NUR 168: CHAPTER 45: SEXUALITY:

Causes of Menstrual Cycle Irregularities: Premature ovarian failure:

- Refers to the loss of normal ovarian function before age 40. Women who have premature ovarian failure, also known as primary ovarian insufficiency, may have irregular or infrequent periods for years.

Causes of Menstrual Cycle Irregularities: Eating disorders, extreme weight loss, extreme exercise:

- Eating disorders (such as anorexia nervosa), extreme weight loss, and increased physical activity can disrupt menstruation.

Sexual Identity:

- Encompasses a person's self-identity, biological sex, gender identity, gender role behavior or expression, and sexual orientation

Categories of Patients Requiring Sexual History:

- Patients seeking care for pregnancy, STI, infertility, or contraception - Patients experiencing sexual dysfunction: d/t painful intercourse (dyspareunia) from medications such as antihistamines for women or blood pressure medications for me. - Patients whose illness will affect sexual functioning: Diabetes and medication, Multiple Sclerosis, Paralysis, - Patients of Sexual Assault, as females are 3 times more likely to suffer from depression - Patient who has suffered a MI & is looking for ways of sexual expression (The Brain for sexual arousal & stimulation)

Gender Dysphoria:

- People who experience discomfort or distress because their biological sex at birth is contrary to the gender they identify with are diagnosed with

Cisgender:

- Refers to a gender identity or role performance that matches society's expectations based on biological sex. - For example, a woman who identifies as cisgender would have a vagina and clitoris (biologically female), and would identify as female (gender).

Sexual Orientation: Gay or Lesbian:

- Refers to a person attracted to members of the same gender. (Note that the term homosexual is outdated and no longer considered appropriate)

Sexual Orientation: Bisexual:

- Refers to a person who is attracted to both men and women. - A bisexual relationship or encounter does not necessarily mean a person is gay.

Sexual Orientation: Questioning:

- Refers to a person who is unsure of his/her/their sexual orientation.

Sexual Orientation: Asexual:

- Refers to a person who lacks romantic or sexual attraction to others.

Sexual Orientation: Heterosexual:

"straight" - Refers to a person who experiences sexual fulfillment with a person of the opposite gender.

Menstruation:

- (Period) menses, vaginal bleeding that is monthly for 3-7 days, with average blood loss 30-80ml. - Cycles are about 28 days but may vary from 21 to 40 days

Male Sexual Dysfunction: Erectile Dysfunction:

- (also called impotence), - is the inability of a man to attain or maintain an erection to such an extent that he cannot have satisfactory intercourse. - Common causes of impotence (which may be physiologic or psychological) include various illnesses, treatments for these illnesses, and personal anxieties. - New medications have revolutionized treatment for erectile dysfunction. Assessment Priorities: • Assess for history of diabetes, spinal cord trauma, cardiovascular disease, surgical procedure, or alcoholism. • Assess for use of certain medications such as antihypertensives, antidepressants, or illicit drugs. • Determine degree of mental depression that may be present. • Obtain specific information regarding the degree of impotence, length of time of disorder, or continuing life factors.

Gender Binary:

- (male or female identification) is not the only option - Gender fluid describes a person whose gender identification and behaviors shift from time to time, whether within or outside of societal, gender-based expectations. - There is an emerging understanding that external genitalia do not always dictate gender identification or gender expression. Some people identify as nonbinary, and may prefer the gender-neutral pronouns they and their rather than him/her or his/her. - Each person's experience is individual, and the vocabulary and terms continue to evolve. - There is a growing understanding that asking people what their preferred pronouns are is appropriate.

Menarche:

- 1st menstrual period occurs approx. age 12 but can range from age 8-17 before it occurs

Female Sexual Dysfunction: Vulvodynia:

- A chronic vulvar discomfort or pain characterized by burning, stinging, irritation, or rawness of the female genitalia that interferes with sexual activity, is particularly problematic because little is known about its cause or treatment.

Causes of Menstrual Cycle Irregularities: Pregnancy or breast-feeding:

- A delayed or missed period can be an early sign of pregnancy. Breast feeding typically delays the return of menstruation after pregnancy.

Transgender (Trans):

- A term that describes a wide range of experiences or identities where gender identification and expression differ from societal expectations that are based on a person's biological sex. - For example, a person born biologically male (penis and scrotum) may identify as female (gender). - Transgender is an inclusive term used to describe those who feel that the sex that was assigned to them at birth incompletely describes or fails to describe them. This term includes: - People who have a gender expression that differs from their biological sex (according to societal norms) - People who are transsexual—that is, people who live full-time as members of a gender that differs from the sex and gender they were assigned at birth - People who are intersex—that is, people whose reproductive or sexual anatomy does not fit the typical definition of male or female - People who identify outside the female/male binary - People who identify as having no gender or multiple genders - For many transgendered people, the solution is to change their bodies, through surgery, hormone therapy, or both, to match their inner feelings; this process is referred to as transitioning. - The surgery is frequently referred to as gender affirmation surgery or gender confirmation surgery. - The terminology used for the surgery is significant: It reinforces the belief that the surgery is realigning a person with their actual gender. - Teens who are transgender face the reality of puberty, where their body will go through biological changes that betray who they feel they are or who they want to be. - Puberty blockers, medications that pause puberty, may be taken to block secondary sex characteristics for a few years. T - hey are generally safe, and their effects are reversible. - Exogenous hormones (testosterone or estrogen) may also be administered. When the teen reaches the age of consent and has solidified his or her gender identification, surgery may be a viable, even medically necessary option. - Typically, genital surgery requires two mental health evaluations to confirm gender dysphoria, capacity for informed consent, 12 continuous months of hormone use, control of significant medical or mental health concerns, and living in the gender to which a person is transitioning

Forms of Sexual Expression: Sexual Intercourse:

- Act of intercourse (coitus or copulation) is the insertion of the penis into the partner's vagina, anus, or mouth. - It usually begins by stimulation of the senses in some way, followed by a period of activity known as foreplay. - "Petting" is part of foreplay; it can involve simple stroking of the breasts, arms, back, and neck without genital involvement or may lead to mutual masturbation and orgasm.

