Knowt
Note
Studied by 26 people
paraphilia
Sexual Disorders
and Gender Dysphoria
■ BACKGROUND ASSESSMENT DATA
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edi- tion (DSM-5) (American Psychiatric Association [APA], 2013), identifies three categories of disorders associated with sexuality: gender dysphoria, sexual dysfunctions, and paraphilic disorders. Gender dysphoria refers to the “distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender” (APA, 2013, p. 451). Not all individuals with a transgender identity will experience clinically significant distress and, as such, it is important to note that the focus of this diagnostic category is on dysphoria as the clinical problem rather than identity per se (APA, 2013). Sexual dysfunction disorders can be described as an impairment or disturbance in any of the phases of the sexual response cycle. These include disorders of desire, arousal, orgasm, and disorders that relate to the experience of gen- ital pain during intercourse. The term paraphilia is used to identify repetitive or preferred sexual fantasies or behaviors that involve (1) nonhuman objects, (2) suffering or humiliation of oneself or one’s partner, or (3) nonconsenting persons (Black & Andreasen, 2014). In a paraphilic disorder, these sexual fantasies or behaviors are recurrent over a period of at least 6 months and cause the in- dividual clinically significant distress or impairment in social, oc- cupational, or other important areas of functioning (APA, 2013).
■ GENDER DYSPHORIA
Gender identity is the sense of knowing to which gender one belongs—that is, the awareness of one’s masculinity or femininity. Gender dysphoria is the distress that may accompany the incon- gruence between one’s experienced and expressed gender and one’s assigned or natal gender (APA, 2013). The DSM-5 identifies two categories of gender dysphoria: gender dysphoria in children and gender dysphoria in adolescents and adults.
Intervention with adolescents and adults with gender dysphoria is multifaceted. Adolescents rarely have the desire or motivation
230
Sexual Disorders and Gender Dysphoria ■ 231
to alter their cross-gender roles. Some adults seek therapy to learn how to cope with their sexual identity, whereas others have direct and immediate request for hormonal therapy and surgical sex re- assignment. Treatment of the adult with gender dysphoria is a complex process. If the transgendered individual intensely desires to have the genitalia and physical appearance of the assigned gen- der changed to conform to his or her gender identity, this change requires a great deal more than surgical alteration of physical fea- tures. In most cases, the individual must undergo extensive psy- chological testing and counseling, as well as live in the role of the desired gender for up to 2 years before surgery.
Treatment of children with gender dysphoria may be initiated when the behaviors cause significant distress and when the client desires it. Determining whether a child is truly experiencing gender dysphoria should be done cautiously, as gender-related behaviors vary widely in this age group. When the issue is identified as real gender dysphoria (e.g., the child is manifesting significant distress, symptoms of clinical depression, or suicidal ideation associated with transgender identity concerns), treatment should include evaluation and management of concurrent mental health problems, social sup- port systems, and in later childhood, nonjudgmental exploration of the individual’s desires with regard to sexual reassignment.
Some practitioners still engage in treatment models that at- tempt to “repair” or change the person’s gender identity, but this approach is contrary to position statements by the American Psy- chiatric Association (Byne et al., 2012) and the practice guidelines established by the American Academy of Child and Adolescent Psychiatry (Adelson, 2012).
Another treatment model suggests that children who have dif- fering gender identity are dysphoric only because of their image within the culture. This model stresses that children should be accepted as they see themselves—different from their assigned gender—and supported in their efforts to live as the gender in which they feel most comfortable. One option for treatment is pubertal delay for adolescents aged 12 to 16 years who have suf- fered with extreme lifelong gender dysphoria and who have sup- portive parents who encourage the child to pursue a desired change in gender (Adelson, 2012; Byne et al., 2012; Gibson & Catlin, 2010). A gonadotropin-releasing hormone agonist is administered to suppress changes associated with puberty. The treatment is reversible if the adolescent later decides not to pur- sue the gender change. When the medication is withdrawn, ex- ternal sexual development proceeds, and the individual has avoided permanent surgical intervention. If he or she decides as an adult to advance to surgical intervention, pubertal delay may facilitate transition, since there have not been clearly established secondary sex characteristics. The type of treatment one chooses
232 ■ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION
for gender dysphoria (if any) is a matter of personal choice. How- ever, issues associated with mental health concerns, such as depres- sion, risk for suicide, anxiety, social isolation, anger, self-esteem, and parental conflict, must be addressed.
Children who demonstrate gender-nonconforming behav- iors are often targets of bullying and violence. Nurses can play a key role in educating families and providing support to iden- tify safe, supportive peer groups for these children (Nicholson & McGuiness, 2014).
