Chapter 44 sexuality

Assessing nursing process part 3

A few of the major dysfunctions and assessment priorities are briefly discussed in Table 44-3. See also Focus on the Older Adult . Physical Assessment Physical examination of the reproductive or genitourinary system is necessary for either male or female patients under the following circumstances: As part of a routine physical examination Annual women's health care examination, including a Pap smear Suspected STI Suspected pregnancy Workup for infertility Unusual lump, discharge, or appearance of the genital organs noticed by the patient Request for birth control Change in urinary function The examiner may routinely perform a complete physical examination along with assessment of the reproductive system if the patient has not had contact with the health care system within 1 year, or if the assessment findings from a complete examination would be useful in diagnosing an ailment or complaint. See Chapter 25 for a detailed description of how to examine the female and male genitalia. (Taylor 1675) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Implenting part 2

After patients have developed some degree of comfort in looking at their bodies, they can progress to experiencing touch. Again, patients should progress from nonthreatening parts of the body until the genitals can be touched without stress. A good exercise for women in developing body awareness is the use of Kegel exercises. These exercises promote good vaginal tone by localizing and strengthening the pubococcygeal muscle. A woman can locate this muscle by stopping a stream of urine midway through urination. Contracting this muscle can be repeated at any time of the day in any circumstance because its performance is undetectable. Some women who practice Kegel exercises have found that their sexual satisfaction is improved. Promoting Responsible Sexual Expression Patients need to know how to gain satisfactory sexual experiences while behaving responsibly in their activities. Responsible sexuality encompasses sexual expression, prevention of unwanted pregnancy, prevention of STIs, and sex education. FORM OF SEXUAL EXPRESSION The form of sexual expression used by patients should not inflict unwanted harm on themselves or others. When sexual expression encroaches on the rights of others, it is neither healthy nor desirable. Sexual acts that violate another's rights are usually considered to be acts of aggression or hostility rather than stemming from sexual need or desire. Rape, in particular, is motivated by a need to dominate and humiliate the victim. PREVENTION OF UNWANTED PREGNANCY Contraception is a process or technique for preventing pregnancy by means of a medication, device, or method that blocks or alters one or more of the processes of reproduction in such a way that sexual union can occur without impregnation. The prevention of unwanted pregnancy must be a conscious decision. Anyone who is unprepared for pregnancy should refrain from intercourse or obtain a contraceptive method from a health care provider or from the pharmacy; it is too late to think about contraception during sexual intercourse. To practice responsible sexuality, the contraceptive method must be used consistently and according to instructions. Prevention of STIs As described earlier, STIs are widespread. The only sure way to avoid an STI is to avoid all types of intimate genital contact. When this is impractical, there are other practices that can decrease a patient's risk for STIs (see Box 44-1). The American College of Obstetricians and Gynecologists' Committee on Health Care for Underserved Women has published a Committee Opinion on Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome and Women of Color (2008). In the United States, women of color (primarily African American and Hispanic women) comprise most new cases of HIV and AIDS among women. Most women of color acquire the disease from heterosexual contact, often from a partner who has undisclosed risk factors for HIV infection. A combination of testing, education, and brief behavioral interventions can help reduce the rate of HIV infection and its complications among women of color. (Taylor 1680-1682) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Childbearing considerations affecting sexuality

All sorts of questions surround childbearing, and the ability (or lack of ability) to procreate can put great pressure on a sexual relationship: Are we ready to be parents? What does it mean to be a responsible parent—especially in this age when an increasing number of prenatal interventions are available to maximize fetal outcomes (quality control)? Should we choose life partners only if genetic testing reveals a good match for reproduction? If we choose to be sexually active and not have children, what are the best means to prevent unwanted pregnancies? If we become pregnant and choose not to continue the pregnancy, what are our options? If we desperately want a child and discover one or both to be infertile, what are our options? The age of biotechnology promises "designer babies" and raises hard questions for individuals and society. People frequently look to nurses for help in sorting through how to respond to these challenges. Experienced nurses are good at detecting when a fear of pregnancy or inability to conceive is interfering with a couple's normal sexual expression or when a changing developmental stage (e.g., menopause) is interfering with normal sexual expression. (Taylor 1667) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Alternate forms of sexual stimulation

Alternate forms of sexual expression include the following: Voyeurism is the achievement of sexual arousal by looking at the body of someone other than one's sexual partner. Some voyeurs develop complex means to spy on others that involve violations of privacy. Sadism refers to the practice of gaining sexual pleasure while inflicting abuse on another person. Masochism refers to gaining sexual pleasure from the humiliation of being abused. Sadomasochism is the act of practicing sadism and masochism together. It might involve being tied up, biting, hitting, spanking, whipping, pinching, and other activities. Pedophilia is a term used to describe the practice of adults gaining sexual fulfillment by performing sexual acts with children. (Taylor 1662) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Assessing nursing process

Assessing Sexual History The comprehensive health history should include information regarding a patient's reproductive and sexual health, depending on the circumstances in which the patient is receiving care. As a rule, three general categories of patients should have a sexual history recorded by the nurse: Any inpatient or outpatient receiving care for pregnancy, STI, infertility, or contraception Any patient experiencing sexual dysfunction Any patient whose illness will affect sexual functioning and behavior in any way Information is best obtained from the patient by beginning with nonthreatening questions and progressing to more sensitive concerns (see the accompanying Focused Assessment Guide 44-1). Patients usually have no difficulty answering questions regarding their bodies and general reproductive issues such as, "When did your menstrual periods first begin?" Explain to patients that this information might help you develop the plan of care and identify any sexual problems or concerns. The assessment provides an excellent opportunity to teach by helping the patient confront fears. Four general levels of sexual history are: Level 1: Sexual history as part of a comprehensive health history—obtained by a nurse Level 2: Sexual history—obtained by a nurse with education and training in sexuality Level 3: Sexual problem history—obtained by a sex therapist Level 4: Psychiatric/psychosocial history—obtained by a psychiatric nurse clinician Each level acquires more specific information from the patient regarding sexual health and also requires the interviewer to have more sophisticated preparation and skills. The professional nurse usually performs a sexual history on level 1. The nurse sets the tone or atmosphere for the interview. The nurse's attitudes will greatly affect the patient's response to the sexual history; patients will be more cooperative if they sense the nurse's security and ease during the interview. Privacy is essential for the sexual history; doors should be closed and no interruptions allowed. Sit close to the patient and speak in a quiet, relaxed, objective tone of voice. Use eye contact and open body posture. Explain to the patient that no one will have access to this information unless it is significant to the patient's care. Obtain reproductive health information first, followed by the sexual health history. The best approach is to begin with general open-ended questions and progress to more specific ones. Try to use the language used by the patient because the patient might be reluctant to admit not understanding certain terms for fear of appearing ignorant or foolish. For example, the patient might use the term "come" to mean climax or orgasm. It is useful to begin questions with phrases such as "many people like" or "many people feel." This gives patients security in knowing they are not alone in how they feel and will encourage them to talk about their problems or concerns. For example, "Many people feel that it's helpful to discuss their concerns about sex with their partner. What do you think about this?" (Taylor 1673) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Implementing part 4