Teaching About Sexual Health:

- Asking about sexual history is sensitive subject. Good way to ask: "How would you describe the problem?" or "Have you noticed this previously?" - Menstrual discharge is odorless until is meets air and then comes pungent. Deodorized pads and tampons do little to minimize odor. - Especially when girls 1st get their menses, we need to emphasize good hygiene and regular bathing. - When teaching about sexuality to teenagers, the nurse should include that sexuality is how one individual experiences maleness or femaleness physically, emotionally, and mentally. This may be when a patient is defining, redefining their sexuality. - Teaching patients to be comfortable with themselves, promoting body awareness, and refuting sexual myths. - Refuting that masturbation is bad. More that it is something that can be done daily and should be considered as normal activity, called self-stimulation. - Self-stimulation is not limited to one gender or an age group. It means, any gender and age group, can do self-stimulation. - Nocturnal emissions (Wet dreams)are normal, common physiology in at least 85% of males. They also occur with women and increase with older women. Stress to parents this is normal phenomena for teenaged boys.

The Better Model Acronym:

- BRING up the topic of sexuality - EXPLAIN that you are concerned with all aspects of patients' lives affected by disease - TELL patients that sexual dysfunction can happen and that you will address their concerns - TIMING is important to address sexuality with each visit - EDUCATE patients about the side effects of their treatments and that side effects may be temporary - RECORD your assessment and interventions in patients' medical records

Health State Affecting Sexuality: Cardiovascular Disease:

- Cardiovascular disease is prevalent in North America, and the sexual response cycle can greatly increase the demands on the heart and other structures. - A person with a cardiovascular disease may experience much anxiety over the effect the illness will have on sexuality and sexual functioning.

Menopause:

- Cessation of menstrual cycle between ages 45-55, experiencing irregular menses over time until it ends

Health States Affecting Sexuality:

- Chronic pain - Diabetes mellitus - Cardiovascular disease: MI, HF need to focus on methods of sexual expression-think Brain as it's most important for arousal and stimulation. - Diseases of the joints and mobility - Surgery and body image - Spinal cord injuries - Mental illness - Medications: antihistamines, b/p meds, pain meds

Female Sexual Dysfunction: Inhibited Sexual Desire:

- Consists of an inhibition in sexual arousal so that congestion and vaginal lubrication are absent or minimal. - Causative factors may be anxiety, negative emotions, fear, interpersonal problems, or physical factors. - Orgasmic dysfunction is defined as the inability of a woman to reach orgasm. - The causes are similar to those of inhibited sexual desire. Assessment Priorities: • Assess for use of oral contraceptives or other hormonal therapy, use of alcohol or certain medications. • Assess for history of sexual abuse, rape or incest, depression, or other sexual dysfunctions. • Assess any other contributing or relationship factors.

Patient Outcomes Regarding Sexuality:

- Define individual sexuality. - Establish open patterns of communication with significant others. - Develop self-awareness and body awareness. - Describe responsible sexual health self-care practices. - Practice responsible sexual expression.

Four Phases of Sexual Response Cycle: 3. Orgasm:

- Defines the climax and sexual explosion of the tension that has been building over the preceding phases. - Orgasm lasts only seconds but is an extremely intense reaction. - Characteristics of the orgasm phase are the involuntary spasmodic contractions of the genital organs. - The number of contractions felt by the person depends on the intensity of the orgasm. - The orgasm phase in the female begins with a heightened feeling of physical pleasure, followed by overwhelming release and involuntary contractions of the genitals. Loss of muscular control may cause spastic contractions and twitching of the arms and legs. - The number of contractions can be as few as 4 or as many as 20. - Areas of the body that contract spasmodically are the uterus, anal sphincter, rectum, and urethral sphincter. - It is believed that women achieve orgasm in a variety of ways. - Although some women can achieve orgasm by penile thrusting in the vagina alone, most women need clitoral stimulation to reach orgasm. - During orgasm in the male, involuntary spasmodic contractions occur in the penis, epididymis, vas deferens, and rectum. - The male orgasm is most often accompanied by ejaculation of semen from the urinary meatus of the penis. - Ejaculation and orgasm usually, but not necessarily, occur at the same time.

Prevention Of Sexually Transmitted Diseases (STIs):

- Delay having sexual relations as long as possible - Have regular checkups for STIs - Learn the common symptoms of STIs, such as HPV which can lead to greater risk of cervical cancer - Avoid having sex during menstruation - Avoid anal intercourse: Anal to vaginal intercourse between men with women puts her at greater risk of vaginal infections. - Avoid douching: Issues occur with daily douching

Male Sexual Dysfunction: Retarded Ejaculation:

- Delayed ejaculation, also called ejaculatory incompetence, refers to a man's inability to ejaculate into the vagina, or delayed intravaginal ejaculation. - The causes of this problem are similar to those of impotence. When it occurs after the man has experienced normal ejaculations, the cause is most likely due to interpersonal problems. Assessment Priorities: • Assess for history of neurologic disorders, Parkinson's disease, or use of certain medications. • Use the same assessment priorities as for premature ejaculation.

