Christy Bowen; Lindsay Draper; Heather Moore

Learning Objectives

By the end of this section, you will be able to:

Describe physiological factors affecting sexuality
Recognize psychological factors affecting sexuality
Identify psychosocial factors affecting sexuality

Sexuality is a vital component of health and one that should never be overlooked or dismissed as unimportant. Though discussing sexual health with patients can be uncomfortable at times, it is a key component of providing holistic, patient-centered care (PCC). It is important that nurses and other healthcare providers gain experience and increased comfort with providing guidance and care in accordance with patient sexuality, including their sexual preferences and any concerns regarding sexuality they may have. It is also important to recognize there are many factors, including physiological, psychological, and psychosocial, that may affect an individual’s sexuality.

Physiological Factors Affecting Sexuality

Physiological factors are biological characteristics that can have a significant influence on an individual’s sexuality and sexual health. Some of the most common physiological factors that can impact sexuality include developmental changes and certain diseases and medications. Each of these factors is discussed in more detail in the following sections.

Developmental Considerations

Though sexuality is most often associated with adolescence and adulthood, sexual development begins in early childhood and extends throughout the life span (Table 33.3).

Life Stage	Considerations
Infancy (birth–1 year)	Physical exploration of genitals after developing sufficient motor skills
Childhood (1–11 years)	Developing curiosity about own body and others’ bodies Begin to ask questions about own genitals and begin differentiating between male and female anatomy Begin to develop own gender identity
Adolescence (12–18 years)	The process of physical changes that results in development of secondary sexual characteristics such as breast enlargement and menstruation in females and facial hair growth in males begins, known as puberty Hormonal changes contribute to development of sexual desire, attraction, and onset of sexual experimentation Period of exploration of sexual identity, preferences, and values, which is often influenced by peers, social media, and cultural norms
Young adulthood (18–40 years)	Exploration of intimate relationships and sexual experiences Sexual identity usually becomes established in this period Period of peak fertility that often involves family planning and new parenthood
Middle adulthood (40–65 years)	Often involves shifts in priorities (e.g., focus on emotional intimacy versus physical attraction) Menopause may impact sexual function
Later adulthood (65+ years)	Sexual development continues; however, function may be impacted by health-related factors such as chronic conditions, medications, and/or physical limitations Intimacy and emotional connection still remain important to most individuals

Table 33.3 Sexual Development Considerations across the Life Span (Source: Cacciatore et al., 2019.)

Diseases and Conditions

There is an array of sexual dysfunction disorders that directly impact aspects of sexual functioning, both in males and females. Some of these conditions are discussed in more detail in the following sections. In addition to these specific sexual dysfunction disorders, many other chronic medical conditions may also impact an individual’s sexual health. Some of these conditions include diabetes mellitus, cardiovascular disease, and chronic pain, as well as conditions that impact mobility.

Sexual Dysfunction Disorders

Difficulty experienced by an individual or a couple during any stage of a normal sexual activity that inhibits one or both partners from achieving sexual satisfaction is known as sexual dysfunction (Table 33.4) (Mandal, 2019; Cleveland Clinic, 2020). Sexual dysfunction disorders can have a profound impact on an individual’s quality of life.

Disorder	Description
low libido	Lack of or significant reduction in sexual interest and arousal. Common causes include certain medications, mental health disorders, and stress.
erectile dysfunction (ED)	Recurrent inability to achieve or maintain an adequate erection during partnered sexual activities. Common causes include hardening of arteries (e.g., atherosclerosis), neurological disorders, stress, penile trauma, and depression.
female orgasmic disorder	A significant change in female orgasm such as delay, reduction of intensity, or cessation.
delayed ejaculation (DE)	Taking a very long time to ejaculate following penetration.
premature (early) ejaculation	Persistent or recurrent pattern of ejaculation occurring either before or during partnered sexual activity within about one minute following vaginal penetration and before the individual wishes it.
substance/medication-induced sexual dysfunction	A condition in which patients have difficulties with sexual desire, arousal, and/or orgasm due to a side effect of certain medications and/or substances (legal or illicit).
vaginismus	Involuntary vaginal muscle wall spasm during intercourse, resulting in pain. The cause is unknown but previous trauma and/or sexual assault has been suggested as a potential trigger.
priapism	Painful erection that may persist for hours, even with a lack of sexual stimulation. It results when there is blood trapped in the penis that fails to drain adequately.
dyspareunia	Persistent or recurrent pain that occurs during sexual intercourse. This pain may occur at the vaginal opening or deep within the pelvis. It can be caused by various factors, including physical conditions such as infections, vaginal dryness, endometriosis, or pelvic floor disorders, as well as psychological factors such as anxiety or past trauma.
vaginal dryness	A condition where the vagina lacks sufficient natural lubrication, resulting in discomfort or pain during sexual intercourse. Vaginal dryness can occur due to various reasons, including hormonal changes (such as during menopause), certain medications, breastfeeding, stress, and certain medical conditions.