Continuous abstinence involves not having any sex with a partner at all. It is 100% effective in preventing pregnancy and STIs. However, individuals may find it difficult to abstain for long periods of time. Ending abstinence without first being prepared to protect against an unplanned pregnancy or infection might cause additional problems. Periodic abstinence and fertility awareness methods are two methods of contraception that involve charting a woman's fertility pattern. Periodic abstinence is a method used by some sexually active women to prevent pregnancy. They become familiar with their fertility patterns and abstain from vaginal intercourse on the days they think they could become pregnant. Women who monitor their fertility to prevent pregnancy either abstain from vaginal intercourse for at least one-third of each menstrual cycle or use barrier methods during the fertile or "unsafe" period. Three basic charting methods can be used to predict ovulation in order to plan or prevent pregnancy: Temperature method: The woman takes her temperature every morning before getting out of bed. Her temperature will rise between 0.4°F and 0.8°F on the day of ovulation and will remain at that level until her next period. Cervical mucus method: The woman observes the changes in her cervical mucus throughout the first part of the menstrual cycle, until after ovulation. Cervical mucus is normally cloudy, but a few days before ovulation it becomes clear and slippery and can be stretched between the fingers. This indicates the most fertile phase of the cycle. The couple must abstain from vaginal intercourse or use a barrier method during this period to avoid pregnancy. Calendar method: The woman charts her menstrual cycle on a calendar. The couple must refrain from intercourse or use a barrier method during "unsafe" days. The best approach to monitoring fertility is a combination of all three methods called the symptothermal method. Of 100 couples who use any of these methods for 1 year, 20 women will typically become pregnant. The failure rate is higher in single women. Using the methods carefully and consistently and avoiding unprotected vaginal intercourse during the fertile phase can give better results. Coitus interruptus, the withdrawal of the penis from the vagina before ejaculation, is one of the oldest and most widely used contraceptive methods. Pregnancy cannot occur if sperm are kept out of the vagina. Of every 100 women whose partners attempt this method, 27 typically will become pregnant during the first year. Pre-ejaculate can contain enough sperm to cause a pregnancy, and pre-ejaculate or semen may spill onto the vulva. Barrier Methods. Barrier methods include the condom, diaphragm, cervical cap, and vaginal sponge used in combination with a spermicidal agent. Diaphragm. Diaphragm approaches have been used in various forms since ancient times. The current diaphragm is a dome-shaped device made of latex rubber that mechanically prevents semen from coming into contact with the cervix. It is also used to hold a spermicidal jelly in place against the cervix. The diaphragm is placed in the vagina before sexual activity. It fits between the pelvic notch at the front of the vagina to behind the cervix at the back. It is not felt by either the woman or her partner when correctly situated in the vagina. A diaphragm must be individually sized during a pelvic examination. The woman needs to be familiar with her body and able to handle her genitals for diaphragm placement and removal. The diaphragm must be worn during each episode of sexual activity and consistently used with a spermicidal agent. Twenty of 100 women who use the diaphragm will become pregnant during the first year of typical use; 6 will become pregnant with perfect use. Condom. The traditional condom, or "rubber," is used by men, although it is appropriate for a woman to have a condom available for her partner's use. The condom is rolled over the erect penis and collects the semen after ejaculation occurs. If the condom does not have a nipple receptacle end, a small space should be left at the end of the condom to collect sperm (this prevents breakage). Condoms are available over the counter and have become more widely used because of the incidence of HIV/AIDS and other STIs. A female condom is also available. The female condom is a ringed pouch that unrolls in the vagina. Advantages include the fact that the male does not need to first have an erection for the pouch to be used, and it offers significant protection from STIs. Of 100 women whose partners use condoms, about 14 will become pregnant during the first year of typical use; 2 women will become pregnant with perfect use. The latex condom protects against STIs, including HIV. The latex condom offers better protection against STIs than any other birth control method because it blocks the exchange of body fluids that may be infected. Cervical Cap. The cervical cap is a thimble-shaped rubber device that is placed over the cervix and may be left there for up to 3 days at a time. Its mechanism of action is similar to that of the diaphragm. Not all women can wear a cervical cap because of individual anatomic differences. There is some evidence to suggest that the cervical cap can cause cervical inflammation and increase the risk for pelvic infection. Spermicides. Spermicides are used with barrier methods but can also be used alone. Spermicides come in creams, jellies, foams, and suppositories. Although readily available, spermicides are not as effective alone as when combined with another method, such as a diaphragm or a condom. Vaginal Sponge. The vaginal sponge is a barrier method that contains a spermicide. The sponge acts not only as a barrier between the semen and the cervix but also as a reservoir to hold semen. The vaginal sponge carries some risk of toxic shock syndrome (TSS) and is contraindicated for use in women who have a past history of TSS. Women who use the vaginal sponge must follow package directions carefully and remove the sponge within 24 hours. The vaginal sponge is about as effective as the diaphragm. Hormonal. Hormonal methods are based on the feedback mechanism of hormones of the menstrual cycle. Synthetic estrogens and progestin chemical compounds are used in the form of a pill, shot, or implant to prevent ovulation. Oral Contraceptives. The oral contraceptive ("the pill") is the most common contraceptive method and the most popular method for women in their 20s. Most of the harmful side effects and dangers associated with taking the pill are related to the estrogen component. However, most pills currently available contain a small dose of estrogen. The pill also has many beneficial noncontraceptive effects. It has been shown to protect women against the development of breast, ovarian, and endometrial cancer. Taken consistently and as prescribed, the pill is almost 100% effective in guarding against pregnancy. However, its cost might be prohibitive to some women. The woman must also be motivated to take a pill every day at the same time. A health history and physical examination by a health care provider are necessary to obtain a prescription for oral contraceptives. Some women should not take the pill if they have certain physiologic disorders or diseases. Smoking increases the risks associated with oral contraceptives. Remind women who are taking the pill to take measures to protect themselves from STIs. Norplant System. The Norplant System is a reversible, 5-year, low-dose, progestin-only contraceptive. The system consists of six matchstick-size capsules (made of Silastic tubing) that are placed just under the skin of the woman's upper arm. The average annual pregnancy rate over 5 years is less than 1%. The most common side effect is a change in the menstrual bleeding pattern, including prolonged menstrual bleeding, spotting between menstrual periods, or no bleeding at all. Implanon. In the Implanon system, a single etonogestrel-containing rod is implanted in the woman through the use of a disposable insertion kit. Removal requires a small incision and takes about 3 minutes. The single-rod system contains 68 mg of etonogestrel in an ethylene vinyl acetate (EVA) copolymer core surrounded by an EVA membrane. The rod releases 67 mcg of etonogestrel daily. This method of contraceptive approaches 100% efficacy. The most common reason for discontinuation is weight gain. Depo-Provera. Depo-Provera is the brand name of a progestin-only hormonal birth control system. It uses a hormone similar to progesterone, one of the hormones made by a woman's ovaries that regulates the menstrual cycle. It is called depot medroxyprogesterone acetate (DMPA). An injection of DMPA in the buttock or arm can prevent pregnancy for 12 weeks and is 99.7% effective. Protection is immediate if the injection is given on the first day of the woman's period. Irregular bleeding is the most common side effect for women using DMPA. Of every 1,000 women who use Depo-Provera, only 3 will become pregnant during the first year of use. Transdermal Contraceptive Patch. The transdermal contraceptive patch (Evra) supplies continuous daily circulating levels of ethinyl estradiol (20 mcg) and norelgestromin (150 mcg). The patch is applied weekly on the same day of each week for 3 weeks, followed by a patch-free week. It may be applied to any of four sites: lower abdomen, upper outer arm, buttock, or upper torso (excluding the breast). Women who use the contraceptive patch demonstrate more effective use than those using oral contraceptive pills. The patch has been found to have an overall annual probability of pregnancy (method failure plus user failure) of 0.8%. This contraceptive method has the same contraindications as oral contraceptives. The most common side effects include breast symptoms, headache, application site reactions, nausea, upper respiratory tract infection, and dysmenorrhea. Vaginal Ring. The vaginal ring (NuvaRing) is a soft, flexible, transparent ring made of ethylene vinyl acetate copolymer. It releases approximately 120 mcg of etonogestrel and 15 mcg of ethyl estradiol daily. Each ring is inserted into the vagina and used for one cycle, which consists of 3 weeks of continuous use followed by a ring-free week. Women can insert and remove the ring themselves. It does not need to be fitted, nor does it require particular placement within the vagina. The ring works by inhibiting ovulation in much the same way as oral contraceptives. Used appropriately, the vaginal ring is 99.3% effective in protecting against pregnancy. Benefits of the vaginal ring include ease of use, self-insertion, high degree of effectiveness, and low incidence of negative or adverse effects. The most common side effects include headache, vaginal discharge, vaginitis, vaginal discomfort, foreign body sensation, coital problems, and ring expulsion. Intrauterine Devices. The intrauterine device (IUD) is an object that is placed by a physician or nurse practitioner within the uterus to prevent implantation of a fertilized ovum. IUDs are small devices made of flexible plastic that provide reversible birth control. IUDs usually prevent fertilization of the egg, but the precise mechanism by which it works is unknown. IUDs seem to affect the way the sperm or egg moves. It may be that substances released by the IUD immobilize sperm. Another possibility is that the IUD prompts the egg to move through the fallopian tube too fast to be fertilized. IUDs that contain copper are more effective for two reasons. The copper affects the behavior of enzymes in the lining of the uterus to prevent implantation and also causes the production of increased amounts of prostaglandin. Only 8 of 1,000 women using copper IUDs will become pregnant with perfect use. Combination hormonal and IUD contraceptive methods include a T-shaped device with a steroid reservoir around the vertical stem (Mirena). It releases 20 mcg of levonorgestrel daily and provides contraception for up to 5 years. Fertilization is prevented because the device causes changes in cervical mucus and endometrial morphology, inhibition of sperm migration, alteration of sperm-egg binding and ovarian function, and a foreign body reaction by the uterus. Failure of implantation may occur in some women. Estradiol levels are managed within the usual range of women who are not using contraceptives. Normal function of the ovaries and fertility are restored as quickly after discontinuation as with any IUD. Efficacy approaches 100%. An additional benefit of this contraceptive method is that it controls menorrhagia in pre- and perimenopausal women. Adverse side effects peak at 3 months of use and reduce in frequency after that. The most common side effects include bleeding, depression, headache, acne, and weight changes. Both types of IUDs have a filament string that serves two purposes. It allows for easier removal by a clinician, and it allows the woman or her clinician to check if the IUD is still in the correct position. (Taylor 1683-1685) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Developmental consideration and culture affecting sexuality

