3.3 Health Promotion

External Genitalia

The external genitalia, known as the vulva, of the person AFAB includes several structures that play a crucial role in sexual function, reproduction, and protection (Figure 3.3).

Figure 3.3 External Female Genitalia The external genitalia protect the urethra and vaginal opening. (modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The mons pubis is a rounded mound of fatty tissue located above the pubic bone. It becomes covered with pubic hair during puberty. The labia majora are the outer, more prominent skin folds and fatty tissue surrounding and protecting the vaginal opening. The labia majora are often covered with pubic hair. The labia minora are the inner, smaller folds of skin located within the labia majora. They lie closer to the vaginal opening and do not have pubic hair. The labia minora can vary in size, shape, and color among people. They contain numerous sweat and oil glands.

The clitoris is responsible for most sexual arousal and orgasm and is composed of erectile tissue containing many nerves. The glans of the clitoris is positioned where the labia minora meet at the hood. The clitoris has an internal and external body. The glans lies under the hood, external to the vulva, while the corpus, suspensory ligament, root, and vestibular bulbs are on the interior of the vulva. The clitoris makes an upside-down V-shape and is attached to the pubic symphysis (Figure 3.4).

Figure 3.4 Anatomy of the Clitoris The clitoris is an internal and external organ. (modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The urethral opening is located just below the clitoral hood and above the vaginal opening. The vaginal opening is also known as the introitus.

Internal Genitalia

The internal genitalia consist of the vagina, cervix, body of the uterus, fallopian tubes, and ovaries. These structures each have specific functions pertaining to sexual function and childbirth. Figure 3.5 illustrates the internal genitalia.

Figure 3.5 Internal Genitalia The internal genitalia play a role in sexual and reproductive function. (modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Fallopian Tubes

The fallopian tubes, also called the uterine tube or oviducts, are a pair of slender, hollow tubes that extend from the uterus out toward the ovaries. The fallopian tubes play a vital role in fertilization and early embryonic development.

The infundibulum is the funnel-shaped fallopian tube opening that surrounds the ovary. At the outer end of each fallopian tube are finger-like projections called fimbriae. The fimbriae create a sweeping motion that helps capture the released egg from the ovary and guide it into the tube. The ampulla is the widest and longest part of the Fallopian tube. The isthmus is the narrowest and shortest fallopian tube segment, connecting the ampulla to the uterine cavity. It contains fewer cilia compared to the ampulla (Figure 3.6).

Figure 3.6 Fallopian Tube The fallopian tubes play a large role in fertilization. (modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Pelvic Floor Muscles

The muscles of the pelvic floor support the pelvic and abdominal organs; control urinary and bowel continence, urination, and defecation; and assist in the expulsion of the fetus during childbirth (Figure 3.7). Pelvic floor muscles can be damaged by pregnancy, birth, constipation, obesity, and prolonged strain or stretching. When these muscles are damaged, the pelvic organs are no longer supported, and urinary incontinence can occur. In persons with pelvic floor damage, nurses can encourage exercise of the pelvic muscles by performing Kegels (the contraction and release of the pelvic muscles). The nurse can also explain that there are health-care providers who specialize in pelvic floor physical therapy.

Figure 3.7 Pelvic Floor The pelvic floor muscles support the abdominal and pelvic organs. (modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

External Genitalia

The external genitalia are involved in sexual arousal, lubrication, protection of internal structures, the passage of urine and menstrual flow, and childbirth. Each structure within the vulva has unique functions and contributes to overall reproductive health and sexual well-being.

The mons pubis and labia majora provide cushioning and protection. The urethra allows the passage of urine, while the vaginal opening allows passage of menstrual flow and a fetus in childbirth. The clitoris contains a high concentration of nerve endings and is central to sexual arousal and orgasm. Bartholin's glands located on either side of the vaginal opening secrete mucus-like fluid that helps lubricate the vagina during sexual arousal.

