SEXUALITY AND SEXUAL DISORDERS

Sex
Described as one of four drives that also include thirst, hunger and avoidance of pain

Sexual Acts
Occur when behaviours involve the genitalia and erogenous zones.

Sexuality
The result of biologic, psychological, social, and experiential factors that mold an individual’s sexual
development, self-concept, body image and behaviour.
Depends on four interrelated psychosexual factors.

Sexual Identity – Whether one is male or female based on biologic sexual characteristics

Gender Identity – How one view’s one’s gender as masculine or feminine; socially derived from
experiences with family, friends, and society

Sexual Orientation – How one views one’s self in terms of being emotionally, romantically, sexually, or
affectionately attracted to an individual of a particular gender

Sexual Behaviour – How one respond to sexual impulses and desires

Sexuality is associated with attractiveness, sensuality, pleasure, intimacy, trust, communication, love
and affection, affirmations of one’s gender identity, and reverence for life
It can be expressed verbally while talking to a significant other, it can be communicated in written forms
such as letters, poetry, or songs; and it can be expressed artistically.
Behavioural expressions of sexuality include actions such as looking, touching, hand-holding, and kissing
Sexuality can be influenced by cultural or ethnic factors, religious views, health status, physical
attributes, age, environment, or a personal

Normal Sexual Behaviour

 Refers to a sexual act that is acceptable in our society
 Occurs between consenting adults
 Lacks any type of force
 Performed in a private setting in the absence of unwilling observers
 Any acts that does not meet the criteria set forth in this definition is referred to as Abnormal
Sexual Behaviour
Nurses who are uncomfortable with or confused about their own sexuality may have difficulty discussing
sexual issues with clients
 Sexual concerns may conflict with the religious beliefs of both clients and staff members.
 Having respect for the client, examining your own feelings, and maintaining a non-judgemental
attitude are the standards for working with clients in any aspect of human sexuality
Overview of Gender Identity and Sexual Orientation
 Identity is the core of human existence.
 Understanding gender identity encompasses knowledge about sexual development,
interpersonal relationships, affection, intimacy, body image, and gender roles.
 Almost no information is available about the prevalence of gender identity disorders. Most
estimates are based on the number of individuals seeking sexual reassignment surgery
Terminology
 Sexual Identity
 The pattern of a person’s biologic sexual characteristics including chromosomes, external
genitalia, hormonal composition, gonads, and secondary sex characteristics.
 Gender Identity
 A person’s sense of maleness or femaleness.
 A boy with gender identity disorders:
 They are at odds with their body image
 They rigidly insist that their male sex organs are disgusting or that they will disappear when they
grow up.
 They elicit a variety of social reactions as they reject their own anatomy and demand that others
accept their feminine names and female identity
A girl with gender identity disorders:
 Have male companions and an avid companion of rough-and-tough play.
 They show no interest in dolls or playing house (unless they play the male role).
 They may refuse to urinate in a sitting position
 Claim that they have or will develop a penis
 Do not want to develop breasts or experience menses
 State that they will grow up to be a man.
Sexual Orientation
 Refers to the object of an individual’s sexual impulses
 Although normal gender identity may be established at an early age, such as 2 to 3 years, sexual
orientation may develop in conflicting or opposite ways as the child progresses through
different developmental stages.
Sexual orientation may be:
Heterosexual
 Opposite sex
Homosexual
 Same sex
Bisexual
 Both sexes
 A conflict between gender identity and sexual orientation may precipitate a gender identity
disorder in which the individual has a persistent desire to be, or believes that one is , of the
opposite sex and experiences extreme discomfort with one’s assigned sex and gender role.
Transgender
 – An umbrella term used to describe Transsexual
 Individuals whose sexual identities are entirely with the opposite sex
 Someone whose gender identity does not coincide with birth gender and the individual can be
bisexual, homosexual, or heterosexual
Transvestites
 Commonly called “cross-dressers”
 Those who derive sexual pleasure from dressing or masquerading in the clothing of the opposite
sex
Hermaphrodites
 A person having both male and female sex organs and other sex characteristics, either
abnormally or as the natural condition
Etiology of Gender Identity Development
 The etiology of gender identity is likely biologically determined and secondarily affected by
environment
Genetic and Biologic Theories
 Chromosomes are the carriers of genetic programing information.
 The male’s sperm cell determines the sex of the embryo at conception by adding either an X or a
Y chromosome to the X chromosome of the ovum.
 XY (male)
 XX (female
Klinefelter’s Syndrome
 Seen in males
 XXY chromosome grouping
 Male appears normal until adolescence, when low levels of testosterone result in small testes,
infertility, and a low level of sexual interest.
Turner’s Syndrome
 Seen in females
 XO grouping instead of XX combination
 Occurs as the result of a missing sex chromosome
 Female appears short in stature and lacks functioning gonads
 During puberty, breasts do not develop and menstruation does not occur
XYY Syndrome
 Seen in males
 Contributes to a slightly taller stature, low sperm count, and abnormalities of the seminiferous
tubules.
Xq21 Marker
 A genetic link between an unknown gene on the human X chromosome and male homosexual
behaviour
 Gene related to male homosexuality
 It was thought that this gene appeared to influence development of homosexual traits.
Imperato-McGinley
 Propose that gender identity continually evolves under the influence of androgens despite
contrary social forces.
Male Pseudohermaphrodites
 Individuals with an inherited deficiency of the enzyme 5 x-reductase
 Born with male genes and male internal organs but lack external male genitalia
 Declared female at birth and raised as girls
Experience a surge in testosterone and gender confusion as they develop emotions and physical signs of
masculinization
Ambiguous Genitalia
 A penis and a small vaginal opening
Psychosocial Theories
 Sigmund Freud theorized that gender identity problems result within the oedipal triangle when
conflict is fueled by both real family events and fantasies

