Learning Objectives
By the end of this section, you will be able to:
- Discuss terminology from the DSM-5-TR relative to sexual dysfunction
- Describe stressors reported by clients associated with sexual dysfunction
- Identify nurses’ potential reactions to clients with sexual dysfunction issues
- Apply evidence-based nursing interventions of client/family distress as related to these conditions
According to the World Health Organization (WHO), sexual health is a critical aspect of human development and well-being (2023a). To realize sexual health, individuals must have sufficient and accurate knowledge about sex and human sexuality and the ability to access health care that affirms sexual health. The term sexual health refers to the absence of reproductive infections and diseases, unintended pregnancy, sexual dysfunction, and harmful practices, such as female genital mutilation and sexual violence.
Although external genitalia play important roles in the arousal and expression of human sexuality, the brain plays a dominant role in sexual arousal. Sexual arousal includes not only physiological responses to stimulation of the external genitalia, but also sexual fantasy and imagination. Here the brain plays a central role in organizing sensory stimuli, including touch, sight, smell, taste, and sound. The brain also processes the role that society and culture play in the experience of sexual arousal and sexual behavior.
The term sexual dysfunction is used to describe difficulties that individuals and couples experience in terms of sexual desire, arousal, physical and psychological response, and specific sexual behavior. Sexual difficulties may occur in myriad ways within the individual and/or between sexual partners. Some such difficulties are associated either directly or indirectly with medical conditions or surgical treatments for specific diseases, such as cancer or metabolic disease. Not all sexual dysfunctions result in diagnosis of a psychiatric condition. Many circumstances of sexual dysfunction are common and temporary. Some remit spontaneously and others may require the professional assistance from a licensed sex therapist (Wincze & Weisberg, 2015).
DSM-5-TR Terminology Related to Sexual Dysfunction
The DSM-5-TR (American Psychiatric Association [APA], 2022) provides detailed descriptions of eight specific sexual dysfunctions:
- delayed ejaculation
- erectile disorder
- female orgasmic disorder
- female sexual interest/arousal disorder
- genito-pelvic pain/penetration disorder
- male hypoactive sexual desire disorder
- premature (early) ejaculation
- substance/medication-induced sexual dysfunction
Two additional categories included in the DSM-5 are other specified sexual dysfunction and unspecified sexual dysfunction (p. 509). These categories are identified to address symptoms of a sexual dysfunction that do not include all of the criteria identified for the eight categories in the preceding list. The DSM-5 descriptions include diagnostic criteria and features of each disorder; associated features, such as greater detail about the specificity of symptoms a person experiences; prevalence; how the dysfunction typically develops; factors that increase risk for and predict prognosis of the disorder; information about comorbidities; and gender- and culture-related diagnostic issues. Each description also carries important information about differential diagnosis to help the practitioner distinguish between the disorder and other conditions with similar symptoms.
Sexual dysfunctions constitute a group of disorders wherein a person’s ability to experience sexual pleasure or to respond sexually to erotic stimuli are diminished or missing. Such experiences cause the individual ongoing and often serious distress. Although sexual dysfunctions have many characteristics in common with one another, they are a group of disorders with wide variation. Sexual dysfunctions affect all sexes and include subtypes such as lifelong, which refers to a dysfunction that has existed since an individual’s first sexual experience, or acquired, which refers to a dysfunction that becomes apparent after the individual has had normal sexual function or behavior for some period of time. Other subtypes include generalized versus situational. Generalized dysfunctions mean that the experience occurs regardless of the circumstances or settings, including one’s partner(s) or with any or all types of stimulation, whereas situational disorders mean that the dysfunction occurs in only select circumstances or settings, with specific types of stimulation, or only with a specific partner or partners. In addition to these subtypes, some of the disorders are further specified as mild, moderate, or severe, referring to the extent of the clinical distress experienced by the individual with the disorder.
Sexual Response Cycle
To understand sexual dysfunction, it is critical to have some understanding of the sexual response cycle, which is a uniquely human process that is the pattern of physiological changes that occur in the human body during sexual arousal, stimulation, and engagement in sexual behavior (Crooks & Baur, 2017). Regarding the physical aspects of this cycle, the research team of obstetrician/gynecologist William Masters and therapist Virginia Johnson pioneered a study of human sexuality characterized by direct observation. Masters and Johnson described a four-phase model for males and females in 1966: excitement, plateau, orgasm, and resolution. There are distinctive differences between males and females. There is also much variation among individuals and their response to actual or imagined sexual activity. Two common physiological processes do occur in both males and females during sexual arousal, however: vasocongestion and myotonia. Vasocongestion refers to the swelling and filling of specific bodily tissues with blood as arteries in the body dilate in areas, such as the penis, clitoris, and nipples. Myotonia refers to muscle tension that occurs in the body throughout sexual arousal and excitement. This tension can be found in both voluntary and involuntary muscles throughout the body and is most evident in the muscle spasms characteristic of orgasm.
