SEXUAL AND GENDER IDENTITY DISORDER
I.Sexual and Gender Identity Disorders
A. Description
1. Disorders of sexual functioning are characterized
by a disturbance in sexual desire and changes in the
sexual response cycle that causes significant distress
and interpersonal difficulty.
2. The four classifications are sexual dysfunctions,
gender identity disorder, paraphilias, and sexual
disorder not otherwise specified.
3. Sexual desire disorders are influenced by a
variety of factors, such as age, availability of a
partner, health, and leisure.
B. Theories of Sexual Disorders
1. Biological causes
a. General illness that may contribute
1) Influenza
2) Colds
3) Fatigue
4) Diabetes
5) Hepatitis
6) Multiple sclerosis
7) Arthritis
8) Back pain
9) Obesity
10) Vaginal infections
11) Late stages of pregnancy
12) Postmenopausal women may need lubrication.
13) Older male responses are slowed.
2. Hormonal causes
a. Medications cause a decrease in androgen levels,
such as hypopituitary problems.
b. Feminizing effects of testicular tumors
c. Alcohol, cocaine, and heroine use
d. Use of hypertensive drugs
e. Use of phenothiazine
f. Selective serotonin reuptake inhibitors (SSRIs)
and other antidepressants may cause sexual
difficulties.
3. Psychological causes of sexual dysfunction
a. Failure to understand the partner’s desires
b. Anxiety due to fear of failure
c. Partner or self-demand for performance or
excessive need to please
d. Perceptual and intellectual defenses
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e. Allowing judgmental thoughts to
intervene
f. Poor relationship choices that can result in partner
rejection
g. Lack of trust
h. Power struggles
i. Sexual sabotage
C. Types of Sexual Dysfunction
1. Hypoactive sexual desire disorder
a. Recurrent or persistent deficit or absence of
sexual fantasies and desire for sexual activity
b. Not diagnosed for older adults and those who
have hormonal abnormalities
c. Primarily developed in puberty to adulthood
d. Disturbance causes marked distress or
interpersonal difficulty.
e. Not explained by a substance abuse or medical
condition
2. Sexual aversion disorder
a. Aversion to and active avoidance of genital
sexual contact with a partner
b. Anxiety, fear, or disgust with sexual encounter
ranging from lack of pleasure to extreme
psychological distress
c. Criteria to meet the disorder need to cause the
marked distress in interpersonal functioning.
d. Dysfunction is not the result of another sexual
disorder.
3. Sexual arousal disorders, male and female
a. May be accompanied by sexual desire disorder or
female orgasmic disorder
b. Male erectile disorder associated with sexual
anxiety
c. Fear of failure and concerns about sexual
performance
d. Decreased subjective sense of sexual excitement
and pleasure
e. Spontaneously remit 15% to 30% of the time
4. Orgasmic disorders
a. Persistent or recurrent delay in or
absence of orgasm
b. Female orgasmic disorder: often not
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interested in orgasm
c. Male orgasmic disorder: persistent or current
delay or absence of orgasm after normal sexual
excitement
d. Inhibited desire could be due to an
endocrinological dysfunction such as an elevation in
the hormone prolactin or a small pituitary tumor
that may reduce libido or sexual interest.
Testosterone levels and normal aging also decrease
sexual interest.
5. Premature ejaculations
a. Male orgasm and ejaculation takes place with
minimal physical stimulation and before expected.
b. Disturbance causes marked distress or
interpersonal difficulty.
c. Not due exclusively to direct effect of substance
abuse
6. Male erectile disorder
a. Difficulty achieving or maintaining an erection
b. Disorder causes marked distress or interpersonal
difficulty.
c. Not explained by the effects of substance abuse
or medical condition
7. Sexual pain disorder
a. Found in both males and females; associated with
genital pain during intercourse
b. Vaginismus consists of contraction of the
peritoneal muscles surrounding the outer third of
the vagina.
c. May still experience desire and pleasure
d. Often found in women who have been sexually
abused or traumatized
D. Assessment
1. Overly concerned with
physical changes occurring
at puberty
2. Prefer opposite-sex behaviors
into adulthood
3. Desire sexual reassignment
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Nursing Interventions
1. Provide sexual counseling consisting of taking a
complete general history.
2. Perform a complete physical examination to rule
out organic causes.
3. Obtain the client’s sexual history.
4. Assess communication patterns and expectations.
5. Assess if primary focus is sexual or psychosocial
in origin.
6. Promote anxiety reduction.
7. Encourage couple counseling to discuss sexual
needs and desires openly.
8. Promote construction of a healthy relationship.
9. Promote mutual respect.
II. Nursing Diagnoses
A. Anxiety
B. Ineffective Role Performance
C. Social Isolation
D. Ineffective Coping
E. Interrupted Family Processes
III. Gender Identity Disorder
A. Description
1. Strong and persistent crossgender identification
2. Persistent discomfort with gender
3. Sense of inappropriateness in gender role
4. In adolescents, there is a preoccupation with
getting rid of primary and secondary sex
characteristics through hormones.
5. Disturbance is not concurrent with physical
intersex condition.
6. Disturbance causes clinically significant distress
or impairment in social, occupational, or other
areas of functioning.
7. Etiology is unknown but childhood patterns seem
to be fairly consistent.
8. Children as early as 2–4 years of age have cross-
gender interests and activities.
9. Childhood history of gender identity disorder;
may report a homosexual or bisexual orientation
10. May not consider herself to be homosexual and
only wants gender reassignment
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B. Assessment
1. Repeatedly stated desire to be the opposite sex
2. In males, preference for crossdressing or
simulating female attire
3. Girls’ insistence on wearing only masculine
clothing
4. Strong and persistent preferences for cross-sex
roles in play or fantasy
5. Intense desire to participate in the stereotypical
games and pastimes of the other sex
6. Strong preference for playmates of the opposite
sex
7. Boys prefer feminine dress and gravitate toward
female friends and activities.
8. Girls exhibit masculine behavior.
9. Anxiety with body changes further defining
gender
C. Medical Management
1. Hormone therapy is the first step.
a. Changes bodily characteristics
b. May require the client to live in crossgender
mode for 1–2 years before reassignment is made
D. Nursing Interventions
1. Encourage the client to verbalize feelings.
2. Encourage counseling for coping solutions.
3. Surgical reassignment
4. Recognize that legal, social, familial, and
employment adjustments may be a factor.
5. Accept the client who is happy and productive
without undergoing surgery.
6. Accept the client who feels unable to function
without surgical reassignment.
IV. Paraphilias
A. Description
1. Consist of several features
a. Recurrent and intense sexually arousing fantasies,
sexual urges, or behaviors involving inanimate
objects
b. Can involve suffering or humiliation of oneself
or one’s partner
c. Can involve use of children or other
nonconsenting individuals, often triggered by stress
2. History, culture, and experience play a role.
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3. Diagnostic criteria must be present for at least 6
months.
4. Fantasies, sexual urges, or behaviors are causing
significant distress or impairment in social
occupational or other areas of functioning.
B. Types of Paraphilias
1. Fetishism: presence of intense sexual arousal
involving inanimate objects; sexual arousal
occurring from contact with a nonliving object such
as an article of clothing
2. Pedophilia involves sexual interest directed
primarily or exclusively toward children 13 years or
younger.
a. May only be recurrent fantasies or urges
b. Pedophile generally conservative married male
but must be at least 16 years old and at least 5 years
older than the child
c. Often occurs in families with older male and
younger female
d. When it occurs in families, it is called incest.
3. Exhibitionism is the intentional display of
genitals in public places, often accompanied by
masturbation, to elicit shock, resulting in sexual
arousal occurring from exposing genitals to
strangers.
a. Typical profile is a sedate middle-class male.
4. Voyeurism is viewing in intimate situations or
fantasizing about observing others disrobing, naked,
or involved in sexual activity.
a. Called “peeping tom” and peeping becomes
compulsive and preferable to other sexual activity
b. Usually heterosexual male who wishes no contact
with those he is watching
c. Typically shy, socially unskilled, and without
close friends
5. Transvestitism is sexual satisfaction by means of
dressing in the clothing of the opposite gender.
a. Usually develops early in life
b. Not related to sexual orientation issues and there
is no desire for sex change
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c. Heterosexuals often receive the cooperation and 7. Engage in activities that are repulsive or
support of partners. uncomfortable to please a partner