Overview of Sexual Disorders

 Sexuality is an important aspect of intimate relationship. The Absence or presence of sexual
intimacy is a powerful indicator of health of a couple’s relationship. The impairment of sexual
function or presence of sexual disorders can make it difficult for partners to enjoy satisfying sex.
 Sexual disorders are generally classified as sexual dysfunction, paraphilia and sexual addiction.
Few systemic epidemiologic data are available regarding the prevalence of various sexual
disorders.

Human Sexual Responses

The Sexual Response Cycle
 The sexual response cycle is characterized by vasocongestion and myotonia.
 Vasocongestion: Engorgement of blood vessels with blood, which swells the genitals and
breasts during sexual arousal.
 Myotonia: Muscle tension.
The sexual response cycle consists of four phases: excitement, plateau, orgasm and resolution
Excitement Phase
 The first phase of the sexual response cycle, which is characterized by erection in the male,
vaginal lubrication in the female, myotonia, and increases in heart rate in both males and
females.
 In the excitement phase, men experience an erection, the scrotal skin thickens and the testes
become enlarged.
 In women, the vagina becomes lubricated, the clitoris swells and flattens. The breasts enlarge
and blood vessels near the surface become more prominent.
Plateau Phase
 The second phase of the sexual response cycle, which is characterized by increases in
vasocongestion, muscle tension, heart rate, and blood pressure in preparation for orgasm.
 In the plateau phase, breathing becomes rapid, like panting. Heart rate may increase to 100 to
160 beats per minute.
 In men the head of the penis shows some size increase and in women, the outer part of the
vagina swells, contracting the vaginal opening in preparation for grasping the penis.
Orgasmic Phase
 Orgasmic Phase: The third phase of the sexual response cycle, which is characterized by pelvic
contractions and accompanied by intense pleasure.
 In the male, semen collects at the base of the penis and muscle contractions propel the
ejaculate out of the body.
 Orgasm in the female is manifested in 3 to 15 contractions of the pelvic muscles that surround
the vaginal barrel.
Resolution Phase
 Resolution Phase: The fourth phase of the sexual response cycle, during which the body
gradually returns to its prearoused state. Unlike women, men enter a refractory period.
 Refractory period: A period of time following orgasm during which an individual is not
responsive to further sexual stimulation.