Health States Affecting Sexuality: Diabetes Mellitus:

- Diabetes mellitus (DM) is a hormonal disease in which an inadequate amount of insulin is secreted by the pancreas. - Although almost all hormonal disorders affect sexuality in some way, diabetes is the most prevalent and well known. - Erectile Dysfunction, or impotence, is a great concern among men with type 2 diabetes. - Treatment to date depends largely on the degree of erectile ability lost. - Some men may be candidates for a penile prosthesis - The prosthesis is surgically implanted below the base of the penis, and inflation of the device produces an erection when sexual activity is desired. - Pharmacologic management (e.g., sildenafil, vardenafil, or tadalafil) may also be indicated. - Women with type 2 diabetes may also experience loss of capacity for orgasm (orgasmic dysfunction). - Difficulty experiencing arousal and loss of vaginal lubrication have also been reported. - Women with diabetes are more prone to urinary tract or vaginal infections, which can cause discomfort during coitus.

Factors Effecting Sexuality: Ethics:

- Healthy sexuality depends on freedom from guilt and anxiety. - What one person believes is wrong may be perfectly natural and correct to another. - Some people may feel that certain forms of sexual expression are bizarre, and the people who participate in them are perverted. - If the sexual expression is performed by consenting adults, is not harmful to them, and is practiced in privacy, it should not be considered a deviant behavior. - People should personally decide which aspects of sexual expression are comfortable for them. - Frequently, all a person needs to alleviate guilt, and consequently enhance sexual satisfaction, is permission from a health care professional to engage in a different form of expression.

Four Phases Of The Menstrual Cycle: Secretory Phase:

- If no fertilized egg then, the endometrial lining disintegrates - If fertilization does not occur, the corpus luteum begins to disintegrate. - During the luteal phase in the ovaries, the uterus also undergoes changes; this phase is called the secretory phase. - The endometrial lining thickens. - However, in the absence of a fertilized egg, the corpus luteum dies and the endometrial lining disintegrates

Health States Affecting Sexuality: Surgery and Body Image: Ostomy:

- Is a surgical opening placed on the outside of the body to allow for the passage of secretions and elimination into a closed drainage bag. - Grieving over the loss of the natural means to eliminate waste, such as urine or feces, accompanies learning to live with an obvious artificial device. - Many people are anxious as to how this apparatus will affect their sex lives and how accepting their partners will be of it. - Odor and leakage concerns need to be addressed to increase comfort with the device.

Four Phases of Sexual Response Cycle: 4. Resolution:

- Is characterized by a return to the normal body functioning present before the excitement phase. - Feelings of relaxation, fatigue, and fulfillment are common. - Some people have a need to be held, fondled, and caressed. - Physical demonstrations of affection may initiate the sexual response cycle once again. - The woman is physiologically capable of immediate response to sexual stimulation. Because of this, many women can achieve multiple orgasms. - The man experiences a period during which the body does not respond to continued sexual stimulation, called the refractory period. - The length of the refractory period varies from a few minutes to longer, even days.

Gender Identity:

- Is the inner sense a person has of being male or female (or other), which may be the same as or different from that person's biological sex.

Health States Affecting Sexuality: Diseases of the Joints and Mobility:

- Joint diseases and disorders affect young and old people. - Pain, fatigue, stiffness, and loss of range of motion can accompany any of the dozens of known diseases of the joints. - The disease itself does not affect sexual functioning, although the manifestation of it can cause discomfort and anxiety.

General Levels of Sexual History:

- Level 1: part of the comprehensive health history, obtained by a nurse - Level 2: sexual history, obtained by a nurse trained in sexuality - Level 3: sexual problem history, obtained by a sex therapist - Level 4: psychiatric/psychosocial history, obtained by a psychiatric nurse clinician

Health States Affecting Sexuality: Chronic Pain:

- Many chronic illnesses are accompanied by constant pain, and a person with persistent pain may not desire any sexual contact. - However, the desire for human warmth and contact does not cease because of pain. - Altered or modified positions for coitus are sometimes necessary; discussing these positions with patients can be an important part of implementing the nursing process, reviewed later in this chapter.

Factors Effecting Sexuality: Lifestyle:

- Modern lifestyles greatly affect sexuality and its expression. - Both men and women are exposed to stress, and many are under considerable strain to perform and function in the workplace as well as at home. - Stressors may be external, such as job and financial demands, or internal, such as a person's competitive nature. - Varied responsibilities may place a time constraint on communication between a couple, as well as on the energy level and motivation for sexual satisfaction. - Although some couples view sexual activity as a release from the stressors of everyday life, most place nurturing relationships and sexual expression far from the top of the list of "things to do." - It is crucial to a relationship's survival that a couple set aside priority time for their relationship—if not for lovemaking, then for intimate, quiet contact. - Lifestyle variables can also influence the sexual expression of adolescents and young adults. - Those with more free time and fewer constructive developmental opportunities (e.g., education, sports, community service) are more likely to engage in risky sexual behavior.