Internal Genitalia

The vagina essentially connects the uterus to the external environment. The rugae lining the vagina allow it to stretch to accommodate various activities, such as sexual intercourse and childbirth. The vagina also produces natural lubrication to reduce friction during sexual intercourse. The lubrication is primarily the result of increased blood flow to the vaginal walls and mucus secretion from the cervix and vaginal walls. Lubrication can also vary depending on arousal level and hormonal changes.

The cervix undergoes dynamic changes during different menstrual cycle phases, sexual arousal, pregnancy, and labor and is influenced by hormones such as estrogen, progesterone, and oxytocin. Estrogen plays a vital role in cervical mucus changes and softening, while progesterone maintains the cervix's integrity during pregnancy. Oxytocin stimulates uterine contractions during labor, leading to cervical dilation.

The cervix contains numerous glands that produce mucus, which, under the influence of hormones, changes in consistency throughout the menstrual cycle. As estrogen levels rise in the cycle, the cervix becomes softer and opens slightly. The cervical mucus becomes abundant, slippery, and stretchy, resembling raw egg whites, to facilitate the passage of sperm through the cervix and into the uterus during ovulation. During sexual arousal, the cervix becomes engorged with blood, and the external os may dilate slightly, allowing easier penetration during intercourse.

The physiology of the uterus is tightly regulated by hormones, including estrogen, progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and oxytocin. These hormones orchestrate the cyclical changes that prepare the uterus for pregnancy and regulate uterine contractions during labor.

The ovaries undergo cyclical changes during the menstrual cycle with the goal of oogenesis. The egg cell development and maturation process within the reproductive system that occurs during the follicular phase of the menstrual cycle is called oogenesis (Figure 3.8). Oogenesis is initiated by follicle-stimulating hormone (FSH) released by the anterior pituitary gland. FSH prompts the development of an ovarian follicle, and as it grows, it produces estrogen.

Figure 3.8 Human Oogenesis The ovarian cycle is responsible for maturing and releasing an egg for potential fertilization. (modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Typically, only one follicle becomes dominant while the others regress. The dominant follicle continues to mature, releasing increasing amounts of estrogen as it approaches ovulation. The surge in estrogen triggers the release of luteinizing hormone (LH) from the anterior pituitary gland. This LH surge causes the dominant follicle to rupture, releasing a mature egg from the ovary, a process known as ovulation.

The physiology of the fallopian tubes is regulated by hormonal and neural control. Hormones such as estrogen and progesterone influence the motility and secretory activity of the tubal epithelium, while neural signals help coordinate muscular contractions for egg and embryo transport.

The ampulla of the fallopian tube is the usual site of fertilization, where the sperm and egg meet. The walls of the ampulla are lined with ciliated epithelial cells that help propel the egg and sperm through the tube toward the body of the uterus. After fertilization, the newly formed embryo begins to divide and undergoes early development. Ciliary movements, muscular contractions, and fluid currents in the fallopian tube help transport the developing embryo toward the uterus for implantation.

Menarche

The onset of menstruation, marking the beginning of reproductive capacity, is menarche. It is a significant milestone in physiologic and psychologic development. Menarche typically occurs during adolescence, between the ages of 10 and 16 with the average age being 12.4, although the exact timing can vary widely among people (Lacroix et al., 2023). Young persons AFAB may experience emotional and psychologic changes as they adapt to the physical changes associated with menarche.

Hormonal changes leading to the development of secondary sexual characteristics, such as the growth of breasts and the widening of hips, occur prior to the first menstrual cycle. The Tanner Scale (Figure 3.9) is often used to assess a person’s development of these characteristics.

Figure 3.9 The Tanner Stages in a Person Assigned Female at Birth Tanner stages can be used to identify the process of puberty a person is experiencing. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

During menarche, hormonal changes occur in the body, primarily involving the hypothalamic-pituitary-gonadal axis. The hypothalamus releases gonadotropin-releasing hormone (GnRH), which stimulates the pituitary gland to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH then act on the ovaries to initiate the maturation of ovarian follicles and the release of an egg (ovulation).

