Altered sexual activity
Altered sexual behavior
Altered sexual partner relations
Altered sexual role
Difficulty with sexual activity
Difficulty with sexual behavior
Value conflict
NANDA-I approved*
Ineffective sexual patterns can also occur as a response to various health problems, situations, and conflicts. Some common sources are listed next.
Pathophysiologic
Related to biochemical effects on energy and libido secondary to:
Endocrine
Diabetes mellitus
Hyperthyroidism
Addison's disease
Decreased hormone production
Myxedema
Acromegaly
Genitourinary
Chronic renal failure
Neuromuscular and Skeletal
Arthritis
Amyotrophic lateral sclerosis
Multiple sclerosis
Disturbances of nerve supply to brain, spinal cord, sensory nerves, or autonomic nerves
Cardiorespiratory
Peripheral vascular disorders
Myocardial infarction
Congestive heart failure
Chronic respiratory disorders
Related to fears associated with (sexually transmitted diseases [STDs]) (specify):
Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)
Human papillomavirus (HPV)
Herpes
Gonorrhea
Chlamydia
Syphilis
Related to effects of alcohol on performance
Related to decreased vaginal lubrication secondary to (specify)
Related to fear of premature ejaculation
Related to pain during intercourse
Treatment Related
Related to effects of:
Medications
Radiation therapy
Related to altered self-concept from change in appearance (trauma, radical surgery)
Related to knowledge/skill deficit about alternative responses to health-related transitions, altered body function or structure, illness, or medical treatment
Situational (Personal, Environmental)
Related to conflict about sexual orientation*
Related to conflict about variant preference*
Related to fear of pregnancy*
Related to fear of sexually transmitted infection*
Related to impaired sexual partner relations*
Related to inadequate alternative sexual strategies*
Related to inadequate role models*
Related to insufficient privacy*
Related to lack of significant other
Related to problem with partner (specify):
Unwilling
Not available
Uninformed
Conflicts
Abusive
Separated, divorced
Related to stressors secondary to:
Job problems
Value conflicts
Financial worries
Relationship conflicts
Related to misinformation or lack of knowledge
Related to fatigue
Related to fear of rejection secondary to obesity
Related to pain
Related to fear of sexual failure
Related to depression
Related to anxiety
Related to guilt
Related to history of unsatisfactory sexual experiences
Maturational
Adolescent
Related to ineffective/absent role models
Related to negative sexual teaching
Related to absence of sexual teaching
Adult
Related to adjustment to parenthood
Related to effects of menopause on libido and vaginal tissue atrophy
Related to values conflict
Related to effects of aging on energy levels and body image
Individuals without a significant other
AUTHOR'S NOTEThe diagnoses Ineffective Sexuality Pattern and Sexual Dysfunction are difficult to differentiate. Ineffective Sexuality Pattern represents a broad diagnosis, of which sexual dysfunction can be one part. Sexual Dysfunction may be used most appropriately by a nurse with advanced preparation in sex therapy. Until Sexual Dysfunction is well differentiated from Ineffective Sexuality Pattern, most nurses should not use it.
This diagnosis focuses on specific interventions for basic sexual concerns that are related to treatments, pain, fatigue, etc. The individual should be referred to their primary care provider or specialist for more detailed and advanced interventions.
Level 2 Extended Focused Assessment (all nonacute settings)
Explore the individual's patterns of sexual functioning using the PLISSIT model (*Annon, 1976). Encourage him or her to share concerns; assume that individuals of all ages have had some sexual experience and convey a willingness to discuss feelings and concerns.
R:The PLISSIT model is a time-tested model for the nurse generalist providing care in the area of sexuality in any setting.
Seek Permission
Convey to the individual and significant other a willingness to discuss sexual thoughts and feelings (e.g., "Some people with your diagnosis have concerns about how it will affect sexual functioning. Is this a concern for you or your partner?").
Have sexual experiences changed since you were diagnosed with, e.g., cancer, heart disease etc. . . . or with some medications or treatments, e.g., antidepressants, etc. . . . Specify.
R:Many individuals are reluctant to discuss sexuality issues. A relaxed approach can encourage the individuals to share feelings and concerns.
NOCBody Image, Self-Esteem, Role Performance, Sexual Identity
The individual will resume previous sexual activity or engage in alternative satisfying sexual activity as evidenced by the following indicators:
- Identifies effects of stressors, loss, or change in sexual functioning.
