain can occur in either men or woman during or after
intercourse.
- Common in woman and associated with Vaginismus.
- Psychological factors: a history of child abuse or rape and anxiety about sex.
VEGINISMUS
-is an involuntary constriction response of the muscles that close the vagina.
OTHER SEXUAL DYSFUNCTIONS AND PROBLEMS
- Sexual desire disorders, orgasm disorders and sexual pain disorders can be caused by a medical
condition, such as cardiovascular, neurological, or endocrine disease.
- The diagnosis substance-induced sexual dysfunction is used when evidence of substance
intoxication or withdrawal is apparent from the history, physical examination, or laboratory
findings.
Sexual problems can also result from head trauma, chromosomal abnormalities and psychosis.
- Patients who have head trauma with damage to the frontal lobe of the brain may display
symptoms of promiscuity, poor judgment, inability to recognize triggers that set off
sexual desires and poor impulse control.
EPIDEMIOLOGY
-20%-30% of men and 40%-45% of women report difficulties.
COMORBIDITY
- Over all the sexual dysfunctions common in aged women and education seems to have a
buffering effect.

- Sexual dysfunction may be affected any time there is a disturbance in an individuals ability to
develop and maintain stable relationships. This is very true for patients with schizophrenia.
- May also be associated with depression and personality.
ETIOLOGY
Sexual dysfunctions are the result of a combination of factors including misinformation of
factors; including
1-misinformation or ignorance regarding and social interaction
2-Unconscious guilt and anxiety regarding sex
3-Anxiety related to performance, especially with erectile and orgasmic dysfunction.
4-Poor communication between partners about feelings and what they desire sexually.
GENERAL ASSESSMENT
Sexual assessment is both subjective and objective data.
Many psychiatric hospitals use a nursing history; biological oriented has few questions on sexual
functioning
SELF-ASSESSMENT
Discomfort in assessing sexual history related;
-Personal embarrassment
-Concerns about embarrassing the patient
-Poor training
-Inexperience
- Inadequate time
-Beliefs that sexual history is not important.
- You may experience discomfort exploring;
- sexual issues with patients
- fearing the discussion personal embarrassing to patient
- what to ask and why the questions should be asked.
Concerns:
- Age and gender differences
- If you grew up in a home where such topics were avoided [relay on friends information
(misinformation) about sex.]
-Remember letting the patient know why you are asking such personal questions increases
openness and cooperation. The most helpful consideration is recognizing that sexuality is part of
holistic nursing care.
-Your role and responsibility in assisting the patient in dealing with responsibility to illness and
or treatment of the illness.
-Understanding your patients concerns
- Patients discomfort
- Providing useful feedback will enhance your professional abilities.
-It is always advisable the nurse first to ask questions about sexual functioning in a general
manner and then proceeds the patients experience.
- The sexual history includes the patients perception:
+ Of physiological functioning and behavioral emotional
+ Spiritual aspect of sexuality. (include cultural and religious beliefs)

With experience, the nurse is able to identify patients who are at greater risk for difficulties in
sexual functioning, which includes patients with history of;
+ Certain medical problems or
+ Surgical procedures and
+ Patient taking some drugs.
DIAGNOSIS
The change is viewed as:
+Unsatisfying
+Unrewarding
+ Inadequate related to body function (Altered from medication, Bio psychosocial abuse
Ineffective sexuality pattern is indicated concerning ones own sexuality related to; +Impaired
relationship +Knowledge deficit in responses to illness.
OUTCOMES IDENTIFICATION
+Use education as a nursing intervention.
+Sexual myths and misinformation can be corrected giving the patient instant relief from
perceived problems.
Short term nursing out comes Identification related to sexual dysfunction and ineffective
sexuality patterns include;
+ Abuse recovery; Emotional, Physical, Sexual
+ Sexual functioning
+ Sexual Identity
+ Self-esteem
PLANNING: as part of care for a coexisting disorder. /Nurses prepared for basic level for
patients treated for a variety of conditions in any setting.
IMPLEMENTATION: Understanding of sexual function and dysfunction is essential for nurses
who work in Psychiatry, Specialty area in nursing (oncology, cardiology and neurology)
All nurses are able to facilitate discussion about sexuality with the patient. To be a facilitator, the
nurse must be nonjudgmental, have basic knowledge of sexual functioning.
+ have the ability to conduct a basic sexual assessment. As a result the nurse know when and to
whom to refer the patient with sexual complaint.
-Depending on the nature of the problem: Marital counselor, Psychiatrist, Gynecologist,Urologist, Clinical nurse specialist, Pastoral counselor.
PHARMACOLOGICAL INTERVENTION
In women, there is a deficiency of approved treatments. Treatment guidelines are negligible
partly due to the vague criteria for this disorder.
Most of the available treatments for sexual dysfunction are targeted at male dysfunction.
HEALTH TEACHING HEALTH PROMOTION
Nurses should help patients weigh the pros and cons of any type of pharmacotherapy.
Helping patients to choose the best course of action and increases their ability to be informed
consumers of mental health services.
General therapies include; psychoanalytic therapy, couples therapy, group therapy, hypnotherapy.
Therapies for sexual dysfunction include; Sensate focus, Systematic Desensitization,
Masturbation training.
EVALUATION of expected out comes relates to the level of control and personal satisfaction
achieved.

