NCP Sexual Dysfunctions and Paraphilias

SEXUAL DYSFUNCTIONS AND PARAPHILIAS

DSM-IV

SEXUAL DESIRE DISORDERS

302.71 Hypoactive sexual desire disorder
302.79 Sexual aversion disorder

SEXUAL AROUSAL DISORDERS

302.72 Female sexual arousal disorder
302.72 Male erectile disorder

ORGASMIC DISORDERS

302.73 Female orgasmic disorder
302.74 Male orgasmic disorder
302.75 Premature ejaculation

SEXUAL PAIN DISORDERS

302.76 Dyspareunia (not due to a general medical condition)
306.51 Vaginismus (not due to a general medical condition)

(Refer to DSM-IV manual for sexual dysfunctions due to a general medical condition)

PARAPHILIAS

302.4 Exhibitionism
302.81 Fetishism
302.89 Frotteurism
302.2 Pedophilia
302.83 Sexual masochism
302.84 Sexual sadism
302.82 Voyeurism
302.3 Transvestic fetishism

Sexual disorders include sexual dysfunctions and paraphilias. Sexual dysfunction is defined as persistent impairment/disturbance of a normal or desired pattern in any phase of the sexual response cycle. Paraphilias are more specific disorders in which unusual or bizarre imagery or acts are necessary for realization of sexual excitement. Because many paraphiliac behaviors are illegal in most states, individuals usually come for psychiatric treatment because of pressure from others, partners, or the authorities/judicial system.

ETIOLOGICAL FACTORS

Psychodynamics

Individual causes of sexual desire disorders may include religious beliefs, obsessive-compulsive personality, conflicts with gender identity or sexual preference, sexual phobias, fear of losing control over sexual urges, secret sexual deviations, fear of pregnancy, inadequate grieving following the death of a spouse, depression, and aging-related concerns. Psychological factors may also be involved in arousal disorders.

Psychoanalytical theories state that paraphilias are the product of childhood desires that survive into adulthood in their immature forms because emotional development has been inhibited, distorted, and diverted. These wishes are believed to be universal and are used to achieve arousal and release when ordinary forms of sexual activity are not available. Deviations arise when these immature forms of libido dominate adult sexual life. Fixation is thought to occur in Freud’s oral, anal, and phallic phases when corresponding body parts provide sources of instinctual gratification. Conflict arises when an imperfect compromise occurs between these impulses and reality, resulting in fear, which the unconscious perceives as castration.

Behavioral theorists believe any paraphilia/sexual dysfunction can be acquired through conditioning, in which an initial pairing of an object is accidentally associated with/then becomes necessary for sexual release. This need may become generalized to other situations of tension/anxiety.

Biological

Sometimes the cause is clearly biological (e.g., temporal lobe epilepsy that may cause changes in sexual behavior between seizures). It has also been suggested that the problem arises out of interference with brain pathways governing rage and sexual arousal. Sex hormones have been studied. Rat studies have demonstrated that small, properly timed doses of androgens (male hormones) or estrogens (female hormones) in the fetus or newborn can influence sexual behavior. Various organic reasons, medication and other drug use, physical illnesses (most notably diabetes mellitus), surgery (such as prostatectomy), and degenerative neural disorders (e.g., multiple sclerosis) may be involved in sexual desire, arousal, and pain disorders.

It is generally accepted that abnormal hormonal activity and biological (genetic) predisposition interacting with social and family factors influence the development of these fantasies/sexual acts. Although these behaviors may occur in normal sexual activity, when they become the primary source of sexual satisfaction they may result in problems for the individual/others.

Family Dynamics

There appears to be some evidence that paraphilias run in families and may be the result of dysfunctional family interactions and social learning.

Sexual dysfunctions are believed to be influenced by what the individual has learned/not learned as a child within the family system and by values and beliefs that may be based on myths and misconceptions.

CLIENT ASSESSMENT DATA BASE

SEXUAL DYSFUNCTIONS

Neurosensory

Mental Status: Findings may indicate intense distress about situation/condition or coexisting psychiatric disorders

Mood and affect may reveal evidence of increased anxiety and depression

Sexuality

Problems may be lifelong or acquired after a period of normal sexual functioning

May report inhibition or interference with some part of the human response cycle (e.g., low sexual desire, aversion to genital sexual contact, arousal/erectile/orgasmic disturbances, premature ejaculation, genital pain during or after sexual intercourse, and involuntary spasm of the outer third of the vagina interfering with coitus)

May display negative attitude(s) toward sexuality

Social Interactions

Impairment may be noted in marital/conjugal relations but rarely affects job performance

Teaching/Learning

Most commonly occur in early adulthood, although male erectile disorder may surface later in life

PARAPHILIAS

Ego Integrity

May express shame or guilt about behavior

May or may not act on fantasies

Neurosensory

Personality disturbances frequently accompany sexual disorder(s)

Safety

Physical injury may be seen following episodes of sadomasochistic activity

Sexuality

Recurrent, intense sexual urges and fantasies involving the exposure of one’s genitals to a stranger that have been acted on, cause severe distress, and may be accompanied by masturbation (exhibitionism)

Use of nonliving object(s) to stimulate recurrent intense sexual urges and sexually arousing fantasies (e.g., female undergarments [fetishism])

Rubbing and touching against a nonconsenting person to invoke recurrent, intense sexual urges and fantasies, with the touching, not the coercive nature of the act, causing sexual excitement (frotteurism)

Sexual activity with a prepubescent child or children (pedophilia)

Participation in the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer (sexual masochism)

Participation in acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person (sexual sadism)

Cross-dressing activities (transvestic fetishism)

Observing unsuspecting person(s), usually a stranger, who is naked, in the process of disrobing or engaging in sexual activity (voyeurism)

Social Interactions

May not view self as ill; however, behavior may cause distress for the individual or may bring suffering to others

May be in conflict with partner or society because of behavior

Possible interference with interpersonal/occupational functioning

Teaching/Learning

Occurs mostly in males

Some evidence of occurrence in families of paraphiliacs and of depressed individual; high correlation between pedophiles and family history of pedophilic activity

DIAGNOSTIC STUDIES

As indicated, to rule out physical causes of sexual dysfunction.

Screening for sexually transmitted diseases (STDs) including HIV/AIDS.

NURSING PRIORITIES

1. Assist client to understand the nature of the behavior (disorder/dysfunction).
2. Encourage use of acceptable methods for reduction of anxiety.
3. Help to recognize the legal/interpersonal consequences of paraphilic behaviors.
4. Explore options for change.
5. Encourage involvement of client/family (significant other) in treatment regimen.

DISCHARGE GOALS

1. The nature of the problem and consequences for the individual/family understood.
2. Anxiety reduced/managed in acceptable ways.
3. Options explored and appropriate one(s) chosen.
4. Confidence in own capabilities/sense of self-worth expressed.
5. Participating in treatment program and using community/treatment resources effectively.
6. Plan in place to meet needs after discharge.