Female Genitalia: External:

- Mons pubis: area of fatty tissue that covers the pubic bone in both - Labia majora (outer folds) and labia minora (inner folds) - Clitoris (a small, sensitive, erectile part of the female genitals at the anterior end of the vulva) - Hymen (a membrane which partially closes the opening of the vagina and whose presence is traditionally taken to be a mark of virginity.)

Causes of Menstrual Cycle Irregularities: Uterine Fibroids:

- Noncancerous growths of the uterus. - They can cause heavy menstrual periods and bleeding between periods.

Premenstrual Syndrome (PMS):

- Occurs several days before menstruation, with symptoms like moodiness, tender breast, headaches/migraines, depression, irritability, sleep disturbance, crying, anger*

Female Genitalia: Internal:

- Ovaries (are the female gonads — the primary female reproductive organs. These glands have three important functions: they secrete hormones, they protect the eggs a female is born with and they release eggs for possible fertilization.) - Fallopian tubes (either of a pair of tubes along which eggs travel from the ovaries to the uterus) - Uterus (the organ in the lower body of a woman where offspring are conceived and in which they gestate before birth; the womb.) - Vagina (an elastic, muscular canal with a soft, flexible lining that provides lubrication and sensation. The vagina connects the uterus to the outside world.)

Sexual Orientation: Transsexual:

- Refers to a person who lives full-time as a member of a gender that differs from the sex and gender he/she/they were assigned at birth. - This term sometimes specifically refers to those transitioning with hormones or confirmation surgery.

Health States Affecting Sexuality: Medications:

- Some medications have side effects that may affect sexual functioning. - These include nitrates, anticonvulsants, antidepressants, antihistamines, antihypertensives, antipsychotics, antispasmodics, barbiturates, and narcotics. - Recreational drugs including cocaine, alcohol, and marijuana are used by some to heighten the sexual experience. - These drugs can have serious and even deadly side effects. - While some use alcohol to release inhibitions and to increase sexual arousal and desire, heavy drinking can decrease libido and negatively affect sexual functioning. (antihistamines, b/p meds, pain meds)

Factors Affecting Sexuality: Religion:

- Some people view organized religion as having a generally negative effect on the expression of sexuality. - For example, in many religions, the concept of virginity came to be synonymous with purity, and sex became synonymous with sin. - In addition, many forms of sexual expression other than male-female coitus are considered unnatural by some religions. - As a result of the rigid regulations and negative connotation of sex dictated by some religious groups, a number of sexual dysfunctions can be related to a person's resulting guilt and anxiety. - Most major religions are reexamining their teachings on sexuality in response to challenges posed by their members. - Organized religions, such as Catholicism, have public figures who are moving toward gender inclusivity by accepting and having frank conversations with and about the LGBT (Lesbian, Gay, Bisexual, Transgender) communities - Many people have recognized the importance of solid sex education within the realm of the church and organized religions. - There is also a new interest in the spirituality of marriage: churches and organized religions are examining their role in supporting the intimate sexual relationship of married couples.

Forms of Sexual Expression: Oral-Genital Stimulation:

- Stimulation of the genitals by the mouth and tongue might be used during foreplay or as a way to reach orgasm. - Cunnilingus is stimulation of the female genitals by licking and sucking the clitoris and surrounding structures. - Fellatio is stimulation of the male genitals by licking and sucking the penis and surrounding structures. - One partner or both may use these techniques simultaneously (commonly known as "69" or "sixty-nine"). - Younger people may use oral-genital stimulation as a replacement for vaginal intercourse to avoid pregnancy.

Health States Affecting Sexuality: Surgery and Body Image:

- Surgery is performed to remove diseased tissue and repair body organs, usually requiring an incision with resulting scars. - The most devastating kinds of surgery are those used to remove cancerous tissue and surrounding structures. - Patients are almost always distressed about a diagnosis of cancer and possible death. - After surgery, patients need to adjust to major alterations in their bodies. - Changes in body image also affect a person's self-perception as a sexual being.

Forms of Sexual Expression: Masturbation:

- Technique of sexual expression in which a person practices self-stimulation. - It is a way for people to learn what they prefer during stimulation and what feels good. - Men masturbate by holding and stroking the shaft of the penis. - Women find manual stimulation of the clitoris enjoyable, although variations of technique are numerous. - Many myths and misinformation surround masturbation. - The reality is that people masturbate regardless of sex, age, or marital status. - People might not masturbate if they feel guilty about it or believe self-stimulation is wrong. - Masturbation is not "dirty" and will not lead to blindness or insanity.

Forms of Sexual Expression: Voyeurism:

- The achievement of sexual arousal by looking at the body of someone other than one's sexual partner. - Although voyeurism itself is not inherently wrong, some voyeurs develop complex means to spy on others that involve violations of privacy that are illegal.

Four Phases of Sexual Response Cycle: 1. Excitement:

- The excitement phase is initiated by erotic stimulation and arousal. - Some of the physiologic changes common in both men and women include an increase in heart rate and blood pressure, and the appearance of a pink to red flush to the skin. - This sex flush, which is more evident in women than in men, spreads over the face, neck, back, and upper torso. - Congestion of the genitals with increased blood flow begins in the excitement phase and causes even more arousal. - The length of the excitement phase varies greatly among people and even from one experience to another. - Women usually enjoy a more prolonged period of stimulation than do men. - During the excitement phase, the woman's breasts swell and the nipples become erect and hard to the touch. - Lubrication of the vagina seeps to the outside of the body along the vulvar creases and makes stimulation of the genitals more pleasurable by decreasing friction. - The upper two thirds or so of the vagina enlarges and expands. - The clitoris enlarges and emerges slightly from the clitoral hood. - The labia also enlarge and separate, and turn a deep rosy red with arousal. - The first obvious sign of arousal in the man is an erection of the penis caused by increased pelvic congestion of blood. - The scrotum noticeably elevates, thickens, and enlarges. - The skin of the penis and scrotum turns a deep reddish-purple in response to congestion and arousal. - Male nipples may also harden and become erect.

