nursing mental health

1. SEXUAL DISORDERS
Prepared by:
Mrs.Akila.A, M.Sc (N), M.Sc (psy)
Associate Professor

2. INTRODUCTION
• In ICD10 gender identity disorders, disorders of sexual
preference and sexual development and orientation disorders
are listed under disorders of adult personality and behavior
• Sexual dysfunctions are listed under behavioral syndromes
associated with physiological disturbances and physical factors
• It is a disturbances in the sexual desire.

3. DEFINITION:
Sexuality is the constitution and life of an individual
relative to characteristics regarding intimacy . It reflect
the totally of the person and does not relate exclusively
to the sex organs or sexual behavior.
Sexual disorder is difficulty experienced by an individual
or a couple during any stage of a normal sexual activity,
including physical pleasure, desire, preference, arousal
or orgasm.

4. Gender identity is a person’s sense of maleness or
femaleness
Sexual identity is the pattern of a person’s biological
sexual characteristics: chromosomes, external and
internal genitalia, hormonal composition, gonads and
secondary sex characteristics

5. CLASSIFICATION
F64 Gender identity disorders:
• F64.0 Trans sexualism
• F64.1 Dual-role transvestism
• F64.2 Gender identity disorder of childhood
• F64.8 Other gender identity disorders
• F64.9 Gender identity disorder, un specified

6. F65 Disorders of sexual preference
• F65.0 Fetishism
• F65.1 Fetishistic transvestism
• F65.2 Exhibitionism
• F65.3 Voyeurism
• F65.4 Paedophilia
• F65.5 Sadomasochism
• F65.6 Multiple disorders of sexual preference
• F65.8 Other disorders of sexual preference
• F65.9 Disorder of sexual preference, unspecified

7. F66 Psychological and behavioural disorders associated
with sexual development and orientation
• F66.0 Sexual maturation disorder
• F66.1 Ego dystonic sexual orientation
• F66.2 Sexual relationship disorder
• F66.8 other psychosexual development disorders
• F66.9 Psychosexual development disorder, unspecified

8. Definition :
• “Gender identity disorders are characterized by disturbance
in gender identity i.e., the sense of one’s masculinity or
feminity is disturbed.” - Niraj
Ahuja-
• “Gender identity disorders as a group whose common
feature is a strong, persistent preference for living is a
person of the other sex.”
- DSM - IV- TR -

9. Epidemiology
Children
Among a sample of boys under age 12 reported desire to be the
opposite sex was 10%. Girls under age 12, the reported desire to be
the opposite sex was 5%
The sex ratio - 4 – 5 boys for each girl
Adults
 A sex ratio of 3 – 5 male patients for each female patient

10. Etiology
(i) Biological Factors
-Maleness and masculanity depend on fetal and perinatal
androgens.
-Testosterone can increase libido and aggressiveness in women
and estrogen can decrease libido and aggressiveness in men.
.

11. (ii) Psychosocial factors
•The interaction of children’s temperament, parents qualities
& attitudes
• The quality of mother – child relationship, A
mother’s death.

12. (i)Transsexualism :
In this, there is a persistent and significant sense of
discomfort regarding one's anatomic sex and a feeling that it is
inappropriate to one's perceived gender.
The person will be preoccupied with the wish to get rid of
one's genitals and secondary sex characteristics and to adopt
the sex characteristics of the other sex.

13. Male primary Female primary transexualism
transexualism
Primary transexualism
Onset - early childhood
Course - stable
Category - homogeneous
Primary transexuals are preoccupied with sex change (or)
sex reassignment surgery.
Two main types

14. Secondary transexualism
Onset – later in life
Course – severe
Category – homogeneous
The only common feature is a wish to change the anatomic sex.

15. Treatment :
- Counseling
- Sex change to the desired gender
Sex reassignment surgery(SRS) :
The first procedure was done in 1951 (Denmark) on an
American soldier George Jorgensen who become christine
Jorgensen after SRS. The first female – to – male SRS was
performed in1956
• The procedures include hormonal treatment phallaplasty,
castration, mastectomy, hysterectomy with salphingo -
oopherectomy which have been used in different combinations

16. Hormonal Treatment :
Biological men are treated with daily doses of oral estrogen for 2
years.
Biological women are treated with monthly or three weekly
injections of testosterone.

