Sexual dysfunctions a.

Historical and Theoretical Perspectives Freud *Normal sexual development: sexual attraction to opposite-sex parent, jealousy of same-sex parent, anxiety from these two emotional reactions, and sexual repression and identification to resolve the complex. Superego develops after identification with the same-sex parent. *believed all humans are inherently bisexual, with capacity for heterosexual and homosexual behavior; *theorized all individuals go through a homoerotic phase as children, thus if homosexuality occurs later in life, it is due to the arrest of normal psychosexual development; *believed homosexuality could occur as a result of pathological family relationships in which the child adopts a negative Oedipal position; that is, there is sexualized attachment to the parent of the same gender and identification with the parent of the opposite sex. *At ages 3 to 6, children are at the phallic stage (the awakening of sexual curiosity and interest in the genitals); if a child does not have a same-sex parent with whom to identify, or if the opposite-sex parent encourages the sexual attraction, fixation can occur. *Fixation in the phallic stage usually involves immature sexual attitudes as an adult. People fixated in this stage, according to Freud, will often exhibit promiscuous sexual behavior (having sexual relations with more than one partner) and be very vain. *The vanity is seen as a cover-up for feelings of low self-worth from the failure to resolve the complex. *The lack of moral sexual behavior stems from the failure of identification and the inadequate information of the superego. *Men with this fixation may be mamas boys who never quite grow up, and women may look for much older father figures to marry. Masters & Johnson *Gynecologist, Dr. William Masters and psychologist Virginia Johnson conducted a study of human sexual response in 700 men and women volunteers in 1957. (controversial, at the time) *They devised equipment that would measure the physical responses that occur during sexual activity. (heart rate and body temperature were measured) *The equipment was used to measure physiological activity in both men and women volunteers who either were engaging in actual intercourse or masturbation. *Sex therapy field was created Kaplan Kaplan's approach. Helen Singer Kaplan (1974) developed an approach to sex therapy that combined some of the insights and techniques of psychoanalysis with behavioral methods. Her approach begins at the surface or behavioral level, and probes more deeply into emotional conflicts only if necessary. Many sexual difficulties stem from superficial causes. If a sexual difficulty is rooted in a lack of knowledge, for example, information and instruction may be all that are needed to treat it. If the trouble is of recent origin, a series of guided sexual tasks may be enough to change patterns of response. If deep-seated emotional problems exist, the therapist may use more analytic approaches to help clients obtain insight into the less-conscious aspects of their personality. This last approach has been designated as psychosexual therapy to distinguish it from sex therapy. Modern Therapists In order to help people with their sexual problems, therapists need to know what exactly these problems are. Simply asking the patients or clients to name or define their problems - while always necessary - is usually not sufficient. Many women and men do not understand the functioning of their own bodies, misunderstand or misconstrue their symptoms or have unrealistic expectations. Therefore: Unless the problem can easily be solved by giving information or making some simple suggestions, a detailed diagnosis is necessary. The diagnosis usually proceeds in two steps: 1. 2. A physical examination A detailed interview ("taking a sex history")

Physical/ biologic sexual dysfunction *Sexual dysfunction may be due to the direct physiological effects of a general medical condition. *It can involve pain associated with intercourse; hypoactive sexual desire; male erectile dysfunction; orgasmic disorders. *It causes marked distress or interpersonal difficulty *Patient history; physical exam; and laboratory findings Psychologic/ behavioral *The individual reports anxiety, fear, or disgust when confronted by as sexual opportunity with a partner. *Aversion may focus on genital secretions or vaginal penetration; some individuals experience revulsion to all sexual stimuli, including kissing and touching. *Intensity of the individuals reaction may range from moderate anxiety and lack of pleasure to extreme psychological distres s. Couple Oriented *The clinician may need to assess both partners when discrepancies in sexual desire prompt the call for professional attention. *Sex therapists usually work with the couple. *Apparent low desire in one partner may instead reflect an excessive need for sexual expression by the other partner. *Alternatively, both partners may have levels of desire within the normal range but at different ends of the continuum.