Table 33.4 Descriptions of Common Sexual Dysfunction Disorders

Diabetes Mellites

It may appear that diabetes mellitus would not impact sexual function; however, it can and often does in several ways. First, men with diabetes are three times more likely to experience erectile dysfunction (ED) than men without diabetes (Seid et al., 2017). Because of the chronic inflammation and subsequent damage to blood vessels and nerves seen with diabetes, it is often difficult to accomplish and/or maintain an erection. Additionally, men with diabetes may deal with a lack of sensation in the penis, even with an erection, due to peripheral neuropathy associated with the condition. The same can be said for women with diabetes—because of decreased blood flow and damaged nerves, they often experience less sensation around the vagina during sex, which can make it less enjoyable.

Clinical Judgment Measurement Model

Take Action: Addressing Diabetes and Sexual Health

John, a 55-year-old male with type 2 diabetes, presents with concerns about ED, which has been affecting his relationship with his partner. The nurse begins by gathering a comprehensive history of John's diabetes, including details about his management regimen, recent changes in medication, and lifestyle factors. A physical examination is conducted to assess for signs of diabetic complications such as peripheral neuropathy or vascular disease, which may contribute to his ED symptoms. Analyzing these cues, the nurse considers the impact of John's diabetes management on his sexual health and orders diagnostic tests to assess diabetes control, cardiovascular risk, and hormonal status. Based on the identified cues and analysis, the nurse forms hypotheses regarding potential diabetes-related causes of ED, such as neuropathy or vascular insufficiency, as well as psychological factors such as depression or anxiety. A collaborative care plan is developed, which includes addressing John's diabetes management goals while providing interventions for ED, such as medication, lifestyle modifications, or referral to a sexual health specialist. By applying a clinical judgment model to John's case, the nurse can systematically address his concerns, optimize his diabetes management, and improve his overall quality of life.

Cardiovascular Disease

Cardiovascular disease is another physiological condition that can negatively impact sexual function. One of the main reasons is related to the fatigue that often accompanies heart disease. Because diseased cardiac muscle must work harder than healthy muscle, it is prone to early fatigue. This translates to a potential decreased ability to fully participate in sexual activities. Patients with cardiovascular disease may tire early, which doesn’t allow them to reach orgasm or achieve sexual satisfaction, or they may lose interest in sexual activity altogether because it seems like it will take too much effort and energy. Additionally, treatment for cardiac disease usually involves medications that reduce the workload of the heart, thus reducing the amount of blood being supplied by the heart to distant areas of the body, such as the genitals. With a diminished blood supply, males may experience erectile dysfunction, whereas women may have difficulty achieving and/or maintaining sexual arousal.

Joint or Mobility Conditions

Any medical condition that causes impaired mobility has the potential to impact sexual function. Most sexual activities involve movement and require some mobility, so these kinds of conditions hinder the ability to fully participate. Some examples of conditions affecting mobility that may impact sexual function include

rheumatoid arthritis,
spinal cord injury,
amyotrophic lateral sclerosis (ALS),
multiple sclerosis (MS),
stroke, and
muscular dystrophy.

Real RN Stories

Spinal Cord Injury

Nurse: Frankie, BSN
Clinical setting: Intensive care unit (ICU)
Years in practice: 5
Facility location: Inner city of a large metropolitan area in California

For weeks, I had been caring for a 17-year-old patient who experienced a cervical spinal cord injury after diving into shallow water. Originally, it was believed that he would require a permanent ventilator, but he has since been weaned from it and is doing surprisingly well for the type of injury he sustained. He has regained some movement in his arms and fingers but has lost all sensation and function below his navel. He is still having trouble forming verbal words, but he has been using an iPad to communicate.

When I went in to check on him at the beginning of my shift, he asked me if I would have some time to come chat with him about a few things later in my day. I said, “of course,” and was able to make it back a few hours later after getting my other patients settled. When I came back in to chat with him, he typed the following on his iPad, “This is uncomfortable for me to ask, but I feel weird talking about it to my parents. Will I ever be able to have sex?” I was taken aback by the question, only because I had never cared for such a young patient with a permanent injury like this one before. I said, “To be honest with you, I’m not sure. I know that it’s probably unlikely just based on the level of your injury, but I won’t be the one to say no for sure, because I just don’t know. I would be more than happy to relay these concerns to your provider to see if I can get some answers for you though.” He replied in agreement, and I made sure the provider would stop by later that day to chat with him about his concerns.