Clinical Symptoms and Diagnostic Characteristics of Sexual Disorders

Sexual disorders are categorized as:
Sexual Dysfunction Disorders
Involve an impairment of the sexual physiologic response.
Paraphilias
 Refer to disorders involving recurrent intense sexual urges and sexually arousing fantasies
generally involving nonhuman objects.
Sexual Desire Disorders
Hypoactive Sexual Desire Disorder
o The diagnosis of this disorder is used only if the lack of desire causes distress to the client or the
client’s partner.
Factors such as age, health, frequency of sexual desire (diminished libido), and lifestyle are considered
when interviewing the person seeking help.
Sexual Aversion Disorder
 This diagnosis is used if anxiety, fear, or disgust occurs when an individual is confronted with a
sexual opportunity.
Sexual Arousal Disorder
 Experience little or no subjective sense of sexual arousal.
 Hormonal pattern may contribute to responsiveness in women who have excitement-phase
dysfunction.
  Alterations in testosterone, estrogen, prolactin and thyroxin levels, as well as medications with
antihistaminic or anticholinergic properties, have also been implicated in sexual arousal disorder
 Termed as Male Erectile Disorder / Erectile Dysfunction is the inability to attain or maintain
erection adequate for sexual activity.
 Causes may be organic or psychological, or both.
 Risk factors include CD, cigarette smoking, and DM.
 Neurologic disorder associated with ED include spinal cord injury, multiple sclerosis, cerebral
vascular accident, Parkinsonism, and multisystem atrophy

Orgasmic Disorders
The diagnoses of female and male orgasmic disorder are used to describe recurrent, persistent inhibited
orgasm after an adequate phase of sexual excitement in the absence of any organic cause.
Females
 Fears of rejection, impregnation, or damage to the vagina; hostility to men; and guilt feelings
related to sexual desires and impulses
Males
 May include premature ejaculation (ie, ejaculation before the person wishes, due to absence of
reasonable voluntary control during sexual act) and retarded or inhibited ejaculation (ie,
ejaculation occurring during coitus with great difficulty).
Sexual Pain Disorders
Dyspareunia
 Used to describe recurrent, persistent genital pain in the female or male that occurs during or
after intercourse and is not due to a general medical condition.
Vaginismus
 Spasms of the musculature of the outer third of the vagina are recurrent, persistent, and
involuntary, thus interfering with the sexual act.

Sexual Dysfunction due to a General Medical Condition

 This disorder us distinguished from the previous disorders by the presence of clinically
significant sexual dysfunction that is due to the direct physiologic effects of a general medical
condition.
 Subtypes of this disorder include:
 Male or female hypoactive sexual desire disorder due to… (indicate the general medical
condition)
 Male erectile disorder due to…
 Male or female dypareunia due to…
 Other male or female sexual dysfunction due to…
Some common physical disorders include:
 Chronic pain syndrome
 Arteriosclerosis
 Diabetes
 Liver disease
 Hypertension
 Thyroid disorder
 STD’s
Can also be caused by treatment such as:
 Radiation therapy
 Nerve blocks
 Surgical procedures that physically alter the CNS
Medication/substances can diminished libido or sexual function by causing changes in the blood flow or
nervous system. Examples are:
 Alcohol
 Antihypertensive drugs
 Chemotherapeutic agents
 Cortisone
 Hormonal therapy used to treat cancer
 Narcotic analgesics such as mophine and codeine
 Antihistamines
 Anticonvulsants
 Antipsychotics
 Sedatives
 Recreational drugs

Paraphilias
 Disorders in which unusual or bizarre sexual imagery or acts are enacted to achieve sexual
excitement.
 These involves nonhuman objects, suffering or humiliation of oneself or another person, or
children.
 SEXUAL SADISM- an individual achieves sexual excitement from the psychological or physical
suffering of another
 SEXUAL MASOCHISM- involves the act of being injured, bound, humiliated, or otherwise made
to suffer.
Characteristics of Pharaphiliacs
 Emotional immaturity
 Fear of a sexual relationship that could result in rejection
 Shyness
 The need to prove masculinity
 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