Developmental Considerations The process of human development affects the psychosocial, emotional, and biologic aspects of life, which in turn affect a person's sexuality. Biologic sex is the only distinguishing trait present at conception. From birth onward, gender, or sex, influences behavior throughout life. Table 44-1 summarizes sexuality throughout the lifespan and the nursing implications for each stage. Culture The manner in which a society perceives sexuality in turn influences the individual. 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 might be expected merely to 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, talk with people from different cultures about 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? The fact that a practice is common in a culture does not mean that it is healthy or ethical. Female genital mutilation (FGM) includes procedures that intentionally alter or cause injury to the female genital organs for nonmedical 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 140 million girls and women worldwide are currently living with the consequences of FGM. In Africa an estimated 101 million girls 10 years old and older have undergone FGM. The World Health Organization (WHO, 2014) writes that "FGM is recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death." There are four major types of FGM: (Taylor 1662) Clitoridectomy: partial or total removal of the clitoris and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris) Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora 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. Other: all other harmful procedures to the female genitalia for nonmedical purposes, for example: pricking, piercing, incising, scraping, and cauterizing the genital area. (Taylor 1664) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Diagnosis and outcome identification.

Diagnosing There are two categories of nursing diagnoses written to address problems of sexuality: Ineffective Sexuality Patterns: The state in which an individual experiences or is at risk for a change in sexual health, which results in concern regarding own sexuality. Sexual health is the integration of somatic, emotional, intellectual, and social aspects of sexual being in ways that are enriching and that enhance personality, communication, and love. Sexual Dysfunction: The state in which an individual experiences or is at risk for change in sexual function that is viewed as unsatisfying, unrewarding, or inadequate. Related diagnoses include Rape-Trauma Syndrome, Impaired (or Risk for Impaired) Parenting, and Readiness for Enhanced Parenting (NANDA International [NANDA-I], 2012). Ineffective Sexuality Patterns or Sexual Dysfunction as the Problem Before a nursing diagnosis is made regarding a sexual problem, carefully review the assessment data to determine whether the situation can be corrected by independent nursing interventions. Although many problems of sexuality experienced by a patient in a health care situation are amenable to nursing action, some require the expertise of other specialties. An impotent diabetic patient who would benefit from a penile implant—such as Jefferson Smith, described at the beginning of the chapter—needs medical consultation. A patient with a serious sexual dysfunction or one who practices destructive sexual expression needs intensive therapy by a clinical psychologist, sex therapist, or counselor. Appropriate referrals by the nurse should follow the identification of such problems. Sexual dysfunction may be specified as erectile failure (impotence), premature ejaculation, retarded ejaculation, inhibited sexual desire, orgasmic dysfunction, vaginismus, or dyspareunia. Common etiologies for sexual dysfunction include effects of medication (specify), effects of alcohol consumption, effects of disease process (specify), history of abuse (specify rape, incest), feelings of depression, guilt, anxiety, fear of rejection, miscommunication with partner, fear of pain, effects of birth control method (specify), lack of knowledge, or effects of surgical procedure (specify). The nursing diagnosis Ineffective Sexuality Patterns can be further specified by loss of desire (to abstinence), increased desire (to promiscuity), or change in sexual expression. Common etiologies for Ineffective Sexuality Patterns include stress (lifestyle, job, family, finances, marital conflict), isolation from partner, effects of pregnancy (specify), feelings of depression, loss of privacy, loss of communication with partner, relationship change (new partner), effects of disease process (sexual position, frequency, mode of expression), change in body image, change in self-concept, or loss of partner. Some nursing diagnoses concerning sexuality are given in Examples of NANDA-I Nursing Diagnoses: Sexuality . Ineffective Sexuality Patterns or Sexual Dysfunction as the Etiology Changes in sexuality can affect other areas of human functioning. In the following nursing diagnoses, problems of sexuality are the etiology of another problem: Impaired Adjustment related to loss of sexual partner, loss of sexual body part Anxiety related to fear of pregnancy, loss of sexual functioning or desire, effects of disease process on sexual functioning Pain related to sexual position, penile penetration, effects of genital surgery, lack of vaginal lubrication Ineffective Coping related to effects of body image on sexual expression, change in sexual partner Fear related to pain during sexual intercourse, history of sexual abuse Anticipatory Grieving related to loss of sexual functioning, effects of surgical excision of genital body part Delayed Growth and Development related to sexual exploitation or abuse, sexual guilt, effects of hormonal imbalance, lack of information about sexuality Deficient Knowledge (specify: contraceptive methods, spread of STIs, sexual response, genital anatomy, modes of sexual expression, self-examination, effects of disease or medications) related to misinformation, sexual myths, lack of interest in learning, cognitive limitation Disturbed Body Image (specify: surgical excision of genital body part, loss of or gain in body weight) related to fear of rejection Impaired Social Interaction related to effects of marital separation or divorce Social Isolation related to fear of contracting STI, fear of sexual encounter Outcome Identification and Planning Nurses should value sexuality as an important aspect of who the patient is and how the patient is identified as a unique human. Specific patient outcomes to promote sexual health follow. The patient will: Define individual sexuality Establish open patterns of communication with significant others Develop self-awareness and body awareness Describe responsible sexual health self-care practices, identifying appropriate resources Practice responsible sexual expression (e.g., by 5/1/15, the patient will use rubber condoms during all sexual encounters) (Taylor 1677) Specific patient outcomes depend on the nature of the patient's problem or concern. Expected outcomes should be patient-oriented—that is, something the patient desires to do or has the ability to accomplish. For example, it is not enough to advise a method of birth control; rather, the nurse needs to know which method the patient is motivated and able to use. (Taylor 1678) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Implenting part 5