Female genital mutilation (FGM):

- The fact that a practice is common in a culture does not mean that it is healthy or ethical. - Includes procedures that intentionally injure or alter the female genital organs for non-medical reasons. - It is a procedure that has no health benefits for girls and women and can cause severe bleeding and problems urinating. - Later in life it can cause cysts, infections, and infertility, as well as complications in childbirth and increased risk of newborn deaths. - About 200 million girls and women worldwide, primarily in Africa, the Middle East, and Asia, are currently living with the consequences of FGM. There are four major types of FGM: 1. Clitoridectomy: partial or total removal of the clitoris and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris) 2. Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora 3. Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris. 4. Other: all other harmful procedures to the female genitalia for nonmedical purposes—for example, pricking, piercing, incising, scraping, and cauterizing the genital area

Four Phases of Sexual Response Cycle: 2. Plateau:

- The intensity of the plateau phase is greater than that of excitement, but not enough to begin orgasm. - Desire and arousal continue to build and intensify. - This phase varies from a few minutes to 15 to 20 minutes. - In the female, the clitoris retracts and disappears under the clitoral hood. - It is thought that the clitoris performs in this mysterious way as the body's protection against overstimulation. - In the male, secretions from Cowper's glands may appear at the glans of the penis during the plateau phase.

Factors Affecting Sexuality: Culture:

- The manner in which a society perceives sexuality influences the person. - Every culture has its own norms regarding sexual identity and behavior. - To some degree, culture dictates the choice of sexual partner, duration of sexual intercourse, methods of sexual stimulation, and sexual positions. - In some cultures, women may be expected to merely tolerate sex; in others, the woman's participation is encouraged. - To gain an appreciation for all the ways that culture can influence sexual expression and health, ask people from different cultures the following questions: - What type of dress is appropriate for children, men, and women? How is nudity viewed? - What role behaviors and social responsibilities are expected of men and women? - Is masturbation acceptable? - At what age is genital sexual intimacy appropriate? - With whom is it appropriate? - What sexual practices are accepted? - What are the rules for marriage? Is premarital sex, extramarital sex, or polygamy accepted?

Health State Affecting Sexuality: Cardiovascular Disease: Hypertension:

- The most significant difficulty a person diagnosed with hypertension faces regarding sexuality is that the medication used to control the disease frequently causes a change in sexual functioning. - These sexual dysfunctions may be relieved by modifying the dose of the medication or switching to a different medication.

Forms of Sexual Expression: Pedophilia:

- The practice of adults gaining sexual fulfillment by performing sexual acts with children. - Unlike the other items on this list that (depending on the circumstances) may be considered adaptive sexual responses, pedophilia involves children who, by nature of their age and maturity, cannot consent to sexual activity. - Pedophilia is wrong, illegal, and maladaptive in all cases.

Health State Affecting Sexuality: Cardiovascular Disease: Myocardial Infarction:

- The primary goal after a myocardial infarction (MI), or heart attack, is to allow the heart ample time to heal. - Activities of daily living, including sexual activity, should be resumed gradually, and stressors such as overexertion, alcohol consumption, and emotional upheavals should be avoided. - After an uncomplicated MI, sexual activity may begin at about the third week of recovery, beginning with masturbation to partial erection in the male. - Generally, this activity is gradually increased until 3 months after the MI, when sexual intercourse may be resumed. - A comfortable position that places the least stress on the affected partner should be used.

Biological Sex:

- The term used to denote chromosomal sexual development: male (XY) or female (XX), external and internal genitalia, secondary sex characteristics, and hormonal states.

Causes of Menstrual Cycle Irregularities: Polycystic ovary syndrome (PCOS):

- This common hormonal disorder can cause small cysts to develop on the ovaries and irregular menstruation.

Causes of Menstrual Cycle Irregularities: Pelvic inflammatory disease (PID):

- This infection of the reproductive organs can cause irregular menstrual bleeding.

Health States Affecting Sexuality: Spinal Cord Injuries:

- This type of injury almost always results in some degree of permanent disability. - Such people face multiple adaptations in their lifestyles, including those related to mobility, bowel and bladder control, sexual functioning, and role expectations. - The extent of sexual response that remains after a spinal cord injury depends primarily on the level and extent of the injury. - Ejaculation and orgasm are most likely to remain with low spinal injuries. - Women are more likely to experience orgasm than men, but they more frequently report a lack of physical sensations during the excitement phase than do men. - Many people find that other erogenous zones become more easily stimulated after the injury.

Health States Affecting Sexuality: Mental Illness:

- Various psychological and physical disorders can cause mental illness. - The mind plays a powerful role in sexuality; any disruption of its functioning will no doubt cause some disturbance in sexual functioning. - Even mild depression can affect desire and sexual functioning. - Sometimes, it is difficult for the partner of a patient who has developed a mental illness to continue the sexual relationship. - People afflicted with Alzheimer's disease can lose the memory of any contact with a partner or spouse. - At times, patients with mental illness act out in a sexual manner, such as touching themselves or removing their clothing at inappropriate times and places.