- Modifies behavior to reduce stressors.
- Identifies limitations on sexual activity caused by a health problem.
- Identifies appropriate modifications in sexual practices in response to these limitations.
NICBehavioral Management, Sexual Counseling, Emotional Support, Active Listening, Teaching: Sexuality
Level 2 Extended Interventions (all nonacute settings)
CARP'S CUESIt is common for healthcare professionals to feel uncomfortable with assessing the sexual desires and functions of all individuals. Comfortable confidence will only come first with the nursing professional's appreciation of the importance of sexual expression for many individuals and partners and second by initiating discussions/assessments. Consider why nurses are comfortable asking detailed questions about bowel movements, e.g., frequency, color, consistency, quantity, and not sexual concerns.
Assess for Causative or Contributing Factors (See Related Factors)
Explore the Individual's Patterns of Sexual Functioning Using the PLISSIT Model (*Annon, 1976)
- Limited Information: Provide information on the effects that certain situations (e.g., pregnancy), conditions (e.g., cancer), and treatments (e.g., medications) can have on sexuality and sexual function.
- Specific Suggestions: Provide specific instructions that can facilitate positive sexual functioning (e.g., changes in coital positions).
- Intensive Therapy: Refer people who need more help to an appropriate healthcare professional (e.g., sex therapist, surgeon).
R:Many individuals are reluctant to discuss sexuality issues. A relaxed approach can encourage the individual to share feelings and concerns.
Discuss the Relationship between Sexual Functioning and Life Stressors
- Clarify the relationship between stressors and problems in sexual functioning.
- Explore options available for reducing the effects of the stressor on sexual functioning (e.g., increase sleep, increase exercise, modify diet, explore stress reduction methods).
R:Explaining that impaired sexual functioning has a physiologic basis can reduce feelings of inadequacy and decreased self-esteem; this may help improve sexual function.
Level 3 Advanced Focused Interventions
Reaffirm the Need for Frank Discussion between Sexual Partners
- Explain how to use role-playing to discuss concerns about sex.
R:Role-playing helps an individual gain insight by placing him or her in another's position and allows more spontaneous sharing of fears and concerns.
- Reaffirm the need for closeness and expressions of caring through touching, massage, and other means.
- Suggest that sexual activity need not always culminate in vaginal intercourse, but that the partner can reach orgasm through noncoital manual or oral stimulation.
R:Sexual pleasure and gratification are not limited to intercourse. Other expressions of caring may prove more meaningful.
Address Causative or Contributing Factors for Individuals with Acute or Chronic Illness
- Eliminate or reduce causative or contributing factors, if possible, and teach the importance of adhering to a medical regimen designed to reduce or control disease symptoms.
- Provide limited information and specific suggestions.
- Provide appropriate information to the individual and partner concerning actual limitations on sexual functioning caused by the illness (limited information).
- Teach possible modifications in sexual practices to assist in dealing with limitations caused by illness.
R:Both partners probably have concerns about sexual activity. Repressing these feelings hurts the relationship.
Provide Referrals as Indicated
Enterostomal therapist
Physician
Nurse specialist
Sex therapist
R:Specialist interventions may be needed.
Level 2 Extended Interventions (older adults, all settings)
CLINICAL ALERTLindau et al. (*2007) revealed that in a study of the prevalence of sexual activity, behaviors, and problems in a national probability sample of 3005 U.S. adults (1550 women and 1455 men) 57 to 85 years of age, current sexual activity was reported in 73% of adults aged 57 to 64, 53% of adults aged 65 to 74, and 26% of adults aged 75 to 84.
Factors that influence sexual activity in older adults are (Agronin, 2021):
- For men, physical health appears to be the most influential factor for sexual activity. Having one of more health conditions reduces the frequency of sexual activity but not necessarily the level of satisfaction.
- For women, the quality of the relationship is the most important factor in sexual activity.
- Cognitive impairments are associated with decreased sexual activity and increased sexual dysfunction. Lack of interest was the most common problem, seen in 40 percent of men and 65 percent of women with dementia.
- The level of sexual activity at a younger age and the availability, interest level, and health of a partner are major predictors of both sexual interest and activity in late life.
