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. DIABETES – hormonal disease in which inadequate insulin secreted by
pancreas
- 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. SPINAL CORD INJURIES – almost always results in some degree of permanent

disability
- 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. APPLICATION OF NURSING PROCESS

A. 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 well-
thought 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)