Sexual desire disorder *Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. *The disturbance causes marked distress or interpersonal difficulty. *The person actively avoids genital sexual contact with a sexual partner. *This is not due to medications or medical conditions. *Low sexual desire may be global and encompass all forms of sexual expression or may be situational and limited to one partner or to a specific sexual activity (ex. Intercourse, not masturbation).

Sexual arousal disorders *Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement. *The disturbance causes marked distress or interpersonal difficulty. *This is not due to medications or medical conditions.

Orgasmic disorders *In females: persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. *Women exhibit a variable range and intensity of stimulation that triggers orgasms. *The clinician bases diagnosis on womans orgasmic capacit y being less than what would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives. *The disturbance causes a marked distress or interpersonal difficulty. *The orgasmic dysfunction is not due exclusively to the direct physiological effects of a substance (drug abuse or medication) or a general medical condition. Sexual pain disorders *Dyspareunia (sexual pain): recurrent or persistent genital pain associated with sexual intercourse in either a male or female. *The disturbance causes marked distress or interpersonal difficulty. *The disturbance is not caused exclusively by vaginismus or lack of lubrication, drug abuse, medications, nor a medical condition. Dyspareunia = recurrent or persistent genital pain associated with sexual intercourse in either a male or a female; may lead to abstention from sexual activity due to discomfort Vaginismus = involuntary constriction of the outer one-third of the vagina that prevents penile insertion and intercourse

Sexual dysfunctions *It is characterized by a disturbance in the processes that characterize the sexual response cycle or pain associated with sexual intercourse. *Disorders of sexual response may occur at one or more of the four phases of the sexual response cycle: 1) desire; 2) excitement; 3) orgasm; 4) resolution *When more than one sexual dysfunction is present, all are recorded. Substance induced *Sexual dysfunction that results in marked distress or interpersonal difficulty predominating in the clinical picture. *Evidence is from the history, physical examination, or laboratory findings that it is fully explained by substance use manifested during or within a month of , Substance Intoxication; or medication use is etiologically related to the disturbance. Sexual dysfunction not otherwise specified *This category includes sexual dysfunctions that do not meet criteria for any specific sexual dysfunction. *No (or substantially diminished) subjective erotic feelings despite otherwise normal arousal and orgasm. *Situations in which the clinician has concluded that a sexual dysfunction is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced. Assessment *Identify the level of comfort in discussion for patient and/ or significant other. It is important for the nurse to create an environment where the couple or patient feels safe and comfortable in discussing feelings. *Assess level of understanding regarding human sexuality and functioning. Many persons have misconceptions about sexual intimacy. *Explore current and past sexual patterns, practices, and degree of satisfaction. This information determines a realistic approach to care planning. *Solicit information from the patient about the nature, onset, duration, and course of sexual difficulty. Problems with sexuality may be long-standing or of short duration. *Identify potential or actual factors that may contribute to current alteration in sexual functioning. The care plan will be developed in the context of the patients overall health status. Different interventions will address specific contributing factors. Nursing diagnosis *Ineffective sexuality patterns related to impaired relationship with significant other as evidenced by alteration in sexual relationship with significant other and reported changes and limitations in sexual activities or behaviors. Patient and family teaching guidelines *Provide accurate and timely health teaching regarding the normal range of sexual practices throughout the life cycle. Satisfying sexual functioning and practice are not automatic and need to be learned. *Discuss range of possibilities and consequences (both positive and negative) associated with sexual expression of all types (ex. Change in relationship, impact on physical and/ or emotional health, possibility of pregnancy, STIs). Information is necessary to support the couple or the individual patient making decisions about sexual activity. *Offer information regarding birth control methods and safe sex practices. The patient and significant other need accurate information about preventing unintended pregnancy or transmission of infections through sexual contact. *Be specific in providing instruction to the patient and significant other regarding any limitations on sexual activity resulting from illness, surgery, medications, or other events. The patient needs to understand the relationship between illness, treatment methods, and sexuality. *Explain alternative means or forms of expressing intimacy and/ or sexual expression (ex. Alternative positions for intercourse) that decrease discomfort or degree of physical exertion for those with impaired mobility or cardiopulmonary disease. Consider concerns imposed by the patients or significant others health status, illness, or other situation. The amount and type of information provided should be mutually pleasing and acceptable to the patient and the significant other. *Consider referral for further workup and/ or treatment (ex. Primary health care provider, specialized physician or mental health consultant, substance abuse treatment program, or sexual dysfunction clinic). The counseling needs of the couple or patient may be beyond the skill or training of the nurse. *Consider referral to self-help and/or support groups (ex. Reach for Recovery, ostomy association, Mended Hearts, Huff and Puff, Sexual Impotence Resolved, Us TOO, HIV support groups, Breast Cancer Network of Strength, Survivors of Abuse, or Resolve). Self-help support groups are unique sources of empathy, information, and successful role models. Those organizations can provide information about sexuality and specific health problems.