Predisposing Factors Associated With Gender Dysphoria
1. Physiological
a. Genetics:Theetiologyoftransgenderidentityisunknown.
There is no significant evidence linking this condition to hormone or chromosome variations (Gooren, 2011). Some small postmortem studies of brain tissue have demonstrated that male to female transgender individuals (also referred to as trans women) had typically female patterns of sexual differentiation in both the stria terminalis and the hypotha- lamic uncinate nucleus, leading researchers to suggest that perhaps this is a sexual differentiation issue that affects the brain (Garcia-Falguras & Swaab, 2008).
2. Psychosocial
a. FamilyDynamics:Genderrolesarecertainlyculturallyin-
fluenced, as parents encourage masculine or feminine be- haviors in their children. However, there is no clear evidence that psychological factors or family dynamics cause gender dysphoria (Gooren, 2011). Parents may present with anxiety over their child’s gender-nonconforming behavior based on their attitudes and perceptions. Likewise, children may present with symptoms of anxiety and depression related to negative attitudes toward their gender-nonconforming behaviors. Interestingly, researchers have observed that many children who show gender-nonconforming behavior do not grow up to become transgender, and many people who identify themselves as transgender in adulthood were not identified as gender nonconforming in childhood (Sadock, Sadock, & Ruiz, 2015).
Symptomatology (Subjective and Objective Data)
In Children or Adolescents:
Insistence that one is of the opposite gender, and emotional distress associated with his or her gender identity.
Interference with social or other areas of functioning that is associated with gender identity distress.
Verbalized or observed signs of mood disturbance related to gender identity concerns.
Sexual Disorders and Gender Dysphoria ■ 233 4. Expresses suicide ideation or other risk factors and warning
signs for suicide.
In Adults:
1. Persistent discomfort or mood disturbance associated with his or her gender identity.
2. Expressed impairment in social or other areas of functioning related to gender identity concerns.
Common Nursing Diagnoses and Interventions
for Gender Dysphoria
(Interventions are applicable to various health-care settings, such as in- patient and partial hospitalization, community outpatient clinic, home health, and private practice.)
■ DISTURBED PERSONAL IDENTITY
Definition: Inability to maintain an integrated and complete perception
of self (NANDA-I, 2018, p. 269)
Possible Contributing Factors (“related to”)
Low self-esteem
Cultural incongruence
Perceived prejudice or discrimination
Defining Characteristics (“evidenced by”)
[Statements that gender identity is a source of internal distress] Ineffective coping strategies
Impaired relationships
Goals/Objectives
Short-term Goals
Client will verbalize effective coping strategies to enhance self-esteem and satisfying interpersonal relationships.
Client will not harm self.
Long-term Goals
Client will express satisfaction in social and other areas of functioning.
Client will remain free from self-harm.
Interventions With Selected Rationales
1. Spend time with the client and show positive regard. Trust and unconditional acceptance are essential to the establishment of a ther- apeutic nurse-client relationship.
234 ■ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION
Be aware of own feelings and attitudes toward this client and his or her behavior. Attitudes influence behavior. The nurse must not allow negative attitudes to interfere with the effectiveness of interventions.
Allow the client to describe his or her perception of the prob- lem. It is important to know how the client perceives the problem before attempting to correct misperceptions.
Behavioral change is attempted with the child’s best interests in mind—that is, to help him or her with cultural and soci- etal integration while maintaining individuality. To preserve self-esteem and enhance self-worth, the child must know that he or she is accepted unconditionally as a unique and worthwhile individual.
Outcome Criteria
Client verbalizes and demonstrates self-satisfaction with gender identity.
Client demonstrates use of effective coping mechanisms to maintain self-esteem and remain free from self-harm.
■ IMPAIRED SOCIAL INTERACTION
Definition: Insufficient or excessive quantity or ineffective quality of social
exchange (NANDA-I, 2018, p. 301)
Possible Contributing Factors (“related to”)
[Social victimization, bullying from peer group]
[Disrupted communication with family or significant others] [Low self-esteem]
Defining Characteristics (“evidenced by”)
Discomfort in social situations
Inability to receive or communicate a satisfying sense of belong-
ing, caring, interest, or shared history
Use of unsuccessful social interaction behaviors Dysfunctional interaction with others
Goals/Objectives
Short-term Goal
Client will verbalize possible reasons for ineffective interactions with others.
Long-term Goal
Client will interact with others in mutually satisfying relationships.