PARAPHILIAS
Bestiality or Zoophilia
 Sexual contact with animals serves as a preferred method to produce sexual excitement. It is
rarely seen.
Exhibitionism
 Adult male obtains sexual gratification from repeatedly exposing his genitals to unsuspecting
strangers, usually women and children. He has strong need to demonstrate masculinity and
potency.
Fetishism
 Sexual contact with inanimate articles (fetishes) results in sexual gratification. Most often is a
piece of clothing or footwear. Its occurrence is almost exclusive to men who fear rejection by
members of opposite sex.
Sexual Masochism
 Sexual pleasure occurs while one is experiencing emotional or physical pain. The willing
recipient of erotic whipping is considered to be masochistic.
Frotteurism
 Sexual excitement is achieved by touching and rubbing against a nonconsenting person.
Necrophilia
 Sexual arousal occurs while the person is using corpses to meet sexual needs.
Pedophilia
 The use of pre-pubertal children is needed to achieve sexual gratification. Pedophilia can be an
actual sex or a fantasy.
Telephone Scatologia
 Sexual gratification is achieved by telephoning someone and making obscene remarks
Sexual Sadism
 Sexual gratification is experienced while the person inflicts physical or emotional pain on other.
Severe forms of this behavior may be present in schizophrenia.
Voyeurism
 The achievement of sexual pleasure by looking at unsuspecting persons who are naked,
undressing, or engaged in sexual activity. Individuals engaging in voyeurism are commonly called
“Peeping Toms”.
Transvestic Fetishism
 A heterosexual male achieves gratification through wearing the clothing of a woman (cross-
dressing). It is learned to response due to encouragement by family members. As a child, the
person was considered more attractive when dressed up as a girl.
SEXUAL ADDICTION
 Define as engaging in obsessive-compulsive sexual behavior that causes severe stress to
addicted individuals and their families.
 Approximately 6% to 8% of the population is affected by sexual addiction.
 Cybersex is a new but growing disorder that often goes undiagnosed.
 Children (middle school-aged boys) are becoming addicted to sex on the Internet.
 The unmanageability of addicts’ lives is seen in the consequences they suffer:
 School absenteeism/difficulty with school work
 Loss of relationship
 Difficulties with work
 Financial troubles
 Loss of interest in things but not sexual
 Low self-esteem
 Many sexual addicts have a dual diagnosis including substance abuse or depression.

EATING DISORDERS
ANOREXIA
 is a life threatening eating disorder characterized by the client's refusal or inability to maintain a
minimally normal body weight, intense fear of gaining weight or becoming fat, significantly
disturbed perception of the shape of the size or size of the body and steadfast inability or refusal
to acknowledge the seriousness of the problem or even the one exists.
Anorexia is classified into two subgroups:
Binge eating
 means consuming a large amount of food in a descrete period of usually 2 hours or less.
Purging
 Involves compensatory behaviors designed to eliminate food by means of self-induced vomiting
or misuse of laxatives, enemas or diuretics.

Clients with anorexia become totally absorbed in their quest of weight loss and thinness. These clients
do not lose their appetite. They still experience hunger but ignore it and signs of physical weakness and
fatigue. They often believe that if they will eat anything, they will not be able to stop eating and become
fat.

ETIOLOGY:
 A specific cause for disorders is unknown. Initially, dieting may be the stimulus that leads to
their development. Biologic vulnerability, developmental problems, and family and social
influences can turn dieting in an eating disorder
BIOLOGICAL FACTORS:
 Studies of anorexia nervosa and bulimia nervosa have shown that these disorders tend to run in
families, genetic vulnerability or it may directly involve a dysfunction of the hypothalamus. A
family history of mood or anxiety disorders places a person at risk for eating disorder.
 Disruptions of the nuclei of the hypothalamus may produce many of the symptoms of eating
disorder. Two sets of nuclei are important in many aspects of HUNGER and SATIETY.
DEVELOPMENTAL FACTORS:
 Two essential tasks of adolescence: Autonomy and Establishment of a unique identity
 May be difficult in families that ae overprotective or in which ENMESHMENT(lack of clear role
boundaries) because they do not support members’ efforts to gain independence and teenagers
may feel as though they have little or no control over their lives
 - So they begin to control their eating through severe dieting and thus gain control over their
weight.
 Characteristics of those who developed an eating disorder included:
 Disturbed eating habits
 Disturbed attitudes toward food
 Eating in secret
 Preoccupation with food, eating, shape or weight
 Fear of losing control over eating
 Wanting to have a competely empty stomach
 SELF-DOUBT and CONFUSION can result if the adolescent does not measure up to the person
he/she wants to be.
 Advertisements, magazines and movies that feature thin models reinforce the cultural belief
that slimness is attractive– Excessive dieting may be the way adolescent chooses to achieve this
ideal.
Body Image – How a person perceives his/her body, that is, a mental self-image
Body Image Disturbance – Occurs when there is an extreme discrepancy between one’s body image and
the perceptions of others and extreme dissatisfaction with one’s body image.