The first menstrual period typically consists of relatively small amounts of blood, referred to as menarcheal bleeding. A regular menstrual cycle may take several months or even years to establish as hormonal regulation becomes more consistent. Menstrual cycles typically range from 21 to 45 days with the average being 32.2 days, with menstrual bleeding lasting around 3 to 7 days (Lacroix et al., 2023). Menarche is considered a rite of passage in many societies, and individuals may receive education and support regarding menstrual hygiene, reproductive health, and sexual education. However, cultural norms and practices can also contribute to stigma, taboos, and limited access to menstrual hygiene products and health-care services, negatively impacting individuals' well-being and empowerment. Transgender men can be traumatized by menarche and may experience significant dysphoria.

Menstrual Cycle

The menstrual cycle is characterized by a series of hormonal and physical changes that prepare the body for the possibility of pregnancy. The menstrual cycle typically lasts an average of 28 to 31 days but can vary from person to person. The cycle is counted from the first day of menstrual bleeding to the first day of the next period. The cycle is controlled by the interaction between the hypothalamus, pituitary gland, and ovaries, collectively known as the hypothalamic-pituitary-ovarian (HPO) axis.

The menstrual cycle actually encompasses two cycles, the ovarian cycle and the uterine cycle. They occur simultaneously. The ovarian cycle involves the changes that occur in the ovaries during the cycle, including the follicular phase (days 1 to 14) and luteal phase (days 15 to 28). The follicular phase begins with menstruation as day 1. During this phase, the pituitary gland releases follicle-stimulating hormone (FSH), which stimulates oogenesis. Ovulation occurs approximately midway through the menstrual cycle, usually around day 14, when one mature follicle releases an egg from the ovary, triggered by a luteinizing hormone (LH) surge from the pituitary gland. After ovulation, the ruptured follicle in the ovary forms the corpus luteum. This begins the luteal phase of the ovarian cycle. The corpus luteum produces progesterone, which prepares the uterus for implantation of a fertilized egg. If fertilization does not occur, the corpus luteum regresses, decreasing estrogen and progesterone levels and initiating menstruation.

The uterine proliferative phase also begins at menstruation, day 1, and ends at ovulation. During the proliferative phase, the endometrium prepares for implantation by thickening. After ovulation, the secretory phase begins, and the endometrium becomes a favorable surface for implantation. If fertilization does not occur, the uterus sheds its endometrium, blood, and tissue. This results in menstrual bleeding, typically lasting 3 to 7 days. The average blood loss during menstruation is approximately 30 to 40 milliliters (mL) over a menstrual period. This information is summarized in Figure 3.10.

Figure 3.10 The Menstrual Cycle The menstrual cycle includes both the ovarian and the uterine cycles. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Various factors influence the menstrual cycle, including a person’s age, overall health, stress levels, and hormonal imbalances. The cycle can vary in length and regularity, and changes in the menstrual cycle can indicate underlying health issues or pregnancy.

Nurses are critical in educating patients about the menstrual cycle and promoting menstrual health. Nurses can educate about what is considered a regular menstrual cycle, including the typical duration, frequency, and amount of menstrual flow. They also discuss what might be considered abnormal, such as irregular cycles or unusually heavy or painful periods. Nurses can offer guidance on proper menstrual hygiene practices, including how to use and dispose of menstrual products (such as pads, tampons, or menstrual cups) safely and hygienically. Nurses can introduce the concept of fertility awareness, which involves tracking and understanding the menstrual cycle, observing cervical mucus, and identifying fertile days to conceive or to prevent pregnancy.

Perimenopause and Menopause

Perimenopause and menopause are two distinct but interconnected stages of reproductive aging. The transitional period leading up to menopause, during which a person's body undergoes hormonal fluctuations and reproductive changes, is perimenopause. It is characterized by irregular menstrual cycles and a decline in ovarian function leading to decreased estrogen, progesterone, and testosterone. Perimenopause usually begins 4 to 9 years prior to menopause and affects most persons AFAB in their mid-40s (Leistikow & Smith, 2022).

