Sexual Dysfunctions, Paraphilias, and Gender Dysphoria

These are some of the most sensitive histories you will ever take. The patient is watching to see if you flinch. Stay clinical, stay neutral, and the assessment goes where it needs to go. The DSM-IV-TR split this material into two categories, paraphilias and sexual dysfunctions. DSM-5 splits it into three: sexual dysfunctions, gender dysphoria, and paraphilic disorders.

What are Sexual Disorders?

Sexual disorders (sexual dysfunctions) are conditions that disrupt one or more aspects of sexual function, satisfaction, or pleasure. They affect people of every gender and age and can carry physical, emotional, and interpersonal fallout.

The terms you need straight:

• Paraphilias are intense, persistent sexual interests in something other than genital stimulation or fondling with a phenotypically normal, physiologically mature, consenting human partner.
• Paraphilic disorder is the DSM-5 term for a paraphilia that causes the person distress or impairment, or that causes harm (or risk of harm) to others. The word "disorder" is what separates an interest from a diagnosis.
• Sexual dysfunction is an impairment or disturbance in any phase of the sexual response cycle.
• Gender dysphoria is the conflict between a person's physical or assigned gender and the gender they identify with.
• Gender identity disorder is strong, persistent cross-gender identification with ongoing discomfort about one's assigned sex.

Types of Paraphilias

Each of these requires recurrent, intense sexual urges, behaviors, or fantasies of at least 6 months duration.

• Exhibitionism. Exposing one's genitals to an unsuspecting stranger.
• Fetishism. In DSM-5, arousal tied to nonliving objects (undergarments, high-heeled shoes) or a highly specific focus on a nongenital body part (often feet).
• Frotteurism. Touching or rubbing against a nonconsenting person; in DSM-5 the person has acted on the urges with a nonconsenting person, or the urges cause clinically significant distress or impairment.
• Pedophilia. Sexual urges, behaviors, or fantasies involving a prepubescent child. The DSM-IV-TR sets the offender at age 16 or older and at least 5 years older than the child. DSM-5 calls it pedophilic disorder: strong, habitual urges toward and fantasies about prepubescent children that are acted upon, or that cause the person distress or interpersonal difficulty.
• Sexual masochism. Arousal from being humiliated, beaten, bound, or otherwise made to suffer. DSM-5 reserves the disorder diagnosis for people who also report psychosocial distress from the interest.
• Sexual sadism. Arousal from the psychological or physical suffering (including humiliation) of a victim.
• Voyeurism. Arousal from observing an unsuspecting person who is naked, undressing, or engaged in sexual activity.

Types of Sexual Dysfunctions

These show up in any phase of the sexual response cycle.

• Hypoactive sexual desire disorder. Persistently or recurrently deficient sexual thoughts, fantasies, and desire for sexual activity.
• Sexual aversion disorder. Persistent extreme aversion to and avoidance of nearly all genital sexual contact. DSM-5 (2013) removed this diagnosis.
• Female sexual arousal disorder. DSM-IV-TR defined it as persistent inability to attain or maintain adequate lubrication or swelling through completion of activity. DSM-5 reframes it as lack of, or significantly reduced, sexual interest/arousal.
• Male erectile disorder. Recurrent inability to achieve or maintain an adequate erection, or a noticeable drop in erectile rigidity during partnered activity.
• Female orgasmic disorder (anorgasmia). Persistent delay in or absence of orgasm after a normal excitement phase; DSM-5 adds markedly reduced intensity of orgasmic sensations.
• Male orgasmic disorder (delayed ejaculation). Inability to ejaculate despite a firm erection and adequate stimulation. Also called delayed ejaculation (DE) or delayed orgasm (DO); DSM-5 defines it as persistent difficulty or inability to reach orgasm despite adequate desire, arousal, and stimulation.
• Premature ejaculation. Ejaculation with minimal stimulation, before or shortly after penetration, before the person wishes it. DSM-5 sets it at a persistent or recurrent pattern within about 1 minute of vaginal penetration.
• Dyspareunia. Recurrent genital pain with intercourse, in a man or woman, not caused by vaginismus, lack of lubrication, another medical condition, or substance effects.
• Vaginismus. Involuntary constriction of the outer third of the vagina that blocks penile insertion. DSM-5 dropped the spasm-based definition and merged vaginismus with dyspareunia into genito-pelvic pain/penetration disorder (GPPPD).

Statistics and Incidences

Gender identity and sexuality disorders are relatively rare next to other psychiatric conditions. There are no large-scale epidemiological studies, but recent estimates run roughly 1:10,000 to 1:30,000. Adult sex ratios for GID, mostly drawn from clinic referrals, have shifted from more males than females in earlier studies toward a more equal ratio in recent reports. Childhood GID is more common in males, roughly 6 to 1; by adolescence the ratio evens out.

Causes

Paraphilias have been tied to biological and psychological factors. On the biological side, destroying parts of the limbic system in animals produces hypersexual behavior, temporal lobe disease (psychomotor seizures, temporal lobe tumors) shows up in some patients, and abnormal androgen levels may drive inappropriate arousal. The psychoanalytic view frames the paraphiliac as someone who failed the normal developmental path toward heterosexual adjustment.

