Sexuality

SEXUALITY I.

FACTORS AFFECTING SEXUALITY

A.

DEVELOPMENTAL CONSIDERATIONS - sexuality is the only distinguishing trait present at conception - gender, or sex, influences behavior throughout life

Stages: Birth – 12 yrs = gender related By 3 yrs. = gender identity - obtain pleasure from touching/fondling genitals - toys are gender related - able to identify own gender Preschooler = increased awareness of body parts - sexuality has been internalized and preference for sexual partners determined - enjoys exploring body parts of self and playmates - engages in masturbation School Aged = gender role behaviors - tendency toward having same-sex friends - increasing self-awareness Adolescence = need information regarding changes; information obtained based on myths - develop opposite-sex relationships - masturbation is common - girls concerned w/reputations and self-image - become “hippy” and w/small waist - boys preoccupied w/competitiveness of sexual activity - increase in testes size and they drop further into place - increased perspirations and vaginal secretions Young / Middle Adulthood = premarital sex is common - may experiment w/various sexual expressions - develop own value system and respects values of others - women are in “childbearing” mode and searching for a mate; become menopausal w/an increased sex drive - men begin graying, having decreased ejaculations and sex drive Older Adulthood = orgasms may become shorter and less intense in both sexes - vaginal secretions decrease and period of resolution in men lengthens - fear loss of sexual abilities B.

CULTURE - every culture has its own norms dictating duration of sexual intercourse, methods of sexual stimulation and sexual positions - some cultures promote childhood sexual play, polygamy/monogamy, and puberty rites including male circumcision

- religious beliefs promote beliefs on premarital / extramarital coitus, homosexuality, and decisions on circumcision (male and female) C.

RELIGION - some view organized religion as having a generally negative effect on expression of sexuality - sexual expression other than male-female coitus are considered unnatural by some - concept of virginity came to be synonymous with purity, and sex became synonymous with sin - double standards and rigid regulations exists in many religions - sexual dysfunctions can be related to anguish over negative connotation of sex dictated by religion - many have recognized the importance of sold sex education w/in the realm of church - new interest in spirituality of marriage, supporting the intimate/sexual relationship of married couples - provides guidelines D.

ETHICS - healthy sexuality depends on freedom from guilt and anxiety - what one views bizarre, perverted or wrong may be natural and right to

another - if sexual expression is performed by consenting adults, is not harmful to them and is practiced in privacy, it is not considered a deviant behavior - many accept sexual expression of various forms E.

LIFESTYLE - both men and women are exposed to stress, and many are under considerable strain to perform and function in workplace as well as at home - stressors may be external (job, financial demands) or internal (competitive) - although some couples view sexual activity as a release from stressors of everyday life, most place sex far from the top of the list of things to do - crucial for relationships to set aside priority time - - if not for lovemaking, then for intimate, quiet contact - sexual expressions from heterosexual, homosexual, bisexual, and transsexual F.

HEALTH STATE 1. CHRONIC PAIN – individuals w/persistent pain might not desire any sexual contact - desire for human warmth and contact does not cease because of pain - altered or modified positions for coitus are sometimes necessary

2. pancreas

DIABETES – hormonal disease in which inadequate insulin secreted by - almost all hormonal disorders affect sexuality - women have more vaginal infections, lose orgasms abilities

and lubrication - most prevalent and well known - erectile dysfunction or impotence is a great concern - circulation problems - some men might be candidate for penile prosthesis - pharmacologic mgmt. may be indicated 3. CARDIOVASCULAR DISEASE – pts might experience much anxiety over the effect the illness will have on sexuality and sexual functioning - suggestions to reduce anxiety include trying different positions, rhythms or forms of intimacy - meds used to control hypertension frequently causes a chg in sexual functioning - may be relieved by modifying dose of med or switching to a different med - primary goal after MI is to allow the heart ample time to heal - ADL, including sexual activity, should be resumed gradually - stressors, (overexertion, alcohol consumption, emotional upheavals) should be avoided - after an uncomplicated MI, sexual activity may begin at about 3rd wk of recovery, beginning w/masturbation to partial erection in male - activity gradually increased until 3 mos after, when sexual intercourse may be resumed - comfortable position that places least stress on affected partner may be an option 4.