During perimenopause, hormones fluctuate significantly. These hormonal shifts can lead to various symptoms, including irregular periods, hot flashes, night sweats, mood swings, fatigue, sleep disturbances, vaginal dryness, changes in libido, and cognitive changes. Perimenopause has been compared to the peripartum period, in which risk of depression and mental illness is greatly increased; health-care providers and nurses must screen for perimenopausal depression as they do during the postpartum period (Leistikow & Smith, 2022). In one study, perimenopausal people had a 9 percent to 15 percent increase in dysmorphic mood and were two to four times more prone to major depressive episodes than premenopausal people (Leistikow & Smith, 2022).

The permanent cessation of ovarian function, signaling the end of reproductive capability, is menopause. It is a natural physiologic process that occurs due to the depletion of ovarian follicles and the subsequent decline in estrogen and progesterone production.

Following menopause, people may continue to experience a range of physical and emotional changes. Common symptoms include hot flashes, night sweats, vaginal dryness, mood swings, sleep disturbances, urinary changes, changes in sexual function, and changes in bone density (Leistikow & Smith, 2022).

Individual experiences through perimenopause and menopause differ, with some experiencing minimal symptoms and others requiring medical interventions to manage symptoms and prevent or treat adverse health conditions. Managing perimenopause and menopause involves a multidimensional approach, including self-care practices, menopausal hormone therapy (MHT), nonhormonal medications, and complementary therapies. MHT can begin during perimenopause and is the gold standard for treatment, reducing morbidity and mortality in women. Nurses and health-care providers play a crucial role in assessing symptoms, addressing concerns, providing guidance, and tailoring treatment plans to support overall health and well-being during this transitional phase. Nurses can encourage patients to see a Menopause Society Certified Practitioner for specialized menopausal care.

Sexual Response

The sexual response is a complex physiologic and psychologic process encompassing several stages. The most recognized model of sexual response is the four-stage model proposed by Masters and Johnson in the 1960s. This model consists of four phases: excitement, plateau, orgasm, and resolution (Masters & Johnson, 1966). However, it is important to note that individual experiences of sexual response can vary.

In the excitement phase, sexual desire and arousal begin in response to sexual stimuli, such as physical touch, erotic thoughts, or visual cues. Physiologic changes occur, including increased blood flow to the genital area, vaginal lubrication, and swelling of the clitoris and labia. Breathing and heart rate may increase, and nipples can become erect.

During the plateau phase, a heightened state of arousal and sexual tension continues to build. The body prepares for a potential orgasm, with increased muscle tension and blood flow to the genital area. Vaginal lubrication increases further, and the clitoris becomes more sensitive.

The peak of sexual pleasure and release of accumulated sexual tension is the orgasmic phase. Rhythmic contractions occur in the pelvic muscles, including the uterus, vagina, and anal sphincter. Intense pleasure and release of endorphins are experienced. The resolution phase refers to the return to baseline where muscles are relaxed and pulse, blood pressure, and respirations return to normal.

It is essential to recognize that sexual response is a diverse and individual experience. Some individuals may experience variations in the stages or have different patterns of sexual response. In addition to providing information about the sexual response, nurses are prepared to discuss the importance of open communication, consent, and the person's desires and boundaries in sexual experiences. Nurses should also encourage patients to discuss problems with sexual response, such as difficulty in achieving orgasm. When nurses ask questions about difficulty with the sexual response, patients are more at ease and open to discuss sexual issues.

Persons AFAB may experience sexual dysfunction, such as low libido (hypoactive sexual desire disorder), difficulty in reaching orgasm (anorgasmia), or arousal difficulties. Conditions such as dyspareunia (pain during sexual intercourse) and vaginismus (involuntary muscle contractions that make penetration difficult or impossible) can significantly impact a person’s sexual health and relationships. Assessing the underlying causes, providing education, and referring to appropriate specialists, such as gynecologists or sex therapists, may be necessary.

