Chapter 35- Sexuality

Sexual Development

*First 3 Years*: - The first 3 years of life are crucial in the development of gender identity. - Child identifies with the parent of the same sex and develops a complementary relationship with the parent of the opposite sex. - Children become aware of the differences between sexes, begin to perceive they are either male or female. - They interpret the behaviors of others as behavior appropriate for a female/male. *School Age Years*: - School age children generally have questions regarding the physical & emotional aspects of sex. - They need accurate info from home & school about changes in their bodies and emotions and what to expect going into puberty - Role models: parents, teachers, and peer groups about how men and women act with and relate to one another. *Puberty/Adolescence*: - Emotional changes are as dramatic as the physical ones. - Adolescents function within a powerful peer group. - Constant anxiety of "am I normal?" "will I be accepted?" - Face many decisions & need accurate info on body changes, sexual activity, emotional responses within intimate sexual relationships, STI's, contraception, and pregnancy. -A time when they explore their primary sexual orientation. - Identity with a group: lesbian, gay, bisexual, or transgender. LGBT >> Transgender: self-recognition as male/female is in conflict with his/her biological sex. Or what is culturally determined as belonging to a male/female >> Transgender patients may pursue treatments/modification procedures to promote physical characteristics with their gender identification >> LGBT individuals are at higher risk for depression; suicide; and abuse of tobacco, alcohol, and drugs than the general pop. - Adolescents face a lot of stress related to sexual identity and benefit from education about sexuality issues. - In the uS 50% of high school students report that they have had sex at least 1 time, and 15% of high school students had 4 or more sexual partners. - Adolescents who engage in risky sexual behaviors experience negative health outcomes, like STIs and unintended pregnancy - The pattern of risk-taking behavior tends to be established and continue throughout life. - Parents need to provide factual information, sharing their values, and promoting sound decision-making skills. - Adolescents need to be held accountable for their own decisions. - Support from peers, family, school counselors, clergy nurses and other health care professionals is important during this time. *Young Adulthood*: - Continue to explore and mature emotionally in relationships - Intimacy and sexuality are issues for all young adults, whether they are in a sexual relationship, choose to abstain from sex, remain single, are homosexual, or widowed. - Young adults require support and education or therapy to achieve mutually satisfying sexual relationships *Middle Adulthood*: - Changes in physical appearance lead to concerns about sexual attractiveness. - Actual physical changes related to aging affect sexual functioning. >>> *WOMEN*: > Decreasing levels of estrogen in premenopausal woman=diminished vaginal lubrication and decrease elasticity > Both of these changes lead to *dyspareunia*, or the occurrence of pain during sex. > Decreased levels of estrogen may also result in a decreased desire for sexual activity. >>> *MEN*: > Increase in the post-ejaculatory refractory period and delayed ejaculation >>*WHAT CAN WE DO?*: > Anticipatory guidance regarding these normal changes, using vaginal lubrication, and creating time for caressing and tenderness ease concerns regarding sexual functioning. -Later in the adult years some people have to adjust to the social and emotional changes associated with children moving away from home. > Can be a time for renewed intimacy or a time when formerly intimate partners realize they no longer care for each other or have common interests. *Older Adulthood*: - Important aspect of health that is often overlooked by health care providers. - Positive correlation between sexual activity and physical health - Many older adults are more sexually active than previously thought - Engage in high-risk sexual encounters, resulting in a steady increase of HIV and STI rates over the past 12 years. - Physiological changes with aging that influence sexual response: > Multifactorial and related to changes in circulation, hormones, and neurological pathways. - Pathological issues with aging sexual response are related to illness, and side effects from meds. - Older adults are hesitant to talk to health care providers about sexual problems. - Older adults who live in extended care facilities lose their privacy and experience a decline in physical and cognitive abilities that affect their sexual expression. - Older adults who live in assisted living facilities have more privacy and are able to live as couples - Increased availability of treatments for male/female sexual dysfunction contribute to continued sexual activity throughout the lifespan. - Older sexually active adults are at risk for contracting STIs because the risk of pregnancy is not an issue, older adults often do not feel the need for protected sex when becoming active with new/multiple partners. - Factors that determine sexual activity in older adults: >> Present health status >> Medications >> Past/present life satisfaction >> Status of marital or intimate relationships >>*WHAT CAN WE DO?*: -Nurses working with older adults need to assess the sexuality of their patients, sexual interest and functioning and plan accordingly. - Maintain an nonjudgmental attitude and convey that sexual activity is normal in later years. - Emphasize that it is essential to maintaining quality of life, especially when patients have decided to not remain sexually active. - Nurses need to understand developmental changes in men/women - Understand that the excitement phase prolongs in both men and women, and it usually takes longer for them to reach orgasm. The regulatory time following an orgasm is also longer. - Both genders experience reduced availability of sex hormones. Men= erections that are less firm and shorter acting. Women= have difficulty maintaining sexual function unless they have a medical condition that impairs their sexual activity. - Urinary incontinence often experience embarrassment during intercourse. - Couples who have physically disabling conditions often need info about which positions are more comfortable when having sex.