Emergency Contraception. Emergency contraception, often called the "morning after" pill, is designed to reduce the risk of pregnancy after unprotected intercourse. Emergency contraception is provided in two ways: Increased doses of specific oral contraceptive pills. Emergency contraceptive pills can reduce the risk of pregnancy when taken up to 120 hours after unprotected intercourse (ideally within 72 hours). Most are up to 89% effective when taken within 72 hours after unprotected sex. They are less effective as time passes. Insertion of a copper IUD within 5 to 7 days after unprotected intercourse. Planned Parenthood reports that anyone can obtain Plan B One-Step over the counter without a prescription at a drugstore or family planning clinic. All other brands of emergency contraception require a prescription from a clinician for those 16 or younger. Sterilization. Sterilization methods should be regarded as permanent and irreversible in both men and women. Although sterilization can sometimes be surgically reversed, the results are not always satisfactory. Sexual desire and ability are unaffected by sterilization. Sterilization in women is accomplished by surgically severing the fallopian tubes. This procedure, known as tubal ligation, prevents the ovum from traveling down the tube. Tubal ligation is usually performed on an outpatient basis, sometimes under local anesthesia. Postoperative care and recovery time are required after a tubal ligation. Sterilization is safe and because it lasts for life is simple and convenient. Sterilization in men is accomplished by surgically severing the vas deferens, which prevents sperm from entering the semen. The vasectomy is usually performed in a physician's office under local anesthesia. Vasectomy is the most effective birth control for men—nearly 100% effective. The man and his partner must use an alternative form of contraception until he has produced two semen analyses with zero sperm. It usually takes about 4 to 6 weeks for all stored sperm to be eliminated from the man's ductal system. Future Trends. Private industry remains a driving force behind contraceptive research and development. More than 100 experimental contraceptive methods are being studied around the world. The U.S. government contributes to contraceptive research primarily by funding research conducted at the National Institutes of Health. Almost 40 million women in the United States are at risk for unintended pregnancy. Given that unintended pregnancies are as likely to end in abortion as in birth, there is a clear need to focus on the prevention of unintended pregnancy. Future trends in contraception are likely to be shaped in part by increased awareness of STIs and continuation of the AIDS pandemic. For at-risk women, the emphasis will be on a highly effective primary means of contraception used in conjunction with a barrier method, such as the condom, to prevent STIs. Female Contraceptives. Most of the contraceptive products that will soon be available for women are refinements of products already available. New barrier methods for women will include enhanced cervical caps and vaginal sponges with microbicides to protect against STIs. New contraceptive pills, patches, and rings for women will use varied combination of hormones. Injectable progestin products might one day protect against pregnancy for up to 90 days. Oral and/or injectable vaccines may one day immunize women against pregnancy. These vaccines might produce antibodies to attack egg or sperm, or the immune system might create antibodies to a crucial type of protein molecule found on the head of sperm. Contraceptive implants designed to remain effective for 2 or 3 years, as well as biodegradable implants with efficacy of up to 18 months, are in development. Computerized fertility monitors that predict ovulation will offer couples who use fertility awareness methods of contraception a much more sophisticated and accurate charting method. Methods for permanent sterilization will expand to include chemical scarring techniques and insertion of fallopian tube chemical plugs and cryosurgery. Temporary sterilization may be effected by the use of silicone plugs. Unisex Reversible Contraceptives. The concept of unisex reversible contraception is being explored. This method involves a group of drugs called gonadotropin-releasing hormone (GnRH) agonists and can be used to prevent the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland. The release of FSH and LH triggers ovulation and spermatogenesis. Blocking the release of these hormones will temporarily suppress fertility for women or men. In addition, various contraceptive injections, implants, and vaccines for men are being researched. Male Contraceptives. Methods of contraception for men continue to be explored. The challenge of developing a reversible method of contraception for men is complicated because men are always producing sperm. Because of this continuous fertility, the opportunities for reversible intervention that are permitted by women's fertility cycles are not available in men. Effective contraceptive methods for men that do not permanently impair fertility have proven elusive, but research continues. Most research has focused on a hormonal approach to decrease spermatogenesis. The major problem is that interference with steroidogenesis might also interfere with the other actions of testosterone such as sexual function, bone and muscle growth, kidney function, and protein anabolism. Facilitating Coping With Special Sexual Needs The nurse can help patients cope with sexual concerns generated by diseases and their treatments. See the accompanying Research in Nursing box. Offer anticipatory guidance and information to patients, stressing the importance of open communication with the patient's partner, and also include the partner in teaching. For appropriate patients, start a discussion about possible sexual positions that can reduce pain during coitus. Show the patient drawings of possible sexual positions. Inform the patient that intercourse may be more comfortable if pain medication is taken before beginning sexual activity. When teaching patients about medications, mention any sexual side effects that may occur to prevent anxiety and depression. Patients should alert the physician if these side effects occur because often the drug dosage can be modified or the drug changed. If patients are unaware of this, they may discontinue the medication on their own rather than sacrifice sexual functioning, if this is an important aspect of life for them. Health Care Needs of Lesbian, Gay Male, Bisexual, and Transgender Individuals The health and well-being of lesbian, gay male, bisexual, and transgender (LGBT) individuals has been made a priority by major federal health care agencies. The Institute of Medicine's (IOM, 2011) consensus report, Healthy People 2020 (2011), and the U.S. Department of Health and Human Services (HHS, 2011) all highlight the need for better science-based knowledge on how best to address the existence of health disparities of LGBT individuals and the lack of compassionate services (Lim, Brown and Jones, 2013). Stigma and a range of other social and cultural factors affect the health of LGBT people as well as the ability of the health care system and providers to care for them. LGBT people come from diverse cultural backgrounds, have varied ethnic or racial identity, and differ in terms of education, age, income, and place of residence. Lesbian, gay, and bisexual people may be defined by their sexual orientation, but this definition is complex and variable. Sexual behavior, cultural factors, disclosure of sexual orientation and/or gender identity, prejudice and discrimination, and concealed sexual identity each present unique health challenges to this population (Box 44-3). (Taylor 1685-1687) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Implementing part 1

Establishing a Trusting Nurse-Patient Relationship It is impossible to address a patient's sexuality if trust has not been developed between you and the patient (see Through the Eyes of a Student). To do so, project an objective, nonthreatening, and nonjudgmental attitude, and emphasize that the information the patient gives will be kept confidential. The nurse who is aware of one's own behavior and verbal and nonverbal cues and anticipates the patient's concerns can help the patient trust the nurse with information of an intimate nature. Be sure to establish respect for the patient and empathy before discussing sexual issues. Consider all of the patient's circumstances and life experiences using a therapeutic, not a pitying, approach. Only when you are accepted as a trusted, caring person will the patient reveal details of his or her private life, including sexual Teaching About Sexuality and Sexual Health Most nursing interventions pertaining to a patient's sexuality involve teaching to promote sexual health. Major goals of patient teaching are a change in knowledge, attitude, or behavior. In some situations, patients need help defining or redefining their sexuality and its importance to their lives. Offering information, dispelling fears, and providing positive reinforcement are some ways to help patients increase their knowledge about their bodies and sexual functioning. Patients might need assistance in modifying behaviors or learning new skills to increase the quality of sexual health and functioning. See the Promoting Health Literacy box. Part of teaching also includes correcting sexual myths and promoting body awareness. Many people believe things about sex that they have heard from family or friends or within their culture that are not true or are not based on scientific data. During the assessment or while providing care, take the opportunity to refute sexual myths and teach factual information (Table 44-4). Patients might need assistance in becoming familiar with what they believe and feel about their sexual selves. Be helpful to patients with difficulty accepting or developing their sexuality by promoting their self-confidence and good self-concept. When patients feel comfortable about themselves and their sensual feelings, they can begin to focus on how they feel about their sexual functioning and specific sexual expressions. Getting to know one's physical body is important to healthy sexual development. Every man and woman, sexually active or not, needs to be aware of the appearance of one's genitalia. Some people, because of their background, feel ashamed and repulsed by their bodies; others feel that touching the body is dirty and might feel guilt and anxiety in stimulating themselves. Patients need assistance in improving body awareness if any of these issues are present. Patients can become accustomed to looking at their bodies by looking at nonthreatening anatomy first and then proceeding to the genitals. This can be done in the shower or with the use of a mirror. Knowing what looks normal can be of great importance so that patients can report the development of an unusual appearance later on. (Taylor 1679) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Evaluating