Forms of Sexual Expression: Masochism:

- gaining sexual pleasure from the humiliation of being abused

Male Sexual Dysfunction: Premature Ejaculation:

- is a condition in which a man consistently reaches ejaculation or orgasm before or soon after entering the vagina. - The result is that his partner usually does not have time to reach sexual satisfaction. Causes of this problem are rarely physical. Assessment Priorities: • Assess what patient defines as his dysfunction and ability to control ejaculation. • Assess any causative relationship factors such as anxiety, guilt, lack of time, or new partner.

Female Sexual Dysfunction: Vaginismus:

- is a rare condition in which the vaginal opening closes tightly and prevents penile penetration. - Vaginismus is due to involuntary spastic contractions of the muscles at and around the vaginal opening and the levator ani muscles. - The cause of vaginismus may be physical, psychological, or both. Assessment Priorities: • Assess knowledge regarding anatomy and sexual response. • Assess the pattern of sexual activity: how often, level of arousal, orgasm. • Assess the presence of other sexual dysfunctions. • Assess for history of sexual abuse, trauma, or rape. • Assess the patient's feelings regarding her partner. • Assess any other causative factors, such as fear of pregnancy, anxiety, or guilt. • Perform physical assessment of internal and external genitalia.

Health States Affecting Sexuality: Surgery and Body Image: Mastectomy:

- is a surgical procedure to remove a breast and surrounding tissue. - After such a surgery, a woman's return to sexual functioning depends on many factors, such as support of her partner, the value placed on the breast by the man or woman, and fear of discomfort during sexual activity. - Allowing the patient time to grieve the loss of her uterus or breast(s) is appropriate and may help with long-term coping.

Gender Non-conformity:

- is behaving and appearing in ways that are considered sociologically or psychologically atypical for a person's gender.

Forms Of Sexual Expression: Abstinence:

- is not having sex. - It is the most effective form of birth control, preventing pregnancy 100% of the time when practiced consistently. - Also prevents the transmission of STIs 100% of the time when practiced appropriately and consistently. - Some STIs spread through oral-genital sex, anal sex, or even intimate skin-to-skin contact without actual penetration (genital warts and herpes can be spread this way). - Therefore, only avoiding all types of intimate genital contact can prevent these STIs. - Avoiding all types of intimate genital contact—including anal and oral sex—is complete abstinence. - There are no side effects or health risks related to abstinence.

Female Sexual Dysfunction: Dyspareunia:

- is painful intercourse. - Although it is most often described by women, some men may also suffer from this disorder. - The cause is usually physical, although psychological problems such as fear and anxiety can cause pain. Assessment Priorities: • Assess for history of diabetes, hormonal imbalance, vaginal infection, endometriosis, urethritis, cervicitis, or rectal lesions. • Assess for use of antihistamines, alcohol, tranquilizers, or illicit drugs. • Assess the patient's ability for vaginal lubrication during the sexual act. • Assess the patient's use of coital positions. • Assess the use of cosmetic or chemical irritants to the genitals, such as deodorant tampons, contraceptive creams or jellies, or condoms. • Perform physical assessment of internal and external genitalia. • Assess any other contributing factors.

Gender Role Behavior or Expression:

- is the behavior a person exhibits in relation to being male or female, which, again, may or may not be the same as biological sex or gender identity

Forms of Sexual Expression: Sadomasochism:

- practicing sadism and masochism together. It might involve being tied up, biting, hitting, spanking, whipping, pinching, and other activities.

Forms of Sexual Expression: Sadism:

- the practice of gaining sexual pleasure while inflicting abuse on another person

Four Phases of the Menstrual Cycle: Follicular Phase:

1. Day 4-14 is Follicular Phase: Follicles mature but only one follicle produces a mature ovum.

Four Phases of Sexual Response Cycle:

1. Excitement: erotic stimulation and arousal. Increased HR & B/P, flushed skin, increased blood flow to genitals. 2. Plateau: Intensity > than excitement, can be minutes -20min 3. Orgasm: climax, lasts only seconds but extremely intense, muscle twitching. Women can have multiple orgasms even with resolution. 4. Resolution: returning to normal, relaxed, fatigue, fulfillment. Men have refractory period when body won't respond to sexual stimulation. Men are incapable of having a sexual response in this phase. •*Know the these phases. They are referred to as the sexual response cycle, how a patient gets sexually excited.*

Three Layers of the Uterus:

1. Perimetrium: The outermost layer and consists of elastic tissue. 2. Myometrium: The muscular middle layer. 3. Endometrium: The innermost layer that thickens and sloughs off with menses.

Four Phases of the Menstrual Cycle: Proliferation Phase:

2. •At same time as follicular phase, uterus prepares itself for fertilized egg. The endometrium becomes thick and velvety. Ovulation occurs around Day 14 when the mature ovum ruptures from the follicle and the surface of the ovary, and is swept into the fallopian tube. - If sperm are present, the ovum is fertilized at this time - Some women can detect ovulation by the presence of a sharp, cramping pain over the ovulating ovary; this pain is called mittelschmerz, or middle pain, because it occurs in the middle of the cycle.

