Appendix E. Sexual and Gender Identity Disorders

People are sexual beings who strive to have satisfying and pleasurable sexual relationships. The concept of sexual health has been defined by the World Health Organization as the synthesis of the somatic, emotional, intellectual and social components of a person in a manner that promotes and enriches the art of communication, interpersonal intimacy, and the expression of love Because sexual health is a complex, individualistic, and ever-changing phenomenon, it is manifested in various ways that people use to express their thoughts, feelings, needs, and desires. Factors such as physiologic health, psychosocial variables, personal choices, and the environment influence the expression of sexuality.

Knowledge of the normal sexual response cycle is based on the work of Masters and Johnson (1966) and Helen Singer Kaplan (1979). The human sexual response cycle consists of four stages: desire, excitement, orgasm, and resolution. The sexual dysfunctions described in the DSM-IV are based on a deficiency or loss in sexual desire or a disturbance in the sexual response cycle. (For additional information, see Phases of Human Sexual Response.)

In addition to the sexual dysfunctions, there are paraphilias and gender identity disorders. Paraphilias are defined as the intense recurrent sexual urges centered on nonhuman objects, human suffering, or situations that cause humiliation of the self a partner, a child, or other unsuspecting person. (For a description of paraphilias, see Definitions of Paraphilias.) Gender identity disorders are characterized by an intense and ongoing cross-gender identification in which a person either desires to be or is insistent about belonging to the opposite gender. Here it becomes evident that the person is distressed about the sex that is physically present and the respective gender role of that sex. (A detailed listing of the appropriate DSM-IV categories can be found in Appendix B.)

SEXUAL HEALTH HISTORY

How the client obtained information on human sexuality

State of client's physical and emotional health and how it affects sex life

Use of any prescription or nonprescription medications

Sexual preference

Quality of the client's relattonship(s) with partner(s)

Satisfaction with current level of sexual activity

What Is viewed as needing to be changed in sex life

Concerns about birth control, sexually transmitted diseases, or pregnancy

SEXUAL HEALTH HISTORY
How the client obtained information on human sexuality State of client's physical and emotional health and how it affects sex life Use of any prescription or nonprescription medications Sexual preference Quality of the client's relattonship(s) with partner(s) Satisfaction with current level of sexual activity What Is viewed as needing to be changed in sex life Concerns about birth control, sexually transmitted diseases, or pregnancy

FACTORS THAT MAY ALTER SEXUAL RESPONSE

Fear, shame, guilt, grief, anger, anxiety, or depression

Having been taught rigid, restrictive sexual values and attitudes in family of origin or perception of sexual activity as sinful or "dirty"

Culbirai, social, or ethnic sexual taboos

Hostility or hatred of the opposite gender

History of physical or sexual abuse or pain associated with sexual activity

History of having contracted a sexuaHy transmitted disease

Fear of getting a sexually transmitted disease or becoming pregnant

Lack of communication skills, whereby a partner can't ask for what is wanted in the relationship, such as what sexual stimulation is needed

History of chronic conflict in overall relationship

Use of recreationat drugs or alcohol

Prescription drugs, such as psychotropic agents, antihypertensive drugs, estrogen therapy, or antihistamines

Physiologic concerns related to the aging process

Chronic conditions or illnesses, such as pain, fatigue, diabetes, cancel, renal disease, AIDS, or peripheral vascutar disease

Injuries such as spinal cord injury or head injury

Surgery on the reproductive tract, such as tubal ligatlon, hysterectomy, or vasectomy

FACTORS THAT MAY ALTER SEXUAL RESPONSE
Fear, shame, guilt, grief, anger, anxiety, or depression Having been taught rigid, restrictive sexual values and attitudes in family of origin or perception of sexual activity as sinful or "dirty" Culbirai, social, or ethnic sexual taboos Hostility or hatred of the opposite gender History of physical or sexual abuse or pain associated with sexual activity History of having contracted a sexuaHy transmitted disease Fear of getting a sexually transmitted disease or becoming pregnant Lack of communication skills, whereby a partner can't ask for what is wanted in the relationship, such as what sexual stimulation is needed History of chronic conflict in overall relationship Use of recreationat drugs or alcohol Prescription drugs, such as psychotropic agents, antihypertensive drugs, estrogen therapy, or antihistamines Physiologic concerns related to the aging process Chronic conditions or illnesses, such as pain, fatigue, diabetes, cancel, renal disease, AIDS, or peripheral vascutar disease Injuries such as spinal cord injury or head injury Surgery on the reproductive tract, such as tubal ligatlon, hysterectomy, or vasectomy