In sexual arousal, arteries dilate throughout the body, but particularly in the external genitalia, and these tissues become swollen, red, and engorged with blood. In males, this is manifest in the erection of the penis, whereas in females this is manifest in enlargement of the clitoris as well as in enlargement of the labia and nipples. This first phase of the sexual response cycle is known as excitement. In this first phase, vaginal lubrication also begins.
The second phase of sexual arousal is known as plateau and is characterized by several physiological changes in the body. Involuntary muscle contractions in the hands and feet begin to occur and cardiorespiratory changes are apparent in increased heart rate, elevated blood pressure, and more rapid breathing. The third phase, orgasm, is marked by involuntary muscle spasms throughout the body, including contractions of the uterus and rectal sphincter. Cardiorespiratory mechanisms continue to be elevated and reach their peaks. During this phase, the male ejaculates seminal fluid into the urethra and out the urinary meatus. Following orgasm, males, but generally not females, experience a refractory period in which orgasm cannot occur again until the tissues return to their pre-arousal states. The length of this period is quite varied, ranging from minutes to hours or days. In contrast to males, females can experience multiple orgasms in quick succession, but this varies depending upon factors, such as age and emotional attraction to one’s partner.
The final phase of sexual arousal, according to Masters and Johnson (1966), is known as resolution and is characterized by genitalia returning to pre-arousal states, the lowering of cardiorespiratory responses, and an overall period of relaxation. There is variation among individuals for each of these phases. In general, however, there is greater variability in the sexual response patterns of females than of males (Crooks & Baur, 2017).
Many sexual dysfunctions are related to one or more chronic conditions, such as spinal cord injury, stroke, diabetes mellitus, sleep apnea, depression, and alcohol abuse. In many cases, the diagnosis of substance use disorder, for example, is made instead of the sexual dysfunction diagnosis. These chronic conditions often compromise the two biological functions of vasocongestion and myotonia, and once the biological condition improves, the sexual dysfunction may improve as well. In some cases, the diagnostic symptoms may actually be attributable to some other nonsexual mental disorder, such as post-traumatic stress disorder.
Sexual dysfunction may be related to a number of psychological factors alone or in combination with the preceding chronic conditions noted. Stressors related to daily living may lead to generalized anxiety, thus forming a deterrent to sexual arousal. Anxiety, for example, may arise out of concern for unplanned pregnancy and result in the lack of sexual desire or arousal. Interpersonal relationships or communication issues between sexual partners may contribute to sexual dysfunctions. A mental disorder such as major depressive disorder is another source of some sexual dysfunctions. Periods of social isolation, such as incarceration or the COVID-19 pandemic, may also contribute to the development of sexual dysfunctions. The experiences of childhood sexual abuse or exploitation (e.g., trafficking) or interpersonal violence in adolescence or adulthood may also result in diagnosable sexual dysfunctions.
Male Sexual Dysfunction
Male sexual dysfunctions include (1) hypoactive sexual desire disorder, (2) erectile disorder, (3) delayed ejaculation, and (4) premature (early) ejaculation. It is important to mention here that the diagnoses of sexual dysfunctions as described in the DSM-5 may appear not to fit gender-diverse individuals. In most instances, the diagnosis is made based on the person’s current anatomy and not on the basis of their sex assigned at birth. This is an area that requires sensitive clinical judgment, which includes serious consideration of the moral and ethical questions that accompany the provision of gender-affirming care. Such care depends on a multidisciplinary approach, including nursing, and a need for more research (Gerritse et al., 2018; Gerritse et al., 2022).
Hypoactive Sexual Desire Disorder
Hypoactive sexual desire disorder includes the lack or negligible experience of sexual desire either prior to or during the sexual experience. This condition of hypoactive desire applies to thoughts and fantasies as well as to actual behavior. To meet the diagnostic criteria, the condition must have persisted for at least six months and cause a clinically significant amount of distress. As in other sexual dysfunctions, it may be further specified as mild, moderate, or severe. Decreased activity of the ovaries or testes, or hypogonadism, can cause endocrine disorders, such as low levels of testosterone. Some prolactin-producing pituitary tumors may result in hypoactive sexual desire.
The prevalence of this disorder increases with age and with alcohol use and may occur with smoking and obesity. It is found more often in males older than sixty years of age than in those under age twenty-five. The prevalence varies across cultures and appears to be higher in males from Southeast Asia than in those from Northern Europe. This disorder is also reported more often by homosexual males than by heterosexual males (APA, 2022).