Four Phases of the Menstrual Cycle: Luteal Phase:

3. Day 15-28 is Luteal Phase: the corpus luteum develops, to produce hormones to encourage the fertilized egg to grow. - The leftover empty follicle fills up with a yellow pigment and is then called the corpus luteum, or yellow body. - The purpose of the corpus luteum is to produce hormones that encourage a fertilized egg to grow.

What male reproductive gland produces sperm and the hormones necessary for the maintenance of male sex characteristics? A. Penis B. Testes C. Scrotum D. Vas deferens

Answer: B. Testes Rationale: The testes are located in the scrotum and produce sperm and hormones that maintain sex characteristics. The penis functions to eliminate urine and ejaculate semen. The scrotum is a loose, bag-like structure that houses the testes. Tubules from the testes drain into the epididymis, which then drains into the vas deferens and ejaculatory ducts.

In which phase of the sexual response cycle does involuntary spasmodic contractions of the genital organs occur? A. Excitement B. Plateau C. Orgasm D. Resolution

Answer: C. Orgasm Rationale: The term orgasm defines the climax and sexual explosion of the tension that has been building in the preceding phases. It only lasts seconds, but it is extremely intense. Involuntary spasmodic contractions of the genital organs occur in this phase.

What is the term for a person of a certain biologic gender who lives full-time as a member of a gender that differs from the sex and gender he/she/they were assigned at birth? A. Heterosexual B. Gay C. Bisexual D. Transsexual

Answer: D. Transsexual Rationale: The term transsexual describes those who feel that the sex that was assigned to them at birth incompletely describes or fails to describe them. A heterosexual enjoys sexual fulfillment with a person of the opposite gender. A gay person experiences sexual fulfillment with a person of the same gender. A bisexual finds pleasure with both opposite-sex and same-sex partners.

Factors Affecting Sexuality: Developmental Considerations: Late adulthood: Age 55 years and older:

Characteristics: • Orgasms may become shorter and less intense in both men and women • Vaginal secretions decrease, and period of resolution in men lengthens • May feel need to conform to stereotypes regarding the aging process, and cease sexual activity • Fear of loss of sexual abilities Nursing Implications & Teaching Guidelines: • Sexual activity need not be hindered by age. • Teach couples that adaptation to bodily changes is possible with use of comfortable positions for intercourse and increased time for stimulation. • Teach alternatives to coitus, such as caressing, hugging, and stroking, when coitus is impossible because of illness or disability. • Couples who have been consistently sexually active throughout their lives may continue their intimate relationship for as long as they desire.

Factors Affecting Sexuality: Developmental Considerations: Young adulthood: Age 20-35 years:

Characteristics: • Premarital sex is common • Knowledge regarding sexual response and activity increases pleasure of relationship • May experiment with various sexual expressions • Develops own value system and respects values of other people • Many couples share financial responsibilities as well as household tasks Nursing Implications & Teaching Guidelines: Encourage communication between partners regarding sexual needs and differences. • Reinforce the use of abstinence and contraceptive measures to prevent unwanted pregnancies. • Counsel against promiscuous behavior to guard against sexually transmitted infections and loss of trust of partner. • Daily communication is necessary to vent stresses and work out difficulties.

Factors Affecting Sexuality: Developmental Considerations: Preadolescence: Age 10-13 years:

Characteristics: • Puberty begins for most boys and girls with development of secondary sex characteristics • Menarche takes place • May test behavioral limits Nursing Implications & Teaching Guidelines: • Information is necessary regarding body changes to alleviate fears. This information should be given to the young person before pubertal changes begin. • Parents need to find a satisfactory middle ground for rule setting. Rules that are either too rigid or too lenient can interfere with the development of self-confidence and an internal value system. • Treat body image changes with a positive attitude to prevent poor self-image.

Factors Affecting Sexuality: Developmental Considerations: Preschooler: Age 4-6 years:

Characteristics: - Becomes increasingly aware of self - Enjoys exploring body parts of self and playmates - Engages in masturbation - Gender identity is formed Nursing Implications & Teaching Guidelines: • Parents may cause anxiety in the child by intolerance of inconsistency of sex-role behavior. • Negative overreaction by parents to child's masturbating behavior can lead to a belief that the genitals and sex are bad and dirty.

Factors Affecting Sexuality: Developmental Considerations: Infancy: Birth to 18 months:

Characteristics: - Needs affection and tactile stimulation - Boys have penile erections, and girls have orgasmic potential - Gradually can differentiate self from others - Obtains pleasure from touching genitals - Dressed according to biological sex Nursing Implications and Teaching Guidelines: • Avoid early weaning to prevent oral deprivation. • Encourage parents to provide ample physical touch, deprivation of which may cause physical and mental underdevelopment. • Self-manipulation of genitals is normal behavior; avoid denoting this as "bad."

Factors Affecting Sexuality: Developmental Considerations: School-aged: Age 6-10 years:

Characteristics: • Attachment to the parent of the opposite sex • Tendency toward having same-sex friends • Curiosity about sex and sharing of fears • Increasing self-awareness Nursing Implications & Teaching Guidelines: - Same-sex preference for relationships is not related to heterosexual or homosexual tendencies. - Give child the information (intercourse, abstinence, STI prevention, pregnancy) in a clear, factual form. May look to peers for information that may be incorrect.

