OBJECTIVES:

1. Describe the behavior and dynamics of the paraphilias.
 

2. Identify responses of the nurse to individuals with maladaptive sexual behaviors.
 

3. Describe male and female sexual dysfunctions..
 

4. Plan interventions for clients who have problems with sexual dysfunction.
 

Required Reading:
Varcarolis(1998). Foundations of Psychiatric Mental Health Nursing. 3^rd edition.
Philadelphia: W.B. Saunders Company. ( Chapter 30, pp. 932- 951)
 

TWO CATEGORIES OF SEXUAL DISORDERS

I. Sexual Dysfunctions
(Note: you may need to read/review material covering human sexual response in a textbook--see Varcarolis or see your OB text(Olds/London/Ladewig), pp.194-196.)
 

Causes of dysfunction: biological, psychological, and couple-oriented factors.
 

NURSE'S ROLE IN SEXUAL DYSFUNCTION
    Think about the following questions:
    1. Where does sex and relationships fit into Maslow's Hierarchy?
    2. How does one's sex/sexuality affect other areas of needs?
    3. What are your personal feelings about your role as a nurse in the sexual functioning of
    clients?
    4. What is your comfort level in dealing with sexual dysfunction in clients?
 

Nursing Assessment
General guidelines for conducting a sexual assessment
    1. Examine your own feelings, attitudes, values and level of comfort before beginning the
    assessment.
    2. Ensure privacy, and ample time for the assessment.
    3. Begin with background information and fit the sexual assessment into the context of the
    overall assessment. Do not ask the questions on sexuality first.
    4. Questions about sexuality should begin with the least sensitive areas and move to the
    areas of greater sensitivity.
    5. Maintain appropriate eye contact and a relaxed interested manner.
    6. Avoid extreme reactions. Be professional and matter of fact about information asked
    or obtained.
    7. Use language that is professional but understood by the client being interviewed.
    8. Your voice and behavior should reflect trust. The client will be more open if he feels
    he can trust you.
 

Some Questions Which May Assist In Client Assessment:
    1. "How satisfactory is your sexual functioning?"
    2. " Many people have unanswered questions or need information about sexual functioning.
       What questions do you have about sex?"
   3. " Do you always engage in 'safe sex' practices? What does that entail for you?"
   4. " Most people are hesitant to discuss. . . Many people have concerns about. . . ."
   5. " Most people have difficulties at some time during their sexual relationships. Have you
      had any problems?"
 

Drug-Induced Sexual Dysfunction
    Drugs which commonly interfere with normal sexual functioning:
    alcohol, Amitriptyline, Cimetidine, Digoxin, Indomethacin, Lithium, Marijuana, Methyldopa,
    Metronidazole, Opiates, Phenytoin, Propanolol, Ranitidine, Thiazide diuretics, tobacco

Critical Thinking Exercise:
    Describe how you would interact with an individual who has a diagnosis of depression,
    is taking amitriptyline, and reports not being interested in his or her usual activities. How
    would you approach finding out if this includes sexual activity?
 

Nursing Diagnoses/Interventions
NANDA Diagnoses for Sexual Dysfunctions
    Sexual dysfunction
    Knowledge deficit, human sexuality
    Fear
    Anxiety
    Role performance, altered
    Self-esteem disturbance
    Communication, impaired, verbal
    Social isolation
    Pain
 

Interventions include client education: human sexual response cycle, sexual dysfunction (possible etiologies, symptoms, treatment options), and communication skills. Also referrals for treatment, support groups, community agencies. Nurse is important in providing support for the client -- allaying anxieties/fears, enhancing self-esteem, and ensuring client's participation in treatment regimen.
 

Netsearch at http://www.cmhc.com/guide/sexual.htm for articles related to the diagnosing and treatment of sexual dysfunctions.
 
 
 
 
 
 

II. Paraphilias(Psychosexual Disorders)

    The paraphilias are a group of behaviors commonly accepted by the clinical description of sexual deviations. Paraphilias include aberrant sexual activity; sexual deviation; expression of the sexual instinct in practices which are socially prohibited or unacceptable or biologically undesirable. It is important to acknowledge that people do not voluntarily decide what types of sexual arousal patterns they will have. Suggested etiologies for these disorders include chromosomal abnormalities, hormonal levels, history of sexual abuse, and possibly hereditary
factors. Most common paraphilias presenting as clinical problems are pedophilia, voyeurism,
and exhibitionism.

1. Fetishism - utilization of objects such as panties, rubber sheeting, for purposes of arousal; transvestic fetishism- the act of cross-dressing ( heterosexual males wearing female clothing ) to achieve sexual arousal

2. Transvestism - A sexual deviation characterized by overwhelming desire to assume the attire and be accepted as a member of the opposite sex; also called cross dressing or eonism.

3. Zoophilia - Sexual contact with animals; bestiality.

4. Pedophilia - Sexual activity of adults with children. Can include voyeurism, sex talk, touching and sex. Subdivided into homosexual or heterosexual ; may be exclusive or nonexclusive.

5. Exhibitionism - An abnormal tendency to display one's body or parts for the purpose, conscious or unconscious, of sexual arousal.

6. Masochism - A form of sexual perversion in which cruel or humiliating treatment gives satisfaction to the recipient; receiving of psychological or physical pain or domination.

7. Sadism - Sexual perversion in which satisfaction is derived from humiliating or hurting another.

8. Transsexualism - A disturbance of gender identity in which the affected person has overwhelming desires to change anatomic sex stemming from the conviction that he or she is a member of the opposite sex.

9. Coprophilia - sexual arousal by contact with feces.

10. Autoerotic Asphyxia - Constriction of the neck to enhance a masturbation experience.

11. Necrophilia - Morbid attraction to corpses; sexual intercourse.

12. Frotteurism - Sexual gratification by rubbing against the clothing of a person of the opposite sex.

13. Telephone scatologia - Calling a nonconsenting person and making sexual noises, using profanity while attempting to seduce or describe sexual activity. Often masturbates during the call.
 

Nursing Assessment
Clients with these disorders may also exhibit perceptual disturbances, cognitive distortions such
as denial and rationalization, disturbance in feelings such as lack of remorse, and other behavioral disturbances. Nurse's role in these disorders is essentially same as in dysfunction.
Many of these disorders , however , may also involve criminal offenses and client may be incarcerated. Psychotherapy and medications (Depoprovera and Depo-Lupron) are the main treatment modalities. No matter the treatment employed (pharmacological, cognitive, behavioral or combination of those) it is unlikely to be effective unless extended over a very long period.
 

Some Questions Which May Assist in Assessment for Paraphilias:
    1. "What brings you here for treatment?" (To assess client's degree of insight)
    2. "Do you think you have a sexual disorder?" (To determine if cognitive distortion is
    present)
    3. "Do you think you've caused any harm, either physically or emotionally to your
    victims?" (To determine if there is disturbance of feelings present)
    4. "What impact has this problem created on your lifestyle? Relationships?" (To
    determine the presence of disturbance in relationships)
 

See what you can find about paraphilias @ http://www.ampulove.com
 

References:
Fortinash and Holoday-Worret. Psychiatric Mental Health Nursing. St. Louis: C.V. Mosby.

Varcarolis, E. Foundations of Psychiatric Mental Health Nursing. 3^rd ed. Philadelphia: W.B.
Saunders.