Introduction
Normal sexuality is difficult to define. But it is easier to
define abnormal sexuality. Sexual behavior is diverse and
determined by a complex interaction of factors. It is affected by
relationships with others, by life circumstances, and by the
culture in which a person lives. Humans, like other animals, have
always been interested in sexuality and have depicted almost every
form of sexual behavior.
Meaning
Sexual dysfunctions are cognitive, affective, and / or behavioral
problems that prevent an individual or couple from engaging in and
/ or enjoying satisfactory intercourse and orgasm. Sexual
dysfunctions are also seen as disturbances in one more of the
sexual response cycle’s phases, or pain associated with arousal or
intercourse. Sexual dysfunction refers to a person’s inability to participate
in a sexual relationship as he or she would wish.
Classification: (DSM IV TR)
1) sexual desire disorder
- hypoactive sexual desire disorder
- sexual aversion disorder
2) sexual arousal disorder
- female sexual arousal disorder
- male erectile disorder
3) Orgasmic disorder
- Female orgasmic disorder
- Male orgasmic disorderPremature ejaculation
4) Sexual pain disorder
5) sexual dysfunction due to a general medical condition
ICD 10 Classification:
1.
Lack or loss of sexual desire
2.
Sexual aversion and lack of sexual enjoyment
3.
Failure of genital response
4.
Orgasmic dysfunction
5.
Premature ejaculation
6.
Non orgaanic vaginismus
7.
Non organic dyspareunia
8.
Excessive sexual drive
9.
Other sexual dysfunction
10.
Unspecified sexual dysfunction
TYPES:
I. sexual desire disorders :
a)Hypoactive sexual desire disorder :
It is characterized by a persistent or recurrent deficiency or
absence of sexual fantasies and desire for sexual activity. The
complaint is more common in women than in men.
b) Sexual aversion disorder :
This disorder is characterized by a persistent or recurrent
extreme aversion to, and avoidance of, all genital sexual contact
with a sexual partner.
Individuals displaying hypoactive desire are often neutral or
indifferent toward sexual interaction, but sexual aversion implies
anxiety, fear or
disgust in sexual situations.
II. Sexual arousal disorder:
a)
Female sexual arousal disorder:
It is characterized by the persistent or recurrent partial or
complete failure to attain or maintain the lubrication swelling
response of sexual excitement until the completion of the sexual
act.
b) Male erectile disorder :
It is characterized by the recurrent and persistent, partial or
complete failure to attain or maintain an erection to perform
the sex act.
Primary erectile dysfunction refers to cases in which the man
has never been able to have intercourse.
Secondary erectile dysfunction refers to cases in which the man
has difficulty getting or maintaining an erection but has been
able to have vaginal or anal intercourse at least once.
III. Orgasmic disorders:
a) Female orgasmic disorder:
It is characterized by persistent or recurrent delay in, or
absence of, orgasm following a normal sexual excitement phase In short, a women’s inability to achieve organism by
masturbation or coitus
Primary orgasmic dysfunction: Never experienced orgasm by
any kind of stimulation.
Secondary orgasmic dysfunction: Experienced at least one
orgasm, regardless of the means of stimulation, but no longer does
so. Sometimes referred to as an anorgasmia.
b) Male orgasmic disorder :
It is characterized by persistent or recurrent delay in, or
absence of orgasm following a normal sexual excitement phase.Sometimes called retarded ejaculation
A man with lifelong orgasmic disorder was never been able to
ejaculate during coitus.
Primary disorder: History of never having experienced an
orgasm.
Secondary disorder: Occasional problems in ejaculation.
c) Premature ejaculation :
It is described as persistent or recurrent ejaculation with
minimal sexual stimulation before, on, or shortly after
penetration and before the person wishes it.
35-40% of men treated for sexual disorders have premature
ejaculation as the chief complaints.
IV. Sexual pain disorders:
a) Dyspareunia: It is recurrent or persistent
genital pain occurring in either men or women before, during, or
after intercourse. More common in women
It is related to, and often coincides with, vaginismus.
In women, the pain may be felt in the vagina, around the vaginal
entrance and clitoris, or deep in the pelvis.
In men, the pain is felt in the penis
b) vaginismus: it is an involuntary constriction of
the outer one third of the vagina that prevents penile insertion
and intercourse.
V. Sexual dysfunction due to a general medical condition and
substance induced sexual dysfunction:
Types of medical conditions that are associated with sexual
dysfunction include; Neurological (multiple sclerosis, neuropathy)
Endocrine (diabetes mellitus, thyroid dysfunctions)
Vascular (atherosclerosis)
Genitourinary (testicular disease, urethral or vaginal
infections).
Substances (alcohol, amphetamines, cocaine, opioids, sedatives,
hypnotics, anxiolytics, antidepressants, antipsychotics and
antihypertensive).
ETIOLOGY: (Hgam, 1978).
1) Psychological causes:
Stress or anxiety from work or family responsibilities Concern about sexual performance
Conflicts in the relationship with partner.
Depression / anxiety
Unresolved sexual orientation issues.
Previous traumatic sexual or physical experience Body image and self esteem problems.
2) Physical causes :
Diabetes, hearts disease, liver disease, kidney disease, pelvic
surgery, pelvic injury or trauma, neurological disorders,
medication side effects, hormonal changes, alcohol or drug
abuse, fatigue.
3) Interpersonal relationship :
Partner performance and technique
Lack of partner
Relationship quality and conflict.
Lack of privacy
4) Socio cultural :
- Inadequate education
- Conflict with religious, personal or family values.