Hypoactive sexual desire disorder may co-occur with erectile and/or ejaculation disorders as well as depression. An erectile disorder is difficulty in obtaining or maintaining a penile erection or experiencing a significant decrease in the rigidity of the erection during sexual activity. An ejaculation disorder is a pattern of ejaculation occurring either prematurely or delayed. The experience of prolonged difficulty in achieving or maintaining an erection may lead to a person’s loss of interest or desire in sexual activity. The condition may also be influenced by the characteristics of the person’s relationship with a sexual partner whose interest in sexual activity may be altogether different. When making this diagnosis, it is important to be mindful of communication and sexual desire patterns of the person as well as situational stressors, such as the loss of a job or death of a close family member or friend. Consider also conservative religious beliefs and practices when describing and treating this disorder. For example, in a study of Orthodox Jewish couples, Friedman (2019) found that one of the most frequently reported problems was inhibited arousal and orgasm in the males related to their religious belief system and attitudes toward sexuality. Moreover, Friedman pointed out that sex education was limited among Orthodox Jewish couples and that they often do not know how to talk with one another about their sexual needs and desires.
Until recently, clinicians, researchers, and the general public have viewed the sexual response cycle of males to be relatively uniform. Researchers in one study, however, documented five different classes of arousal and response that are unique to males, different in duration of sexual experiences, and variable in terms of relationship satisfaction (Busby et al., 2020). These researchers found that despite differences in arousal and desire, the groups of males in this study did not differ significantly from each other by age, income, educational level, religiosity, number of children, or sexual orientation. Although this study was limited by not including a representative sample, it does provide findings that could help reduce the stigma or pressure some males may feel surrounding this disorder.
Erectile Disorder
Erectile disorder refers to a person’s difficulty in obtaining or maintaining a penile erection or a significant lack of rigidity of the erection during sexual activity at least 75 percent of the time they engage in sexual activity. This disorder may be further classified as mild, moderate, or severe in terms of the amount of distress it causes.
Erectile disorder has been implicated in fertility problems among males and may be identified in individuals with other sexual dysfunctions, such as early ejaculation. In addition, many individuals who experience erectile disorder may experience reduced self-esteem and self-efficacy. They may also feel a loss of masculinity and an increase in anxiety and depression.
The condition varies by age. It is seen more often in males over seventy years of age and much less often in those under forty years of age. When erectile disorder occurs in younger populations, the distress associated with it is higher than when it occurs in older populations. Although relatively less is known about childhood sexual abuse in boys compared with what is known about girls, boys who are victims of sexual abuse often suffer from altered feelings of masculinity, shame, and guilt (Gewirtz-Meydan & Ofir-Lavee, 2021). According to literature reviewed by Gewirtz-Meydan and Ofir-Lavee (2021), males who have experienced childhood sexual abuse are much more likely than other males to experience sexual dysfunction accompanied by feeling anxious and distressed. In addition, as children, the survivors of sexual abuse may lack the ability to trust others and thus develop difficulties with intimate relationships.
Certain surgical and medical factors can play a substantial part in the occurrence of acquired erectile disorder later in life. For example, transurethral resection of the prostate (TURP) and diabetic neuropathy are known causes of erectile dysfunction in males. In the case of TURP, prostate tissue is removed through the urethra, and often causes swelling and pain or it may result in damage to nerves that affect the process of erection. More recent robotic surgery for prostate cancer has reduced the damage to the urethra, but urinary problems remain to some extent during the healing process, which may lead to erectile difficulties in some males (Feng et al., 2020). In diabetes mellitus type 2 (T2DM), elevated blood sugars over a long period of time damage nerves and blood vessels in the penis. Males with erectile dysfunction related to T2DM may find improvement with better glucose control, weight loss, decreased intake of alcohol, and increased exercise.
Difficulty in obtaining and/or maintaining sufficient erection of the penis for sexual activity may also be related to the use of both legal and illicit drugs. It is likewise not uncommon among clients who have cardiovascular, endocrine, and/or neurological conditions, including those with spinal cord injuries. Users of enzyme inhibitors and neuropsychiatric medications report a high incidence of adverse effects in this regard (Kaplan-Marans et al., 2022).
Life-Stage Context
Age Differences between Client and Nurse
The sexual response cycle in adulthood has both biological and psychosocial underpinnings. After reaching sexual maturity, physiological changes in hormones, muscles, and the circulatory system may contribute uniquely to the development of a sexual dysfunction. For example, an adult with cancer may experience changes in sexual functioning (e.g., difficulty with erection of the penis) related to the location of the disease or the negative effects of the treatment.
Many nursing students and new graduate nurses may have only recently completed puberty. They may still be trying to figure out their own sexual orientation and gender identity when they find themselves observing the struggles of clients with concerns about sexuality. Given that sexual dysfunctions tend to increase with age, discussing this diagnosis with clients may be particularly difficult for young nurses. Similarly, older nurses may find that a client who is experiencing a sexual dysfunction is near their own age, or the age of their parents. An encounter with such a client may trigger conflicting feelings within the nurse. Nevertheless, whereas it is important for the nurse to acknowledge their own feelings and concerns, the focus should be on giving the client permission to express their feelings about their condition and working together to seek a solution.