DISEASES OF JOINTS AND MOBILITY – affects young and old people - pain, fatigue, stiffness, and loss of ROM are most common - disease itself does not affect sexual functioning, although manifestation of it can cause discomfort and anxiety - motivation and positioning are influenced 5. SURGERY AND BODY IMAGE – performed to remove diseased tissue and repair body organs usually requires incision - most devastating kinds remove cancerous tissue and surrounding structures - pts need to adjust to major alteration in their bodies - after a mastectomy, a woman’s return to sexual functioning depends on many factors, such

as support of her partner, value placed on breast by the man or woman, and fear of discomfort during sexual activity - after an ostomy, pt may grieve over the loss of the natural means to eliminate waste (urine or feces), accompanied by learning to live with an obvious artificial device - many are anxious as to how this apparatus will affect their sex lives and how accepting their partner will be 6. disability

SPINAL CORD INJURIES – almost always results in some degree of permanent

- pts face multiple adaptations related to mobility, bowel and bladder control, sexual functioning, and role expectations - extent of sexual response depends primarily on level and extent of injury - ejaculation and orgasm are most likely to remain with low spinal injuries - women are more likely to experience orgasm than men but complain more about lack of physical sensations - many find other erogenous zones become more easily stimulated 7. MENTAL ILLNESS – the mind plays a powerful role in sexuality and any disruption of its functioning will no doubt cause some disturbance in sexual functioning - disorder such as mild depression can affect desire and functioning - some w/mental illness act out in sexual manner, such as touching themselves or removing clothing at inappropriate times and places 8. SEXUALLY TRANSMITTED DISEASE – describe infections that are almost always transmitted through direct sexual contact - fear of getting (or transmitting) STD may impair sexual functioning for some, but others engage in risky sexual behaviors w/out giving sufficient thought to their health - hard to control because partner(s) also need treatment which is difficult if partner is promiscuous or a one-time contact - condoms are not foolproof in preventing STDs Types: Chlamydia – most prevalent to date - intracellular bacteria w/vaginal discharge, burning on urination, urinary frequency, dysuria, and urethral soreness

- many women do not have symptoms Gonorrhea – “clap” or “drip” - men have purulent penile discharge, dysuria, frequency of urination - women have dysuria, abnormal menses, vaginal discharge, pelvic inflammatory disease - pharyngitis if oral sex practiced - untreated can result in infertility, skin rash w/lesions, and acute arthritis Syphilis – primarily has single painless genital lesions 10 days to 3 mos after exposure - secondarily has generalized skin rash, enlarged lymph nodes, fever that may appear 2 – 4 wks after appearance of lesions and may last several yrs - latently usually has no clinical symptoms present for as long as 20 yrs; may continue to involve and damage neurologic and cardiovascular organs; dementia; confusion; paralysis and paresis HIV (AIDS) – incidence high in IV drug users and homosexual and bisexual men - fatigue, diarrhea, wt loss, enlarged lymph nodes, fever, anorexia, and night sweats Human Papilloma Virus (Warts) – pale, soft, papillary lesions found around internal and external genitalia and perianal and rectal areas, varying in size - profuse watery vaginal discharge, dyspareunia, intense pruritus and vulvar irritation - males may or may not have lesions Trichomoniasis (Yeast Infections) – foul-smelling vaginal discharge, thin, foamy, and green in color, causes itching of vulva and vagina, burning on urination and dyspareunia; “strawberry” cervix may be seen on speculum exam G.

MEDICATIONS - some meds have side effects that affect sexual functioning - some people use illegal drugs because of their reputed ability to heighten sexual experience, but can have serious and even deadly side effects

II. A.

APPLICATION

OF

NURSING PROCESS

ASSESSMENT 1. SEXUAL HISTORY – information should include pt’s reproductive and sexual health

- pt who should have sexual history recorded include 1) any inpt or outpt receiving care for pregnancy, STD, infertility or contraception, 2) any pt experiencing sexual dysfunction, and 3) any pt whose illness will affect sexual functioning and behavior - begin with nonthreatening questions and progress to more sensitive concerns - begin with open-ended questions and progress to more specific - use language used by pt - assume all people do all things - excellent opportunity for nurse to teach by helping pts confront fears - nurse’s attitude will greatly affect pt’s response to interview - privacy is essential - - doors should be closed and no interruptions allowed - nurse sits close to pt and speaks in quiet, relaxed, objective tone of voice - eye contact and open body posture should be used - narrative form of recording is generally used because it allows interviewer to document data in many of pt’s own words 2.