17. (ii)Gender identity disorder of childhood:
This is a disorder similar to trans sexualism, with a very
early age of onset.
This is characterized by
i. persistent and significant desire to be of the other gender
ii. Marked distress regarding the anatomic sex with strong
denial of anatomic sex in transexualism
iii. Involvement in traditional activities games and clothing
pattern of the perceived gender.
iv. Onset before Puberty

18. iii)Dual-role transvestism:
It is characterized by wearing clothes of the opposite sex
in order to enjoy the temporary experience of membership of
the opposite sex but without any desire for permanent sex
change.
(iv)Intersexuality:
The patients have gross anatomical or physiological
features of the other sex. For example, Turner's syndrome,
congenital adrenal hypoplasia.

19. PSYCHOLOGICAL AND BEHAVIOURAL DISORDERS
ASSOCIATED WITH SEXUAL DEVELOPMENT AND
MATURATION
• Sexual relationship disorder
• Sexual maturation disorder
• Ego dystonic sexual orientation

20. HOMOSEXUALITY
• Homosexuality in contrast to heterosexuality is the sexual relationship
between persons of the same sex.
Types
• Male homosexuals- Gay
• Female homosexuals- Lesbians or sapphic
Prevalence :
• In USA 4-6% of males
1-2% of females
5-10% of bisexuals.

21. Types of homosexual behaviour
• Only homosexuality
• No hetero sexuality
Obligatory
homosexuality
• Predominant homosexuality
• Occasionally hetero sexuality
Preferred
homosexuality
• Equal homosexuality and hetero
sexuality
Bisexuality
• Predominant hetero sexuality
• Occasional homosexuality
Situational
homosexuality
• Only hetero sexuality
• Fantasies of homosexuality
Latent homosexuality

22. TREATMENT
For seeking a change in sexual orientation:
• Psychoanalytic psychotherapy
• Behavior therapy
Aversion therapy
Covert sensitization
Systematic desensitization
• Supportive therapy
• Androgen therapy
For seeking removal of distress only :
• Psychoanalytic and supportive psychotherapy
• Drug therapy
Antidepressant and / or benzodiazepines

23. DEFINITION
“Paraphilias are disorders of sexual preference in which
sexual arousal occurs persistently and significantly in response to
objects which are not a part of normal sexual arousal.”
“A sexual deviation perversion or paraphilia is defined as
any sexual behaviour that is regarded as significantly different
from the standard establishment of local culture or subculture.”

24. TYPES
1.Fetishism
The word ‘FETISH’ means magical.
Seen in males
• The sexual arousal occurs either solely or predominantly with
a non-living object which is usually intimately associated with
the human body.”
• Fetish objects - shoes, gloves, bras, underpants, stockings
etc.
2. Fetishistic Transvestism
“The person actually or in fantasy wears clothes of the opposite
sex (cross-dressing) for sexual arousal.”
• Occurs in heterosexual males.
• “

25. 3. Exhibitionism
• “Exhibitionism is a persistent (or recurrent) and significant
method of sexual arousal by the exposure of one’s genitalia to
an unsuspecting stranger.”
• Seen in males
4. Voyeurism
• Voyeurism is a persistent or recurrent tendency to observe
unsuspecting persons (usually of the other sex ) naked,
disrobing or engaged in sexual activity.”
• Seen in males.

26. 5.Paedophilia
• Paedophlia is a persistent or recurrent involvement of an adult
(age >16 years and atleast 5 years older than the child) in
sexual activity with pre pubertal children, either heterosexual or
homosexual.”
• Common in males.
6. Sadomasochism
• “The person (the masochist) is sexually aroused by physical
and/or psychological humiliation, suffering or injury inflicted on
self by others (usually sadists).”Most often the masochist is a
female.

27. 7. Sexual sadism
• “The person (the sadist) is sexually aroused by physical and/or
psychological humiliation, suffering or injury of the sexual
partner.”
8. Multiple disorders of sexual preference
• Sometimes more than one disorder of sexual preference occurs
in one person.
• The most combination is fetishism, transvestism and
sadomasochism.

28. 9.Frotteurism
“This is a persistent or recurrent involvement in the act of
touching and rubbing against an unsuspecting, non- consenting
person (usually of other sex).”Seen in adolescent males.
10. Zoophilia:
It is a persistent and significant involvement in sexual activity
with animals.
11.Coprophilia
Coprophilia is sexual pleasure associated with the desire to
defecate on a partner and/or to be defecated on.

29. 12. Urophilia
Urophilia is a form of urethral eroticism, is interest in sexual
pleasure associated with the desire to urinate on a partner and/or
to be urinated on.
13.Klimpsaphilia
Klimpsaphilia is sexual arousal with enemas.
14.Necrophilia
Necrophilia is an obsession with obtaining sexual gratification
from cadavers.

