Sexual Disorders

❑ Human beings are sexual beings

❑ Sexuality is a basic human need and an innate part of the total personality.
❑ Sexuality: is the result of biologic, psychological, social and experiential factors that mold an
individuals’ sexual development, self-concept, body image and behavior.
❑ Sex: is described as one of four primary drives that also include thirst, hunger, and avoidance of
pain.
❑ Sexual acts: occur when behaviors involve genitalia and erogenous zones.

Human Sexual Response Cycle

Phase 1: Excitement
General characteristics of the excitement phase, which can last from a few minutes to several hours,
include the following:
▪ Muscle tension increases.
▪ Heart rate quickens and breathing is accelerated.
▪ Skin may become flushed (blotches of redness appear on the chest and back).
▪ Nipples become hardened or erect.
▪ Blood flow to the genitals increases, resulting in swelling of the woman's clitoris and labia
minora (inner lips), and erection of the man's penis.
▪ Vaginal lubrication begins.
▪ The woman's breasts become fuller and the vaginal walls begin to swell.
▪ The man's testicles swell, their scrotum tightens and begin secreting a lubricating liquid.

Phase 2: Plateau
General characteristics of the plateau phase, which extends to the brink of orgasm, include the
following:
▪ The changes begun in phase 1 are intensified.
▪ The vagina continues to swell from increased blood flow, and the vaginal walls turn a dark
purple.
▪ The woman's clitoris becomes highly sensitive (may even be painful to touch) and retracts under
the clitoral hood to avoid direct stimulation from the penis.
▪ The man's testicles tighten.
▪ Breathing, heart rate, and blood pressure continue to increase.
▪ Muscle spasms may begin in the feet, face, and hands.
▪ Muscle tension increases.

Phase 3: Orgasm
The orgasm is the climax of the sexual response cycle. It is the shortest of the phases and generally lasts
only a few seconds. General characteristics of this phase include the following:
▪ Involuntary muscle contractions begin.
▪ Blood pressure, heart rate, and breathing are at their highest rates, with a rapid intake of
oxygen.
▪ Muscles in the feet spasm.
▪ There is a sudden, forceful release of sexual tension.
▪ In women, the muscles of the vagina contract. The uterus also undergoes rhythmic contractions.
▪ In men, rhythmic contractions of the muscles at the base of the penis result in the ejaculation of
semen.
 ▪ A rash, or "sex flush" may appear over the entire body.

Phase 4: Resolution
During resolution, the body slowly returns to its normal level of functioning, and swelled and erect body
parts return to their previous size and color.
▪ This phase is marked by a general sense of well-being, enhanced intimacy and, often, fatigue.
▪ Some women are capable of a rapid return to the orgasm phase with further sexual stimulation
and may experience multiple orgasms.
▪ Men need recovery time after orgasm, called a refractory period, during which they cannot
reach orgasm again.
▪ The duration of the refractory period varies among men and usually lengthens with advancing
age.