Sexual Disorders and Gender Dysphoria ■ 235 Interventions With Selected Rationales
Explore positive coping strategies. Once client feels comfort- able with new coping skills in role-playing or one-to-one nurse-client interactions, the new behaviors may be tried in group situations. If possible, remain with the client during initial interactions with others. Presence of a trusted individual provides security for the client in a new situation. It also provides the potential for feedback to the client about his or her behavior.
Observe client behaviors and the responses he or she elicits from others. Give social attention (e.g., smile, nod) to desired behaviors. Follow up these “practice” sessions with one-to-one processing of the interaction. Give positive reinforcement for efforts. Positive reinforcement encourages repetition of desirable behaviors. One-to-one processing provides time for discussing the appropriateness of specific behaviors and why they should or should not be repeated.
Offer support if client is feeling hurt from peer ridicule. Encourage the client to discuss feelings and explore positive coping strategies. Validation of the client’s feelings is important.
Create a trusting, nonthreatening atmosphere for the client in an attempt to promote effective coping skills and improve social interactions.
Outcome Criteria
Client expresses satisfaction with his or her responses in social interaction.
Client verbalizes and demonstrates comfort with gender iden- tity in interactions with others.
■ LOW SELF-ESTEEM
Definition: Negative evaluation and/or feelings about one’s own capabilities
(NANDA-I, 2018, pp. 272–275)
Possible Contributing Factors (“related to”)
[Rejection by peers]
Lack of approval and/or affection
Repeated negative reinforcement
[Lack of personal satisfaction with assigned gender]
Defining Characteristics (“evidenced by”)
[Inability to form close, personal relationships] [Negative view of self]
236 ■ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION
[Expressions of worthlessness]
[Social isolation]
[Hypersensitivity to slight or criticism] Reports feelings of shame or guilt Self-negating verbalizations
Lack of eye contact
Goals/Objectives
Short-term Goal
Client will verbalize positive statements about self, including past accomplishments and future prospects.
Long-term Goal
Client will verbalize and demonstrate behaviors that indicate self- satisfaction with gender identity, ability to interact with others, and a sense of self as a worthwhile person.
Interventions With Selected Rationales
To enhance the child’s self-esteem:
Encourage the child to engage in activities in which he or
she is likely to achieve success.
Help the child to focus on aspects of his or her life for
which positive feelings exist. Discourage rumination about situations that are perceived as failures or over which the client has no control. Give positive feedback for these behaviors.
Help the client identify behaviors or aspects of life he or she would like to change. If realistic, assist the child in problem- solving ways to bring about the change. Having some control over his or her life may decrease feelings of powerlessness and increase feel- ings of self-worth and self-satisfaction.
Offer to be available for support to the child if he or she is feeling rejected by peers. Explore opportunities for enhancing peer acceptance. Having an available support person who does not judge the child’s behavior and who provides unconditional acceptance assists the child to progress toward acceptance of self as a worthwhile person.
Assess risk factors and warning signs for suicide and collabora- tively engage the client in developing a plan for personal safety. Client safety is a nursing priority.
Outcome Criteria
Client verbalizes positive perception of self.
Client verbalizes self-satisfaction about accomplishments and
demonstrates behaviors that reflect self-worth.
Client remains free from self-harm.
Sexual Disorders and Gender Dysphoria ■ 237 ■ SEXUAL DYSFUNCTIONS
Sexual dysfunctions may occur in any phase of the sexual response cycle. Types of sexual dysfunctions include the following:
1. Sexual Interest/Arousal Disorders
a. FemaleSexualInterest/ArousalDisorder:Thisdisorder is characterized by a reduced or absent interest or pleasure in sexual activity (APA, 2013). The individual typically does not initiate sexual activity and is commonly unreceptive to partner’s attempts to initiate. There is an absence of sexual thoughts or fantasies and absent or reduced arousal in re- sponse to sexual or erotic cues. The condition has persisted for at least 6 months and causes the individual significant distress.
b. MaleHypoactiveSexualDesireDisorder:Thisdisorder is defined by the DSM-5 as a persistent or recurrent defi- ciency or absence of sexual fantasies and desire for sexual activity. In making the judgment of deficiency or absence, the clinician considers factors that affect sexual functioning, such as age and circumstances of the person’s life (APA, 2013). The condition has persisted for at least 6 months and causes the individual significant distress.
c. Erectile Disorder: Erectile disorder is characterized by marked difficulty in obtaining or maintaining an erection during sexual activity or a decrease in erectile rigidity that interferes with sexual activity (APA, 2013). The problem has persisted for at least 6 months and causes the individual significant distress. Primary erectile disorder refers to cases in which the man has never been able to have intercourse; sec- ondary erectile disorder refers to cases in which the man has difficulty getting or maintaining an erection but has been able to have vaginal or anal intercourse at least once.