Nutrition

Throughout the lifespan, good nutrition is crucial to health, vitality, and overall well-being. From childhood to the later stages of life, adequate and balanced nutrition is essential for optimal growth, development, disease prevention, and maintaining a healthy body.

As persons AFAB enter their reproductive years, nutrition plays a critical role. For those planning to conceive, proper nutrition supports fertility and reproductive health. A well-balanced diet, including various nutrients, vitamins, and minerals, ensures optimal hormone regulation and menstrual regularity. Reproductive persons AFAB should be encouraged to take a folic acid supplement because of its importance in preventing neural tube defects. During pregnancy, adequate nutrition becomes paramount to support the growing fetus. It provides the essential nutrients needed for fetal development, reduces the risk of birth complications, and promotes the health of the pregnant person and fetus. Proper nutrition also plays a crucial role during lactation, providing the necessary nutrients for breast-feeding and supporting the birthing person’s and infant’s health.

As individuals transition into perimenopause and menopause, nutrition remains of utmost importance. The risk of osteoporosis increases during this stage, making adequate calcium and vitamin D intake crucial for maintaining bone health and reducing fractures. A heart-healthy diet low in saturated fats and high in fruits, vegetables, whole grains, fiber, and healthy fats helps reduce the risk of cardiovascular diseases that can become more prevalent during this time. Adequate nutrient intake is essential for maintaining energy levels, cognitive function, and a strong immune system. Nutrient-dense foods provide the necessary vitamins, minerals, and antioxidants to support cellular health and combat age-related oxidative stress.

The most recent dietary guidelines available are the Dietary Guidelines for Americans 2020–2025, published jointly by the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (HHS) (2020). These guidelines provide evidence-based recommendations for healthy eating patterns to promote overall health and prevent chronic diseases.

In addition to educating patients about good nutrition habits, it is important to understand common unhealthy nutrition practices. Unhealthy nutrition practices refer to behaviors and dietary habits that negatively affect a person's health and well-being. Unhealthy nutrition practices can have both immediate and long-term consequences for health. They can contribute to obesity, diabetes, heart disease, hypertension, certain cancers, and other chronic health conditions. Additionally, poor nutrition can lead to fatigue, weakened immune function, and impaired cognitive abilities.

Exercise

A sedentary lifestyle, characterized by little to no physical activity and prolonged periods of sitting or lying down, can have numerous negative consequences on physical and mental health. Consequences of a sedentary lifestyle include obesity and weight gain, increased risk of heart disease, reduced bone density, insulin resistance, increased risk of some cancers, and reduced overall well-being. Physical activity plays a crucial role in promoting overall well-being especially for persons AFAB. Regular aerobic exercise, such as brisk walking, jogging, cycling, or swimming, helps strengthen the heart and improve cardiovascular health (Figure 3.11).

Figure 3.11 Physical Activity Guidelines for Americans The Physical Activity Guidelines for Americans provide evidence-based guidance to help Americans maintain or improve their health through physical activity. (credit: modification of “Physical Activity Recommendations for Different Age Groups” by Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity, and Obesity/ Centers for Disease Control and Prevention, Public Domain)

Physical activity supports weight management and helps prevent weight gain. Regular exercise, combined with a balanced diet, assists in maintaining healthy body weight and reducing the risk of obesity. Weight-bearing exercises like walking, jogging, dancing, or weightlifting also help build and maintain bone density, reducing the risk of osteoporosis and fractures.

Exercise improves mental health and well-being by stimulating the release of endorphins, neurotransmitters that promote positive mood and reduce stress and anxiety. Exercise can positively impact hormonal balance to regulate menstrual cycles, reduce premenstrual syndrome (PMS) symptoms, and improve symptoms associated with menopause (Basile, 2020). Nurses are well trained to provide education, encouragement, and support of physical activity for all ages.