Sexual dysfunction has its own predisposing factors by category:

• Desire disorders. In men, linked to low serum testosterone and elevated serum prolactin; there is also evidence that serum testosterone tracks with female libido. Antihypertensives, antipsychotics, antidepressants, anxiolytics, anticonvulsants, and chronic alcohol or cocaine use are all implicated.
• Arousal disorders. May follow decreased estrogen in postmenopausal women; antihistamines and cholinergic blockers can do the same. Erectile dysfunction in men points to arteriosclerosis, diabetes, temporal lobe epilepsy, multiple sclerosis, certain medications (antihypertensives, antidepressants, tranquilizers), spinal cord injury, pelvic surgery, and chronic alcohol use.
• Orgasmic disorders. In women, tied to hypothyroidism, diabetes, depression, and medications (antihypertensives, antidepressants). In men, genitourinary surgery (such as prostatectomy), Parkinson's disease, and diabetes interfere with orgasm.
• Sexual pain disorders. In women, caused by disorders of the vaginal entrance, clitoral irritation or damage, vaginal or pelvic infections, endometriosis, tumors, or cysts. In men, penile infections, phimosis, urinary tract infections, or prostate problems.

Clinical Manifestations

Paraphilias present as: exposing genitals to strangers; arousal around nonliving objects; touching or rubbing genitals against a nonconsenting person; sexual attraction to or activity with a prepubescent child; arousal from being humiliated, beaten, bound, or made to suffer; arousal from inflicting psychological or physical suffering; arousal from cross-dressing; and arousal from observing unsuspecting people naked or having sex. Masturbation often accompanies these acts when done alone, and the person is markedly distressed by the activity.

Sexual dysfunctions present as: absent sexual fantasies and desire; mismatched levels of desire between partners; disgust, anxiety, or panic at genital contact; inadequate lubrication; absent subjective sense of excitement; failure to attain or maintain an erection through completion; inability to reach orgasm (or ejaculate) after adequate stimulation; ejaculation with minimal stimulation or before the person wishes it; genital pain before, during, or after intercourse; and constriction of the outer third of the vagina that blocks penetration.

Medical Management

For gender dysphoria, treatment runs across pharmacologic therapy, psychological and other nonpharmacologic therapies, and sexual reassignment surgery (SRS).

• Psychological and speech therapy. Individual work focuses on understanding and managing gender issues. Group, marital, and family therapy build a supportive environment. Speech therapy can help male-to-female individuals use a more feminine voice.
• Sexual reassignment surgery. Whether adolescents should pursue SRS is contested, and many countries deny it to minors. Early treatment may benefit adolescents whose secondary sex characteristics (facial hair, lowered voice, breast development) have not fully developed; parental involvement and approval are essential.

Pharmacologic Management

The goal is to inhibit or promote secondary sex characteristics.

• Progestins. Inhibit secretion of pituitary gonadotropins.
• Gonadotropin-releasing hormone (GnRH) agonists. Produce a hypogonadotrophic-hypogonadal state by down-regulating the pituitary gland.
• Selective aldosterone antagonists. Block androgen receptors.
• Antiandrogens (antineoplastics). First-line for hirsutism.
• Oral contraceptives. Inhibit ovarian androgen production; often the first choice for young women with hirsutism who do not want to become pregnant.
• Estrogen derivatives. Replacement therapy in hypogonadism with deficient or absent endogenous testosterone or estrogen.
• Androgens. Replacement therapy in hypogonadism with deficient or absent endogenous testosterone.

Nursing Management

Nursing Assessment

Assess the patient's own experience of the change in sexual function, and how they view it: unsatisfying, unrewarding, inadequate, or socially inappropriate.

Nursing Diagnosis

• Sexual dysfunction related to physical or psychosocial abuse.
• Ineffective sexuality pattern related to conflicts with sexual orientation or variant preferences.
• Disturbed personal identity related to parenting patterns that encourage culturally unacceptable behaviors for the assigned gender.
• Impaired social interaction related to socially and culturally unacceptable behavior.
• Low self-esteem related to rejection by peers.

Nursing Care Planning and Goals

• Patient resumes sexual activity at a level satisfactory to self and partner (timeline is individual).
• Patient expresses satisfaction with their own sexuality pattern.
• Patient and partner express satisfaction with the sexual relationship.
• Patient demonstrates behaviors appropriate and culturally acceptable for the assigned gender.
• Patient expresses comfort in the assigned gender.
• Patient interacts with others using culturally acceptable behaviors.

Nursing Interventions

• Determine stressors. Pin down when the problem started and what was happening in the patient's life at that time.
• Open up the disease process. Have the patient talk through any condition contributing to the dysfunction, and make sure they know alternative methods of sexual satisfaction exist and can be learned through sex counseling if they and their partner want it.
• Identify factors that shape sexuality. Note cultural, social, ethnic, racial, and religious factors that feed conflict over variant sexual practices.
• Stay accepting and nonjudgmental. This is deeply personal territory; the patient shares more when they do not fear judgment.
• Reinforce the positive. Watch the patient's behaviors and the responses they draw from others; give social attention (a smile, a nod) to desired behaviors.

Evaluation

Goals are met when the patient resumes satisfying sexual activity, expresses satisfaction with their sexuality pattern and relationship, demonstrates culturally acceptable behaviors for the assigned gender, and reports comfort in that gender.

Documentation Guidelines

Document individual findings (factors affecting function, interactions, the nature of social exchanges, specific behaviors), cultural and religious beliefs and expectations, the plan of care, the teaching plan, responses to interventions and teaching, and progress toward the desired outcome.