Nursing Process: *Sexual Assessment of Children and Adolescents*

- Use language that is accurate and that the child or adolescent understands - Promote normal development, avoid minimizing problems, and screen for sexual concerns while making the child or adolescent feel at ease - Sexual counseling of minors raises legal/ethical issues regarding a patients right to health care and education on the one hand and a parents or guardians right to surpervise information on the other hand - Children and adolescents will respond when they know that having questions about sexuality is normal - Be open, positive and interested when introducing sexual questions

Nursing Process: *General Sexual Assessment*

*ASSESSMENT*: - Questions like "What would you like to have happen in regard to your sexual health problems?" and " What initial steps might you take?" help a patient identify desired outcomes - Set aside personal views, and consider a patients needs and preferences for care. - Ask patients to describe factors that influence their sexual desire. >>Hx: >In gathering sexual history, consider physical, functional, relationship, lifestyle, developmental, and self-esteem factors that influence sexual functioning. > Sexual desires vary among individuals: sexual desire becomes an issue if the person wants to satisfy it more often, if he or she believes that it is necessary to measure up to some cultural norm, or if there is a discrepancy between the sexual desires of the partners in a relationship > Know patients medical history, minor illness, medication and fatigue often decrease sexual desire. > Know patients lifestyle factors: use/abuse of alcohol, lack of sleep, lack of time, or the demands of caring for a new baby >Know patients self-concept issues: identity, body image, role performance, and self-esteem (poor body image associated with a chronic disease increases feelings of rejection) > Ask couples to describe how close they feel to each other and how often they interact on an intimate level >> Use the PLISSIT Model to assess sexuality in patients

*Nonprescription* Contraceptive Methods

*Abstinence*: Although 100% effective, it is difficult for men and women to use it consistently *Barrier methods*: > spermicide (put into vagina before sex, create a spermicidal barrier between uterus and sperm) > condoms > diaphragm (must be used with spermicide with each sexual encounter) > Vaginal spermicides and condoms are most effective when instructions are followed, their combined use is more effective in preventing pregnancy than the use of either one alone. *Timing sex to a woman's ovulation cycle*: > Include the rhythm, basal body temperature, cervical mucus, and fertility awareness methods >Couples need to understand the reproductive cycle of the woman's body and subtle signs that her body gives during the cycle > They need to abstain from sex during these designated fertile periods.

Decisional Issues:

*Contraception*: -Factors that influence effectiveness: method of contraception, understanding of the method, consistency of use, compliance with requirements. - Choice of contraception Method: varies in relation to age, ethnicity, sexual orientation and previous pregnancies of the woman *WHAT CAN WE DO?*: -Mobile Apps available to help patients health: reminds you when to take oral contraceptives, to replace your transdermal patch, or vaginal ring, or when your most fertile time is occurring. Ex: Clue, Period Tracker, Glow, Glow Nurture, Ovia Fertility, and iBreast Check - Health professionals monitor reproductive health

Nursing Process: *Implementation*

*Health promotion* - Educate patients about sexual health. - Have regular health and screening examinations. > *Women*: regular breast self-examinations, mammograms, and Pap smears; offer the 9-valent HPV vaccine for females who are between 11-26 y/o. Vaccine is safe for girls as young as 9 y/o. 3 vaccinations. Booster doses are not recommended. Most effective if administered before sexual activity or exposure. > *Men*: testicular self-examinations; offer the 9-valent HPV vaccine to males Strategies that enhance sexual functioning: • Avoid alcohol (in excess) and tobacco. • Eat well-balanced meals. • Plan sexual activity for times when the couple feels rested. • Take pain medication if needed before sexual intercourse. • Use pillows and alternate positioning to enhance comfort. • Encourage touch, kissing, hugging, and other tactile stimulation. • Communicate concerns and fears with partner and health care provider. Barriers to reproductive health services: - Cultural beliefs - Low Socioeconomic status - Low health literacy >> The Affordable Health Care Act offers increased access to health care for previously uninsured individuals. *Acute care* - Illness and surgery create situational stressors that often affect a person's sexuality. *Restorative and continuing care* - In the home environment, it is important to provide information on how an illness limits sexual activity and to give ideas for adapting or facilitating sexual activity. >> Interventions: giving permission for a partner to lie in bed, and hold a patient to coordinating nursing care and medications to provide opportunity for privacy and intimacy. >> Nurses help create an environment that is comfortable for sexual activity in the home, this sometimes involves making recommendations for ways to arrange the bedroom to accommodate physical limitations. >> In LTC facilities, need to make proper arrangements for the privacy during residents sexual experiences. The ideal situation is to set up a pleasant room that is used for a variety of activities that the resident is able to reserve for private visits with a spouse or partner. If need be, make arrangements for the Roomate to be somewhere else to allow a couple time alone. Never leave patients alone in a situation in which they can injure themselves. - Address needs by taking a sexual history and implementing a basic model such as PLISSIT to provide options for patients.

Methods that require a health care providers intervention:

*Hormonal Contraception*: > Available in several forms: oral pills, vaginal rings, hormonal injections, subdermal implant, transdermal skin patches, and IUDs. > Alters the hormonal environment to prevent ovulation, thicken the cervical mucus and thin the lining of the uterus. > IUDs: plastic device inserted by a health care provider into the uterus through the cervical opening. Either contain copper or progesterone. They stop sperm from fertilizing an egg. The release of progesterone may also increase cervical mucus thickness and alter the lining of the uterus. *Diaphragm*: > Round, rubber dome that has a flexible spring around the edge. It is used with contraceptive cream or jelly, and is inserted in the vagina so it provides a contraceptive barrier over the cervical opening. > Woman needs to be refitted after a significant change in weight (10 lb gain/loss) or pregnancy *Cervical Cap*: > Functions like the diaphragm, but only covers the cervix. > May be left in place longer, and some perceive it as more comfortable *Sterilization*: > Most effective contraception method other than abstinence > Female sterilization: tubal ligation, involves cutting, tying or otherwise ligating the Fallopian tubes. > Male sterilization: vasectomy, the vas deferens, which carries the sperm away from the testicles is cut and tied. > Both tubal ligation and a vasectomy usually are considered permanent surgical procedures.