SEXUAL DYSFUNCTION Men – erectile failure (impotence) = history of diabetes, spinal cord trauma, cardiovascular disease, surgical procedure, alcoholism - use of antihypertensions, antidepressants, or illicit drugs - mental depression that may be present premature ejaculation = pt defines dysfunction and ability to control - causative relationship factors like anxiety, guilt, lack of time, new partner retarded ejaculation = history of neurologic disorders, Parkinson’s disease, certain meds Women – inhibited sexual desire = use of oral contraceptives or hormonal therapy, alcohol or certain meds - history of sexual abuse, rape or incest, depression, or other sexual dysfunctions orgasmic dysfunction = communication pattern between pt and partner - usual sexual pattern and behavior dyspareunia = history of diabetes, hormonal imbalance, vaginal infection, endometriosis, urethritis, cervisitis or rectal lesions - use of antihistamines, alcohol, tranquilizers, or illicit drugs - ability for vaginal lubrication during sex - use of coital positions

- use of cosmetic or chemical irritants to genitals vaginismus = pattern of sexual activity (how often, level of arousal, orgasm) -

presence of other sexual dysfunctions history of sexual abuse, trauma or rape feelings regarding partner causative factors (fear of pregnancy, anxiety, guilt)

3. NURSING EXAMINATION – explain progressive steps of exam and what pt may feel during exam - responsibilities include providing information about exam, teaching, providing support during exam, assisting examiner, if appropriate, with any procedures or lab studies - keeping pt comfortable and respecting his/her privacy and modesty should be primary - some females are uncomfortable w/male examiners and vice versa for religious, cultural, or other reasons B.

ANALYSIS / DIAGNOSIS 1. INEFFECTIVE SEXUALITY PATTERNS – state in which an individual experiences or is at risk for chg in sexual health - sexual health is integration of somatic, emotional, intellectual, and social aspects of sexual being in ways that are enriching and that enhance personality, communication, and love - determine whether situation can be corrected by independent nursing interventions - some pts require expertise of other specialties - common etiologies are effects of meds, effects of alcohol consumption, effects of disease process, history of abuse, feelings of depression, guilt, anxiety, fear of rejection, miscommunication, fear of pain, effects of birth control methods, lack of knowledge, or effects of surgical procedure - further specified by loss of desire, increased desire, or chg in sexual expression - common etiologies include stress (lifestyle, job, family, finances, marital conflict), isolation, effects of pregnancy, feelings of depression, loss of privacy, loss of communication, relationship chg, effects of disease process, chg in body image, chg in self-concept, or loss of partner 2. SEXUAL DYSFUNCTION – state in which individual experiences or is at risk for chg in sexual function that

is viewed as unrewarding or inadequate - etiology of other problems such as loss of sexual partner, fear of pregnancy, loss of sexual functioning or desire, effects of disease process, sexual position pain, ineffective coping with body image, history of sexual abuse, loss of functioning due to surgical excision of genital body part, sexual guilt, effects of hormonal imbalance, lack of information, fear of rejection, marital separation or divorce, and fear of contracting STD C.

PLANNING - define individual sexuality - establish open patterns of communication w/significant others - develop self-awareness and body awareness - describe responsible sexual health self-care practices - practice responsible sexual expression - specific outcomes depend on nature of pt’s problem or concern, should be pt-oriented D.

IMPLEMENTING 1. ESTABLISHING TRUSTING RELATIONSHIP - impossible to address pt’s sexuality if trust has not been developed - project an objective, nonthreatening, and nonjudgmental attitude - stress information pt gives will be kept confidential - important to establish respect and empathy before discussing sexual issues - consider all of pt’s circumstances and life experiences 2. TEACHING ABOUT SEXUALITY AND SEXUAL HEALTH – major goals are a chg in knowledge, in pt attitude, or in behavior - offer information, dispel fears, and provide positive reinforcement - assist in modifying behaviors or learning new skills to increase quality of sexual health and functioning a. Correcting Sexual Myths and Promoting Body Awareness – many believe things about sex that have been heard from family or friends or as part of their culture that are not true or not based on scientific data - refute sexual myths and teach factual information during assessment - promote self-confidence and good self-concept - getting to know one’s physical body is important to healthy sexual development

- need to be aware of appearance of genitalia - assist in improving body awareness - knowing what looks normal can be of great importance so that abnormalities can be reported - Kegel exercises promote good vaginal tome by localizing and strengthening pubococcygeal muscle E.