Factors Affecting Sexuality: Developmental Considerations: Adulthood: Age 35-55 years:

Characteristics: • Bodily changes as a result of menopause • Couples focus on quality rather than quantity of sexual experiences • Divorce is common • Grown children begin their own lives and sexual experiences • Sexual satisfaction may actually increase because of loss of fear of pregnancy Nursing Implications & Teaching Guidelines: • Both men and women need positive reinforcement of what is good about themselves and their relationships. • Teach parents that empty nest syndrome (feelings of loss caused by children leaving) is common. Accentuate positive aspects of this situation. • Encourage couple to use this period as one of renewal for themselves.

Factors Affecting Sexuality: Developmental Considerations: Toddler: Age 1-3 years:

Characteristics: • Establishes control over bowels and bladder • Both sexes enjoy fondling genitals • Able to identify own gender • Develops vocabulary related to anatomy Nursing Implications & Teaching Guidelines: • Allow toddler to designate his or her readiness to toilet training. Strict measures may lead to compulsive behaviors later. • Punishment of genital fondling may lead to guilt and shame regarding sexual behavior later in life. • Use proper terms for body parts.

Factors Affecting Sexuality: Developmental Considerations: Adolescence: Age 13-19 years:

Characteristics: • Primary and secondary sex characteristics develop • Sexual fantasies are common • Masturbation is common • May begin to partake in sexual activity ranging from light to heavy petting to full genital intercourse • May experiment with same-sex relationships • At risk for pregnancy and sexually transmitted infections • Gender expression and identification is often solidified during adolescence Nursing Implications & Teaching Guidelines: • Parents share their beliefs and moral value systems with their children. • Teenagers may share their feelings with parents. Not taking them seriously may lead to lack of trust and a communication gap. • Teens need information regarding contraceptive measures and the potential for contracting sexually transmitted infections.

Sexual Orientation:

Refers to romantic, emotional, affectionate, or sexual attraction to other people

Factors Affecting Sexuality:

•Developmental considerations •Culture •Religion •Ethics •Lifestyle •Health state

STI: Cytomegalovirus (CMV):

• A virus in the same family as herpes and Epstein-Barr • A first-time infection may cause mononucleosis, a mild illness with fever and swollen glands, liver, and spleen • May be asymptomatic • Not exclusively sexually transmitted

STI: Chlamydia:

• Chlamydia trachomatis—intracellular bacteria • Primarily affects young people ages 15-24a • Many people are asymptomatic • Symptoms in women: vaginal discharge, burning on urination, urinary frequency, dysuria, and urethral soreness • Symptoms in men: penile discharge, burning sensation with urination, pain and swelling in testicles

STI: Genital Herpes:

• Herpes simplex virus type 2 (HSV-2) • Can be caused by HSV-1 through oral sex • Lesions develop around the genitals, rectum, or mouth • Appear as single or multiple painful vesicles, which rupture and form ulcer-like lesions; these form scabs as they heal • First infections last about 10-14 days, whereas subsequent infections are shorter in duration • Recurrences are usually preceded by prodromal symptoms of tingling and fullness • Oral herpes (cold sores) typically caused by HSV-1

STI: Acquired immunodeficiency syndrome (AIDS):

• Human immunodeficiency virus (HIV) • Positive ELISA and Western Blot tests • Incidence high in IV drug users and gay and bisexual men; increasing heterosexual transmission • Fatigue, diarrhea, weight loss, enlarged lymph nodes, fever, anorexia, and night sweats

STI: Bacterial vaginosis (BV):

• Imbalance of bacteria (alters flora in the vagina) • Symptoms in women: foul-smelling, thin, grayish white vaginal discharge • Men typically asymptomatic

Obtaining Sexual Information:

•Asking about sexual history is a sensitive subject. Good way to ask: "How would you describe the problem?" or "Have you noticed this previously?" •Description of the problem •Onset and cause of the problem •Past attempts at resolution •Goals of the patient •*Most nursing interventions pertaining to sexuality involve education on promoting sexual health.*

Internal Male Genitalia:

•Epididymis: a highly convoluted duct behind the testis, along which sperm passes to the vas deferens. •Vas deferens: the duct which conveys sperm from the testicle to the urethra •Seminal vesicles: (also known as the vesicular or seminal glands) are a pair of glands found in the male pelvis, which function to produce many of the constituent ingredients of semen. They ultimately provide around 70% of the total volume of semen. •Prostate gland: walnut-sized gland located between the bladder and the penis. The prostate is just in front of the rectum. The urethra runs through the center of the prostate, from the bladder to the penis, letting urine flow out of the body. The prostate secretes fluid that nourishes and protects sperm. •Cowper's glands: pea sized glands present inferior to the prostate gland in the male reproductive system. They produce thick clear mucus prior to ejaculation that drains into the spongy urethra

Forms of Sexual Expression:

•Masturbation •Sexual intercourse •Oral-genital stimulation •Abstinence •Alternate forms -Voyeurism, sadism, masochism, sadomasochism, pedophilia The Brain is the most important area for sexual arousal and stimulation. It is how we use touch, physical closeness and intimacy.

External Male Genitalia:

•Testes (an organ which produces spermatozoa (male reproductive cells) •Scrotum (a part of the external male genitalia located behind and underneath the penis. It is the small, muscular sac that contains and protects the testicles, blood vessels, and part of the spermatic cord) •Penis (the male genital organ of higher vertebrates, carrying the duct for the transfer of sperm during copulation. In humans and most other mammals, it consists largely of erectile tissue and serves also for the elimination of urine.)