Nursing Process: *Assessment (S/S that indicate possible Sexual Abuse or Hx of Sexual Abuse)*

*INJURIES AND OR PHYSICAL FINDINGS* Children: - Bruises - Bleeding - Soreness - Infection or Irritation of external genitalia, anus, mouth or throat - STIs - Recurrent UTIs - Unintended Pregnancy - Chronic pain - Difficulty walking or sitting - Unusual odor in genital area - Penile discharge - Torn, stained, or blood underclothing Adults: - Welts - Bruising - Swelling - Scars - Burns or lacerations on arms, legs, breasts or abdomen - Wounds that do not match the patients "story" - Multiple bruises in various stages of healing, vaginal or rectal bleeding, fractures of the face, nose, ribs or arms - Trauma to labia, vagina, cervix, or anus - Vomiting or abdominal tenderness *BEHAVIOR: NONVERBAL AND/OR VAGUE SOMATIC COMPLAINTS:* Children: - Physical aggression - Sexual acting out - Excessive masturbation - Expressions of low-self esteem - Poor school performance - Poor peer relationships - Sleep Disturbances - Social withdrawal and excessive day dreaming - Running away from home - Substance abuse or suicide attempts Adults: - Facial grimacing - Absence of facial response or flat affect - Anxiety - Depression - Panic attacks - Difficulty sleeping - Anorexia - Slow, unsteady gait

Alterations in Sexual Health: *Illnesses and Medications That Affect Sexual Functioning in Men and Women*

*Illnesses* - Diabetes Mellitus - Cancer (prostate, breast, colon, ovarian, testicular, rectal) - Neuropathy - Spina Bifida - Spinal Cord Injury - Unstable Angina - Uncontrolled Hypertension - COPD - HIV - Substance Abuse - Depression *Medications* - Antihypertensives - Antipsychotics - Antidepressants - Antianxiety - Diuretics - Oncological agents - Recreational or illicit drugs

*PLISSIT* Assessment of Sexuality

*Permission* to discuss sexuality issues *Limited Information* related to sexual health problems being experienced *Specific Suggestions*—only when the nurse is clear about the problem *Intensive Therapy*—referral to professional with advanced training if necessary

Nursing Process: *Planning; Goals and Outcomes*

*Planning:* -Create an atmosphere where the patient can explore sexual concerns - Refer to appropriate resources for exploration of sexual concerns - Explore the patients understanding, beliefs, and attitudes regarding sexuality, and sexual functioning - Ex: *Sexual Dysfunction related to decreased sexual desire*: outcomes include that the patient does the following: > Discuss stressors that contribute to sexual dysfunction with partner within 2 weeks > Identifies alternative, satisfying and acceptable sexual practices for self and partner within 4 weeks. Goal: > Patient will express satisfaction with sexual relationship with wife within 1 month > Patient expresses renewed sexual interest within 2 weeks, patient sustains arousal through orgasm within 3 weeks.

STIs

- About 20 million people in the United States are diagnosed each year with an STI each year; almost half of them are 15 to 24 years of age. - Highest incidence in men who have sex with men, bisexual men, and youths between 15-24 - Black/Hispanic populations are diagnosed with STIs more frequently than whites, and women have more complications associated with STIs than men. -Race, poverty, access to health care and sexual practices contribute to disparities in the STI rates. - STIs are transmitted from infected individuals to partners during intimate sexual contact. Could be genital, oral-genital, or anal-genital, - *Usually curable with Abx STIs*: syphilis, gonorrhea, chlamydia, pelvic inflammatory disease (PID) trichomoniasis - *Not Curable*: HSV types 1 and 2, HPV, HIV - *Viral STIs*: human papillomavirus (HPV) and herpes simplex virus (HSV) type II, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). *Common Problem with STIs* - Usually in people who have unprotected sex with multiple partners - Some people do not know they are infected because symptoms are absent/unnoticed - Common symptoms: discharge from vagina, penis, anus, or throat, pain during sex or when urinating, unexplained rash or lesions - Because sex includes whole body rather than just genitalia, many parts of the body are potential sites for an STI - Perineum, anus and rectum frequently are involved in sexual activity - Any contact with another persons body fluids around head or open lesson on the skin, anus, or genitalia can transmit an STI *WHAT CAN WE DO?* - Sometimes people don't seek treatment because they're embarrassed to discuss sexual symptoms or concerns - They may be hesitant because they think it is not normal - Nurses need to develop communication skills and a nonjudgmental attitude to provide effective care for those diagnosed with one. - Detect valuable clues about an STI by establishing trust, talking with patients, and asking questions in a caring manner. -Assess attitudes toward sexuality, and adjust the intervention to make it acceptable to the patients sexual value system

Nursing Process: *Nursing Diagnosis*

- Assessment data that will include defining characteristics related to sexuality often include: > Hx of surgery of reproductive organs > Changes in appearance or body image > Hx of or current physical/sexual abuse, chronic illness > Developmental milestones like puberty or menopause - To make a nursing dx related to sexual dysfunction: > Consider anatomical, physiological, sociocultural, ethical and situational issues Possible Nursing Dx related to Sexual Functioning: - Anxiety - Ineffective Coping - Interrupted Family Processes - Deficient Knowledge (Contraception/STIs) - Sexual Dysfunction - Ineffective Sexuality Pattern - Social Isolation - Understand nursing interventions are different in both sexual functioning and dysfunction Nursing Dx related to Sexual Dysfunction: - *Sexual Dysfunction related to physical abuse*: needs counseling and referral to community resources (crisis services and physical abuse support group) - *Sexual Dysfunction related to misinformation about the risk of STI*- requires counseling and education on how to maintain safe sexual practices. -*Sexual Dysfunction related to decreased sexual desire*: you and your patient develop a goal to report decreased anxiety and greater satisfaction with sexual activity within 1 month.

STIs: *Chlamydia* (Bacteria: Chlamydia Trachomatis)

- Causes infertility, pelvic inflammatory disease (PID), and neonatal complications - Most commonly reported infectious disease in the US affecting about 3 mil/year. - Spread by contact with fluids from the infected site. - Can be transmitted during birthing process, and cause conjunctivitis and pneumonia in newborn babies - Frequently infects the cervix, and if left untreated causes PID, ectopic pregnancy, and infertility, from damage to the female reproductive organs - Most people don't know their infected because it causes few symptoms. *WHAT CAN WE DO?*: -CDC recommends annual screening for all sexually active women up to age 25. - High risk populations: people who have multiple sexual partners or are infected with other STIs and men who have sex with men.