Evaluating The nurse works with the patient to evaluate the effectiveness of sexual counseling or intervention. Stuart (2013) suggests considering the following three factors: Sense of well-being. Has the patient's sense of well-being improved during the treatment? Functional ability. If the person was dysfunctional, has functional ability improved or been restored? Satisfaction with treatment. Does the patient believe the treatment was helpful? Were the patient's goal and expectations met? To evaluate the plan of care, the nurse needs to use information from the patient for most outcomes. The nurse cannot evaluate patients by observing their expression of sexuality, but the nurse can evaluate how patients are progressing toward sexuality-oriented goals by their appearance, self-confidence, and manner. For example, a patient who has expressed feelings of anxiety in the past over a sexual concern should be observably more confident and free of anxiety if the patient outcomes are being met. Ask the patient about progress toward outcomes. Some outcomes need to be "stepping stones," because not all problems are easily resolved with one-time intervention and direction. When evaluating a patient's progress, it may help to ask: "In what ways have you been able to achieve [orgasm, increased desire, comfortable intercourse, erection]?" "What methods seemed most effective? Which were not?" "What do you think should be the next step?" Determine from this interaction with the patient whether something more needs to be accomplished. It is not enough to assume that because a set of outcomes has been met, the patient is satisfied with the results. See the Nursing Plan of Care 44-1 for Pete Manheim. (Taylor 1689) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Female primary sexual dysfunctions

Female Primary Sexual Dysfunctions INHIBITED SEXUAL DESIRE 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. DYSPAREUNIA 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. VAGINISMUS 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. VULVODYNIA 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. (Taylor 1669-1670) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Sexual harassment

Harassment is any annoying or distressing comment or conduct that is known or should be known to be unwelcome. Sexual harassment is unwelcome behavior that is based on one's sex or gender. This type of harassment usually occurs in the context of an asymmetrical relationship in which one person has more formal power than the other (e.g., a faculty member over a student) or more informal power (e.g., one peer over another). Sexual harassment can be directed toward people of any age, either gender, and any sexual orientation. There are two forms of sexual harassment: quid pro quo and environmental harassment (also called a "hostile" environment). Quid pro quo means something given or withheld in exchange for something else. Quid pro quo harassment occurs when a person's employment or well-being is dependent on agreeing to unsolicited and unwelcome sexual demands. This type of harassment is typically initiated by a person in a position of authority who offers either direct or indirect reward or punishment based on the granting of sexual favors. Quid pro quo harassment is a clear abuse of power and is legally, morally, and ethically wrong. Hostile environment harassment occurs when sex- or gender-based behaviors create a hostile, intimidating environment that hurts a person's work performance, classroom performance, or general sense of well-being. In the workplace, for example, the negative behaviors in hostile environment harassment are not directly linked to job-related consequences; instead, the employee's willingness to suffer the experience of the demeaning environment becomes a condition of employment. This type of harassment is not necessarily caused by a person with formal power. Hostile environment is sometimes difficult to identify, as it is not always easy to determine when offensive speech or behavior actually turns to true harassment. Coworkers and peers can create a hostile environment for a member of the group through the following: Unwelcome sexually oriented and gender-based behaviors Sexual bantering Sexual jokes Offensive pictures and language Sexual innuendoes Sexual behavior Effects of Harassment Harassment can cause feelings of helplessness, worthlessness, and guilt in the victim. This can often lead to less career satisfaction and feelings of loss of control. Anger is commonly experienced by those who have been harassed, which may lead to requests for transfer, resignation, or withdrawal from the environment where the harassment occurs. In many cases, job performance is affected due to reduced levels of concentration. Loss of job motivation and skill confidence, along with reduced job satisfaction and organizational commitment, are common. Responding to Harassment in the Nursing Environment Inappropriate sexual behavior by a patient may cause the nurse to respond with either passive avoidance or aggressive retaliation. An assertive response is recommended that supports the nurse in maintaining one's self-respect and encourages the patient to accept responsibility for one's behavior: Be self-aware: Do not deny feelings about being harassed. Confront: Provide feedback to the patient in a nonthreatening way and clearly state what behavior is or is not acceptable. Set limits: Define clear and reasonable consequences that will be enforced if the behavior continues. Enforce the stated limits: Maintain boundaries. Report: Document the incident and submit to supervisor. Colleagues may also be a source of harassment. The objective of employers should be to create a positive work environment that is characterized by mutually respectful behavior. Many have taken steps to eliminate hostile work environments by educating employees, developing policies against workplace harassment, and outlining guidelines for responding to sexual harassment: If harassed by a coworker, confront the behavior immediately. An assertive statement is sometimes sufficient to stop the behavior. If the harassment continues, document the date and time, and describe the behavior. Consult your supervisor. If the harassment still does not stop, file a grievance with administration. Seek legal advice if all previous efforts to stop the behavior have been unsuccessful. (Taylor 1689-1690) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Assessing nursing process part 4

Initially, ask whether the patient has had this type of examination in the past (if this information is not evident in the patient's records). Depending on the patient's knowledge base, explain the progressive steps of the examination and what the patient may feel during the examination. This will give the patient some feeling of control and security during the examination. The nurse's responsibilities during an examination of the reproductive system are as follows: Provide information about the examination. Teach the patient. Provide support to the patient during the examination. Perform the examination or assist the examiner, if appropriate, with any procedures or laboratory studies. Keeping the patient comfortable and respecting the patient's privacy and modesty should be primary nursing considerations. Some female patients might be uncomfortable with a male examiner, or vice versa, for religious, cultural, or other reasons. The examiner can adapt to such concerns, for example, by ensuring that a female nurse is in the room when a female patient is undergoing a pelvic examination by a male physician. (Taylor 1676-1677) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Primary male sexual dysfunctions

Male Primary Sexual Dysfunctions ERECTILE 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. (Taylor 1669) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. PREMATURE EJACULATION 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 the problem are rarely physical. RETARDED EJACULATION Retarded 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 probably due to interpersonal problems. (Taylor 1669) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Factors affecting sexuality

Many factors influence a person's sexuality and contribute to personal feelings regarding sexuality. The brain, rather than the genitals, plays the most significant role in how people perceive themselves as sexual beings. (Taylor 1662) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Masturbation and sexual intercourse

Masturbation Masturbation is a technique of sexual expression in which an individual 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. Sexual Intercourse The 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. (Taylor 1661) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Menstration affecting sexuality