Sexual disorders

Paraphilias
▪ These are characterized by any intense and persistent sexual interest other than sexual interest
in genital stimulation or preparatory fondling with phenotypically normal, physiologically
mature, consenting human partners.
Paraphilic Disorder
▪ With the term ‘disorder’ that was specifically added to DSM-5 to indicate a paraphilia that is
inducing distress or impairment to the person or a paraphilia whereby satisfaction caused
personal harm, or risk of harm, to others.
Sexual dysfunction disorders
▪ This can be described as an impairment or disturbance in any of the phases of the sexual
response cycle.
▪ It includes disturbance in the processes that characterize the sexual response cycle or the
presence of pain during sexual intercourse.
Gender dysphoria
▪ It involves a conflict within a person’s physical or assigned gender and the gender with which
he/she/they identify.
▪ It is the feeling of discomfort or distress that might occur in people whose gender identity differs
from their sex assigned at birth or sex-related physical characteristics.
▪ Transgender and gender-nonconforming people might experience gender dysphoria at some
point in their lives
Gender identity disorders
▪ These are characterized by strong and persistent cross-gender identification accompanied by
persistent discomfort with one’s assigned sex.
▪ The gender identity disorders (GID) are defined as disorders in which an individual exhibits
marked and persistent identification with the opposite sex and persistent discomfort (dysphoria)
with his or her own sex or sense of inappropriateness in the gender role of that sex.
Statistics and Incidences
Gender identity and sexuality disorders are relatively rare compared to other psychiatric disorders.
▪ Although there are no large-scale epidemiological studies to provide true estimates recent
studies suggest roughly 1:10,000 to 1:30,000.
▪ Sex ratios of adults with GID (largely based on referrals to clinics) have fluctuated with more
males than females in earlier studies to a more equal ratio in many recent reports.
▪ Childhood GID is more prevalent in males, roughly 6 to 1; in adolescence, the ratio is more equal
Paraphilias
▪ Are disorders in which unusual or bizarre sexual imagery or acts are enacted to achieve sexual
excitement.
▪ These fantasies, urges, or behaviors generally involve nonhuman objects, the suffering and
humiliation of oneself or another person, or children or other non-consenting persons.
▪ These behaviors are recurrent over a period of at least 6 months and cause the individual
significant clinical distress or impairment in social, occupational or other important areas of
functioning.

Causes Predisposing factors to paraphilias

Biological factors
Various studies have implicated several organic factors in the etiology of paraphilias
▪ destruction of parts of the limbic system in animals has been shown to cause hypersexual
behavior
▪ temporal lobe diseases, such as psychomotor seizures or temporal lobe tumors, have been
implicated in some individuals with paraphilias
▪ abnormal levels of androgens also may contribute to inappropriate sexual arousal.
Psychoanalytic theory
▪ The psychoanalytic approach defines a paraphiliac as one who has failed the normal
developmental process toward heterosexual adjustments.
▪ A person who failed the normal development process toward heterosexual adjustment (failure
to resolve the oedipal crisis)
▪ Severe castration anxiety during the oedipal phase leads to the substitution of a symbolic
objects (inanimate or anatomic part) for the mother- fetishism and transvestitism.
Behavioral theory
▪ Recalling memories of experiences from an individual’s early life (esp. the first shared sexual
experience)
▪ Modeling behavior depicted in the media, and recalling past trauma such as one’s own
molestations
Characteristics of paraphilia
▪ Emotional immaturity (seen in pedophiliac or ‘peeping Tom”, who is unable to engage in a
mature sexual relationship because of feelings of inadequacy.
▪ Fear of sexual relationship that could result in rejection
▪ Shyness
▪ The need to prove masculinity, demonstrated by the exhibitionist.
▪ The need to inflict pain on another to achieve sexual satisfaction
▪ The need to endure pain to achieve sexual satisfaction
▪ Low or poor self-concept
▪ depression
Historical background of paraphilia
▪ Historically, some restrictions on human sexual expression have always existed.
▪ Under the Code of Orthodox Judaism, masturbation was punishable by death.
▪ In ancient Catholicism it was considered a carnal sin.
▪ In the late 19th century, masturbation was viewed as a major cause of insanity.
▪ Sexual exploitation of child was condemned in Ancient cultures, as it continues to be today.
 ▪ Incest remains the one taboo that crosses cultural barriers. It was punishable by death in
Babylon, Judea, and ancient China, and offenders were given the death penalty as late as 1650
in England.
▪ Oral-genital, anal, homosexual, and animal sexual contacts were viewed by the early Christian
church as unnatural and were considered greater transgressions than extramarital sexual
activity because they did not lead to biological reproduction

Types of Paraphilias
The term “paraphilia” is used to identify repetitive or preferred sexual fantasies or behaviors