Nursing Process: *Evaluation*

- Determine if their expectations have been met. - Have follow-up discussions with the patient or partner to determine if they were satisfied with your approaches. Sexuality is felt more than observed, and sexual expression requires an intimacy that is not amendable to observation. - Evaluate if patient achieved outcomes established in plan of care. - Ask patients questions about risk factors, sexual concerns, and their level of satisfaction. Observe behavioral cues like eye contact, posture, and extraneous hand movements that indicate comfortable or suggest continued anxiety or concern as topics are addressed. - When outcomes are not met, ask questions to determine the changes needed in interventions: • What other questions do you have about your sexual health? • Did you experience less pain during sexual intercourse after taking your pain medication? • Which positions did you find most comfortable when you had sexual intercourse? Which positions were most awkward? • What barriers are preventing you from discussing your feelings and fears with your partner?

Sociocultural Patient-Centered Care: *WHAT CAN WE DO?*

- Establish a therapeautic relationship with a patient/family before discussing sexual heath - Provide both males/females written and verbal information in English, Spanish, or in their native language. Regarding contraception, STIs, HIV testing and management options - Target adolescents by expanding education on STIs, HIV, and contraception in middle-and high-school curriculum - Promote gender neutrality by addressing assertive communication and negotiation strategies among females. - Increase HIV testing at community clinics and offer combined laboratory work for STIs and HIV to promote acceptance - Promote cultural-specific bilingual multimedia and community education about HIV risk-reduction strategies.

Nursing Process: *Physical Assessment*

- Important in evaluating the *cause of sexual concerns* or problems and usually provides the best opportunity to teach someone about sexuality *WHAT CAN WE DO?* - In examining a woman's breast and the external and internal genitalia, a nurse has the opportunity to assess the woman's reaction, answer questions and provide information about the examination and physiological structures - Knowledge of normal scrotal anatomical structures helps men detect signs of testicular cancer. Instruct both men and women on signs and symptoms of STIs during the examination when patients histories suggest risks for them.

Alterations in Sexual Health: *Infertility*

- Infertility is the inability to conceive after 1 year of unprotected intercourse. - The couple who wants to conceive but cannot is special needs. - Some experience a sense of failure and think their bodies are defective. - Sometimes the desire to become pregnant grows until that is all they think about. - Some people become preoccupied with just creating the right circumstances for conception - Infertile Couples face many choices that involve religious, and ethical values and financial limitations. *WHAT CAN WE DO?* - Choices for the infertile couple include adoption, medical assistance with fertilization, or adapting to the probability of remaining childless. - Organizations like RESOLVE: The National Organization of Infertility, is a national support group for couples with infertility, or international adoption groups provide couples with support and offer referral sources.

Sexuality

- Is a part of a person's personality and is important for overall health. - Patients will share feelings when the nurse addresses sexuality in a relaxed, matter-of-fact manner.

Contraception

- Many options are available - Provide varying levels of protection against unwanted pregnancies - Some methods do not require a prescription, while others require a prescription or some other type of intervention from a healthcare provider.

Nursing Process: *Teamwork and Collaboration*

- Nurses who have specialized education in sexual functioning and counseling can provide more intensive sex therapy. -Sex therapists - Clinical psychologists - Social workers Ex: conflicts in marriage require intensive treatment with a mental health professional, or certified sex therapist For the woman who is currently in an abusive relationship, the nurse collaborates with special women's shelters that provide counseling and serve as a safe place for her while further plans are made.

Factors Influencing Sexuality: *Sociocultural Dimensions of Sexuality*

- People assign different meanings of sexuality on the basis of their culture, gender, education, socioeconomic status, and religion -Society plays a powerful role in shaping sexual values and attitudes and supporting specific expression of sexuality in members - Each cultural and social group has its own set of rules and norms that guide sexual behavior, sexual health and the willingness to discuss this private part of life - Cultural norms: influence how people find partners, whose they choose as partners, and how they relate to one another, how often they have sex, and what they do when they have sex. - Impact of pregnancy and menstruation on sexuality - Discussing sexual issues Sexual assessment and interventions need to be included in health care. - Nurses who have difficulty discussing topics related to sexuality need to explore their discomfort and develop a plan to address it.

What influences our *value systems* (both patients, and care providers)?

- Religious teachings - Cultural Influences on gender roles - Beliefs about sexual orientation - Social and environmental climates

Scientific Knowledge Base: What do you need to know as a nurse regarding sexuality?

- Sexual Development - Sexual Orientation - Contraception - Abortion - STI (sexually transmitted infections)

Alterations in Sexual Health: *Sexual Abuse*

- Widespread health problem - Abuse crosses all gender, socioeconomic age, and ethnic groups -Most often it is at the hands of a former intimate partner, or family member. - Far-ranging effects on physical and psychological functioning. - Can begin, continue or even intensify during pregnancy - Cues: extreme jealousy and refusal to leave a woman's presence. *WHAT CAN WE DO?* - Nurses are in an ideal position to assess occurrences of sexual violence, help patients confront these stressors and educate individuals regarding community services - Nurses are mandated reporters and must report suspected abuse to the proper authorities. *When you suspect or recognize abuse*: >mobilize support for the victim, and the family. > When abuse is suspected, remember not to ask the potential victim about any abusive behaviors in the presence of the suspected abuser. > Provide privacy for the victim, and ask questions in a protective environment > When there is abuse, all family members usually require therapy to promote healthy interactions and relationships *Rape Victims*: > Need to work through the crisis before feeling comfortable with intimate expressions of affection > The partner needs to know how to help and support the victim. *Child Molestation:* > Children who have been molested sexually, need to understand that they are not at fault for the incident > Parents need to understand that their response is critical to how the child reacts and adapts.