SEXUAL DISORDERS.
-Classification of sexual disorders as either Gender Identity disorder and/or one of the following
paraphilia;-Fetishism, -Pedophilia, -Exhibitionism, -Voyeurism, -Transvestic fetishism, -Sexual
sadism, -Frotteurism and -Paraphilia
GENDER IDENTITY DISORDER
Is the sense of maleness or femaleness is not inborn but usually is established by the time a child
is 3 years old.
Gender Identity is mainly a product of how we are raised.
It is defined as strong and persistent cross gender identification.
Paraphilias; also known as sexual impulse disorders, an acts or sexual stimuli that are outside of
what society considers normal but necessary for some individuals to experience desire, arousal
and orgasm.
Fetishism;a sexual focus on objects such as shoes, gloves pantyhose and stockings associated
with the human body.
Pedophila; involves sexual activity with a prepubescent child (generally 13 years or younger)
A significant number of pedophiles have previous or current movement in; -Voyeurism,Exhibitionism or Rape.
Exhibitionism; is an illegal activity that involves the international display of the genitals in a
public place.
Voyeurism; is marked by seeking sexual arousal through viewing, usually secretly, other people
in intimate situations. E.g. Naked, in the process of disrobing, or engaging in sexual activity.
Transvestic Fetishism; sexual satisfaction is achieved by dressing in the clothing of the opposite
gender.
Sexual Sadism; This disorder involves the achievement of sexual satisfaction from the physical
or psychological suffering (including humiliation) of the victim.
Sexual Masochism; involves the achievement of sexual satisfaction by being humiliated, beaten,
bound, or otherwise made to suffer.
Frotteurism; is characterized by rubbing or touching a nonconsenting person.
Paraphilia Not Otherwise specified; includes
Telephone and Computer Scatologia; Obscene phone calling to an unsuspecting person or
sending obscene messages or video images by email.
Necrophilia - obsession with having a sexual encounter with a cadaver.
Partialism - a concentration of sexual activity on one part of the body to the exclusion of all other
parts.
Zoophilia; Incorporation of animals in to sexual activity.
Urophilia-Sexual activity that involves urinating on ones partner or being urinated on.
Hypoxphilia- desire to achieve an altered state of consciousness secondary to hypoxia while
experiencing orgasm.
Epidemiology;
-50% of paraphilias arousal is before age 18 years.
It tends to peak between 15 and 25 years of age and nonexistent by age 50.
Comorbidity:
-Borderline
-Antisocial
-Narcissistic

-Substance abuse and

-Self-destructive behavior.
Pharmacological Interventions
-Antiandrogens
-Serotonergic antidepressants
- Drugs that reduce levels of testosterone used to treat sex offenders. The drugs that are
frequently used are progestin derivatives including;
+Medroxyprogesterone acetate (MPA) an analog of progesterone
+Cyproterone acetate (CPA) an inhibitor of testosterone.
Both this drugs decrease libido and break patients pattern of compulsive deviant sexual behavior.
Both drugs are good for a high sexual drive (pedophiles and Exhibitionists)
Advanced Practice Interventions:
- Psychotherapy is recommended to address gender dysphoria and comorbid condtions.