Exhibitionism
▪ The major symptoms include recurrent, intense sexual urges, behaviors, or sexually arousing
fantasies, of at least 6 months duration, involving the exposure of one’s genitals to an
unsuspecting stranger.
Fetishism
▪ It involves recurrent, intense sexual fantasies, of at least 6 months duration, involving the use of
nonliving objects (such as undergarments or high-heeled shoes) or a highly specific focus on a
body part (most often nongenital, such as feet) to attain sexual arousal.
▪ Its occurrence is almost exclusive with men who fear rejection by members of the opposite sex.
▪ Objects maybe used during masturbation
Frotteurism
▪ It is the recurrent preoccupation with intense sexual urges or fantasies, of at least 6 months
duration, involving touching or rubbing against a nonconsenting person and the individual has
acted on these sexual urges with a non-consenting person, or the sexual urges or fantasies cause
clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
Pedophilia
▪ It is the recurrent, sexual urges, behaviors, or sexually arousing fantasies, of at least 6 months
duration, involving sexual activity with a prepubescent child; the age of the molester is 16 or
older and is at least 5 years older than the child.
▪ Pedophilia is termed pedophilic disorder in DSM-5 and the manual specifies it as a paraphilia
involving strong and habitual sexual urges towards and fantasies about prepubescent children
that have either been acted upon or which cause the person with the attraction distress or
interpersonal difficulty.
Sexual masochism
▪ The identifying behavior of this disorder is recurrent, intense sexual urges, behaviors, or sexually
arousing fantasies, of at least 6 months duration, involving the act of being humiliated, beaten,
bound, or otherwise made to suffer.
▪ DSM-5 indicates that a person may have a masochistic sexual interest but that the diagnosis of
sexual masochism disorder would only pertain to individuals who also report psychosocial
distress because of it.

Sexual sadism (similar to masochistic)

▪ The essential feature of sexual sadism is identified as recurrent, intense sexual urges, behaviors,
or sexually arousing fantasies, of at least 6 months duration, involving acts in which the
psychological or physical suffering (including humiliation) of the victim is sexually exciting
Voyeurism
▪ This disorder is identified as recurrent, intense, sexual urges, behaviors, or sexually arousing
fantasies, of at least 6 months duration, involving the act of observing an unsuspecting person
who is naked, in the process of disrobing, or engaging in sexual activity.

Bestiality or zoophilia
▪ sexual contact with animals
▪ Animals serve as a preferred method to produce sexual excitement
▪ Bestiality, also referred to as zooerasty, refers to any sexual act with an animal, while zoophilia,
or preferential bestiality, refers to “a clear preference for engaging in sex with animals”.

Necrophilia
▪ Sexual arousal occurs while the person is using corpses to meet sexual needs
▪ is a pathological fascination with dead bodies, which often takes the form of a desire to engage
with them in sexual activities, such as intercourse.
▪ Though prohibited by the laws of many countries, there have been many reported cases of
necrophilia throughout history.

Telephone scatologia/scatophilia
▪ Sexual gratification is achieved by telephoning someone and making lewd or obscene remarks
Urophilia
▪ Fascination with urine and urination
▪ Urophilia, also known as “golden showers” or “watersports,” is a sexual variation where people
derive pleasure from urine or urination.
▪ The arousal is associated with smelling, feeling, or tasting urine, as well as urinating on someone
or being urinated on by someone else.
▪ Sometimes, the pleasure derives from the physical urine (i.e., the warmth and the smell).
▪ Other times the person associates the urine and urination with intimacy, closeness, and trust.
Coprophilia
▪ Fascination with feces (dung-animal manure)
▪ It is the condition of desire for sexual gratification and sexual arousal derived from the smell,
taste, or sight of feces or from the act of defecation