Nursing Process: Assessment *Sexual Dysfunction*

-Many illnesses, injuries, medications and aging changes have a negative effect on sexual health. - Sexual dysfunction is either temporary or permanent - Awareness of the possible effects of physical problems, like altered self-concept, medications and all the factors addressed this far helps in conducting a thorough physical assessment. Assessment Activities: - Review medical and medication history > Defining Characteristics: hx of HTN, hx of uncomplicated MI, takes propranolol (Inderal) - Have patient describe sexual problems > Defining Characteristics: Less interested in having intercourse with wife since taking propranolol, rarely has sexual intercourse with wife, sometimes has trouble having an erection -Patients fears and concerns > Defining Characteristics: Fearful will have chest pain or another MI while having intercourse

Decisional Issues: *Prevention of STIs*

-Only abstinence is 100% effective. - Responsible Sexual Behavior: knowing ones sexual partner, and the partners sexual history, being able to openly discuss drug-use history with the partner, not allowing drugs or alcohol to influence decision making and sexual practices and using STI and contraceptive protective devices.

Discussing Sexual Issues:

-Sexual assessment and interventions need to be included in health care. -Nurses who have difficulty discussing topics related to sexuality need to explore their discomfort and develop a plan to address it. *WHAT CAN WE DO?* - You need to be aware of your personal beliefs before discussing sexuality with your patients.

When it comes to sexuality, nurses need to be knowledgable about:

-Sexual functioning - Issues -Assessment

Impact of Pregnancy and Menstruation on Sexuality

-Sexual interest and activity of women and their partners vary during pregnancy and menstruation - Some cultures encourage sexual intercourse or male-female contact during menstruation and pregnancy, but others strictly forbid it - Ex: Hindu culture a women avoids worship, cooking, and other members of the family during menstruation. -Female sexual interest tends to fluctuate during pregnancy, with increased interest during the second trimester, and often decreased interest during the first and third trimesters. *1-3 Trimesters:* - There is often a decrease in libido during the first trimester because of nausea, fatigue, and breast tenderness - During the second trimester, blood flow to the pelvic area increases to supply the placenta, resulting in increased sexual enjoyment and libido -During the third trimester, the increased abdominal size often makes it difficult finding a comfortable position.

Alterations in Sexual Health: *Sexual Dysfunction*

-The absence of complete sexual functioning, is common. 40% in men, and 60-80% in women - More prevalent in men and women with poor emotional and physical health -Sometimes the exact cause cannot be determined *Erectile Dysfunction*: - Erectile Dysfunction (ED) increases with age, but can occur in men under 40 - Risk factors are similar to those for heart disease, (ex: diabetes mellitus, hyperlipidemia, hypertension, hypothyroidism, chronic renal failure, smoking, obesity, alcohol abuse, and lack of exercise) -Neurogenic problems, medications or endocrine or psychogenic factors can cause ED - Age related decrease in testosterone often results in decreased tone of the erectile tissues *HYPOactive Sexual Disorder* - HSDD - one of the most common problems affecting women of all ages. - Biological, organic, or psychosocial factors can contribute to the incidence of HSDD. - Chronic medical conditions like breast or gynecological cancers and hormone fluctuations, pain or depression and anxiety can contribute to a decreased interest in sexual intimacy

3. An adolescent who is pregnant for the first time is at her initial prenatal visit. The women's health nurse practitioner (NP) informs her that she will be screening her for sexually transmitted infections (STIs). The patient replies, "I know I don't have an STI because I don't have any symptoms." How should the NP respond? (Select all that apply.) 1. "Untreated STIs can cause serious complications in pregnancy so we routinely screen pregnant women." 2. "Bacterial STIs don't usually cause symptoms, but you could have an asymptomatic viral STI." 3. "Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic." 4. "People between the ages of 15 and 24 have the highest incidence of STIs." 5. "There is no need to screen for infection since you aren't having any problems or symptoms."

3. Answer: 1, 3, 4. Serious complications can result from untreated STIs in pregnancy such as preterm labor, rupture of membranes, and premature delivery of the newborn. The risk of untreated STIs in any female is pelvic inflammatory disease, which, if untreated, can cause serious problems such as infertility. Routine screening for chlamydia is recommended for all sexually active women up to age 25. Many people do not know they are infected because they do not experience symptoms.

4. A 42-year-old sexually active female is being assessed by a nurse during her annual physical. The woman states that she has not had a period for the last 2 months. The nurse knows that the most likely cause of this occurrence is: 1. Pregnancy. 2. Illicit drug use. 3. Chlamydia infection. 4. Early-onset menopause.

4. Answer: 1. Half of the pregnancies in the United States are unplanned, with women ages 18 to 24 and over 40 accounting for the highest incidence. Chlamydia often causes the cervix to be friable and bleed easily, resulting in irregular bleeding and spotting versus amenorrhea. Menopause is defined as the absence of cyclic bleeding for 12 consecutive months.

8. The nurse is completing an admission history on a patient and says, "As a routine part of your medical history, it's important to include the sexual aspects of your life. Would it be alright if we discussed this?" This is an example of the nurse using the PLISSIT model to: 1. Place the patient in control of the situation. 2. Ask permission to discuss sexuality issues. 3. Provide the patent with limited information about sexual issues. 4. Ask the patient to provide sensitive information.

Answer: 2. According to the PLISSIT assessment of sexuality, the nurse should first ask for permission to discuss sexual issues with the patient, followed by open-ended questions to determine the patient's concerns.

10. The nurse is providing education on sexually transmitted infections (STIs) to a group of older adults. The nurse knows that further teaching is needed when the participants make which statements? (Select all that apply.) 1. "I don't need to use condoms since there is no risk for pregnancy." 2. "I should be screened for an STI each time I'm with a new partner." 3. "I know I'm not infected because I don't have discharge or sores." 4. "I was tested for STIs last year so I know I'm not infected." 5. "The infection rate in older adults is low because most are not sexually active."