2. Orgasmic Disorders
a. Female Orgasmic Disorder: Female orgasmic disorder
is defined by the DSM-5 as a marked delay in, infrequency of, or absence of orgasm during sexual activity (APA, 2013). It may also be characterized by a reduced intensity of orgasmic sensation. The condition, which is sometimes referred to as anorgasmia, has lasted at least 6 months and causes the individual significant distress. Women who can achieve orgasm through noncoital clitoral stimulation but are not able to experience it during coitus in the absence of manual clitoral stimulation are not necessarily catego- rized as anorgasmic. A woman is considered to have primary orgasmic disorder when she has never experienced orgasm by any kind of stimulation. Secondary orgasmic disorder exists if the woman has experienced at least one
238 ■ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION
orgasm, regardless of the means of stimulation, but no
longer does so.
b. Delayed Ejaculation: Delayed ejaculation is characterized
by marked delay in ejaculation or marked infrequency or absence of ejaculation during partnered sexual activity (APA, 2013). The condition has lasted for at least 6 months and causes the individual significant distress. With this dis- order, the man is unable to ejaculate, even though he has a firm erection and has had more than adequate stimulation. The severity of the problem may range from only occa- sional problems ejaculating (secondary disorder) to a history of never having experienced an orgasm (primary disorder). In the most common version, the man cannot ejaculate dur- ing coitus but may be able to ejaculate as a result of other types of stimulation.
c. Premature (Early) Ejaculation: The DSM-5 describes premature (early) ejaculation as persistent or recurrent ejac- ulation occurring within 1 minute of beginning partnered sexual activity and before the person wishes it (APA, 2013). The condition has lasted at least 6 months and causes the individual significant distress. The diagnosis should take into account factors that affect the duration of the excite- ment phase, such as the person’s age, the uniqueness of the sexual partner, and frequency of sexual activity (Sadock et al., 2015). Premature (early) ejaculation is the most com- mon sexual disorder for which men seek treatment. It is par- ticularly common among young men who have a very high sex drive and have not yet learned to control ejaculation.
3. Sexual Pain Disorders
a. Genito-pelvicPain/PenetrationDisorder:Withthisdis-
order, the individual experiences considerable difficulty with vaginal intercourse and attempts at penetration. Pain is felt in the vagina, around the vaginal entrance and clitoris, or deep in the pelvis. There is fear and anxiety associated with anticipation of pain or vaginal penetration. A tensing and tightening of the pelvic floor muscles occurs during at- tempted vaginal penetration (APA, 2013). The condition may be lifelong (present since the individual became sexually active) or acquired (began after a period of relatively normal sexual function). It has persisted for at least 6 months and causes the individual clinically significant distress.
4. Substance/Medication-Induced Sexual Dysfunction
a. Withthesedisorders,thesexualdysfunctiondevelopedafter substance intoxication or withdrawal or after exposure to a medication (APA, 2013). The dysfunction may involve pain, impaired desire, impaired arousal, or impaired orgasm. Some substances/medications that can interfere with sexual
Sexual Disorders and Gender Dysphoria ■ 239
functioning include alcohol, amphetamines, cocaine, opi- oids, sedatives, hypnotics, anxiolytics, antidepressants, an- tipsychotics, antihypertensives, and others.
Predisposing Factors to Sexual Dysfunctions
1. Physiological
a. Sexual Interest/Arousal Disorders: Studies have corre-
lated decreased levels of serum testosterone with hypoactive sexual desire disorder in men. Evidence also suggests a re- lationship between serum testosterone and increased female libido (Sadock et al., 2015). Diminished libido has been ob- served in both men and women with elevated levels of serum prolactin (Wisse, 2015). Various medications, such as antihypertensives, antipsychotics, antidepressants, anxi- olytics, and anticonvulsants, as well as chronic use of drugs such as alcohol and cocaine, have also been implicated in sexual desire disorders, especially after chronic use. Prob- lems with sexual arousal may occur in response to decreased estrogen levels in postmenopausal women. Medications such as antihistamines and cholinergic blockers may pro- duce similar results. Erectile dysfunction in men may be attributed to arteriosclerosis, diabetes, temporal lobe epilepsy, multiple sclerosis, some medications (e.g., antihy- pertensives, antidepressants, anxiolytics), spinal cord injury, pelvic surgery, and chronic use of alcohol.