FAMILY INFLUENCES
 Girls growing up with family problems and no emotional support, abuse are at high risk for both
anorexia and bulimia. They place an intense focus on something concrete: Physical appearance.
 Childhood adversity – significant risk factor in the development of problems with eating or
weight in adolescence or early adulthood.
 *Adversity- physical neglect, sexual abuse, parental maltreatment: little care, affection, empathy
as well as excessive parental control, unfriendliness or overprotectiveness.
SOCIOLOGICAL FACTORS
 In some countries (US and Western countries), the media fuels the image of “IDEAL WOMAN” as
“Thin” is equal to beauty, desirability, and ultimately, happiness with being very thin, perfectly
toned, and physically fit.
 Adolescent often idealize actresses and models as having the PERFECT LOOK or body even
though many of them are underweight or use special effects to look thinner.
  Books, magazines, dietary supplements, exercise, equipments, plastic surgery advertisements &
weight loss Programs abound.
 Pressure from others may also contribute to eating disorder:
 COACHES, PARENTS, AND PEEERS
Emphasis placed on body form in sports such as GYMNASTICS, BALLET, WRESTLING can promote eating
disorders in athletes.

Teasing from parents or peers (bullying/peer harassment) reinforces a girl’s body dissatisfaction and her
need to diet or control eating in some way.

ANOREXIA NERVOSA:
ONSET AND CLINICAL COURSE
 Anorexia nervosa typically begins between 14 and 18 years of age. In early stages, clients often
deny they have negative body image or anxiety regarding their appearance. They are very
pleased with their ability to control body weight. As the illness progresses, depression and
liability in the mood become more apparent and client start to isolate themselves. This social
isolation can lead to basic mistrust of others and paranoia. Client may believe their peers are
jealous of their weight loss and believe that family and health care professional are trying to
make them “fat and ugly”.
TREATMENT AND PROGNOSIS
 Inpatient specialty eating disorders unit, partial hospitalization or day treatment programs and
outpatient therapy.
 The choice of setting depends on the severity of the illness such as weight loss, physical
symptoms, duration of binging and purging, drive for thinness, body dissatisfaction, and
comorbid psychiatric conditions.
 Short hospital stay are most effective for client who are amenable to weight gain, and gain
weight rapidly while hospitalized. Longer inpatients stays are required for those who weight
more slowly and are more resistant to gaining additional therapy.
MEDICAL MANAGEMENT:
Focuses on:
 Weight restoration
 Nutritional rehabilitation
 Correction of electrolyte imbalances
 Client must receive nutritionally balanced meal and snacks to increase caloric to normal
 *Severely malnourished clients may be required total parental nutrition, tube feedings or hyper-
alimentation to receive adequate nutritional intake.
 Access to the bathroom is supervised to prevent purging
PSYCHOPHARMACOLOGY:
DRUGS: USAGE:
Amitriptyline (Elavil) and Antihistamine Promote weight gain in patients with anorexia
cyprheptadine (Periactin) (28mg/day) nervosa
Olanzapine (Zyprexa) Used with success because of its antipsychotic
effect on bizzarre body image distortions)
Fluoxetine (prozac) Effective in preventing relapse in client whose
weight has been partially or completely restored

PSYCHOTHERAPY:
 Therapy focuses on the clients particular issues and circumstances such as coping skills, self-
esteem, self-acceptance, interpersonal relationships, and assertiveness.
 Cognitive behavioral therapy, long used with clients with bulimia, has been adopted with
anorexia nervosa and used successfully in initial treatment as well as relapse prevention.