Answer: 1, 3, 4, 5. Screening after each new sex partner is the most effective method to detect and manage STIs. One of the challenges in reducing the incidence of STIs is that most STIs have few symptoms in males or females. Asymptomatic STIs can be diagnosed during a physical examination with appropriate laboratory tests. Older adults may engage in risky sexual behaviors because of lack of knowledge about STIs and condom usage. Research indicates that older adults are remaining sexually active longer than previously believed and the incidence of STI and human immunodeficiency virus (HIV) infections has steadily increased for the past 12 years.

14. The school nurse is counseling an adolescent male who is returning to school after attempting suicide. He denies substance abuse and has no history of treatment for depression. He says he has no friends or family who understand him. Critical thinking encourages the nurse to consider all possibilities, including which of the following? (Select all that apply.) 1. Adolescents often explore their sexual identity and expose themselves to complications such as sexually transmitted infections (STIs) or unplanned pregnancy. 2. Peer approval and acceptance are not important in this age-group. 3. Lesbian, gay, bisexual, and transgender (LGBT) youth often experience stress from identification with a sexual minority group. 4. Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety. 5. Adolescence is a time of emotional stability and self-acceptance.

Answer: 1, 3, 4. Adolescents are establishing their identity and exploring their sexual preference. Those who identify with a sexual minority group often experience stress and isolation from peers. They need clear and accurate information about physiological and emotional changes occurring in their body. Peer influence is high during this time, but support from family and health care professionals is equally important to adolescents.

12. The nurse is gathering a sexual health history on a patient being admitted to the hospital for surgery. Which question asked by the nurse demonstrates a nonjudgmental attitude? 1. Can you tell me your sexual orientation? 2. How do you and your wife feel about intimacy? 3. Do you have sex with men, women, or both? 4. Do you have sexual intercourse at your age?

Answer: 1. A nonjudgmental attitude facilitates trust and open communication between the nurse and patient. Using a term such as sexual orientation allows the patient to identify his or her sexual preference.

11. The nurse is providing community education about how the sexual response changes with age. Which statement made by one of the adults indicates the need for further information? 1. "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual functioning and desire." 2. "It usually takes longer for both sexes to reach an orgasm." 3. "Most of the normal changes in function are related to alteration in circulation and hormone levels." 4. "Many medications can interfere with sexual function."

Answer: 1. Pathological processes can interfere with sexual function and desire. Changes in circulation, neurological pathways, and hormone levels account for many of the normal physiological changes that occur with the aging process. Common medications such as diuretics, antihypertensives, antianxiety medications, and antidepressants can contribute to sexual dysfunction. Older males and females take longer to reach orgasm, and the refractory period lengthens.

2. Place the following in order of sequence for condom application and usage. 1. Gently squeeze air out from the tip of the condom; leave space at the tip. 2. Check the condom package for damage, expiration date, and protection from STIs. 3. After ejaculating, hold onto condom while pulling out. 4. Place on erect penis and unroll to the base of the penis.

Answer: 2, 1, 4, 3. Use a latex or rubber condom and read package label to ensure that condom protects against sexually transmitted infections (STIs). Animal skin or natural skin condoms do not protect against STIs but help prevent pregnancy.

7. According to Healthy People 2020, certain ethnic groups in the United States are disproportionately affected by sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). What are the likely causes of this issue? (Select all that apply.) 1. The large percentage of lesbian, gay, bisexual, or transgender individuals in the culture 2. Values and expectations about sexual behavior by the men or women in the culture 3. Religious beliefs and cultural attitudes toward the use of contraceptives 4. Educational background and knowledge of health risks associated with sexual behaviors 5. The higher incidence of sexual abuse in the affected ethnic groups

Answer: 2, 3, 4. Factors such as gender, education, socioeconomic status, religion, language, and values influence the use of the health care system and health care practices. Each cultural group has their own set of norms that determine acceptable sexual behavior. Contraception choice is influenced by age, ethnicity, marital status, income, sexual orientation, and previous pregnancies. Populations who are at increased risk for HIV are people who are intravenous drug users, those who practice unprotected sex, and men who have sex with men. According to Healthy People 2020, Hispanic, African-American, and American Indian/Alaska Native populations experience higher rates of STIs than whites.

15. A 53-year-old female being treated for breast cancer tells the nurse that she has no interest in sex since her surgery 2 months ago. The nurse is aware that: (Select all that apply.) 1. Sexual issues are expected in a woman this age. 2. Women experience sexual dysfunction more frequently than men. 3. Hypoactive sexual desire disorder (HSDD) occurs in women over 65 years of age. 4. It is not unusual for medical conditions such as cancer to contribute to HSDD. 5. Disturbances in self-concept affect sexual functioning.

Answer: 2, 4, 5. Women of all ages (not just older women) can experience HSDD. Biological, organic, or psychosocial factors; pain; depression; and body image concerns can result in sexual problems in men and women. Sexual dysfunction is estimated to occur in 40% of men and 60% to 80% of women. Self-concept issues, including changes in body image, self-esteem, and role performance, can impact sexual functioning.

13. The nurse reviews the health history of a 48-year-old man and notes that he was started on medications for elevated blood pressure and depression at his last annual physical. He tells the nurse that over the past 6 months he is having difficulty sustaining an erection. The nurse understands that: (Select all that apply.) 1. Nurses are not expected to discuss sexual issues with male patients and the physician should address this. 2. Sexual function can be affected negatively by some medications. 3. Sexually transmitted infections (STIs) can cause complications such as erectile dysfunction and screening should be done. 4. It is not unusual for men with health issues to experience erectile dysfunction. 5. Medications used to treat hypertension and depression seldom interfere with sexual function.

Answer: 2, 4. Nurses should complete a holistic assessment on all patients to be able to personalize a plan of care. Nurses who are not comfortable discussing sexual concerns of patients should seek out training and resources to develop this skill. Many drugs and illnesses can affect sexual function. Antidepressants can alter sexual functioning by blocking neurotransmitters. Antihypertensives can affect sexual function by altering circulation. Erectile dysfunction occurs more frequently in older men but can occur in men as young as 40. STIs may affect sexual functioning but are less likely than medications or illness to be the cause of erectile dysfunction.