Clinical Manifestations
Subjective and objective data of symptoms of paraphilias include the following:
▪ Exposure of one’s genitals to strangers.
▪ Sexual arousal in the presence of nonliving objects.
▪ Touching and rubbing of one’s genitals against an unconsenting person.
▪ Sexual attraction to, or activity with, a prepubescent child.
▪ Sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer.
▪ Sexual arousal by inflicting psychological or physical suffering on another individual.
▪ Sexual arousal from dressing in the clothes of the opposite sex.
▪ Sexual arousal from observing unsuspecting people either naked or engaged in sexual activity.
▪ Masturbation often accompanies the activities described when they are performed solitarily.
▪ The individual is markedly distressed by these activities.
 Medical treatment modalities

(paraphilia)
Biological treatment
▪ Blocking and decreasing the level of circulating androgens.
▪ Most extensively used anti-andronergic medications are the PROGESTIN derivatives that block
testosterone synthesis or block androgen receptors
Psychoanalytical therapy
▪ The therapist helps the client to identify unresolved conflicts and traumas from early childhood.
▪ Helping resolve these conflicts, thus relieving the anxiety that prevents him forming appropriate
sexual relationships
Behavioral theory
▪ It includes skills training and cognitive restructuring in an effort to change the individual's
maladaptive beliefs

Gender Identity Disorders

Theories of gender development

Genetic and biologic theories

a. Chromosomes: are carriers of genetic programming.
▪ The male’s sperm cell determines the sex of the embryo at conception by adding either an X or a
Y-chromosomes to the chromosome in the ovum.
▪ X and Y chromosome – male fetus
▪ 2X chromosomes result in the female fetus
b. Klinefelter’s syndrome:
▪ Seen in males, occurs as the result of an XXY chromosome grouping.
▪ The male appears normal until adolescence, when low level of testosterone result in small
testes, infertility, and low level of sexual interest
c. Turner’s syndrome:
▪ Seen in females, occurs as the result of a missing sex chromosomes or XO grouping.
▪ The female appears short in stature and lacks functioning gonads.
▪ During puberty, breasts do not develop and menses do not occur
d. pseudo hermaphrodites:
▪ 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.
▪ 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 masculinity.
▪ Hormonal imbalances may result in a genetic boy or girl developing ambiguous genitalia ( a
penis and a small vaginal opening)

Psychosocial theories
▪ Gender identity is thought to be shaped by attitudes, values, beliefs, sex roles, religious and
ethnic communities.

Gender identity disorders

The diagnostic features of this disorder are:
▪ Evidence of a strong and persistent cross-gender identification in which one expresses the desire
to be or the insistence to be the opposite sex.
▪ Experiences persistent discomfort about his or her assigned sex or feel inappropriate in the role
of the assigned sex.
▪ Impairment occurs in social, occupational, or other important areas of functioning

Variations in sexual orientation

Homosexuality
▪ Homo- Greek word meaning same and refers to sexual preference for individuals of he same
sex. (Same sex)
▪ May be a general way to homosexuals of both gender but this often denotes male
homosexuality
▪ Lesbianism is used to identify females homosexuals. Is traced to the Greek poet SAPPHO who
lived on the island of LESBOS and is known for the love poems she wrote to other women.
▪ Most homosexuals prefer the term ‘gay’ as it is less derogatory in its lack of emphasis on the
sexual aspects of the orientation.
▪ It is no longer considered a mental disturbance.
▪ The DSM IV TR is concerned only with the individuals who experience ‘persistent’ and marked
distress about his or her sexual orientation
Etiological implications

Biological theories
▪ 52% in monozygotic twins
▪ 22% in dizygotic twins
▪ Possibility of a gene that can be inherited
▪ Lower testosterone and increased estrogen level in homosexual
▪ Suggests that exposure to inappropriate level of androgen during the critical fetal period of
sexual differentiation may contribute to homosexual orientation.
Psychoanalytic theory
▪ Freud believed that all humans are inherently bisexual with the capacity to both heterosexual
and homosexual behaviors
▪ He theorized that all individuals go through a homo-erotic phase as children.
▪ He also believed that homosexuality occurs as the result of pathological family relationship in
which the child adopts a negative oedipal position.
▪ Homosexual men often have a dominant supportive mother and a weak, remote, or hostile
father.