Having a support group of other nurses may help them to process their feelings and thoughts about how to give supportive care to others. It is important to remember, as well, that many of the sexual dysfunctions may be secondary to another disorder, such as substance misuse or spinal cord injury. Thus, it is possible to discover, for example, that a young male who sustained a spinal cord injury from a skiing accident also experiences an erectile dysfunction. It is good to remember that sexual dysfunction, in general, may have multiple causes.
Premature and Delayed Ejaculation
Premature or early ejaculation is the most common sexual dysfunction, seen almost universally in males’ first sexual experiences. It is defined as ejaculation that occurs within one minute of penetration. To be a dysfunction, the concern must have been apparent 75 to 100 percent of the time for at least six months (APA, 2022). It may also occur in nonvaginal sexual contact (e.g., males having sex with males). Some estimates state that 20 to 30 percent of males ejaculate early at some time in their lives. As with any sexual dysfunction, it is important to consider the many factors that may be contributing to the dysfunction. These factors include the partner’s health, communication patterns, one’s history of sexual or emotional abuse, comorbidities, such as anxiety or depression, and medical history. The condition is more common in cultures where arranged marriages are the norm (APA, 2022).
Delayed ejaculation means that an individual experiences either a marked delay or absence of ejaculation. To be diagnosed with this, according to the DSM-5, the client must have experienced these symptoms for a period of at least six months and it must cause the client serious distress. The term “marked delay” does not have a precise definition and could vary with the male’s sexual partner at a given time.
The lifelong subtype begins with early sexual experiences and the prevalence of the condition increases with age. Delayed ejaculation has been associated with reduced androgen levels within the aging process. Several medical conditions may interfere with one’s ejaculatory function. Endocrine and neurological disorders, such as spinal cord injury, epilepsy, and stroke, may lead to delayed ejaculation. Similarly, several drugs, including alcohol, may disrupt ejaculation. It is not unusual to find older adult males who stop taking their antihypertensive medications because of the associated delayed ejaculation experience.
Delayed ejaculation causes substantial psychosocial distress in males and in their partners. In couples who hope to have children, this disorder might be a major hurdle and needs to be discussed during fertility assessment. Although the issue might not meet the full set of criteria as a psychiatric diagnosis, it is a treatable condition well known to psychotherapists.
Female Sexual Dysfunction
Female sexual dysfunctions include (1) female orgasmic disorder, (2) sexual interest/arousal disorder, and (3) genito-pelvic pain/penetration disorder. The female sexual response cycle has been shown to be highly variable, but many practitioners have historically been unaware of this, leading to erroneous labeling of female arousal as “dysfunctional” (Leavitt et al., 2019).
Orgasmic Disorder
An orgasmic disorder is disordered frequency or intensity of orgasm during sexual arousal and stimulation. The diagnosis of female orgasmic disorder is made when a client has either infrequent, delayed, low-intensity, or absent orgasm the majority (i.e., 75 to 100 percent) of the time the client engages in sexual activity. This situation must have existed for at least six months at the time of diagnosis and caused a great deal of stress in the client. As with many other sexual dysfunctions, this disorder may be classified as mild, moderate, or severe (APA, 2022).
Female orgasm is a highly unique and varied phenomenon. Some females require stimulation of the clitoris to experience orgasm whereas others may have this experience solely through penile-vaginal intercourse. For many females, orgasm may be consistently stronger and satisfying with self-stimulation than with sexual intercourse. As a diagnosed sexual dysfunction, female orgasmic disorder is accompanied by anxiety and is frequently associated with relationship problems. Physical health problems, such as spinal cord injury, radical hysterectomy, diabetes, or multiple sclerosis and medications used to treat these conditions may contribute to the development of this disorder. Sociocultural factors, such as religion or arranged marriages, may also contribute to the development of this disorder.
Although sexologists have studied the female sexual response cycle for decades, there is no precise definition of what female orgasm is. Individual females describe the sensation of orgasm in different terms and have unique expectations for what it “should” be. As already noted, the sexual response cycle consists of two physiological processes of vasocongestion and myotonia. In the models described by Masters and Johnson as well as Bancroft and Janssen, female orgasm occurs when cardiorespiratory rates reach a peak during sexual activity and the female experiences involuntary muscle spasms in areas throughout the body, including the muscles of the pelvic floor and the uterus. Sexologists have investigated the reports that numerous females have made about experiencing orgasm that is connected to an area of sensitivity in the anterior wall of the vagina. This area is known as the Gräfenberg spot (a.k.a. “G-spot”), named for the gynecologist who first described this erotic area (Crooks & Baur, 2017). The phenomenon of the “G-spot” remains controversial. Physicians from Yale Medical School conducted a systematic review of literature and concluded that there is “no irrefutable evidence” for its existence (Kilchevsky et al., 2012, p. 724). These researchers also confirmed that the anterior wall of the vagina is quite sensitive and that scientific attention to this phenomenon has contributed to a more positive view of female sexuality by the public.