Sleep and Rest

Rest is of utmost importance for overall health and well-being. It is an essential physiologic and psychologic process that allows the body and mind to recover, rejuvenate, and perform optimally. Establishing healthy sleep patterns is important for overall well-being and especially important during hormonal changes, pregnancy, menopause, and certain health conditions.

Hormonal fluctuations during pregnancy, perimenopause, and menopause can disrupt sleep. Pregnant people often experience sleep disruptions due to physical discomfort, frequent urination, hormonal changes, and fetal movement. As pregnancy progresses, finding a comfortable sleep position can become challenging. Sleep disturbances increase as people age, and 50 percent of persons over age 65 have issues with sleep (Haufe & Leeners, 2023). Perimenopause and menopause can cause hot flashes and night sweats, leading to night awakenings and difficulty in falling back to asleep. Hormonal changes can also contribute to insomnia, mood changes, and sleep-disordered breathing.

Certain sleep disorders are more prevalent in persons AFAB, for example, insomnia, restless legs syndrome (RLS), and sleep apnea. Chronic diseases such as diabetes, obesity, cardiovascular disease, and depression can be caused or exacerbated by insufficient sleep (CDC, 2022b). Persons AFAB often juggle multiple roles and responsibilities, contributing to sleep disturbances. Stress, caregiving duties, work-life balance challenges, and demands of family life can affect sleep patterns.

Nurses are well trained to evaluate sleeping patterns and to intervene with sleep hygiene counseling. The following is a key point to recommend for good sleep hygiene:

Establish a consistent sleep schedule by going to bed and waking up at the same time every day, including weekends. An established sleep cycle helps regulate the body's internal clock and improves sleep quality.

Sexuality

Sexuality is a fundamental aspect of a person’s overall well-being, and it is essential that providers of health care address the various issues that can arise. Due to time constraints and discomfort, discussions about sexual health are often neglected, and health-care providers may shy away from initiating conversations about sexual concerns, leaving patients to struggle in silence. Nurses must create a safe, nonjudgmental environment that encourages open dialogue about sexual health.

Many people AFAB receive inadequate or limited sexual education, leaving them uninformed about contraception, STIs, consent, and sexual pleasure. This knowledge gap can lead to misinformation, fear, and risky sexual behaviors. Providers of health care and nurses play a key role in discussing contraception options, including hormonal methods (e.g., oral contraceptives, contraceptive injections, patches, implant), intrauterine devices (IUDs), barrier methods (e.g., condoms), and fertility awareness-based methods. Counseling should involve a discussion of effectiveness, side effects, potential interactions with other medications, and considerations based on individual needs and preferences.

Health-care providers can address issues related to menstruation, such as irregular periods, heavy bleeding (menorrhagia), painful periods (dysmenorrhea), or premenstrual syndrome (PMS). Assessing and managing these concerns can improve a person's quality of life and overall sexual well-being.

Providing a safe and inclusive environment for LGBTQIA+ persons is essential. Health-care providers should know the unique health-care needs of lesbian, bisexual, and transgender persons and offer nonjudgmental support, appropriate screenings, and referrals as needed. A more detailed discussion of this topic is found in Chapter 2 Culturally Competent Nursing Care.

Immunizations

Immunizations are essential tools in public health that play a crucial role in preventing and controlling infectious diseases. Immunizations have significantly impacted global health and saved millions of lives. The timing of immunizations throughout the lifespan varies depending on the person’s age, health status, and specific risk factors. The CDC publishes a recommended immunization schedule on their website.

The CDC (2023h) recommends that all adults receive the COVID-19 and influenza vaccine yearly. They recommended that adults ensure they are up to date on the Tdap or Td vaccines as well. Table 3.12 presents recommendations for adult vaccines.

The CDC also recommends immunizations for patients with certain health conditions, such as diabetes, cardiovascular disease, HIV, lung disease, renal disease, and weakened immune systems (2023h).