b. Orgasmic Disorders: In women, these may be attributed to some medical conditions (hypothyroidism, diabetes, and depression) and certain medications (antihypertensives, an- tidepressants). Medical conditions that may interfere with male orgasm include genitourinary surgery (e.g., prostatec- tomy), Parkinson’s disease, and diabetes. Various medica- tions have also been implicated, including antihypertensives, antidepressants, and antipsychotics. Transient cases of the disorder may occur with excessive alcohol intake. Although early ejaculation is commonly caused by psychological fac- tors, general medical conditions or substance use may also be contributing influences. Particularly in cases of secondary dysfunction, in which a man at one time had ejaculatory con- trol but later lost it, physical factors may be involved. Examples include a local infection such as prostatitis or a degenerative neural disorder such as multiple sclerosis.
c. Sexual Pain Disorders: In women, sexual pain disorders may be caused by intact hymen, episiotomy scar, vaginal or urinary tract infection, ligament injuries, endometriosis, or ovarian cysts or tumors. Painful intercourse in men may be attributed to penile infections, phimosis, urinary tract in- fections, or prostate problems.
240 ■ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION
2. Psychosocial
a. Sexual Interest/Arousal Disorders: A variety of individual
and relationship factors may contribute to hypoactive sexual desire or sexual arousal disorders. Individual factors include fears associated with sex; history of sexual abuse and trauma; chronic stress, anxiety, depression; and aging-related concerns (e.g., changes in physical appearance). Among the relationship causes are interpersonal conflicts; current physical, verbal, or sexual abuse; extramarital affairs; and desire or practices that differ from those of one’s partner. In general, the presence of sexual desire is influenced by sexual drives, self-esteem, ac- cepting oneself as a sexual person, good stress management, and good relationship skills; disruption in any of these areas can contribute to lower desire (Sadock et al., 2015).
b. OrgasmicDisorders:Numerouspsychologicalfactorsare associated with inhibited female orgasm. They include fears of becoming pregnant or damage to the vagina, rejection by the sexual partner, hostility toward men, and feelings of guilt regarding sexual impulses (Sadock et al., 2015). Vari- ous developmental factors may also have relevance to or- gasmic dysfunction. Examples include negative messages about sexuality from family, religion and culture, unwanted sexual experiences, or punishment for childhood sexual ex- perimentation (Donahey, 2016).
Psychological factors are also associated with inhibited male orgasm (delayed ejaculation). In the primary disorder (in which the man has never experienced orgasm), the man often comes from a rigid, puritanical background. He per- ceives sex as sinful and the genitals as dirty, and he may have conscious or unconscious incest wishes and associated guilt (Sadock et al., 2015). In the case of secondary disorder (pre- viously experienced orgasms that have now stopped), inter- personal difficulties are usually implicated. Premature (early) ejaculation may be related to a lack of physical aware- ness on the part of a sexually inexperienced man. The ability to control ejaculation occurs as a gradual maturing process with a sexual partner in which foreplay becomes more give- and-take “pleasuring” rather than strictly goal-oriented. The man becomes aware of the sensations and learns to delay the point of ejaculatory inevitability. Relationship problems such as a stressful marriage, negative cultural con- ditioning, anxiety over intimacy, and lack of comfort in the sexual relationship may also contribute to this disorder.
c. Sexual Pain Disorders: Penetration disorders may occur after having experienced painful intercourse for any or- ganic reason, after which involuntary constriction of the vagina occurs in anticipation and fear of recurring pain.
Sexual Disorders and Gender Dysphoria ■ 241
The diagnosis does not apply if the etiology is determined to be due to another medical condition. A variety of psy- chosocial factors have been identified in clients with sexual pain disorder. Clinicians report that frequently an individ- ual with this disorder has been raised in a strict religious environment where sex was associated with sin (Sadock et al., 2015). Early traumatic sexual experiences (e.g., rape or incest) may also contribute to penetration disorder. Other etiological factors that may be important include painful childhood experiences with surgical, dental, or pelvic examination; phobias associated with pregnancy, sex- ually transmitted infections or cancer; and catastrophizing or fear of pain (Bergeron, Rosen, & Corsini-Munt, 2016; Dreyfus, 2012; King & Regan 2014; Sadock et al., 2015).
Symptomatology (Subjective and Objective Data)
Absence of sexual fantasies and desire for sexual activity.
Discrepancybetweenpartners’levelsofdesireforsexualactivity.
Inability to produce adequate lubrication for sexual activity.
Absenceofasubjectivesenseofsexualexcitementduringsexual
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.
Genitalpainoccurringbefore,during,oraftersexualintercourse.
Fear or anxiety in anticipation of vaginal penetration, with
tensing or tightening of the pelvic floor muscles.
Common Nursing Diagnoses and Interventions
for Sexual Dysfunctions
(Interventions are applicable to various health-care settings, such as in- patient and partial hospitalization, community outpatient clinic, home health, and private practice.)