Sexologists’ descriptions of female orgasms simply address the physiological changes that occur in the body, but the individual brings myriad psychosocial factors into the experience of orgasm, and there is undoubtedly much variation in expectations and outcomes among diverse females (Vieira-Baptista et al., 2021). As noted in the descriptions of other sexual dysfunctions, psychosocial factors, such as cultural and religious upbringing, adverse childhood experiences, and sex education or the lack thereof, may converge to form the context in which the individual anticipates and experiences orgasm.
Female Sexual Interest/Arousal Disorder
A sexual interest/arousal disorder is greatly reduced or lack of interest in or arousal by sexual stimulation. To meet DSM-5 diagnostic criteria of female sexual interest/arousal disorder (APA, 2022), the client must exhibit at least three of the following six symptoms:
- absence or reduction of interest in sexual activity
- absence or reduction of erotic or sexual thoughts and fantasies
- absence or reduction of initiating or responding to sexual activity with a partner
- absence or reduction of pleasure or excitement during sexual activity
- absence or reduction of sexual interest or arousal to a variety of visual, written, or verbal erotic cues
- absence or reduction of physical sensations in genital and nongenital areas of the body during sexual encounters
This arousal disorder is estimated to exist in about one of every three females (APA, 2022) and is often found in tandem with other female sexual dysfunctions, such as dyspareunia (painful intercourse) and orgasmic disorder. These conditions depend a great deal on context and a complete assessment of the client's biopsychosocial history, relationships, communication patterns, levels of stress, and mood disorders. Religion and cultural beliefs may also play a major role in the development or continuation of this disorder. The condition is also affected by age; duration of symptoms is an important feature to consider.
Sexual Pain Disorders
In females, genito-pelvic pain/penetration disorder is also known as dyspareunia. Genito-pelvic pain/penetration disorder may be attributed to a female’s frequent and persistent experience of (a) pain with vaginal penetration, (b) anxiety or actual pain felt in the vulva, vagina, or pelvis during attempts at vaginal penetration, (c) anticipation of such pain, leading to anxiety or fear, or (d) intense tightening of the pelvic floor muscles (vaginismus) during attempts or actual vaginal penetration (APA, 2022). Very strong, involuntary contractions of the pelvic muscles during vaginal penetration is called vaginismus.
Approximately one out of every ten females experience vestibulodynia, which refers to an experience of severe pain at the entrance to the vagina (Crooks & Baur, 2017). A recent randomized clinical trial showed that a multimodal treatment of physical therapy combined with biofeedback and dilation had better treatment outcomes than application of topical lidocaine ointment in reducing this pain (Morin et al., 2021). Other conditions that can cause pain deep in the pelvis during intercourse include stretching of the uterine ligaments and endometriosis. Painful intercourse may be related to a wide variety of other factors: inadequate arousal, lack of adequate lubrication, hormonal changes throughout the menstrual cycle and aging process, and sexual transmitted infections (STIs). Painful intercourse has also been found to be related to the client having a negative self-image of her genitalia (Crooks & Baur, 2017).
Both males and females can experience dyspareunia, but it is more common among females. In males, dyspareunia may be associated with uncircumcised foreskin that is too tight. Infections of the genitourinary system can also lead to experiences of dyspareunia in either sex. Males who are diagnosed with Peyronie disease also experience dyspareunia. This condition is the result of calcium deposits in the shaft of the penis, and it often leads to a curved or “bent” position of the shaft, which may interfere with erections and sexual intercourse (Crooks & Baur, 2017).
Chronic pelvic pain (CPP) in females as well as males has been associated with opioid use disorder (OUD) and its treatment and is worthy of investigation in populations undergoing OUD treatment (Reichmann et al., 2022). For females, CPP may be associated with menstrual cramping as well as sexual intercourse. For males, CPP is generally associated with prostatitis and sexual dysfunction. In both sexes, CPP diminishes quality of life.
Stressors Reported by Clients Associated with Sexual Dysfunction
Clients with sexual dysfunctions have reported a wide range of stressful experiences, which they may view as antecedents or consequences of the specific disorder. Sexual behavior is intimately connected to one’s sexual identity and is highly visible in American society. Childhood experiences of sexually curious exploration are normative, but other childhood experiences of abuse and exploitation are traumatic and may leave indelible and damaging impressions on individuals. The adolescent phase of development is characterized by an expanded view of oneself as a sexual being. Learning to accept the changes of one’s physical body from that of a child to that of an adult, capable of reproduction, is a significant part of this development. Sexual awareness and arousal become more important as puberty unfolds. When sexual expectations are met, human sexuality can become an exciting and valuable part of life, while unmet expectations may create stress.