- Societal taboos.
TREATMENT:
Basic principles of direct treatment of sexual dysfunction (Lopiccolo,
1978)
- mutual responsibility information and education attitude change
- eliminating performance anxiety increasing communication and effectiveness of sexual technique
- changing destructive life styles and sex roles
- prescribing changes in behavior
1) Biological treatment :
a) Pharmacotherapy :
Sildenafil, oral phentolamine, alprostadil transurethral
alprostadil (erectile disorder)
Intravenous methohexital sodium has been used in desensitization
therapy.
Antianxiety agents.
Bromocriptive, a dopamine agonist, may improve sexual function
impaired by hyperprolocatinemia.
Dopaminergic agents have been reported to increase libido and
improve sex function.
b) Hormone therapy :
androgens increase the sex drive.
Antiandrogens have been used to treat compulsive sexual behavior
in men.
Antiestrogens increases libido
c) Mechanical treatment approaches :
Vacuum pump:
These are mechanical devices that patients
without vascular diseases can use to obtain erections. The blood
drawn in to the penis following the creation of the vacuum is kept
there by a ring placed around the base of the penis.
EROS: A device developed to create clitoral erections in
women. It is a small suction cup that fits over the clitoral
region and drawn blood in to the clitoris.
d) Surgical treatment:
Male prostheses
Vascular surgery
Hymenectomy for dyspareunia
Vaginoplasty and release of vaginal adhesions
2) Dual sex therapy: (William masters & Virginia Johnson)
Treatment is based on a concept that the couple must be treated
when a dysfunctional person is in a relationship Both are involved in a sexually distressing situation, both must
participate in the therapy program.
The keystone of the program is the round table session in which
a male and female therapy team clarifies, discusses, and works
through problems with the couple.
Treatment is short term and behaviorally oriented
Therapist suggests specific sexual activities.
Initially, intercourse is inter directed and the couple learn to
give and receive bodily pleasure without the pressure of
performance or penetration.
The aim of the therapy is to establish an effective
communication within the marital unit. Psychotherapy sessions follow each new exercise period, and
problems and satisfactions are discussed.
Specific techniques of exercises:
Vaginismus: Woman is advised to dilate her vaginal opening with
her fingers or with dilators
Premature ejaculation :
a) sequeeze technique is used to raise the
threshold of penile excitability. In this exercise the man or the
woman stimulates the erect penis until the earliest sensations of
impending ejaculation are felt. At this point, the woman
forcefully sequeezes the coronal ridge of the gland, the erection
is diminished, and ejaculation is inhibited.
b) stop start technique in which the woman
stops all stimulation of the penis when the man first senses an
impending ejaculation
Erectile disorder: sometimes told to
masturbate to prove that full erection and ejaculation are
possible. ·
Lifelong female orgasmic disorder: women is
directed to masturbate, sometimes using a vibrator.
3) Hypnotherapy :Focus specifically on the anxiety producing situation – that is,
the sexual interaction that results in dysfunction.
4) Behavior therapy : Behavior therapists assume that sexual dysfunction is learned
maladaptive behavior, which causes patients to be fearful of
sexual interaction. Hierarchy of anxiety provoking situations
Ranging from least threatening to most threatening
Systematic desensitization
Assertiveness training
5) Group therapy : Used to examine both intra psychic and interpersonal problems in
patients with sexual disorders. Groups can be organized in several ways.
6) Analytically oriented sex therapy : The sex therapy is conducted over a longer period than usual,
which allows learning or relearning of sexual satisfaction under
the realities of patient’s day-to-day lives.
Nursing management :
1) Sexual dysfunction: Assess client’s sexual history and previous level of
satisfaction in sexual relationship. Assess client’s perception of the problem Assess client’s level of energy
Review medication regimen, observe for side effects
Provide information regarding sexuality and sexual functioning
Refer for additional counseling or sex therapy if required.
2) Ineffective sexuality patterns.
- Take sexual history, noting client’s expression of areas of
dissatisfaction with sexual pattern.
- Assess areas of stress in client’s life and examine relationship
with sexual partner. Note cultural, social, ethnic, racial, and religious factors that
may contribute to conflict regarding variant sexual practices.
- Be accepting and non judgmental Assist therapist in plan of behaviour modification to help client
decrease variant behaviours.
- Teach client that sexuality is a normal human response and is not
synonymous with any sexual act. Client must understand that sexual
feelings are human feelings.
Conclusion: Nurse may become involved in the primary prevention process. The
focus of primary prevention is to intervene in home life or other
facets of childhood in an effort to prevent problems from
developing. An additional concern of primary prevention is to
assist in the development of adaptive coping strategies to deal
with stressful life situation.
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- Katherine MF, Worret PAH. Psychiatric mental health nursing. Mosby, St. louis : 2008.
- Louise Rebance shives. Psychiatric mental health nursing. Lippincott Williams & wilkins; Philadelphia : 2008.
- Leonardo F F et al. Sexual dysfunction in patients with OCD and Social anxiety disorder. The J of Nervous and Mental Disease. 195(3): 2007
- Anita HC et al. Symptoms of sexual dysfunction in patients treated for major depressive disorder. J Clin Psychiatry, 2007: 68: 1860-1866
- Rakesh G et al . A variant o Dhat syndrome. Indian journal of psychiatry, 49: 2007
- Arackal BS et al. prevalence of sexual dysfunction in male subjects with alcohol dependence. Indian journal of Psychiatry. 49(2):2007.
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