BULIMIA
 A serious eating disorder that occurs chiefly in females, is characterized by compulsive
overeating usually followed by self-induced vomiting or laxative or diuretic abuse, and is often
accompanied by guilt and depression —called also bulimia nervosa.
ONSET AND CLINICAL COURSE
 Begins in late adolescence or early adulthood. 18-19 y/o is the typical age of onset.
 Between binging and purging episodes, clients may eat restrictively, Choosing salads and other
low-calorie foods. This restrictive eating effectively sets them up for the next episode of binging
and purging, and the cycle continues.
 Death rate from Bulimia is estimated at 3% or less
TREATMENT AND PROGNOSIS
Cognitive-behavioural therapy
 CBT is the MOST EFFECTIVE treatment for Bulimia. Strategies designed to change client’s
thinking and actions about food on interrupting the cycle of dieting, binging and purging and
altering dysfunctional thoughts and beliefs about food, weight, body image, and overall self-
concept
PSYCHOPHARMACOLOGY:
 ANTI-DEPRESSANTS to treat bulimia
 Desipramine (Norpramin)
 Imipramine (Tofranil)
 Amitriptyline (Elavil)
 Nortriptyline (Pamelor)
 Phenelzine (Nardil)
 Fluoxetine (Prozac) – approved to treat BULIMIA
GENERAL APPEARANCE AND MOTOR BEHAVIOR:
ANOREXIA NERVOSA
appear slow, lethargic, fatigue
BULIMIA NERVOSA
may be underweight or overweight but are
generally close to expected body weight for age
and size

slow respond to questions and have difficulty generally appearance is not unusual and they
deciding on what to say appear open and willing to talk
often reluctant to questions because they don’t
want to answer any problem
often wear loose fitting clothes regardless of the
weather
eye contact may be limited
clients may turn away to nurses indicating their
unwillingness to discuss problems

MOOD AND AFFECT:

ANOREXIA NERVOSA
seldom laugh, smile or enjoy attempts at humor;
they are somber and serious most of the time
BULIMIA NERVOSA
Initially pleasant and cheerful as though nothing is
wrong. The pleasant way fades when they begin
describing binge eating and purging; they may feel
or express of guilt, shame and embarrassment

THOUGHT PROCESS AND CONTENT

 Clients with eating disorders spend most of the time thinking about dieting, food and food
related behavior. Clients cannot think about themselves without thinking of weight and food.
The body image can be delusional; even if clients are underweight, they can point to areas on
their buttocks or thighs that are still fat, there by fueling their need to continue dieting.
 Clients with anorexia who are underweight severely believe they have" enemies" who are trying
to make them fat by forcing them to eat.

SENSORIUM AND INTELLECTUAL PROCESS

 Generally, clients with eating disorders are alert and oriented; their intellectual functions are
intact. Except for anorexia who are severely malnourish and showing signs of starvation, such as
mild confusion, slowed mental process and difficulty with concentration and attention.

JUDGEMENT AND INSIGHT:

ANOREXIA NERVOSA
have very limited insight and poor judgement
about their health status. They do not believe they
have a problem; rather they believe other are
trying to interfere with their ability to lose weight
and to achieve desired body image
BULIMIA NERVOSA
are ashamed of the binge eating and purging. They
recognize these behaviors as abnormal and go to
great lengths to hide them. They feel out of
control even though they recognize their
behaviors as pathologic.
SELF CONCEPT
 Low self-esteem is prominent with clients with eating disorders. They see themselves only in
terms of their ability to control food intake and weight. Client often perceive themselves as
helpless, powerless, ineffective, this feeling of lack of control over themselves and their
environment only strengthens their desire to control their weight.

ROLES AND RELATIONSHIP

 Clients with anorexia may begin to fail at school, which is in sharp contrast to previously
successful academic performance; Withdraw from peers and pay little attention to friendships
because they believe others will not understand them.
Clients with bulimia feel great shame about their binge eating and behaviour. As a result, they tend to
lead secret lives that include sneaking behind the backs of friends and family to binge and purge in
privacy.

PHYSIOLOGIC AND SELF-CARE CONSIDERATIONS

 Health status of these clients relates directly to the severity of self-starvation, urging behaviour
or both. Clients may exercise excessively almost to the point of exhaustion to control weight,
have sleep disturbances such as insomnia. Those who frequently vomit have many dental
problems such as dental carries

NURSING DIAGNOSIS
 Imbalanced Nutrition: Less than/More than body requirements
 Ineffective Coping
 Disturbed body image