Menstruation Menstruation, often referred to as a woman's "period" or menses, is a cycle during which the body prepares for the presence of a fertilized ovum. Cycles are about 28 days long but may vary from 21 to 40 days. The first menstrual period, called menarche, is experienced at about 12 years of age, but the age of menarche is particular to the individual and may occur anywhere between 8 and 17 years of age. Menopause, the cessation of a woman's menstrual activity, occurs between the ages of 45 and 55 years. The woman may experience irregular menses over time before menstruation ends. The Menstrual Cycle The menstrual cycle is controlled by a series of reactions that rely on feedback from the ovaries to the pituitary gland. Two cycles occur simultaneously: one in the ovaries and one in the endometrium of the uterus (Fig. 44-1). In the ovaries, in a typical 28-day cycle, the phase from day 4 to 14 is called the follicular phase. During this phase, a number of follicles mature, but only one produces a mature ovum. At the same time, in the uterus, the endometrium is becoming thick and velvety in preparation for receiving a fertilized egg. This phase in the uterus is called the proliferation phase. Ovulation generally occurs on 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. FIGURE 44-1. Schematic representation of one ovarian cycle and the corresponding changes in the endometrium. From day 15 to day 28, the phase in the ovaries is called the luteal phase. 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. 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. At day 28, menses, or the menstrual flow, begins as a result of the uterus shedding the useless portion of its endometrium. Menses lasts for 3 to 7 days, the average length of flow being 5 days. The menstrual discharge is a bloody fluid that also contains endometrial debris, mucus, and enzymes. It is odorless until exposed to the air, when the woman may notice a light, fleshy, pungent odor. Deodorized pads and tampons do little to minimize odor and can cause chemical irritation to the vulva and vagina. Good hygiene and regular bathing are much more effective during menses to prevent odor. Normal blood loss averages 30 to 80 mL. Pads and tampons should be changed frequently to prevent odor and irritation from wetness. Women using tampons should read and follow the manufacturer's suggestions to reduce the risk for toxic shock syndrome. Usually, the flow is the heaviest and is bright red on the first day or two of menses, gradually tapering off to light-brown staining. Many women experience some degree of discomfort either premenstrually or during menses. Menstrual cycle irregularities can have many different causes, including: 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. Eating disorders, extreme weight loss, or excessive exercising. Eating disorders (such as anorexia nervosa), extreme weight loss, and increased physical activity can disrupt menstruation. Polycystic ovary syndrome (PCOS). This common hormonal disorder can cause small cysts to develop on the ovaries and irregular menstruation. Premature ovarian failure. 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, might have irregular or infrequent periods for years. Pelvic inflammatory disease (PID). This infection of the reproductive organs can cause irregular menstrual bleeding. Uterine fibroids. Uterine fibroids are noncancerous growths of the uterus. They can cause heavy menstrual periods and bleeding between periods (Mayo Clinic Staff, 2014). p. 1665 p. 1666 There is no scientific rationale supporting abstinence from sexual activity during menses. Many women enjoy sex during menses owing to the increase in vascularity in the pelvic region, which heightens enjoyment. Men may also enjoy the warm wetness the menstrual flow provides to the vagina. If flow is heavy, a diaphragm can be used to hold it back during sexual activity, or a towel can be used to protect bedding. Some women who experience abdominal cramping during menses, called dysmenorrhea, find that sexual activity and orgasm relieve their discomfort. In May 2007, the U.S. Food and Drug Administration (FDA) approved the first oral contraceptive designed to be taken 365 days a year by women who want to avoid menstruating altogether. Women who use the drug don't have regular menstrual periods although they can have breakthrough bleeding (spotting or light bleeding). While there are obvious advantages to not having menstrual periods, women should be counseled that there are no long-term safety data on these drugs. Risks are thought to be similar to those of conventional oral contraceptives: an increased incidence of blood clots, heart attacks, and stroke, especially in women who smoke. Positive benefits may include lowering the risk for ovarian cancer and endometrial cancer (Richardson, 2007). Premenstrual (Tension) Syndrome Menstrual cycle-related distress, commonly called premenstrual (tension) syndrome (PMS), reportedly occurs in 50% to 90% of the menstruating female population. PMS is characterized by the appearance of one or more of the following several days before the onset of menstruation: irritability, emotional tension, anxiety, mood changes, headache, breast tenderness, and water retention. Although it is often used to explain unusual behavior (and has been used as a legal defense), its etiology is still uncertain (both physiologic and psychogenic theories have been postulated), as are its effects on women's roles and relationships. Some literature perpetuates a twofold myth: (1) biology and physiology are destiny (many females do and should experience premenstrual distress), and (2) female biology and physiology result in psychiatric disorder, destruction, and violence. Nurses have a great role to play in researching PMS and ensuring that women and the public correctly understand its effects. (Taylor 1664-1666) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Nurse as Role Model

Nurses' attitudes, biases, and prejudices regarding sexuality are readily transmitted to patients through their actions, manner of speech, avoidance of certain circumstances, and types of discussion (see the accompanying box, Focused Critical Thinking Guide 44-1). A nurse's knowledge about sexual issues can inhibit or promote discussions of sexual health. The nurse who does not have a sound knowledge base of reproductive anatomy and physiology, sexual response, sexual expression, and other issues surrounding sexuality will be unable to assess, teach, or counsel patients with sexual concerns. (Taylor 1671) Nursing goals to enhance interactions with patients and to promote individual sexual health are as follows. The nurse will be able to: Feel comfortable as a sexual being Develop self-awareness regarding sexual topics Develop communication skills that promote discussion of sexual concerns with patients Identify patients with problems related to sexuality and intervene competently and comfortably to meet these needs Practice responsible sexual expression (Taylor 1671) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Assessing nursing process part 2

One helpful structure for obtaining information about sexual problems follows: Description of the problem: "How would you describe the problem?" Onset and cause of the problem: "What do you think caused the problem, or what was happening when you first noticed it?" Past attempts at resolution: "What have you tried in the past to correct the problem?" Goals of the patient: "What do you wish to accomplish?" A narrative format is generally used for recording a sexual history because it allows the interviewer to document the data in many of the patient's own words. If a patient is seeking help for a sexual problem, a more specific format is used to record information obtained by a skilled therapist. THE BETTER MODEL The BETTER model was created to help oncology nurses conduct sexual assessments with their cancer patients more effectively. The acronym BETTER stands for (Mick, Hughes, & Cohen, 2003): Bring up the topic of sexuality so that patients know they can discuss sexuality openly. Explain that you are concerned with all aspects of patients' lives affected by disease. Tell patients sexual dysfunction can happen and that you will find appropriate resources to address their concerns. Timing is important to address sexuality with each visit to let patients know they can ask for information at any time. 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. (Taylor 1674) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Oral gel stimulation and abstinence

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 (referred to in the vernacular as "sixty-nine"). Younger people often use oral-genital stimulation as a replacement for vaginal intercourse to reduce the incidence of pregnancy. Abstinence Abstinence is not having sex. It is the most effective form of birth control, preventing pregnancy 100% of the time when practiced consistently. Abstinence 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. (Taylor 1662) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Implenting part 6