That afternoon, the provider came by and told the patient that it was highly unlikely that he would be able to have sex, but that until more time had passed and he was given more time to heal, that we just don’t know what will happen. He also said, “There have been a lot of advancements in this area in recent years, so there may be some kind of assistive device that you could use to help you regain some sexual function. Because you have lost sensation below the waist, it’s unlikely that you will be able to feel much, but again, we just don’t know until we have given your body ample time to heal. In the future, if you ever start thinking about having children, there are options available for obtaining sperm, so it’s not completely impossible for you to father biological children, should you desire to.” I could tell that the patient was a little bit upset at these words, but he appeared to remain hopeful that he might regain some function in the future.

Chronic Pain

Chronic pain (pain lasting more than six months), especially when uncontrolled, can negatively impact sexual health in several ways. First, pain can make some sexual positions uncomfortable, or even impossible. For example, chronic conditions such as arthritis and back pain can inhibit flexibility and/or cause discomfort during sexual intercourse. Second, chronic pain often causes fatigue, making it difficult for the individual to have enough energy to participate in sexual activities. Even if they are interested in sex, fatigue may limit their ability to fully participate or achieve an orgasm. Addressing sexual function in the context of chronic pain often requires a holistic approach that includes treating the pain, addressing emotional concerns, and maintaining open communication with healthcare providers and partners. Therapies such as cognitive behavioral therapy, physical therapy, and couples counseling can be beneficial in managing both pain and its impact on sexual function.

Medications

There are many medication classes that can have a significant impact on sexual function (Table 33.5). It is important to note that not every single drug in the class of medications causes all (or any) of the listed effects, but they are commonly associated with many of the drugs in that class.

Medication Class	Effect on Sexual Function
Antidepressants	Decreased libido Delayed orgasm Erectile dysfunction
Antipsychotics	Decreased libido Erectile dysfunction Difficulty achieving orgasm
Hormonal medications (e.g., contraceptives, hormone replacement therapy)	Decreased libido Vaginal dryness
Antihypertensives	Erectile dysfunction Decreased libido
Opioids	Decreased testosterone levels Decreased libido Erectile dysfunction Difficulty achieving orgasm

Table 33.5 Medication Classes That Can Affect Sexual Function

Unfolding Case Study

Unfolding Case Study #5: Part 1

Mr. Morales, a 46-year-old male, is being seen in the clinic for an annual wellness examination. During the examination, Mr. Morales reports that he has been having trouble achieving and maintaining erections during sex. He states, “My wife is getting frustrated and so am I. I’m not even that old yet. Why is this happening to me?”

Past Medical History

Medical history: Type 2 diabetes, hypertension, depression
Family history: Both parents alive and well, mother has hypertension and depression.
Social history: Married x twenty years, two teenage children. Wife recently diagnosed with breast cancer.
Current medications:

Fluoxetine (Prozac) 20 mg PO daily
Metoprolol (Lopressor) 50 mg PO twice daily

1.

Recognize cues: Based on the provided information, what cues are most significant for the nurse to recognize?

2.

Analyze cues: What might be some contributing factors to the patient’s reported erectile dysfunction (ED) symptoms?

3.

Prioritize hypotheses: The nurse recognizes the patient’s symptoms are consistent with erectile dysfunction (ED) and that it may be partially caused by his current health status and medications. What other information should the nurse obtain from the patient at this time regarding potential causes of his ED symptoms?

Psychological Factors Affecting Sexuality

In addition to physical factors, psychological factors also have a significant impact on sexual function and health. Human sexuality is influenced by many psychological variables, including but not limited to, mental health, body image, and stress. Nurses play a vital role in recognizing and addressing the psychological dimensions of sexual health and function, thereby promoting holistic well-being for individuals across the life span.

Mental Health

Mental health and sexual health often go hand in hand. Although sexual dysfunction is often a result of physical conditions (e.g., heart disease, diabetes), they can also have underlying psychological causes. Specifically, depression, anxiety, substance use disorders, and schizophrenia have all been shown to contribute to the development of sexual dysfunction (Sewalem et al., 2022). It is vital that nurses and other healthcare providers treat patients with mental health disorders holistically and not shy away from conversations about sexuality and sexual health. Studies have shown that sexual health needs, especially those of individuals with concurrent mental health disorders, are not addressed appropriately (Hortal-Mas et al., 2022). Though discussing mental health and sexuality can be uncomfortable topics for some, it is imperative that they are addressed appropriately to ensure that all of the patient’s needs are being met and holistic, patient-centered care is being provided.