Transsexualism
▪ It is a disorder of gender identity or gender dysphoria (unhappiness or dissatisfaction with one’s
gender) of the most extreme variation.
▪ An individual, despite having the anatomical characteristics of a given gender, has the self-
perception of being the opposite gender.
▪ They do not feel comfortable wearing the clothes of their assigned gender and often engage in
cross-dressing.
 ▪ They may repeatedly submit requests to the health care system for hormonal and surgical
gender reassignment.
▪ Depression and anxiety are common and are usually caused by inability to live in the desired
gender role.
▪ Has been theorized that there is a combination of biological and environmental factors
particularly family dynamics.
▪ Individuals who desire to go into surgery must undergo extensive psychological therapy for at
least 2 years before the surgery.
▪ Hormonal treatments: males- estrogens; females- testosterone

Medical Management
Modalities that may be considered in the treatment of gender dysphoria include pharmacologic
therapy, psychological and other nonpharmacologic therapies, and sexual reassignment surgery (SRS)

Psychological and speech therapy

▪ Psychological intervention may be beneficial; individual treatment focuses on understanding
and dealing with gender issues; group, marital, and family therapy can provide a helpful and
supportive environment.
▪ Speech therapy may help male-to-female individuals use their voice in a more feminine manner.
Sexual reassignment surgery
▪ Controversy exists regarding whether adolescents should be allowed to pursue SRS; many
countries deny SRS to adolescents; however, early treatment may be beneficial in adolescents
whose secondary sex characteristics (eg, facial hair, lowered voice, and breast development)
have not yet developed fully. In such cases, parental involvement and approval are essential.
Pharmacologic Management
The goal of pharmacotherapy is to inhibit or promote the expression of secondary sex characteristics in
males and females
▪ Progestins
✔ These agents may be used to inhibit the secretion of pituitary gonadotropins.
▪ Gonadotropin-releasing hormone agonists
✔ Gonadotropin-releasing hormone (GnRH) analogs produce a hypogonadotropic-
hypogonadal state by down-regulation of the pituitary gland.
▪ Aldosterone antagonists, selective
✔ Aldosterone antagonists may block androgen receptors.
▪ Antineoplastic, antiandrogens
✔ Antiandrogens are another group of agents used as a first-line therapy for hirsutism.
▪ Oral contraceptives
✔ Oral contraceptives inhibit ovarian androgen production and are probably the first
choice for young women with hirsutism who do not want to become pregnant.
▪ Estrogen derivatives
✔ These hormones are used for replacement therapy in hypogonadism associated with a
deficiency or absence of endogenous testosterone or estrogen.
▪ Androgens
✔ Androgens are used for replacement therapy in hypogonadism associated with a
deficiency or absence of endogenous testosterone.
Nursing Goals
The major nursing care planning goals for sexual dysfunctions, gender dysphoria, and paraphilias are:
▪ Client will resume sexual activity at level satisfactory to self and partner by (time is individually
determined).
▪ Client will express satisfaction with own sexuality pattern.
▪ Client and partner will express satisfaction with sexual relationship.
▪ Client will demonstrate behaviors that are appropriate and culturally acceptable for assigned
gender.
▪ Client will express personal satisfaction and feelings of being comfortable in assigned gender.
▪ Client will interact with others using culturally acceptable behaviors.