■ SEXUAL DYSFUNCTION
Definition: A state in which an individual experiences a change in sexual function during the sexual response phases of desire, excitation, and/or or- gasm, which is viewed as unsatisfying, unrewarding, or inadequate (NANDA International [NANDA-I], 2018, p. 305)
242 ■ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION Possible Contributing Factors (“related to”)
Ineffectual or absent role models Physical [or sexual] abuse Psychosocial abuse
Values conflict
Lack of privacy
Lack of significant other
Altered body structure or function (pregnancy, recent childbirth,
drugs, surgery, anomalies, disease process, trauma, radiation) Misinformation or deficient knowledge
[Depression]
[Pregnancy phobia]
[Sexually transmitted disease phobia] [Cancer phobia]
[Previous painful experience] [Severe anxiety]
[Relationship difficulties]
Defining Characteristics (“evidenced by”)
[Verbalization of problem:
Absence of desire for sexual activity
Absence of lubrication or subjective sense of sexual excite-
ment during sexual activity
Failure to attain or maintain penile erection during sexual
activity
Inability to achieve orgasm or ejaculation
Premature ejaculation
Genital pain during intercourse
Constriction of the vagina that prevents penile penetration]
Inability to achieve desired satisfaction
Goals/Objectives
Short-term Goals
1. Client will identify stressors that may contribute to loss of sexual function within 1 week.
or
2. Client will discuss pathophysiology of disease process that con- tributes to sexual dysfunction within 1 week.
For client with permanent dysfunction due to disease process:
3. Client will verbalize willingness to seek professional assistance from a sex therapist in order to learn alternative ways of achiev- ing sexual satisfaction with partner by (time is individuallydetermined).
Long-term Goal
Client will resume sexual activity at level satisfactory to self and partner by (time is individually determined).
Sexual Disorders and Gender Dysphoria ■ 243 Interventions With Selected Rationales
Assess client’s sexual history and previous level of satisfaction in his or her sexual relationship. This establishes a database from which to work and provides a foundation for goal setting.
Assess the client’s perception of the problem. The client’s idea of what constitutes a problem may differ from that of the nurse. It is the client’s perception on which the goals of care must be established.
Help the 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. Stress in all areas of life can affect sexual functioning. Client may be unaware of correlation between stress and sexual dysfunction.
Assess the client’s mood and level of energy. Depression and fatigue decrease desire and enthusiasm for participation in sexual activity.
Review medication regimen; observe for side effects. Many medications can affect sexual functioning. Evaluation of the drug and the individual’s response is important to ascertain whether the drug may be contributing to the problem.
Encourage the client to discuss the disease process that may be contributing to sexual dysfunction. Ensure that the client is aware that alternative methods of achieving sexual satisfaction exist and can be learned through sex counseling if he or she and the partner desire to do so. Client may be unaware that satisfactory changes can be made in his or her sex life. He or she may also be un- aware of the availability of sex counseling.
Provide information regarding sexuality and sexual functioning.
Increasing knowledge and correcting misconceptions can decrease feel-
ings of powerlessness and anxiety and facilitate problem resolution.
Make a referral for additional counseling or sex therapy, if re- quired. Client may even request that an initial appointment be made for him or her. Complex problems are likely to require assis- tance from an individual who is specially trained to treat problems related to sexuality. Client and partner may be somewhat embar- rassed to seek this kind of assistance. Support from a trusted nurse can provide the impetus for them to pursue the help they need.
Outcome Criteria
Client is able to correlate physical or psychosocial factors that interfere with sexual functioning.
Client is able to communicate with partner about their sexual relationship without discomfort.
Client and partner verbalize willingness and desire to seek assistance from a professional sex therapist.
or
4. Client verbalizes resumption of sexual activity at level satisfac- tory to self and partner.
244 ■ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION ■ PARAPHILIC DISORDERS
Paraphilic disorders are characterized by recurrent and intense sexual arousal of at least 6 months’ duration involving any of the following:
The preference for use of a nonhuman object.
Repetitive sexual activity with humans involving real or simu- lated suffering or humiliation.
Repetitive sexual activity with nonconsenting partners.
The individual has acted on these sexual urges, or the urges or
fantasies cause clinically significant distress or impairment in so- cial, occupational, or other important areas of functioning (APA, 2013). Many paraphilic behaviors are illegal sex acts, so an indi- vidual may come to the attention of legal authorities before he or she is introduced to psychiatric treatment for this disorder. It is not uncommon for individuals with paraphilias to exhibit multiple
paraphilias (APA, 2013).