6. Frotteurism involves the sexual touching, rubbing C. Nursing Interventions

against, or fondling of a nonconsenting individual, 1. Encourage the client to seek out a safe, caring,
usually a stranger, to achieve sexual satisfaction. and understanding community.
a. Usually occurs in public places where there is an 2. Provide the client with individual counseling.
easy escape after the behavior 3. Encourage support groups or friends.

7. Sexual sadism and masochism

a. Giving (sadism) and receiving (masochism)
psychological or physical pain, or both
b. Domination to achieve sexual gratification
occurs.
c. Treatment is usually cognitive and behavioral
therapy with an attempt to help the individual learn
a new sexual response pattern.
d. Positive reinforcement is given for appropriate
object choices.
e. Aversion techniques in which mild electric shock
may be used for inappropriate choices
f. Psychodynamic techniques to help the client
understand the etiology of the disorder

C. Medical Management for

Paraphilias
1. Pharmacological
2. Cognitive therapy
3. Behavioral therapy
4. Psychodynamic therapy

5. Combination therapy is usually effective over an

extended period of time.

V. Sexual Addictions
A. Description: sexual addictions occur when sex
and sexual encounters become the primary way of
attempting to fill emptiness.

B. Assessment
1. Compelled to have frequent sex
2. Bewildered by own sexual behavior
3. Pattern of unsuccessful love relationships
4. Chaos and drama are often present.
5. Sexual encounters involve alcohol, drugs, or
compulsive eating.
6. Need to escape after sex
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