General Hygiene

General hygiene is an important aspect of education when caring for persons AFAB. Good hygiene practices can help prevent infections, maintain overall health, and promote well-being.

1. Encourage people to maintain good personal hygiene habits, including regular bathing or showering, washing hands thoroughly with soap and water, and brushing their teeth at least twice daily. Emphasize the importance of proper hand hygiene to prevent spreading infections, especially before meals and after using the restroom.
2. Provide education on proper menstrual hygiene practices. Menstrual hygiene includes using clean and appropriate menstrual hygiene products (such as sanitary pads, tampons, or menstrual cups) and changing them regularly to prevent bacterial growth and reduce the risk of infections. Encourage persons to maintain cleanliness during menstruation and properly dispose of used menstrual products.
3. Educate persons AFAB on maintaining good vulvar hygiene. Emphasize the importance of gentle cleaning with warm water and mild, fragrance-free cleansers. Avoid harsh soaps or douches, as they can disrupt the natural balance of vaginal flora and increase the risk of infections. Encourage wearing clean cotton underwear and changing them regularly and as soon as possible after exercising.
4. Encourage the use of sunscreen to protect against harmful ultraviolet (UV) rays.
5. Discuss the importance of proper wound care and cleanliness to prevent infections.
6. Discuss hygiene practices related to sexual activity, such as washing before and after intercourse, using condoms or other barrier methods to prevent STIs, and properly cleaning sex toys to avoid bacterial growth. Voiding after sexual intercourse is commonly recommended to reduce the risk of urinary tract infections (UTIs) in persons AFAB. While empirical evidence specific to this practice is limited, several mechanisms and observations support its potential effectiveness.

Nurses should ask about the patient's access to showers, soap, and hygiene products prior to teaching about hygiene. Some patients may lack running water, soap, or money. Nurses can help patients find resources for hygiene.

Self-Esteem and Empowerment

The subjective evaluation of one's worth and capabilities is one’s self-esteem. It is the degree to which a person believes in their value, abilities, and self-worth. Various factors, including personal achievements, social interactions, upbringing, and external validation, can influence self-esteem. There are key aspects of self-esteem that are important to recognize (Table 3.13).

Having a healthy level of self-esteem is essential for several aspects of life. Self-esteem contributes to lower levels of anxiety, depression, and stress. Healthy self-esteem enables more positive and fulfilling relationships with others. Those with higher self-esteem are more likely to set and pursue ambitious goals. Healthy self-esteem fosters the ability to bounce back from setbacks and learn from failures.

Having a healthy level of empowerment is essential for several aspects of life, and as with self-esteem, there are key elements of empowerment (Table 3.14). Empowerment fosters personal development and self-awareness. Empowered people can be catalysts for positive social change and collective empowerment. In addition, empowering communities can lead to greater resilience and problem-solving abilities.

People with low self-esteem have negative self-perceptions and may feel unworthy or inadequate. Having low self-esteem can lead to behaviors that are problematic, such as violence, and progress to mental health issues (Auttama et al., 2021). Those with low self-esteem can experience depression, stress, and anxiety that can eventually lead to suicide (Auttama et al., 2021). They are more likely to become targets for bullies, as bullies often prey on those they perceive as vulnerable. Nurses need to be vigilant in recognizing signs of bullying, such as unexplained injuries, changes in behavior, or emotional distress. Nurses can make sure that health-care settings are safe and non-threatening by providing a private space for the patient to talk and ensuring confidentiality.

Nurses can help teach self-care and positive mental health behaviors that can lead to increased self-esteem. Research has shown that self-care behaviors for mental health allow patients to deal with stress and anxiety, making them more resilient in dealing with life’s difficulties (Auttama et al., 2021). Empowered individuals can make positive changes. Promoting empowerment includes teaching assertiveness, building resilience, and encouraging a supportive network of friends and family.

Mental Health Hygiene

Addressing mental health hygiene when providing health care is crucial for promoting overall well-being. It is essential to approach mental health hygiene holistically and individually, considering each person's unique circumstances, cultural background, and specific mental health needs.