6. The nurse is gathering a history from a 72-year-old male patient being admitted to a nursing home. The patient requests a private room. The nurse understands that: 1. The patient cannot be sexually active since he is moving into a nursing home. 2. The patient may be requesting a private room to facilitate an intimate relationship with his partner. 3. There is no need to take a sexual history since most older adults are uncomfortable discussing intimate details of their lives. 4. Older adults in nursing homes usually do not participate in sexual activity.

Answer: 2. Studies have shown an increase in sexual dysfunction with aging but no decrease in sexual activity or interest. Sometimes sexual health is not addressed by the nurse, but it is important to include a sexual history as a routine aspect of assessment to communicate that sexual activity is normal. Long-term care facilities need to make arrangements to allow for continuation of sexual experiences of residents as long as no health risks are involved.

5. A cardiac nurse who recently graduated from nursing school is providing discharge instructions to a patient who suffered a myocardial infarction (MI). The nurse knows that sexual issues are common after an MI but doesn't feel comfortable bringing up this topic. What is the best way for the nurse to handle this situation? (Select all that apply.) 1. Instruct the patient to discuss any sexual concerns with his or her partner after discharge 2. Avoid discussing the topic unless the patient brings it up 3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training in the near future on how to discuss such issues 5. Encourage the patient to discuss any personal concerns with the cardiologist

Answer: 3, 4. Nurses often avoid discussing sexual issues with patients because they are uncomfortable, lack knowledge, or have personal values in conflict with the patients. Nurses who have difficulty addressing sexual issues need to seek education and experiences to increase knowledge and explore their personal values.

1. A 16-year-old female tells the school nurse that she doesn't need the human papillomavirus (HPV) vaccine since her partner always uses condoms. The best response by the nurse to this statement is: 1. Latex condoms are the most effective way to eliminate the risk of HPV transmission. 2. Your parents may not want you to receive the HPV vaccine since it has been shown to increase sexual risk taking and sexual activity. 3. The HPV 9-valent vaccine is recommended for males and females and targets the specific viruses that cause cancer and genital warts. 4. You are past the recommended age to receive the vaccine.

Answer: 3. An HPV vaccine that protects both men and woman against the types of HPV that causes serious health issues is available and recommended for individuals ages 11 to 26. The use of latex condoms reduces the risk of contracting a sexually transmitted infection (STI), but abstinence is the only practice that eliminates the risk. Research indicates that vaccination does not increase sexual risk-taking behaviors among youths.

9. A 17-year-old girl asks for more information about birth control methods and says that she does not want her parents to know she is using birth control. The nurse informs the patient that the most effective option for her situation would be: 1. An effective long-term method such as a subdermal implant. 2. A hormonal method such as birth control pills or the transdermal patch. 3. A long-acting hormonal injection given every 12 weeks. 4. Abstinence during her most fertile time.

Answer: 3. The progesterone (Depo-Provera) injection is an effective method of birth control in which the patient receives an injection of progesterone every 12 weeks. Although the transdermal patch or subdermal implant is an effective method, it would be easier for others to see it in place on the skin. The use of latex condoms is recommended in addition to hormonal methods to decrease the risk for sexually transmitted infections. Any birth control method that must be used consistently with each occurrence of intercourse is a less reliable method (because of the margin for human error) than longer-acting methods that are not required with each act of sex.

1. Which of the following populations have the highest incidence of STI? (Select all that apply.) A. Hispanic women age 15 to 24 years B. African-American men age 15 to 24 years C. Caucasian men age 50 to 58 years D. Caucasian women age 42 to 53 years

Answer: A+B: Hispanic women age 15 to 24 years and African-American men age 15 to 24 years Rationale: The highest incidence of STI occurs in the 15-to-24-year-old age group and in Hispanic and African American populations.

2. Upon admission, when gathering a patient's sexual history, nurses should: A. focus only on physical factors that affect sexual functioning. B. discuss sexual concerns only if the patient raises questions or concerns. C. use emotionally laden terms when discussing sexual concepts. D. include questions related to sexual function.

Answer: D Rationale: Sexual function is an important part of taking a sexual history, as it can indicate other problems the patient may be having.

Sexual Health

a state of physical, emotional, mental, and social well-being in relation to sexuality ex: people who are sexually healthy have a positive and respectful approach to sexuality and sexual relationships. They have a potential for having pleasurable and safe sexual experiences that are free from coercion, discrimination and violence.

Sexual orientation

Describes the predominant pattern of a persons sexual attraction over time. - Many stereotypical myths remain about people who are LGBT - LGBT experience decreased access to health care and do not readily seek preventative care. >> *WHAT CAN WE DO?*: - Nonjudgmental nurses who have a solid knowledge base help to discourage these myths and provide nursing care that includes attention to the persons sexual orientation

What influences our *expression* of sexuality?

Factors: - Biological - Sociological - Psychological - Spiritual - Economic - Political - Religious - Cultural

Critical Thinking

Integrate knowledge from nursing and other disciplines. Have understanding of sex practices and risks associated with sexual problems. *KNOWLEDGE* - Ways to phrase questions about sexuality - Sexual development and the human sexual response patterns - Impact of self-concept on sexuality - Sexual orientation - Effective contraceptive methods - STIs and associated risk factors - Safe sex practices - Behaviors suggestive of current or past sexual abuse - Diseases and/or medications that affect sexual dysfunction - Interpersonal relationship factors and sexual functioning *EXPERIENCE:* - Communicating with patients and developing rapport - Working with patients and exploring sexual concerns (like working in an OBGYN setting) - Personal sexual experience and response *ASSESSMENT:* - Assess the patients developmental stage with regard to sexuality - Perform physical assessment of urogenital area - Determine the patients sexual concerns - Assess the presence of high-risk behaviors, use of safe sex practices and contraception - Assess medical conditions and mediations that might affect sexual functioning *STANDARDS*: - Apply intellectual standards of relevance and plausibility for care to be acceptable to the patient - Safegaurd the patients right to privacy by protecting confidential info - Demonstrate ethics of care *ATTITUDES:* - Display curiosity: consider why a patient may behave or respond in a particular manner - Display integrity: your beliefs and values differ from a patients: admit to any inconsistencies between your values and the patients - Take risks if necessary to explore both personal and sexual issues and concerns and those of the patient.