Paraphilias *Recurrent , intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or ones partner, or 3) children or other nonconsenting pers ons that occur over a period of at least 6 months. *For some individuals, paraphilic fantasies or stimuli are obligatory for erotic arousal and are always included in sexual activity. *In other cases, the parphilic preferences occur only episodically ( ex. Perhaps during periods of stress), whereas at other times the person is able to function sexually without parphilic fantasies or stimuli. *Diagnosis is made if the behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Legal implications *It is against the law to take paraphilia to the level of indecent exposure. *Few arrests are made in the older age groups, which may suggest that the condition becomes less severe after age 40 years. Etiology *The cause of parahilia is unknown; but the content of many paraphilic fantasies seems to be associated with childhood experiences. *Although the expression of paraphilic fantasies typically begins in adolescence, the disorder does not seem to be caused by adolescent or adult experiences except perhaps in rare cases of severe trauma. DSM-IV-TR Criteria- Paraphilias *Recurrent , intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or ones partner, or 3) children or other nonconsenting persons that occur over a period of at least 6 months. Exhibitionism *The paraphilic focus in Exhibitionism involves the exposure of ones genitals to a stranger. *Sometimes the individual masturbates while exposing himself (or while fantasizing exposing himself). *If the person acts on these urges, there is generally no attempt at further sexual activity with the stranger. *In some cases, the individual is aware of a desire to surprise or shock the observer. *In other cases, the individual has the sexually arousing fantasy that the observer will become sexually aroused. *The onset usually occurs before age 18 years, although it can begin at a later age. *Few arrests are made in the older age groups, which may suggest that the condition becomes less severe after age 40 years. Fetishism *The paraphilic focus in fetishism involves the use of nonliving objects (the fetish). *Among more common fetish objects are womens underpants, bras, stockings, shoes, boots, or other wearing apparel. *The person with Fetishism frequently masturbates while holding, rubbing, or smelling the fetish object or may ask the sexual partner to wear the object during their sexual encounters. *Usually the fetish is required or strongly preferred for sexual excitement, and in its absence there may be erectile dysfunction in males. *This paraphilia is not diagnosed when the fetishes are limited to articles of female clothing used in cross-dressing, as in Transvestic fetishism, or when the object is genitally stimulating because it has been designed for that purpose (ex. Vibrator). *Usually the paraphilia begins by adolescence, although the fetish may have been endowed with special significance earlier in childhood. *Once established, fetishism tends to be chronic. Pedophilia *Paraphilic focus involves sexual activity with a prepubescent child (generally age 13 years or younger). *The individual with pedophilia must be age 16 years or older and at least 5 years older than the child. *For individuals in late adolescence with pedophilia, no precise age difference is specified, and clinical judgment must be used; both the sexual maturity of the child and the age difference must be taken into account. *Individuals with pedophilia generally report an attraction to children of a particular age range. Some individuals prefer males, others females, and some are aroused by males and females. *Those attracted to females usually prefer 8- to 10- year olds, whereas those attracted to males usually prefer slightly older children. *Pedophilia involving female victims is reported more than pedophilia involving male victims. *The individual with pedophilia may act on their urges of sexual fantasies to different degrees such as undressing the child and looking, exposing themselves, masturbating in the presence of the child, or gentle touching and fondling of the child. Others perform fellatio or cunnilingus on the child or penetrate the childs vagina, mouth, or anus with their fingers, foreign objects, or penis and use varying degrees of force to do so.