Nursing interventions
▪ Determine stressors. Help client determine time dimension associated with the onset of the
problem and discuss what was happening in his or her life situation at that time.
▪ Encourage discussion of disease process. Encourage client to discuss disease process that may
be contributing to sexual dysfunction; ensure that client is aware that alternative methods of
achieving sexual satisfaction exist and can be learned through sex counseling if he or she and
partner desire to do so.
▪ Identify factors that affect client’s sexuality. Note cultural, social, ethnic, racial, and religious
factors that may contribute to conflicts regarding variant sexual practices.
▪ Be accepting and nonjudgmental. Sexuality is a very personal and sensitive subject; the client is
more likely to share this information if he or she does not fear being judged by the nurse.
▪ Provide positive reinforcement. Observe client behaviors and the responses he or she elicits
from others; give social attention (e.g., smile, nod) to desired behaviors.

Surgery
▪ male to female- removal of the penis and testes and creation of an artificial vagina; female to
male- is more complex and usually less successful.
▪ A mastectomy and sometimes hysterectomy are performed.
▪ A penis and scrotum are constructed from tissues in the genital and abdominal area, the vaginal
orifice is closed, a penile implant is used to attain erection
Nursing care of post sex reassignment surgery is similar to other post-surgical patients:
▪ Maintaining comfort
▪ Preventing infection
▪ Preserving the integrity of the surgical site
▪ Maintaining elimination
▪ Meeting nutritional needs and psychosocial needs

Sexual Addiction
▪ Considerable controversy surrounds the diagnosis of “sex addiction.” It’s been excluded from
the fifth edition of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM-5), but it’s
still written about and studied in psychology and counseling circles.
▪ Additionally, it can still be diagnosed using both DSM-5 (as “Other specified sexual dysfunction”)
and the “International Statistical Classification of Diseases and Related Health Problems” (ICD-
10) criteria (as “Other sexual dysfunction not due to a substance or known physiological
condition”).
Sexual Addiction
▪ Is defined as engaging in obsessive-compulsive sexual behavior that causes severe stress to
addicted individuals and their families.
▪ Sexual addicts make sex a priority more important than family, friends, work and values
▪ Sex becomes the source of nurturing and trust, and addicts are willing to sacrifice what they
cherish most to preserve their behavior.
▪ Sexual addicts have admitted that their unhealthy use of sex began with an addiction to
masturbation, paraphilia, pornography, or a heterosexual or homosexual behavior.
▪ Sexual addiction also includes prostitution, exhibitionism, voyeurism, indecent phone calls, child
molestation, incest, rape or violence.
▪ Addicts experience powerlessness over the compulsive behavior that has made their lives
unmanageable.
▪ They may feel out of control; experiences tremendous shame, pain and self-loathing; and try to
stop yet repeatedly fail to do so.

Symptoms of sex addiction

A person may have a sex addiction if they show some or all of the following signs:
▪ chronic, obsessive sexual thoughts and fantasies
▪ compulsive relations with multiple partners, including strangers
▪ lying to cover behaviors
▪ preoccupation with having sex, even when it interferes with daily life, productivity, work
performance, and so on
▪ inability to stop or control the behaviors
▪ putting oneself or others in danger due to sexual behavior
▪ feeling remorse or guilt after sex
▪ experiencing other negative personal or professional consequences