Other issues that affect health care delivery to the LGBT population include the following: Public health infrastructure: Efforts to research and address the health care needs of LGBT persons are hindered by an inadequate infrastructure to support and fund population-specific initiatives. Access to quality health services: Financial, structural, personal, and cultural barriers limit access to screening and prevention services and cause delays in care for acute conditions in the LGBT population. Health communication: Negative provider attitudes, lack of provider education regarding unique aspects of lesbian and gay health, and exclusion of same-sex partners in care planning seriously hamper therapeutic communication between members of the LGBT population and those who provide care. Educational and community-based programs: Some government agencies, professional organizations, and health care organizations address health issues of the LGBT population, but this population still relies heavily on self-created community-based programs to address their special health care requirements. (Taylor 1687-1688) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. Advocating Sexuality Needs of Patients A hospital experience or institutionalization puts a strain on a person's individuality and sexual self. Illness may diminish feelings of sexual desire, and the desire for sexual interaction can signal a patient's improving health. The nurse should provide anticipatory guidance because many patients may hesitate to request help for fear of being ridiculed. Often, a patient merely desires privacy to hold and caress one's partner. The intimacy of this act often fulfills the patient's feelings of longing to be needed and loved. There are many ways to advocate for a patient's sexual needs. Some may seem obvious and commonplace, whereas others may first require coming to terms with your own sexuality (Box 44-4). (Taylor 1688) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. Counseling the Patient Regarding Sexuality Not all patients with sexual concerns need intensive therapy. Some patients benefit greatly from simply having someone listen to their concerns. Voicing their concerns allows patients to put the information into perspective and focus on what the problem is and how to solve it. When counseling patients, do not offer your own advice, because what is right for one person may be wrong for another. Also, offering false reassurances, such as, "It'll be all right," is unproductive. Rather, adopt an objective, empathic, and receptive attitude to facilitate open communication with the patient. Abortion Counseling Abortion remains an issue that deeply divides people. Many believe it is a woman's right to choose whether to continue a pregnancy and to take safe and legal action on a decision to terminate. Others believe that from fertilization onward, the embryo and fetus is a human being with the full respect and protection we afford adult humans; these people view abortion as always wrong. Some would allow abortion only if it is indicated for a woman's health or in cases of rape. You should examine what you believe, why you believe this, and how your beliefs are likely to influence your ability to counsel women and couples. Counseling in Cases of Abusive Relationships and/or Rape Nurses encounter children, adolescents, women, and sometimes men who have experienced sexual abuse or rape. The Rape, Incest and Abuse National Network (RAINN) reports that: 1 out of every 6 American women has been a victim of an attempted or completed rape in her lifetime (14.8% completed rape; 2.8% attempted rape). 17.7 million American women have been victims of attempted or completed rape. 9 of every 10 rape victims were female in 2003. While about 80% of all victims are white, minorities are somewhat more likely to be attacked. About 3% of American men—or 1 in 33—have experienced an attempted or completed rape in their lifetime. 15% of sexual assault and rape victims are under age 12. Date rape occurs when there is forced or coerced sex within a dating relationship. With acquaintance rape, the act is committed by someone known to the victim. Nearly two-thirds of all victims between the ages of 18 and 29 report that they had a prior relationship with their attacker (Center for Family Justice, 2012). Victims of sexual assault are 3 times more likely to suffer from depression, 6 times more likely to suffer from posttraumatic stress disorder, 13 times more likely to abuse alcohol, 26 times more likely to abuse drugs, and 4 times more likely to contemplate suicide. Clearly, nurses need to be alert to evidence of sexual abuse while taking the history and conducting physical examinations. Abuse crosses all socioeconomic and ethnic groups. Become familiar with your legal and clinical responsibilities when a victim is identified. The first priority is getting the victim into a safe environment and mobilizing support for the victim and family. Multiple parties may need therapy. Be familiar with local resources and make appropriate referrals. The National Sexual Assault Online Hotline is a free, confidential, secure service that provides live help over the RAINN Web site (https://ohl.rainn.org/online/). (Taylor 1688-1689) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Religion ethics and lifestyle 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 re-examining their teachings on sexuality in response to challenges posed by their members. Many have recognized the importance of solid sex education within the realm of the church. There is also a new interest in the spirituality of marriage: churches are examining their role in supporting the intimate/sexual relationship of married couples. Ethics Healthy sexuality depends on freedom from guilt and anxiety. What one person believes is wrong might be perfectly natural and correct to another. Some individuals might 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. Individuals 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. 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 might be external, such as job and financial demands, or internal, such as a competitive nature. Varied responsibilities may place a time restraint 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—if not for lovemaking, then for intimate, quiet contact. Lifestyle variables can also influence the sexual expression of adolescents and young adults. Those with "time on their hands" and fewer constructive developmental opportunities (e.g., education, sports, community service) are more likely to engage in risky sexual behavior. (Taylor 1664) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Implementing part 3

SEX EDUCATION Sex education is critical to healthy sexual development and safe sexual behaviors. See Examples of Nursing Interventions and Nursing Outcomes Classifications (NIC/NOC): Safe Sex Activities. Information received from peers and friends is almost always inadequate and may be erroneous. Parents should be taught to answer children's questions immediately and accurately. Considering Contraception Unintended pregnancy remains a significant women's health issue in the United States as well as a critical social issue. Healthy People 2020 aims to improve pregnancy planning, spacing, and preventing unintended pregnancy. One objective is to increase the proportion of intended pregnancies to 56%. The statistics that follow about contraceptive methods were obtained from Planned Parenthood Federation of America, Inc. (Planned Parenthood, 2014). Many unintended pregnancies result from the use of less effective methods of contraception, such as condoms, spermicide, or barrier methods. The past several years have seen the development of new, easier to use, and more effective methods of contraception. Nurses and nurse practitioners have a responsibility to provide information to women regarding their many contraceptive options. Patients choose contraception for many reasons and might contact health care providers specifically to obtain information about birth control. Some people use contraception for the orderly spacing of pregnancies in a family; others may want to prevent pregnancy from occurring until a family is desired. Some people choose a permanent method to prevent pregnancy from ever occurring. Factors that affect a person's choice of a contraceptive method include age, marital status, desire for future pregnancy, religious beliefs, level of education, cost, and ease of use. Other considerations are the woman's knowledge about available methods, her perceptions of the various methods, and in many cases, her previous experience with contraception. All contraceptive methods have advantages and disadvantages. Understanding and explaining the available methods thoroughly is a must so that patients can choose the one that will best meet their situation and needs (Box 44-2). When choosing a contraceptive method, the patient should consider the following: How well will it fit into my lifestyle? How convenient will it be? How effective will it be? How safe will it be? How affordable will it be? How reversible will it be? Will it protect against STIs? METHODS OF CONTRACEPTION Behavioral. Abstinence is a behavioral method of contraception. There are two types of abstinence: continuous and periodic. Choosing abstinence does not mean that a person is sexless. Most people are abstinent at some time in their lives. Abstinence can be a positive way of dealing with sexuality when it represents a well-thought-out decision regarding one's mind, body, spirit, and sexual health. (Taylor 1682) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Sexual response cycle affecting sexuality

Sexual Response Cycle The physiologic responses to sexual activity of females and males are more similar than different (Fig. 44-2). Also, the body's response is essentially the same regardless of the source of stimulation; that is, fantasy, masturbation, and sexual intercourse can all bring about the same body reactions. The sexual response cycle is not limited to the genital organs but is a total-body response that causes many physiologic changes throughout the body. The cycle has four phases: (1) excitement, (2) plateau, (3) orgasm, and (4) resolution; there is a smooth progression from one phase to the next. Although only physiologic responses are discussed here, the emotional and mental involvement of sexual response contributes a great deal to the pleasure and satisfaction of sexual activity. (Taylor 1666) The human body contains many erogenous zones, areas that when stimulated cause sexual arousal and desire. The genitals are an obvious source of sexual pleasure for both men and women, but other areas of the body are also considered erogenous zones. The skin is the largest erogenous zone. Other areas include the ears, lips, thighs, and breasts. Some people can reach orgasm simply by stimulation of erogenous zones other than the genitals. The most important body organ for sexual arousal and stimulation is the brain. It allows people the freedom to enjoy a sexual experience but also may prevent satisfaction by inhibitions, doubts, and guilt. 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. 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. Orgasm The term 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 individual 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. Resolution The resolution phase 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. (Taylor 1666-1667) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Sexual dysfunctions