CONTRACEPTIVE METHODS 1. BEHAVIORAL – abstinence can be a positive way of dealing w/sexuality when it represents a wellthought out decision regarding one’s mind, body, spirit, sexual health continuous abstinence involves not having any sex with a partner at all periodic abstinence and fertility awareness methods are two methods of contraception that involve charting a woman’s fertility pattern - used to prevent pregnancy temperature method = woman takes temp every morning before getting out of bed; temperature will rise between 0.4 – 0.8° F on day of ovulation and remain until next period cervical mucus method = mucus is normally cloudy, but a few days before ovulation becomes clear and slippery and can be stretched between the fingers indicating most fertile phase of cycle calendar method = chart menstrual cycle on calendar refraining from intercourse or using barrier method during “unsafe” days coitus interruptus (withdrawal) – oldest and most widely used contraceptive method - withdrawal of penis from vagina before ejaculation - pre-ejaculation can contain enough sperm to cause pregnancy - pregnancy is also possible if pre-ejaculation or semen is spilled onto vulva 2.

BARRIER METHODS diaphragm – dome-shaped device made of latex rubber that mechanically prevents semen from coming into contact w/cervix - fits between pelvic notch at front of vagina to behind cervix at back - must be individually fitted during pelvic exam

condom – rolled over erect penis and collects semen after ejaculation - if it does not have nipple receptacle end, sm space should be left at end to collect sperm - female condom also available - ringed pouch that unrolls in vagina - advantages include fact that male does not need to have an erection for pouch to be used and offers significant protection from STDs - better protection against STDs than any other birth control method because it blocks exchg of body fluids that may be infected cervical cap – thimble-shaped rubber device that is placed over cervix and may be left there for up to 3 days at a time - similar to diaphragm - can cause cervical inflammation and increase risk for pelvic infection spermicides – used with barrier methods but can be used alone - comes in creams, jellies, foams, and suppositories - not as effective alone as when combined w/another method 3.

HORMONAL oral contraceptives – “the pill” is most common contraceptive method - almost 100% effective in guarding against pregnancy - cost might be prohibitive to some women - woman must be motivated to take pill every day - health history and physical exam are necessary to obtain

prescription - smoking increases risks associated w/oral contraceptives norplant system – reversible, 5-yr, low-dose progestin-only contraceptive - consists of 6 matchstick-size capsules placed just under the skin of upper arm - most common side effect is chg in menstrual bleeding pattern, including prolonged menstrual bleeding, spotting between menstrual periods, or no bleeding at all transdermal contraceptive patch – supplies continuous daily circulating levels of ethinyl estradiol and norelgestromin - applied weekly on same day of ea wk for 3 wks, followed by a patch-free wk - four sites of application include lower abdomen, upper outer arm, buttock, or upper torso - demonstrates more effective use compared w/use of oral contraceptives

- most common side effects include breast symptoms, headache, application site reactions, nausea, upper respiratory tract infection and dysmenorrheal intrauterine devices – (IUD)object that is placed by physician or nurse practitioner w/in uterus to prevent implantation of fertilized ovum - made of flexible plastic that provides reversible birth control - mechanism by which it works is unknown - - seem to affect the way the sperm or egg moves 4.

EMERGENCY CONTRACEPTION “morning after” pill is designed to reduce risk of pregnancy after unprotected intercourse - provided as increased doses of specific oral contraceptive pills ideally w/in 72 hrs or insertion of copper IUD w/in 5 – 7 days 5.

Sterilization tubal ligation – regarded as permanent and irreversible (procedure for

females) - surgically severing of fallopian tubes - prevents ovum from traveling down tube - usually performed on outpt basis, sometimes under local anesthesia vasectomy- regarded as permanent and irreversible (procedure for males) - surgically severing vas deferens which prevents sperm from entering semen - must alternative form of contraception until 2 semen analyses with 0 sperm are produced (usually takes 4 – 6 wks)