Types of paraphilic disorders include the following:
Exhibitionistic Disorder: The major symptoms include re- current, 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 (APA, 2013). Mas- turbation may occur during the exhibitionism. Most individuals with exhibitionistic disorder are men, and the behavior is gen- erally established in adolescence.
Fetishistic Disorder: Fetishistic disorder involves recurrent, intense sexual urges, behaviors, or sexually arousing fantasies, of at least 6 months’ duration, involving the use of nonliving objects, a specific nongenital body part, or a combination of both (APA, 2013). Commonly, the sexual focus is on objects intimately associated with the human body (e.g., shoes, gloves, stockings) or on a nongenital body part (e.g., feet, hair). The fetish object is generally used during masturbation or incorpo- rated into sexual activity with another person to produce sexual excitation.
Frotteuristic Disorder: This disorder is defined as the recur- rent preoccupation with intense sexual urges or fantasies, of at least 6 months’ duration, involving touching or rubbing against a nonconsenting person (APA, 2013). Sexual excitement is de- rived from the actual touching or rubbing, not from the coercive nature of the act. The disorder is significantly more common in men than in women.
PedophilicDisorder:TheDSM-5describestheessentialfea- ture of pedophilic disorder as 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 years or older, and he or she is at least 5 years
Sexual Disorders and Gender Dysphoria ■ 245
older than the child. This category of paraphilic disorder is the
most common of sexual assaults.
Sexual Masochism Disorder: The identifying feature of this
disorder is recurrent, intense sexual urges, behaviors, or sexu- ally arousing fantasies, of at least 6 months’ duration, involving the act of being humiliated, beaten, bound, or otherwise made to suffer (APA, 2013). These masochistic activities may be fan- tasized, solitary, or with a partner. Examples include becoming sexually aroused by self-inflicted pain or by being restrained, raped, or beaten by a sexual partner.
Sexual Sadism Disorder: The essential feature of sexual sadism disorder is identified as recurrent, intense, sexual urges, behaviors, or sexually arousing fantasies, of at least 6 months’ duration, of acts involving the psychological or physical suffer- ing of another person (APA, 2013). The sadistic activities may be fantasized or acted on with a nonconsenting partner. In all instances, sexual excitation occurs in response to the suffering of the victim. Examples include rape, beating, torture, or even killing.
Voyeuristic Disorder: This disorder is identified by recur- rent, intense sexual urges, behaviors, or sexually arousing fan- tasies, 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 (APA, 2013). Sexual excitement is achieved through the act of looking, and no con- tact with the person is attempted. Masturbation usually accom- panies the “window peeping” but may occur later as the individual fantasizes about the voyeuristic act.
Transvestic Disorder: This disorder involves recurrent and intense sexual arousal (as manifested by fantasies, urges, or be- haviors of at least 6 months’ duration) from dressing in the clothes of the opposite gender. The individual is commonly a heterosexual man who keeps a collection of women’s clothing that he intermittently uses to dress in when alone. The sexual arousal may be produced by an accompanying fantasy of the individual as a woman with female genitalia or merely by the view of himself fully clothed as a woman without attention to the genitalia. Transvestism is identified as a disorder when it causes marked distress to the individual, or interferes with so- cial, occupational, or other important areas of functioning.
Predisposing Factors to Paraphilic Disorders
1. Physiological
a. Biological: Many studies have identified biologic abnor-
malities in individuals with paraphilias. Two common find- ings are that 74% have abnormal hormone levels and 24% have chromosomal abnormalities (Sadock et al., 2015).
246 ■ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION
Temporal lobe diseases, such as psychomotor seizures or tumors, have been implicated in some individuals with para- philic disorder. Abnormal levels of androgens also may con- tribute to inappropriate sexual arousal. The majority of studies have involved violent sex offenders, and the results cannot accurately be generalized.
2. Psychosocial
a. PsychoanalyticTheory:Thepsychoanalyticapproachde-
fines an individual with paraphilic disorder as one who has failed the normal developmental process toward heterosex- ual adjustment (Sadock et al., 2015). This occurs when the individual fails to resolve the Oedipal crisis and either iden- tifies with the parent of the opposite gender or selects an inappropriate object for libido cathexis.
b. Behavioral Theory: The behavioral model hypothesizes that whether or not an individual engages in paraphilic behavior depends on the type of reinforcement he or she receives following the behavior. The initial act may be com- mitted for various reasons. Some examples include recalling memories of experiences from an individual’s early life (especially the first shared sexual experience), modeling be- havior of others who have carried out paraphilic acts, mim- icking sexual behavior depicted in the media, and recalling past trauma, such as one’s own molestation (Sadock et al., 2015).
c. Oncetheinitialacthasbeencommitted,theindividualwith paraphilic disorder consciously evaluates the behavior and decides whether to repeat it. A fear of punishment or per- ceived harm or injury to the victim, or a lack of pleasure de- rived from the experience, may extinguish the behavior. However, when negative consequences do not occur, when the act itself is highly pleasurable, or when the person with the paraphilic disorder immediately escapes and thereby avoids seeing any negative consequences experienced by the victim, the activity is more likely to be repeated.