30. TREATMENT
• Behaviour therapy
• Psychoanalysis
• Drugs:
- Antipsychotics----> Aggression

31. SEXUAL DYSFUNCTIONS
• It is a significant disturbance in the sexual response cycle,
which is not due to an underlying organic cause.
• SEXUAL RESPONSE CYCLE:
Phase I - desire
Phase II - excitement
Phase III - orgasm
Phase IV- resolution

32. TYPES OF SEXUAL DYSFUNCTION

33. SEXUAL DESIRE DISORDER
• It refers to a low level of sexual interest resulting in a failure to initiate or
respond to sexual intimacy.
PRE DISPOSING FACTORS:
1.Biological factors:
• Levels of serum testosterone
• Increased levels of serum prolactin
• Various medications
• Alcohol and cocaine use

34. Psychosocial factors:
Individual causes
• Religious orthodory
• Sexual identity conflict
• Post sexual abuse
• Financial, family or job problem
• Depression
• Aging- related concerns
Relationship causes
• Interpersonal conflict
• Current physical, verbal or sexual abuse
• Extramarital affairs
• Desire or practices that differ from those of the partner

35. Hypoactive sexual desire disorder
Definition:
Hypoactive sexual desire disorder is defined by the DSM IV TR(
APA,2000) as a persistent or recurrent deficiency or absence of
sexual fantasies and desire for sexual activity.

36. SEXUAL AVERSION DISORDER
Definition:
Sexual aversion disorder is characterized by a persistent or
recurrent extreme aversion to, and avoidance of, all (or almost
all) genital sexual contact with a sexual partner.
- APA(2000)

37. SEXUAL AROUSAL DISORDER
• It is an aberraction during any stage of the sexual response
cycle that prevents the experience of satisfaction through
sexual activity

38. PREDISPOSING FACTORS
Biological factors:
• Postmenopausal women
• Various medication
• Arteriosclerosis
• Some neurological
disorder
oDiabetes
oTemporal lobe
epilepsy
oMultiple sclerosis
oTrauma
• Chronic use of alcohol
Psychosocial factors:
• Psychological factors
• developmental factors
• Relationship factors

39. Female sexual arousal disorder
Female sexual arousal disorder is identified in the DSM-IV-TR as a
persistent or recurrent inability to attain, or to maintain until
completion of the sexual activity, an adequate lubrication /
swelling response of sexual excitement.
Male erectile disorder:
Male erectile disorder is characterized by persistent or
recurrent inability to attain, or to maintain until completion of the
sexual activity, an adequate erection.
-APA, 2000

40. ORGASMIC DISORDERS
• FEMALE ORGASMIC DISORDER(anorgasmia) : It is a persistent or
recurrent delay in, or absence of, orgasm following a normal sexual
excitement phase.
Types:
• Primary orgasmic dysfunction
• Secondary orgasmic dysfunction
• MALE ORGASMIC DISORDER: The man is unable to ejaculate,
even though he has a firm erection and has had more than adequate
stimulation.
• PREMATURE EJACULATION: persistent or recurrent ejaculation
with minimal sexual stimulation before, on, or shortly after
penetration and before the person wishes it

41. SEXUAL PAIN DISORDERS
• A condition in which sexual intercourse and intimacy evoke
discomfort and pain.
1.Dyspareunia: It is recurrent or persistent genital pain associate
with sexual intercourse either a men or a women.
Treatment:
• Physical and gynecological examinations
• Investigate sexual functioning
• Systematic desensitization

42. 2.Vaginismus is an involuntary constriction of the outer one third
of the vagina that prevents penile insertion or intercourse.
- APA,2000
Treatment:
• Education to couples.
• Hypnosis
• Systematic desensitization-Behaviour therapy
• Physical therapy
• Treat relationship problems
• Group therapy

43. Nursing intervention for the patient with sexual disorders:
• Assess patient’s sexual history .
• Note cultural, socio, ethnic, racial and religious factors that contribute to
conflicts regarding sexual practices.
• Refer for additional counseling or sex therapy if required.
• Provide information regarding sexuality and sexual functioning, correct any
misconceptions if necessary.
• Both the patient and their parents may need additional assistance if problems
in sexual relationship are severe or remain unsolved
• Assist therapist as necessary in plan of behaviour modification to help
decrease variant behaviour
• In all cases, an accepting and non-judgemental attitude on the part of the
nurse is highly essential for the successful resolution of these problems as
these are highly sensitive issues and may be causing significant distress to
the patient