Treatments for sex addiction

Inpatient treatment programs
▪ Often, people with a sex addiction are removed from their normal daily lives for at least 30 days
to help them regain control of their impulses and start healing. These types of programs
typically include in-depth individual and group therapy sessions.
12-step programs
▪ Programs such as Sex Addicts Anonymous (SAA) follow the same recovery model as Alcoholics
Anonymous (AA).
▪ Members aren’t required to give up sex entirely, but they are encouraged to refrain from
compulsive and destructive sexual behavior. Group meetings with others addressing the same
challenges provide a good support system.
Cognitive behavioral therapy
▪ This type of therapy can help a person identify triggers for sexual impulses and ultimately teach
them how to alter behaviors. This is achieved through one-on-one sessions with a licensed
mental health therapist.
Medication
▪ Some people may benefit from a course of drug therapy.
▪ Certain antidepressants might help alleviate urges (which is separate from the potential side
effects of some antidepressants that can cause decreased libido or impair other aspects of the
sexual experience).
 Types of Sexual Dysfunctions
These may occur in any phase of the sexual response cycle; types of sexual dysfunctions include the
following:
Hypoactive sexual disorder
▪ This disorder is defined by the DSM-5 as persistent or recurrently deficient sexual or erotic
thoughts, fantasies, and desire for sexual activity.
Sexual aversion disorder
▪ This disorder is characterized by a persistent or recurrent extreme aversion to, and avoidance
of, all (or almost all) genital sexual contact with a sexual partner.
▪ In the development from DSM-IV-TR to DSM-5 (APA, 2013), the diagnosis of sexual aversion
disorder (SAD) has been removed.
Female sexual arousal disorder
▪ This disorder is identified in the DSM-IV-TR (APA, 2000) as a persistent or recurrent inability to
attain, or to maintain until completion of the sexual activity, an adequate lubrication or swelling
response of sexual excitement.
▪ It is defined in the DSM-5 as lack of, or significantly reduced, sexual interest/arousal.
Male erectile disorder
▪ This disorder is defined in the DSM-5 as the recurrent inability to achieve an erection, the
inability to maintain an adequate erection, and/or a noticeable decrease in erectile rigidity
during partnered sexual activity.
Female orgasmic disorder
▪ (anorgasmia)
▪ This disorder is defined by the DSM-IV-TR as a persistent or recurrent delay in, or absence of,
orgasm following a normal sexual excitement phase.
▪ As classified by the DSM-5, female orgasmic disorder is characterized by difficulty experiencing
orgasm and/or markedly reduced intensity of orgasmic sensations.
Male orgasmic disorder
▪ (retarded ejaculation)
▪ With this disorder, the man is unable to ejaculate, even though he has a firm erection and has
had more than adequate stimulation.
▪ This disorder is also known as delayed ejaculation (DE) or delayed orgasm (DO).
▪ Delayed ejaculation (DE) is defined in DSM-5 as a persistent difficulty or inability to achieve
orgasm despite the presence of adequate desire, arousal, and stimulation.
Premature ejaculation
▪ The DSM-IV-TR describes this disorder as persistent or recurrent ejaculation with minimal sexual
stimulation before, on, or shortly after penetration and before the person wishes it.
▪ In DSM-5, premature ejaculation is defined as a persistent or recurrent pattern of ejaculation
occurring during partnered sexual activity within about one minute following vaginal
penetration and before the individual wishes it.
Dyspareunia
▪ Dyspareunia is defined as recurrent or persistent genital pain associated with sexual intercourse,
in either a man or a woman, that is not caused by vaginismus, lack of lubrication, another
general medical condition, or the physiological effects of substance use (APA, 2000).
Vaginismus
▪ Vaginismus is characterized by an involuntary constriction of the outer third of the vagina, which
prevents penile insertion and intercourse.
 ▪ In DSM-5, the spasm-based definition of vaginismus was omitted, and vaginismus was combined
with dyspareunia, the other “sexual pain disorder,” which resulted in genito-pelvic
pain/penetration disorder (GPPPD).