Body Image

Body image plays a significant role in achieving sexual health and well-being. When individuals have a positive body image, they tend to feel more confident and comfortable with their bodies, which can enhance sexual experiences and intimacy. Conversely, negative body image can lead to feelings of self-consciousness, shame, and insecurity, which may contribute to sexual dysfunction, avoidance of sexual activity, or dissatisfaction with sexual relationships. For example, individuals with poor body image may avoid being seen naked or engaging in certain sexual positions due to feelings of embarrassment or fear of judgment. This avoidance can lead to decreased sexual pleasure and intimacy within relationships. Body image concerns can also affect communication and openness in sexual relationships. Individuals may feel hesitant to express their desires or preferences, fearing rejection or judgment from their partner. This lack of communication can hinder sexual satisfaction and intimacy, as partners may not fully understand each other's needs or feel emotionally connected during sexual interactions. Furthermore, societal standards of beauty and unrealistic media portrayals can exacerbate body image issues, leading individuals to compare themselves unfavorably to idealized images and to feel inadequate. These cultural influences can contribute to body dissatisfaction and impact sexual self-esteem.

Patient Conversations

Body Image Concerns During Sex

Scenario: The patient is a 56-year-old female being seen in the clinic for an annual follow-up appointment following a double mastectomy and chemotherapy treatment for breast cancer.

Nurse: Good morning, Mrs. Johnson. How are you feeling today?

Patient: Good morning. I'm doing okay, thank you. I've been feeling a bit anxious lately, though.

Nurse. I'm sorry to hear that. Is there anything specific that's been on your mind?

Patient: Well, it's a bit embarrassing to talk about, but I've been feeling self-conscious about my body lately. Since my mastectomy, I can't help but feel insecure about how I look. It’s starting to affect my sex life and I can tell my husband is getting irritated.

Nurse: It's completely normal to have concerns about body image, especially after such a significant change. I want you to know that you're not alone, and it's okay to feel this way. Have you and your husband had the chance to discuss these feelings together?

Patient: We've touched on it briefly, but I think we're both struggling to find the right words. I worry that he doesn't find me attractive anymore.

Nurse: It's understandable that you would feel that way, but I want to assure you that physical appearance doesn't define your worth. Your husband is likely navigating his own emotions surrounding your mastectomy. It might be helpful to have an open and honest conversation with him about your concerns. Would you like some guidance on how to approach this conversation?

Patient: Yes, please. I'm not sure where to start.

Nurse: I recommend choosing a time when you both feel relaxed and comfortable, perhaps over a quiet dinner at home. Begin by expressing your feelings honestly and openly, using "I" statements to convey your emotions without placing blame. Let him know that you value his support and understanding, and that you want to work together to strengthen your intimacy and connection. Remember, communication is key in any relationship, and sharing your vulnerabilities can bring you closer together.

Patient: Thank you so much. That's really helpful advice. I'll try to talk to him tonight.

Nurse: You're welcome, Mrs. Johnson. Remember, I'm here to support you. If you ever need someone to talk to or have any questions, don't hesitate to reach out. You're not alone in this.

Stress

Stress can have a significant impact on sexual health, affecting both physical and psychological aspects of sexual function in several ways. First, high levels of stress can cause preoccupation with worries or responsibilities, leaving no physical or mental energy leftover for sexual activity. Second, stress can cause an inability for males to get an erection and for females to achieve orgasm. This is especially true in cases of chronic stress. Chronic stress disrupts hormone balance, increasing cortisol and adrenaline levels, which can inhibit sexual arousal and responsiveness. Lastly, chronic stress is linked to mental health conditions including depression and anxiety, both of which can further exacerbate sexual dysfunction. These conditions can also increase feelings of inadequacy, guilt, or shame related to sexual performance or desire. Chronic stress is a vicious cycle that affects many aspects of life, including sexual health and functioning.

Psychosocial Factors Affecting Sexuality

Psychosocial factors, which encompass both psychological and social aspects of an individual's life, can profoundly influence sexual health. These factors interact with biological and environmental elements to shape attitudes, behaviors, and experiences related to sexuality.