Some individuals experience great conflict if they are prescribed medications that are intended to enhance their quality of life but result in a sexual dysfunction. Some of these drugs, including antihypertensives, have unintended consequences that affect sexual arousal and functioning. Experiencing a sexual problem in response to taking prescribed drugs may be very stressful to some people. Similarly, some individuals who experience chronic pain may develop sexual difficulties in response to their pain, or the pain may exacerbate an existing sexual dysfunction (Wincze & Weisberg, 2015). The lack of estrogen may result in vaginal dryness that is then accompanied by pain with vaginal penetration. Although this is not an uncommon complaint as people age, it may be associated with other symptoms of sexual dysfunction and become an added stressor for the client. There is also confusion about terminology to address the experience of pain. Such terms include vulvodynia, vaginismus, and vestibulodynia, which are not included in the DSM-5 (APA, 2022).
Clients with serious mental illnesses may seek to maintain intimate relationships, including sexual activities, with partners. Stress related to expressing this wish honestly to family and health-care providers, and utilizing treatment strategies, can be overwhelming. This could result in the client ignoring their sexual needs. Nurses can provide permission for these clients to open up about their needs for intimacy. They can also provide staff education to promote the sexual health and safety of their psychiatric clients (Hortal-Mas et al., 2020).
Stressors Reported by Males
Sexual dysfunctions in males may occur at any stage of development, but they tend to increase with age. As already noted, however, some dysfunctions are temporary and may be related to intrapersonal and interpersonal experiences. For example, low self-esteem or a feeling of weak masculinity may result in lack of confidence in the ability to attain or maintain an erection of sufficient rigidity or time to satisfy the partner. Thus, the intrapersonal psychological state will influence the interpersonal sexual relationship. This complexity of factors blends with biological and cultural factors to create perplexing situations related to sexual functioning. Comorbidities, such as diabetes and hypertension, may contribute to the increased prevalence of sexual dysfunctions in older males. Sociocultural influences, such as the use of drugs, including alcohol and marijuana, may also contribute to the sexual dysfunction experience (Ghadigaonkar & Murthy, 2019).
The development of sexual dysfunctions in males depends, in part, on several of the social determinants of health, including knowledge deficit. Despite their overall educational level, many males lack knowledge about their sexual anatomy and physiology that can lead to an undesired alteration in sexual functioning. Inadequate role models during critical times of sexual development may subsequently impact both knowledge, skills, and confidence in pursuing sexual activity with a consenting partner. Early childhood experiences that included trauma may contribute to sexual dysfunction. Children who have been sexually abused can often develop feelings of guilt and shame (Gewirtz-Meydan & Ofir-Lavee, 2021). Depending on the situation and the communication patterns within the family, these victims may not have received help. Communication skills are essential for effective sexual expression, and these skills have their origins in early childhood.
Persons who have diagnosable sexual dysfunctions experience distress that may include (Gewirtz-Meydan & Ofir-Lavee, 2021):
- feeling guilt or shame
- feeling anxiety or anger associated with sexual behavior
- being afraid of being touched by a potential sexual partner
- lacking the ability to trust others
- feeling helpless to change one’s feelings or behaviors
Stressors Reported by Females
Hamilton and Meston (2013) examined the effect chronic stressors may have on sexual arousal in females. Distraction was found to be a significant factor. Of note is that the distractions were naturally occurring, ongoing stressors in the females’ lives and not those manipulated for the purpose of the study. According to Sathyanarayana et al. (2018), one study in the United States revealed over 40 percent of females experience some form of sexual dysfunction, with 22 percent of females experiencing low sexual desire. Sathyanarayana et al. (2018) investigated the effect of addictive disorders and chronic use of substances on sexuality. Individuals may turn to substance use to enhance sexual performance, though this may have the opposite effect (Sathyanarayana et al., 2018). The research found that therapy is best focused on the couple, the relationship, and the individual aspects of their sexual function (Sathyanarayana et al., 2018). Literature review by Galanakis et al. (2015) found that females’ daily life stressors of fatigue, anxiety, and disease (such as diabetes or psoriatic arthritis) negatively affect relationship quality and, therefore, negatively affect sexual desire and sexual experience.
Cultural Context
Culture and Female Genital Mutilation (FGM)
Sexual dysfunctions in some females are related to cultural practices involving various forms of circumcision or genital cutting. Referred to as female genital mutilation/circumcision (FGM/C) by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), FGM/C is practiced in many countries in the Middle East and Africa. There are several types of FGM/C, mostly performed on five to fourteen-year-olds, that include clitoridectomy, in which all or part of the clitoris is removed; excision of the clitoris and the labia minora and majora; infibulation; and nicking or pricking. Infibulation is the most severe form of this procedure and involves removal of the external genitalia and stitching the vaginal opening to prevent penetration. The infibulated area must be forced open to allow for sexual intercourse and childbirth. These procedures are now considered child abuse by the WHO and the United Nations. These practices have great cultural meaning that revolves around femininity, premarital virginity, and marital fidelity (WHO, 2024a). Strong beliefs are related to the specific cultures that condone these practices, but there are signs of shifts occurring in specific countries where females are beginning to share their voices and fathers are joining in the efforts to end these practices (Mwendwa, 2020).