Nurses can provide education about mental health and common mental health conditions such as anxiety, depression, and stress. Raising awareness reduces stigma and encourages people to seek support when needed. Encourage them to prioritize self-care activities that promote mental well-being. Self-care practices include engaging in regular physical exercise, practicing relaxation techniques (such as deep breathing, meditation, or mindfulness), maintaining a balanced diet, getting adequate sleep, and pursuing activities that bring joy and fulfillment.

Substance Use

Substance misuse in persons AFAB is a significant public health concern with unique considerations and consequences. The problematic use of alcohol or drugs that leads to adverse physical, psychologic, social, and functional outcomes is considered substance misuse. Substance misuse rates in persons AFAB have steadily risen in recent years, with an increasing number of persons engaging in harmful alcohol and drug use. While persons AMAB historically had higher rates of substance misuse, the gender gap has been narrowing (Fonseca et al., 2021).

Persons AFAB experience the effects of substances differently due to brain structure, metabolism, and endocrine function (McHugh et al., 2019). Factors such as body size, composition, metabolism, and the menstrual cycle can influence how substances are processed and their impact on the body. Persons AFAB may face unique risk factors for substance misuse, including a history of trauma (such as physical or sexual abuse), co-occurring mental health disorders (like depression or anxiety), and social or cultural influences contributing to substance use. They may use substances to cope with stress, trauma, or mental health issues. Societal and cultural factors, including gender roles and expectations, can influence substance use patterns in people.

Substance misuse can have specific health effects on persons AFAB. Persons AFAB metabolize alcohol differently than persons AMAB leading to higher blood alcohol levels in those AFAB (McHugh et al., 2019). Persons AFAB also have more side effects of chronic substance use as seen by changes in brain volume (McHugh et al., 2019). These patients also have higher impairment in functioning such as medical, social, family, employment, and psychiatric functions compared to those AMAB (McHugh et al., 2019). Substance misuse during pregnancy can lead to adverse outcomes for the pregnant person and fetus.

Persons AFAB may also face unique barriers to seeking help for substance misuse, such as stigma, concerns about child custody, fear of judgment, or limited access to gender-specific treatment programs and resources. In addition, substance misuse often co-occurs with mental health disorders. Depression, anxiety, and posttraumatic stress disorder (PTSD) can contribute to developing or exacerbating substance misuse issues (McHugh et al., 2019).

Addressing substance misuse in persons AFAB requires a comprehensive and gender-responsive approach. Nurses play a vital role in screening, prevention, early intervention, and referral to specialized treatment services. It is essential to provide tailored and culturally sensitive care that addresses the unique needs and experiences of those struggling with substance misuse.

Injury Prevention

Nurses play a vital role in injury prevention across various health-care settings. They are uniquely positioned to identify risk factors, educate patients and communities, and implement interventions to reduce the incidence of injuries. Nurses assess patients for individual risk factors that may increase their vulnerability to injuries. Assessment includes evaluating age, mobility, cognitive status, and underlying health conditions. Falls are a common cause of injury, especially among older adults. Nurses implement fall prevention strategies, such as conducting fall risk assessments, ensuring a safe environment, and assisting patients with mobility when needed.

Occupational health nurses promote workplace safety by conducting safety training, advocating for safe working conditions, and supporting injury prevention initiatives. Furthermore, nurses monitor and report data on injuries and accidents, contributing to injury surveillance systems that help identify trends and prioritize prevention efforts.

Nurses often engage in community outreach programs to raise awareness about injury prevention and collaborate with local organizations to implement safety initiatives. Nurses are trained to recognize signs of domestic violence and abuse. They can intervene by providing support, resources, and referrals to help break the cycle of violence.

By focusing on injury prevention, nurses can significantly reduce the burden of injuries on individuals, families, and communities. Their expertise and advocacy contribute to creating safer environments and promoting overall well-being for patients and the general population.