COMMUNICATION STRATEGIES

Provide private opportunities for the client to talk about human sexuality.
Convey an open, positive attitude while communicating that it is normal for clients to have sexual concerns.
Encourage the client to verbalize feelings about sexual concerns, performance, and values.
Initiate discussion about what consists of sexual behavior and how sexual behavior is learned. (For further information, see Sexual Health History and Factors That May Alter Sexual Response.)
Help the client understand that sexuality is a combination of emotional and physical responses, communication between partners, and sexual knowledge and skills.
Talk about the many types of sexual self-expression.
Initiate a discussion about how emotional needs for self-esteem, respect, love, and intimacy influence sexual expression.
Help the client differentiate between love and sex and how sexual acre's resulting from feelings of love enhance sexual and emotional satisfaction.
Assist the client to identify if sexual expression is adequate or inadequate in meeting personal needs, and help the client learn to express needs in an acceptable manner.
Help the client identify how changes in health, role behaviors, self-esteem or losses can influence sexual desire, feelings, and behaviors in self and in one's partner.
Help the client determine if changes in physical health have altered previous sexual practices, and examine how alternative sexual practices can be initiated.
Discuss with the client the importance of a health care evaluation if hormonal, vascular, or neurologic problems have an impact on the client’s sexual functioning.
Give information and talk to the client about sexual anatomy.
Explain and talk to the client about the sexual response cycle.
Work with the client to identify myths about sexuality, and provide information to dispel such myths.
If the client uses slang or street terms for body parts or sexual activities. be certain that both the nurse and the client are using or defining the term in the same way.
Discuss with the client how spiritual beliefs may have an impact on sexual expression.
If appropriate, help the client identify the inappropriateness of using over-sexual behaviors instead of proper communication skills to establish relationships with another person. A client who acts out sexually has problems with initiating and maintaining interpersonal relationships.

PHASES OF HUMAN SEXUAL RESPONSE

DESIRE PHASE — libido, or the drive to be responsive to or seek out sexual interactions.

EXCITEMENT PHASE — physiologic arousal, seen in women as vaginal lubrication and expansion and in men as penile erection. Sexual tension builds.

ORGASM — the reflex response to the peaking of sexual pleasure and the release of sexual tension characterized by the rhythmic contractions of the pelvic muscles and reproductive organs.

RESOLUTION — the period of general well-being and muscle relaxation when the reproductive organs return to the preexcitatlon phase.

PHASES OF HUMAN SEXUAL RESPONSE
DESIRE PHASE — libido, or the drive to be responsive to or seek out sexual interactions.
EXCITEMENT PHASE — physiologic arousal, seen in women as vaginal lubrication and expansion and in men as penile erection. Sexual tension builds.
ORGASM — the reflex response to the peaking of sexual pleasure and the release of sexual tension characterized by the rhythmic contractions of the pelvic muscles and reproductive organs.
RESOLUTION — the period of general well-being and muscle relaxation when the reproductive organs return to the preexcitatlon phase.

DEFINITIONS OF PARAPHILIAS

Exhibitionism — the exposure of one's genitals to an unsuspecting person accompanied by sexual arousal and masturbation during or after the exposure.

Fetishism — sexual arousal involving the use of a nonliving object, such as shoes or undergarments.

Frotteurism — sexual arousal associated with touching or rubbing up against a nonconsenting person, such as when on a train or in a crowded public place.

Pedophilia — sexual fantasies, urges, or behaviors with a child who is age 13 or younger, usually involving manipulation or fondling of the child's genitals.

Sexual masochism — sexual arousal that occurs from actually being humiliated, experiencing physical pain, and being made to suffer.

Sexual sadism — when the physical and emotional suffering of a victim is sexually arousing to a person.

Transvestic fetishism — cross-dressing (typically, a heterosexual male dressed in female attire) tor the purpose of sexual arousal before masturbation or intercourse.

Voyeurism — becoming sexually aroused by observing an unsuspecting person who is undressing, grooming, or being sexualty active.

DEFINITIONS OF PARAPHILIAS
Exhibitionism — the exposure of one's genitals to an unsuspecting person accompanied by sexual arousal and masturbation during or after the exposure. Fetishism — sexual arousal involving the use of a nonliving object, such as shoes or undergarments. Frotteurism — sexual arousal associated with touching or rubbing up against a nonconsenting person, such as when on a train or in a crowded public place. Pedophilia — sexual fantasies, urges, or behaviors with a child who is age 13 or younger, usually involving manipulation or fondling of the child's genitals. Sexual masochism — sexual arousal that occurs from actually being humiliated, experiencing physical pain, and being made to suffer. Sexual sadism — when the physical and emotional suffering of a victim is sexually arousing to a person. Transvestic fetishism — cross-dressing (typically, a heterosexual male dressed in female attire) tor the purpose of sexual arousal before masturbation or intercourse. Voyeurism — becoming sexually aroused by observing an unsuspecting person who is undressing, grooming, or being sexualty active.

BASIC NURSING CARE

Nurses can play a significant role in promoting sexual health. After rapport is established with the client, much work can be done to educate and supper-clients who struggle with sexual and relationship issues. Helping the client overcome psychosocial concerns, health care problems, and the lack of knowledge about human sexuality, the sexual response cycle, and reproductive anatomy and physiology are the basic interventions that nurses can provide to the health care consumer. In addition, nurses can help clients identify sexual problems and refer those clients who require sex therapy to appropriate practitioners. Advanced-practice nurses who have obtained the necessary education and clinical experience can provide counseling and therapy clients with sexual problems or sexual disorders. Nurses who provide sex therapy must meet the requirements of the American Association of Sex Educators, Counselors, and Therapists.