Sexual dysfunction is a problem that prevents an individual or couple from engaging in or enjoying sexual intercourse and orgasm. Dysfunctions might occur as a result of physiologic malfunctions, conflicts with cultural norms, interpersonal problems, or any combination of these. Anxieties and fears concerning the sexual act are almost always present. Patients with severe sexual dysfunctions require intensive professional therapy from a qualified sex therapist. (Taylor 1669) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

sexual health

Sexual health may be defined as the integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love. Because our sexuality is so basic to our sense of self, nurses need to value sexuality as a critical element of health and well-being in general and must be skilled in identifying and meeting problems related to sexual self-concept, body image, and sexual identity. (Taylor 1659) Sexual identity encompasses a person's self-identity, biologic sex, gender identity, gender role behavior or orientation, and sexual orientation or preference. Biologic sex is the term used to denote chromosomal sexual development: male (XY) or female (XX), external and internal genitalia, secondary sex characteristics, and hormonal states. An intersex condition occurs in about 1 in every 2,000 babies, in which there are contradictions among chromosomal sex, gonadal sex, internal organs, and external genital appearance, resulting in ambiguous gender. Gender identity is the inner sense a person has of being male or female, which may be the same as or different from that person's biologic gender. People whose biologic sex at birth is contrary to the gender they identify with are diagnosed with gender dysphoria. Gender role behavior is the behavior a person exhibits about being male or female, which, again, may or may not be the same as biologic sex or gender identity (Pillitteri, 2012). (Taylor 1659) People experience sexual gratification in many ways; what is considered normal differs from one individual to another and among cultures. Sexual orientation refers to the preferred gender of a person's partner. The origins of sexual orientation are unknown, but many studies claim a genetic basis. Certainly, some sexual preferences are culturally determined or may be dictated by opportunity. (Taylor 1659) Common sexual orientations are as follows: A heterosexual is one who experiences sexual fulfillment with a person of the opposite gender. A homosexual is one who experiences sexual fulfillment with a person of the same gender. Homosexual males often use the term gay; homosexual females use the term lesbian. Heterosexuality and homosexuality can be placed at opposite ends of a continuum, with many variations in between. A bisexual is a person who finds pleasure with both opposite-sex and same-sex partners. Homosexual or heterosexual people may have bisexual relationships at times. Asexuality, the lack of romantic or sexual attraction to others, is sometimes listed as another category. Transgender (often abbreviated to "trans") 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 are transsexual (live as members of the sex other than the sex they were assigned to at birth) People who are intersex (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 have a gender expression that differs from their perceived sex, including cross-dressers and drag performance artists For many transsexuals, the solution is to change their bodies, through surgery and hormone therapy, to match their inner feelings. A cross-dresser is a person who desires to take on the role or wear the clothes of the opposite sex in order to make the outer appearance consistent with the inner identity and gender role. Most are not interested in permanently altering their bodies since they are comfortable with their birth identities. Most cross-dressers are heterosexual, and many keep their cross-dressing hidden. (Taylor 1660-1661) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

sexually transmitted infections (STIs) affecting sexuality

Sexually Transmitted Infections Sexually transmitted infections (STIs) or diseases (STDs), once called venereal diseases, are infections that are spread primarily through sexual contact. They are among the most common infectious diseases in the United States today. More than 20 STIs have been identified. The Center for Disease Control and Prevention (2014) estimates that nearly 20 million new sexually transmitted infections occur every year in the United States, half among young people ages 15 to 24. Each of these infections is a potential threat to a person's immediate and long-term health and well-being, and can lead to severe reproductive health complications, such as infertility. Table 44-2 lists common types of STIs and their signs and symptoms. The annual comprehensive cost of STIs in the United States is estimated to be almost $16 billion. (Taylor 1667) According to the National Institute of Allergy and Infectious Diseases (NIAID), understanding the basic facts about STIs—the ways in which they are spread, their common symptoms, and how they can be treated—is the first step toward prevention. News releases, fact sheets, and other NIAID-related materials are available on the NIAID website at www.niaid.nih.gov. NIAID recommends understanding at least five key points about all STIs in the United States today: p. 1668 p. 1669 STIs affect men and women of all backgrounds and economic levels. They are most prevalent among teenagers and young adults. The incidence of STIs is rising, in part because in the last few decades, young people have become sexually active earlier yet are marrying later. In addition, divorce is more common. The net result is that sexually active people today are more likely to have multiple sex partners during their lives and are potentially at risk for developing STIs. Most of the time, STIs cause no symptoms, particularly in women. When symptoms develop, they may be confused with those of other diseases not transmitted through sexual contact. Even when an STI causes no symptoms, a person who is infected may be able to pass the disease on to a sex partner. That is why many doctors recommend periodic testing or screening for people who have more than one sex partner. Health problems caused by STIs tend to be more severe and more frequent for women than for men, in part because the frequency of asymptomatic infection means that many women do not seek care until serious problems have developed. Some STIs can spread into the uterus (womb) and fallopian tubes to cause pelvic inflammatory disease (PID), which is a major cause of both infertility and ectopic (tubal) pregnancy. The latter can be fatal. STIs in women also may be associated with cervical cancer. One STI, human papillomavirus infection (HPV), causes genital warts and cervical and other genital cancers. STIs can be passed from a mother to her baby before, during, or immediately after birth; some of these infections of the newborn can be cured easily, but others may cause a baby to be permanently disabled or even die. When diagnosed and treated early, many STIs can be treated effectively. Some infections have become resistant to the drugs used to treat them and now require newer types of antibiotics. Experts believe that having STIs other than HIV increases one's risk for becoming infected with the HIV virus (NIAID, 2013). Having an STI might affect one's self-concept and keep a person from becoming intimate for fear of spreading the infection. (Taylor 1668-1669) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

sexual expression

The methods by which people gain satisfaction through sexual stimulation are varied. Touch, smell, sight, sounds, feelings, thoughts, and fantasy can all contribute to sexual fulfillment in any form of expression chosen by people. Feelings of love for another person are closely associated with desire. Forms of sexual stimulation include kissing, hugging, stroking, squeezing, breast stimulation, manual stimulation of the genitals, oral-genital stimulation, and anal stimulation. Sexual stimulation may be physical or psychological. Erotic stimulation through the use of films, magazines, and photographs is common. Fetishism, more often practiced by males, is sexual arousal with the aid of an inanimate object not generally associated with sexual activity. Items such as shoes, leather, rubber, and women's undergarments might be used. On a continuum, sexual behavior ranges from adaptive to maladaptive. Adaptive responses meet the following criteria: Between two consenting adults Mutually satisfying to both Not psychologically or physically harmful to either Lacking in force or coercion Conducted in private Maladaptive sexual responses are behaviors that do not meet one or more of the criteria for adaptive responses (Stuart, 2013, p. 499). (Taylor 1661) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Vaginal and anal intercourses

Vaginal Intercourse The act of placing the penis in the vagina, penile-vaginal intercourse, can be accomplished in various positions. The most common position in Western cultures is the "missionary position," in which the woman lies horizontally underneath the man. (The Polynesians named this position because it was the preferred position for intercourse used by religious missionaries.) Couples may find other positions to be more stimulating and comfortable. Clitoral stimulation is difficult to achieve in the missionary position. Lying side by side, female on top, and rear entry are some examples of coital positions that enable clitoral stimulation. Sexually inhibited people may believe they need "permission" to engage in alternative sexual positions. When the penis is pushed into the vagina, the man begins rhythmic thrusting movements of his hips to move the penis back and forth along the vaginal walls. The woman might match her partner's hip movements with movements of her own body. These movements continue until orgasm is attained by one person or both. Simultaneous orgasms, or both people attaining orgasm at the same moment, are difficult to achieve. A preoccupation with attaining simultaneous orgasms might disrupt the ultimate intimacy and satisfaction possible during coitus. The period after coitus is just as significant as the events leading up to it. Caressing, hugging, and kissing deepen the couple's intimacy and should be nurtured, not rushed. Anal Intercourse Anal intercourse, the act of inserting the penis into the anus and rectum of a partner, is another form of intercourse. Commonly practiced by gay men, it is also used by heterosexual couples. Once the penis (or any object) is placed in the rectum, it should not be introduced into the vagina without thorough cleansing because many microorganisms present in the rectum can cause vaginal infections. Care should be used to avoid injury to the delicate rectal mucosa, and lubrication is essential for comfort. Condoms are now recommended for both types of intercourse to prevent sexually transmitted infections (STIs). (Taylor 1661-1662) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.