Symptomatology (Subjective and Objective Data)
Exposure of one’s genitals to a stranger.
Sexual arousal in the presence of nonliving objects.
Touching and rubbing one’s genitals against a nonconsenting
person.
Sexual attraction to or activity with a prepubescent child.
Sexual arousal from being humiliated, beaten, bound, or oth-
erwise made to suffer (through fantasy, self-infliction, or by a
sexual partner).
Sexual arousal by inflicting psychological or physical suffering
on another individual (either consenting or nonconsenting).
Sexual Disorders and Gender Dysphoria ■ 247
Sexual arousal from dressing in the clothes of the opposite gender.
Sexual arousal from observing unsuspecting people either naked or engaged in sexual activity.
Masturbationoftenaccompaniestheactivitiesdescribedwhen they are performed solitarily.
The individual is markedly distressed by these activities.
Common Nursing Diagnoses for Clients With Paraphilic
Disorders
(Interventions are applicable to various health-care settings, such as inpatient and partial hospitalization, community outpatient clinic, home health, and private practice.)
■ INEFFECTIVE SEXUALITY PATTERN
Definition: Expressions of concern regarding own sexuality (NANDA-I, 2018,
p. 306)
Possible Contributing Factors (“related to”)
Lack of significant other
Ineffective or absent role models
[Illness-related alterations in usual sexuality patterns] Conflicts with sexual orientation or variant preferences [Unresolved Oedipal conflict]
[Delayed sexual adjustment]
Defining Characteristics (“evidenced by”)
Reports difficulties, limitations, or changes in sexual behaviors or activities
[Expressed dissatisfaction with sexual behaviors]
[Reports that sexual arousal can only be achieved through variant
practices, such as pedophilia, fetishism, masochism, sadism,
frotteurism, exhibitionism, voyeurism]
[Desires to experience satisfying sexual relationship with another
individual without need for arousal through variant practices]
Goals/Objectives
(Time elements to be determined by individual situation.)
Short-term Goals
1. Client will verbalize aspects about sexuality that he or she would like to change.
2. Client and partner will communicate with each other ways in which each believes their sexual relationship could be improved.
248 ■ ALTERATIONS IN PSYCHOSOCIAL ADAPTATION Long-term Goals
Client will express satisfaction with own sexuality pattern.
Client and partner will express satisfaction with sexual
relationship.
Interventions With Selected Rationales
Take sexual history, noting client’s expression of areas of dis- satisfaction with his or her sexual pattern. Knowledge of what client perceives as the problem is essential for providing the type of assistance he or she may need.
Assess areas of stress in the client’s life and examine the rela- tionship with his or her sexual partner. Variant sexual behaviors are often associated with added stress in the client’s life. The relation- ship with his or her partner may deteriorate as individual eventually gains sexual satisfaction only from variant practices.
Note cultural, social, ethnic, racial, and religious factors that may contribute to conflicts regarding variant sexual practices. The client may be unaware of the influence these factors exert in cre- ating feelings of discomfort, shame, and guilt regarding sexual atti- tudes and behavior.
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.
Assist the therapist in a plan of behavior modification to help the client who desires to decrease variant sexual behaviors. Individuals with paraphilic disorders are treated by specialists who have experience in modifying variant sexual behaviors. Nurses can intervene by providing assistance with implementation of the plan for behavior modification.
Explain to client that sexuality is a normal human response and does not relate exclusively to the sex organs or sexual behavior. Sexuality involves complex interrelationships among one’s self- concept, body image, personal history, family and cultural influences, and all interactions with others. If client feels “abnor- mal” or very unlike everyone else, the self-concept is likely to be very low—he or she may even feel worthless. To promote feelings of self- worth and desire to change behavior, help him or her to understand that even though the behavior is variant, feelings and motivations are common.
Outcome Criteria
Client is able to verbalize fears about abnormality and inappro- priateness of sexual behaviors.
Client expresses desire to change variant sexual behavior and cooperates with plan of behavior modification.
Client expresses satisfaction with own sexuality pattern or sat- isfying sexual relationship with another.