Sexual masochism *It involves the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer. *Some individuals are bothered by their masochistic fantasies, which may be invoked during sexual intercourse or masturbation but not otherwise acted on. *Masochistic fantasies usually involve being raped while being held or bound by others so that there is no possibility of escape. *Others act on the masochistic sexual urges by themselves (ex. Binding themselves, sticking themselves with pins, shocking themselves electronically, or self-mutilation) or with a partner. *Masochistic acts that may be sought with a partner include restraint (physical bondage) blindfolding (sensory bondage), paddling, spanking, whipping, beating electrical shocks, cutting, pinning and piercing (infibulations), and humiliation (ex. Being urinated defecated on, being forced to craw and bark like a dog or being subjected to verbal abuse). Sexual sadism *Involves acts in which the individual derives sexual excitement from the psychological or physical suffering (including humiliation) of the victim. *Some individuals with the paraphilia are bothered by their sadistic fantasies, which make be invoked during sexual activity but not otherwise acted on; in such cases the sadistic fantasies usually involve having complete control over the victim, who is terrified by anticipation of the impending sadistic act. *Others act on the sadistic urges with a consenting partner (who may have sexual masochism) who willingly suffers pain or humiliation. *Still others with sadistic sadism act on the sadistic sexual urges with nonconsenting victims. Transvestic fetishism *It involves cross-dressing by a male in womens attire. *In many or most cases, sexual arousal is produced by the accompanying thought or image of the person as a female (referred to as autogynephilia). *These images can range from being a woman with female genitalia to that of a view of the self fully dressed as a woman with no real attention to genitalia. *Womens garments are arousing primarily as symbols of the individuals femininity, not as fetishes with specific objective properties (ex. Objects made of rubber). *Usually the male with transvestic fetishism keeps a collection of female clothes that he intermittently uses to cross-dress. *This disorder has been described only in heterosexual males. Voyerism *It involves the act of observing unsuspecting individuals, usually strangers who are naked, in the process of disrobing or engaging in sexual activity. *The act of looking (peeping) is for the purpose of achieving sexual excitement, and generally no sexual activity with the observed person is sought. *Orgasm, usually produced by masturbation, may occur during the voyeuristic activity or later in response to the memory of what the person has witnessed. *Often these individuals have the fantasy of having a sexual experience with the observed person, but in reality this rarely occurs. *In its severe form, peeping constitutes the exclusive form of sexual activity. Paraphilia not otherwise specified *This category is included for coding paraphilias that do not meet the criteria for any of the specific categories. *Examples include, but are not limited to, telephone scatologia (obscene phone calls), necrophilia (corpses), partialism (exclusive focus on part of body), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), and urophilia (urine).

Assessment * Assessment (General client history) Depression Anxiety Decreased sexual desire Diagnosis Sexual dysfunction; Ineffective sexuality patterns Planning Concept mapping; nursing care plan Implementation Patient and family education Referral to support services Evaluation (Reassessment of problem) Nursing diagnosis Sexual dysfunction; Ineffective sexuality patterns related to altered sexual function as evidenced by recurrent , intense sexually arousing fantasies, sexual urges, or behaviors that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Pharmacological treatment Hormones given to block or decrease the level of circulating androgens Medications focused on decreasing the libido to interrupt the pattern of compulsive deviant sexual behavior Psychotherapy/ psycho education groups Psychoanalytical therapy Unresolved conflicts/childhood trauma Aversion techniques Paring of noxious stimuli with the impulse Cognitive restructuring