Read this article on FGM/C by Costello. In this article, Costello identifies several cultures in which this practice is ongoing and identifies variations in the types of procedures that are done to young girls. She also discusses the physical, emotional, and spiritual harm that these rituals can cause in young girls and how this affects them as they get older. The article concludes with specific suggestions for practitioners working with female clients who have experienced FGM, which begins with health-care professionals becoming familiar with the various types of FGM and communicating with sensitivity and cultural humility.
Many females who immigrate to the United States have undergone female circumcision or infibulation with subsequent complaints of vaginismus, orgasmic disorder, or vestibulodynia. Although these may not rise to the level of psychiatric diagnoses, they are aspects of sexual dysfunctions about which nurses must be aware and a sensitive area of client-centered care.
Link to Learning
The young woman in this video experienced FGM at age six as part of her culture in Somalia. At the age of twenty-nine, she discusses the trauma of the actual cutting, the lack of discussion about it within her family after the fact, and the lack of response from medical personnel in the years since that day.
Nurses’ Potential Reactions to Clients with Sexual Dysfunction Issues
Nurses may encounter adults with sexual dysfunction issues in many different settings, ranging from general adult health clinics to postoperative in-hospital settings. They may also encounter such clients in psychiatric outpatient or inpatient settings. Regardless of the settings, nurses need self-awareness of their own attitudes about sexuality, knowledge about the vast variety of sexual issues related to health, and communication skills that enable them to assess and respond to clients with actual or potential problems. The less aware nurses are of their own sexuality, the less likely they are to respond in a sensitive, timely, and appropriate manner to the sexual concerns of their clients.
Nurses may fail to see potential or actual sexual concerns in their clients for several reasons. First, they may not think of their clients as sexual beings. They may lack confidence in their knowledge of human sexual development and behaviors and, similarly, they may lack experience in discussing aspects of human sexuality with other individuals. Their own culture and upbringing may create barriers as well (Williams & Addis, 2021).
In a descriptive study of nursing students in Pakistan, Jadoon et al. (2022) found that baccalaureate students had generally positive attitudes about addressing sexual health in their clients, but they felt uncomfortable or embarrassed in doing sexual assessments of people of the opposite gender. In another study of midwifery students in Turkey, researchers found that the students were restricted in asking questions about sexual health as part of their care plan; the students did not complete the sexuality component of their care plans (Serin et al., 2020). Many of these students felt the topic was private, and they were embarrassed to ask clients about sexual matters. Moreover, these students felt that their culture and religion established sexual taboos that restricted their ability to provide this aspect of client care.
Nursing education has a responsibility to include information about human sexuality in prelicensure programs as well as in graduate programs for advanced practice roles. Without exposure and opportunities to practice assessment, communication, and referral skills, nurses may feel confused and embarrassed when issues related to sexuality arise. Lack of adequate preparation leads to avoidance of this essential topic in health-care settings. Nurses need to be aware of the salience of sexuality and intimacy to overall health and well-being of persons in their care (Quinn & Happell, 2011; Quinn & Happell, 2013). Moreover, students should consider enrolling in electives in sociology, psychology, or human development on the topic of human sexuality.
Nurses may have encountered adverse childhood experiences that included sexual abuse or exploitation that stand as a barrier between them and providing sexual health care to clients. Some nurses in clinical settings experience sexual harassment by clients, visitors, and other hospital staff members. If nurses feel sexually unsafe in their work environment, this will present an enormous barrier to their ability to provide competent nursing care, particularly in areas that include sexual health matters.
Nursing Interventions and Management
Nursing interventions and management of individuals experiencing sexual dysfunctions are related to the nurse’s self-confidence and competencies in dealing with sexual health issues in general. Nurses’ responses to their clients are influenced by their own upbringing and sociocultural experiences throughout their lifetime. It is important to acknowledge that issues concerning sexual health may trigger earlier or ongoing sexual experiences of the nurse. This is a very critical area in which nurses, and nursing students, must be willing to do some serious self-reflection to determine their comfort with and ability to address the sexual issues of those persons entrusted to their care. If nurses have unresolved conflicts or trauma related to sexual experiences in their earlier lives or if they are currently experiencing their own issues related to sexuality or sexual relationships, they will not be able to provide the compassionate and knowledgeable care that is required of them in giving care to clients with actual sexual dysfunctions.
Basic human sexuality education is critical in preparing nurses to manage clients who have been diagnosed with sexual dysfunctions. Such education provides the student and the graduate nurse with a beginning vocabulary and understanding of the erotic and reproductive organs and processes within the human body. Utilizing cues from nursing assessment, which includes client collaboration, priority problems may be identified as:
- altered interest in others
- altered self-interest
- altered sexual activity
- altered sexual excitation
- altered sexual role
- altered sexual satisfaction
- decreased sexual desire
- perceived sexual limitation
- seeks confirmation of desirability
- undesired alteration in sexual function
Accompanying these priority problems are related factors, including clients having inaccurate information and inadequate knowledge about sexual function, lack of privacy, unaddressed abuse, value conflict, inadequate role models, and perceived vulnerability. Each of these factors constitutes an area in which nurses can begin a conversation with clients about sexual dysfunction.