CLINICAL ALERTMultiple publications have reported the challenges and difficulties for older people with respect to the expression of their sexuality in the care environment (Bauer et al., 2014). Complicating the problem are the negative and judgmental staff attitudes, inadequate knowledge, and training (Bauer et al., 2014) around the needs of people who identify as gay, lesbian, bisexual, transgender, or intersex (GLBTI); a problem-based view of sexuality for people with dementia; the prioritization of other aspects of a resident's well-being over sexuality; and a lack of privacy.
Use the PLISSIT Model to Assess Sexual Concerns and Issues with Older Adults. Refer to the Above for Specifics (Kazer, 2012a)
The PLISSIT model and the questions suggested may be used with older adults in a variety of clinical settings. Despite the findings that sexuality continues throughout all phases of life, little material, scientific or otherwise, exists in the literature to guide nurses toward assessing the sexuality of older adults (Kazer, 2012b).
Prove Factual Information of Treatment-Related Negative Effects on Sexual Desire/Function
Discuss normal age-related physiologic changes.
- Women experience decreased breast tone, thinning and loss of elasticity of the vaginal wall, decreased vaginal lubrication, and shortening of vaginal length from loss of circulating estrogen (Miller, 2019).
- Men experience decreased production of spermatozoa, decreased ejaculatory force, and smaller, less firm testicles. Direct stimulation may be required to achieve an erection; however, the erection may be maintained for a longer time (Miller, 2019).
R:Explanations of age-related changes related to sexuality can be addressed with remedies such as lubricants, estrogen cream, and oral medications for erectile dysfunction.
Ensure the Residential Community Facility Has a Program for:
- Provision of education on the ongoing sexual needs of older adults and appropriate interventions to manage these needs with dignity and respect.
- Inclusion of sexual health questions in routine history and physicals.
- Provision of needed privacy for individuals to maintain privacy, dignity and sexual health (e.g., in long-term care).
R:This is critical to ensure empathetic and correct approaches to sexuality and expression.
Level 2 Extended Focused Pediatric Interventions
CLINICAL ALERTFor parents, "Be clear that safety is nonnegotiable. Think about your bottom-line priorities for your children. Chances are nothing matters more to you than their safety. Be very clear, and repeat often, that nothing matters more than knowing they are going to be okay. Establish a code word they can use to get your attention and help when they need to get out of a potentially dangerous or uncomfortable situation. Set a standard for protecting themselves from disease and unwanted pregnancy regardless of whether you agree with their decision-making about sex. Make sure that they know they can come to you for help if something goes wrong" (Ginsberg, 2015).
To reduce the tension, have the conversation in the car or while cooking to eliminate the need for eye contact and/or the early termination of the dialogue.
- Do not abstain from educating your own children (Ginsberg, 2015).
- Right time, right place (Ginsberg, 2015).
- Avoid sexuality conversations that are all "don'ts" (Ginsberg, 2015).
- Find out what your child is thinking when talking about their relationships or sexual experiences (Ginsberg, 2015).
- Talking about sex is difficult. When necessary, identify and encourage them to ask for help from other trusted adults; it does not always have to be you.
- Emphasize no means no to female and male adolescents.
CLINICAL ALERTEach year since 2010, adolescent and young adults (AYA) ages 13 to 24 years have been estimated to account for more than 1 in 5 new individuals who contract HIV (Guilamo-Ramos, Benzekri, & Thimm-Kaiser, 2019). Similarly, AYA ages 15 to 24 years consistently account for more than 50% of individuals who contract an STI annually (Ibid). Holistic, well-planned sexuality education programs, taught by informed and up-to-date teachers make a significant difference to the learning and overall sexual health of young people (Byers et al., 2013).
Engage with Adolescents in Discussions of:
- consent and coercion;
- the sexualization of young people, particularly girls;
- the effects of pornography on young people's understanding of sexuality and relationships;
- the bias that opposite sex relationships are normal (heteronormativity).
Provide Information Rather Than Focusing on the Risks of Sexual Activity
R:Programs should engage, empower, and inform young people rather than focus on risk (Fine & McClelland & Geraldine, 2006; Fitzpatrick, 2014). Research suggests that abstinence programs make no difference in affecting sexual decision-making while programs with a more holistic and comprehensive approach significantly reduce risk factors and risky behaviors (Guilamo-Ramos, Benzekri, & Thimm-Kaiser, 2019).