Predisposing factors to sexual dysfunction

Sexual desire disorders

▪ In men, these disorders have been linked to low levels of serum testosterone and to elevated
levels of serum prolactin
▪ evidence also exists that suggests a relationship between serum testosterone and increased
female libido
▪ various medications, such as antihypertensives, antipsychotics, antidepressants, anxiolytics, and
anticonvulsants
▪ chronic use of drugs such as alcohol and cocaine, have also been implicated in sexual desire
disorders.
Sexual arousal disorders
▪ These may occur in response to decreased estrogen levels in postmenopausal women
▪ Medications such as antihistamines and cholinergic blockers may produce similar results;
▪ Erectile dysfunctions in men may be attributed to arteriosclerosis, diabetes, temporal lobe
epilepsy, multiple sclerosis, some medications (antihypertensives, antidepressants,
tranquilizers), spinal cord injury, pelvic surgery, and chronic use of alcohol.
Orgasmic disorders
▪ In women these may be attributed to some medical conditions (hypothyroidism, diabetes, and
depression) and certain medications (antihypertensives, antidepressants)
▪ Medical conditions that may interfere with male orgasm include genitourinary surgery (e.g.,
prostatectomy), Parkinson’s disease, and diabetes.
Sexual pain disorders
▪ In women these can be caused by disorders of the vaginal entrance, irritation or damage to the
clitoris, vaginal or pelvic infections, endometriosis, tumors, or cysts.
▪ Painful intercourse in men may be attributed to penile infections, phimosis, urinary tract
infections, or prostate problems.

Subjective and objective data of symptoms of sexual disorders

▪ Absence of sexual fantasies and desire for sexual activity.
▪ Discrepancy between partners’ levels of desire for sexual activity.
▪ Feelings of disgust, anxiety, or panic responses to genital contact.
▪ Inability to produce adequate lubrication for sexual activity.
▪ Absence of a subjective sense of sexual excitement during sexual activity.
▪ Failure to attain or maintain penile erection until completion of sexual activity.
▪ Inability to achieve orgasm (in men, to ejaculate) following a period of sexual excitement judged
adequate in intensity and duration to produce such a response.
▪ Ejaculation occurs with minimal sexual stimulation or before, on, or shortly after penetration
and before the individual wishes it.
▪ Genital pain occurring before, during, or after sexual intercourse.
▪ Constriction of the outer third of the vagina prevents penile penetration.
Assessment
Taking a sexual history
Basic principles of doing a sexual assessment
▪ Be comfortable and at ease with the client.
▪ Present an open and accepting attitude
▪ Be empathic
▪ Avoid personal values and biases during the interview.
▪ Ensure a thorough knowledge base.
▪ Establish familiar terminology with the client
▪ Encourage the client to verbalize any sexual concerns or emotions
▪ Support the expression of feelings and validate them.
▪ Ask specific, open-ended questions.
▪ Approach emotional or more sensitive questions gradually
▪ Progress from how information was learned, to attitudes, then behaviors
▪ State that certain sexual behaviors are common before asking questions about them
Providing a safe environment
▪ Clients’ safety is a priority
▪ Clients with impulsive, unpredictable sexual behavior can pose a threat to the safety of others as
well as themselves

Medication management
Various pharmacological approaches are used to treat clients with sexual disorders and the nurse should
be familiar with their application and potential side effects.
▪ Hormonal replacement therapy for females with dyspareunia
▪ Hormonal therapy for males with low testosterone levels
▪ Homeopathic remedies such as aromatherapy, massage therapy, and therapeutic touch are
used to reduce pain, depression, or anxiety and may promote sexual health:
▪ Sildenafil citrate (viagra) is used to treat erectile dysfunction
▪ Two pharmaceutical manufacturers are testing new drugs to treat erectile dysfunction:
phentolamine (Vasomax)
apomorphine (spontane), an antiparkinson’s drug
▪ Hormonal therapy with progestins, such as medroxyprogesterone acetate, as well as SSRIs, is
used as adjunctive therapy to reduce libido n sex addicts, paraphiliacs and other sex offenders

Interactive therapy
Individual psychotherapy
▪ Recommended for clients who had a recent life changes, such as illness, loss, divorce, surgery
and any other factors resulting in the change of self-esteem and body image.
▪ Clients should be encouraged to seek counseling for themselves and their partners
Marital therapy
▪ Effective in resolving marital conflicts.
Family therapy
▪ Adolescents and young adults struggle with emerging sexual identity, parents and families go
through a parallel coming-out process and are affected by the stigma associated with being gay
or lesbians
Sex therapy
▪ Individuals who are trained and certified generally provide sex therapy