PLISSIT Model
In 1976, Jack Annon developed and published the Permission Limited Information Specific Suggestions, and Intensive Therapy (PLISSIT) model to address behavioral problems related to human sexuality. This acronym has provided an easy-to-remember set of steps that nurses can follow in delivering sexual health care to clients. The four steps of the PLISSIT model are:
- P = permission
- LI = limited information
- SS = specific suggestions
- IT = intensive therapy
Each step in this model requires additional comfort, education, and experience before the practitioner can apply it, but having an awareness of the steps involved in managing the nursing approach to sexual dysfunction is a good place to start. Annon’s original assumption was that most people who had sexual problems could solve these problems by following the steps of having permission to discuss them, and by receiving limited information, specific suggestions, or intensive therapy. Although nursing students and recent graduates may not have received adequate and detailed sexuality education to enable them to provide specific suggestions or intensive therapy, they can give clients permission to talk about sexuality and may also be able to provide limited information that would be helpful to the client. A recent study of nurse practitioners (NPs) revealed that even with advanced education, these NPs felt inadequately prepared to manage clients with dyspareunia, pelvic pain, or erectile dysfunction (Cappiello & Boardman, 2022).
Link to Learning
The PLISSIT model of sex communication demonstrates the steps of giving permission, limited information, specific suggestions, and intensive therapy as a conceptual approach to working with clients experiencing sexual health issues.
In 2007, Taylor and Davis expanded the PLISSIT model, revising the name to be Extended PLISSIT or ExPLISSIT (explicit) model as it has come to be known. In their extension, Taylor and Davis reiterated that the very first step, permission (i.e., giving permission to a client to talk about their sexual health and concerns), should not be assumed or overlooked by rushing to more detailed steps. They underscored the importance of giving the client permission at any and all steps to talk about their sexual health needs and concerns. The Extended PLISSIT model outlines a process that begins with self-awareness, leads to reflection, then moves on to review, knowledge, and challenging assumptions. Each of the four steps includes permission, followed by reflection and review. Reflection and review apply to both client and nurse. The nurse needs to understand that just because the subject has been discussed on one occasion, it has not necessarily been resolved. Rather, it provides the opportunity for further permission-giving, reflection, and review.
Link to Learning
The video of the ExPLISSIT model of sex communication demonstrates ways for clinicians to reflect and review the steps of giving permission, limited information, specific suggestions, and intensive therapy when working with clients experiencing sexual health issues.
Overall Health Benefits on Sexual Health
The World Health Organization (2024b) describes sexual health as similar to overall health, that is, not only the absence of disease, but also general well-being for every person. Cardiac health is essential for circulatory function, physical energy, and endurance—all of which can affect sexual activity and response. Individuals living with hypertension may have these concerns. The American Heart Association (AHA) (2023) recommends partnership with health-care providers to manage high blood pressure. The AHA further endorses heart-healthy measures to contribute to overall health, and to sexual health, consisting of balanced low sodium diet, maintenance of physical activity and healthy weight, low alcohol consumption, no tobacco use, and stress reduction (2023).
Kudesia et al. (2021) describe a plant-based dietary approach to women’s health. Addressing topics of fertility, sexual disorders, and menopause, the authors assert a dietary connection, even phrasing this as a public health initiative. Kudesia et al. advocate a wellness focus for the U.S. health-care system, while acknowledging existing disparities within the system (2021).
Proposing an orientation away from risk and disease, Mitchell et al. (2021) call for a wellness public health focus concerning the concept of sexual well-being. Utilizing a biopsychosocial model, the authors address public health aspects that impact sexual well-being, such as human migration patterns and the COVID-19 pandemic.
Human sexuality is evident throughout the lifespan. As people age, they may experience changes in hormonal structure as well as changes in muscle tissue that create dysfunctions involving the pelvic floor. This can result in urinary incontinence in addition to a lack of interest and arousal for sexual activity (Buyuk et al., 2021). Learning to strengthen the pelvic floor may be important for clients who have experienced trauma to the external genitalia and may also enhance their ability to experience sexual arousal and satisfaction. Teaching clients how to do Kegel exercises may be part of the limited information or specific suggestions that nurses can share. Kegel exercises are also important following childbirth for the person who has given birth to strengthen the muscles of the pelvic floor.
Link to Learning
This video about Kegel exercises shows a detailed view of the musculature of the female perineum. In this video, a physical therapist with specialized training in sexual functioning provides guidance to female clients about how to know they are doing Kegel exercises correctly.