Culture

Cultural beliefs, societal expectations, and norms surrounding sexuality can influence how individuals perceive and express their sexuality. Attitudes toward gender roles, sexual orientation, and sexual behaviors are shaped by cultural and societal influences, which can affect sexual identity, self-expression, and access to sexual health resources. In some cultures, such as in many Western countries, there is growing acceptance and support for diverse sexual orientations and gender identities. This acceptance is reflected in laws that protect LGBTQIA+ rights, societal norms that encourage open discussion about sexual orientation, and widespread availability of sexual health resources tailored to LGBTQIA+ individuals. Conversely, in more conservative cultures, such as in some Middle Eastern or African countries, traditional beliefs and societal norms often dictate strict gender roles and heteronormative expectations. Homosexuality may be stigmatized or even criminalized, and gender nonconformity may be met with discrimination or violence. The main takeaway is that nurses and other healthcare professionals must remain open-minded and nonjudgmental to provide culturally competent care that accounts for cultural variations in beliefs about sexuality.

Cultural Context

Female Genital Mutilation (FGM)

Female genital mutilation (FGM) involves the partial or total removal of the external female genitalia for nonmedical reasons, most often related to cultural or religious beliefs. It has been estimated that more than 200 million females that are alive today have experienced FGM (World Health Organization, n.d.). FGM is nationally recognized as a violation of human rights of girls and women and a severe form of gender discrimination. The World Health Organization (WHO) has developed a goal to rid the world of FGM by the year 2030.

Religion

Religion can have a significant influence on sexual health by shaping attitudes, beliefs, and behaviors related to sexuality. The impact of religion on sexual health varies widely depending on specific religious teachings, cultural practices, and individual interpretations. Religious teachings often provide a moral framework for understanding sexuality and guiding sexual behavior. Values such as monogamy (having only one partner at a time) and abstinence, or refraining from engaging in sex before marriage, may be emphasized within some religious communities, influencing individuals' choices regarding sexual activity, contraception, and relationships. Some religions may stigmatize certain sexual behaviors or identities, leading to feelings of guilt, shame, or self-judgment among individuals who do not conform to religious norms. Stigmatization of premarital sex, extramarital affairs, nonheterosexual orientations, or gender nonconformity can create barriers to seeking sexual health services and support. It is important to recognize that the impact of religion on sexual health is complex and multifaceted, and individuals' experiences may vary widely within and across religious traditions. Nurses should approach discussions of sexual health with sensitivity to patients' religious and cultural backgrounds, respecting their beliefs and values while providing accurate information and support to promote positive sexual well-being.

Ethics

There are several ethical factors that may affect an individual’s sexuality. First, the importance of informed consent in all sexual interactions cannot be understated. All parties must freely and willingly consent to all aspects of sexual activity without coercion or pressure. Second, the ethical principle of autonomy should be emphasized for all individuals, regardless of their sexuality. Individuals should be able to make informed decisions about their sexual health and relationships, free from outside coercion or judgment. Additionally, ethical sexual behavior involves the individual respecting the autonomy and dignity of themselves and others. It means treating others with kindness, empathy, and understanding, and not sexually objectifying them. Third, ethical considerations related to sexuality mean that nurses and other healthcare professionals must recognize and respect the rights of individuals, regardless of gender, sexual orientation, or any other factor related to one’s sexuality. Additionally, it involves challenging power imbalances and advocating for equitable treatment and opportunities for all, both inside and outside of the healthcare system. Lastly, ethical considerations related to sexuality prioritize the safety and well-being of all parties involved. This includes practicing safe sex to prevent the spread of STIs and taking measures to prevent unwanted pregnancies. Ethical sexual behavior also involves being aware of and addressing the emotional, psychological, and physical consequences of sexual activity.

Lifestyle

Certain lifestyle choices can have an impact on sexual health and functioning (Table 33.6).

Lifestyle Factor	Impact on Sexual Health
Diet and nutrition	Good nutrition supports overall health, including sexual health. Maintaining healthy weight can prevent conditions such as heart disease and diabetes, both of which can negatively impact sexual health.
Smoking and substance use	Smoking has been shown to increase risk of erectile dysfunction in men and decrease fertility in women. Alcohol and drugs can impair sexual function, decrease libido, and contribute to risky sexual health behaviors.
Sleep	Chronic sleep deprivation can lead to fatigue and decreased libido.
Relationships	Communication and emotional connection with a sexual partner can impact sexual satisfaction and health. Healthy relationships foster intimacy and enhanced sexual experiences.

Table 33.6 Lifestyle Factors and Impact on Sexual Health

33.3 Factors Affecting Sexuality