Decisional Issues: *Abortion*

It is essential to choose specialties or places of employment where personal values are not compromised and the care of a patient in need of health care is not jeopardized. - Approx 40% of unintended pregnancies end in abortion - Safer and less costly when performed in the early weeks of pregnancy - Reasons for choosing an abortion vary and include terminating an unwanted pregnancy or aborting a fetus known to have birth defects. - Women and her partner often experience a sense of loss, grief, and or guilt. *WHAT CAN WE DO?* - If caring for a patient contemplating abortion, provide an environment in which the patient is able to discuss the issue openly, allowing exploration of various options with unwanted pregnancy. - Discuss religious, social, and personal issues - Be aware of your own personal values. You are entitled to your own personal views, and you should not be forced to participate in counseling or procedures that you do not believe in. - it is essential to choose a place of employment where your personal values are not compromised and the care of a patient in need of health care is not jeopardized.

STIs: *HPV* (Human Papillomavirus Infection)

Most common STI in United States (14 mil/year); spread through direct contact with warts, semen, or other fluids -Most HPV infections are asymptomatic and self-limiting. BUT, certain types can cause cervical cancer in women and anogenital cancers and genital warts in both men and women. - Textured warts have cauliflower appearance and are most common on the penis and scrotum in men, and the vagina and cervix in women *WHAT CAN WE DO?*: - A vaccine that protects both men and woman against the nine types of HPV that most commonly cause health concerns. - Recommended for all youths ages 11-26 - Vaccination rates in the US are low - Parental acceptance of the vaccine influences vaccination status and parents have voiced concern that vaccination will promote sexual risk taking in youths, despite evidence indicating otherwise. - Recommend the vaccine to increase vaccine acceptance by the public and reduce the risk of HPV related cancers - Discuss benefits of the vaccine with parents and youths ages 11-26 and offer catch-up vaccines as needed - Reduce parental concerns by sharing research that indicates that vaccine administration does not increase sexual activity or risk behaviors - Continue to teach safe sex practices

STIs: *HIV* (Human Immunodeficiency Virus)

Primary routes of transmission include contaminated IV needles, anal intercourse, vaginal intercourse, oral-genital sex, and transfusion of blood, blood products 3 STAGES: 1. *Primary Infection Stage*: lasts for a month after contracting. Person experiences flu like symptoms. 2. *Clinical Latency Phase*: no symptoms of infection. HIV antibodies appear in the blood about 6 weeks to 3 months after infection. If left untreated, people who are infected with HIV life about 10 yrs 3. *AIDS*: happens when a person begins to show symptoms of the disease. AIDS is a serious, debilitating, and eventually fatal disease. *WHAT CAN WE DO?*: -Highly Active Antiretroviral Therapy (HAART) and having an experienced HIV clinician greatly increase the survival time of people who live with HIV/AIDS

To feel comfortable about addressing sexuality, nurses need _________________ communication skills.

Therapeutic

Alterations in Sexual Health: *Personal and Emotional Conflicts*

You will care for patients who have problems with one or more of the stages of sexual activity, including the feeling of wanting sex, the physiological processes and emotions of having sex, and the feelings experienced after sex. ex: some women and men who are taking antidepressants report that their ability to reach an orgasm is affected negatively

Nursing Assessment *Questions*:

• Are you sexually active? • With whom do you have sex: men, women, or both? • How many sexual partners do you have (or have you ever had)? • How do you feel about the sexual aspects of your life? • Have you noticed any changes in the way you feel about yourself? • How has your illness, medication, or surgery affected your sex life? • It is not unusual for people with your condition to be experiencing some sexual changes. Have you noticed any changes, or do you have any concerns? • Are you in a relationship in which someone is hurting you? • Has anyone ever forced you to have sex against your will? • Tell me what you know about safe sex practices, use of contraceptives, or prevention of sexually transmitted infections. • Tell me the safe sex practices that you follow.

Key Points:

• Attitudes toward sexuality vary widely. Religious beliefs, society values, the media, the family, and other factors all influence it. • Nurses' attitudes toward sexuality vary and often differ from those of patients; be sensitive to patients' sexual preferences and needs. • Sexual development begins in infancy and involves some level of sexual behavior or growth in all developmental stages. • The physiological sexual response changes with aging, but aging does not lead to diminished sexuality. • Sexual health contributes to an individual's sense of self-worth and positive interpersonal relationships. • Interventions for sexual dysfunctions depend on the condition and the patient; they often include giving information, teaching specific exercises, improving communication between partners, and referral to a knowledgeable professional. • Most nursing interventions that enhance sexual health require providing education. • Evaluate patient satisfaction with outcomes of care by talking with patients regarding satisfaction with sexual functioning and through observations of nonverbal behaviors that suggest anxiety. Include the partner when appropriate. • Sexual biases, comfort with touching genitalia, desire for future fertility, financial status, ability to plan sexual contact, and ability to communicate with the sex partner all affect the choice and use of effective contraceptive methods.

Community Resources Relating to Sexuality

• Community and free clinics offering contraceptive information and resources • Health department (often for both family planning and sexually transmitted infections) • Groups that provide education/services for those with particular conditions include the following: • American Diabetes Association • American Heart Association • Muscular Dystrophy Association • Muscular Sclerosis Society • Sexual abuse support groups and hot lines • Women's shelters (for those who have been physically and/or sexually abused) • Resolve: The National Infertility Association (http://www.resolve.org) • North America Menopause Society (http://www.menopause.org)