1. MASTURBATION
1. Definition—act of achieving sexual arousal and orgasm through manual or mechanical stimulation of the sex organs.
2. Characteristics:
1. Can be an interpersonal as well as a solitary activity.
2. "It is a healthy and appropriate sexual activity, playing an important role in ultimate consolidation of one's sexual identity."^*
3. Accompanied by fantasies that are important for:
1. Physically disabled.
2. Fatigued.
3. Compensation for unreachable goals and unfulfilled wishes.
4. Rehearsal for future sexual relations.
5. Absence or impersonal action of partner.
4. Can help release tension harmlessly.
3. Concepts and principles related to masturbation:
1. Staff's feelings and reactions influence their responses to client and affect continuation of masturbation (i.e., negative staff actions increase client's frustration, which increases masturbation).
2. Masturbation is normal and universal, not physically or psychologically harmful in itself.
3. Pleasurable genital sensations are important for increasing self-pride, finding gratification in own body, increasing sense of personal value of being lovable, helping to prepare for adult sexual role.
4. Excessive masturbation—some needs not being met through interpersonal relations; may use behavior to avoid interpersonal relations.
5. Activity may be related to:
1. Curiosity, experimentation.
2. Tension reduction, pleasure.
3. Enhanced interest in sexual development.
4. Fear and avoidance of social relationships.
4. Nursing care plan:
1. Long-term goals:
1. Gain insight into preference for masturbation.
2. Relieve accompanying guilt, worry, self-devaluation (Figure 10-2. Operationalization of the Behavioral Concept of Masturbation).
2. Short-term goals:
1. Clarify myths regarding masturbation.
2. Help client see masturbation as an acceptable sexual activity for individuals of all ages.
3. Set limits on masturbation in inappropriate settings.
5. Nursing implementation:
1. Examine, control nurse's own negative feelings; show respect.
2. Avoid: reinforcement of guilt and self-devaluation; scorn; threats, punishment, anger, alarm reaction; use of masturbation for rebellion in power struggle between staff and client.
3. Identify client's unmet needs; consider purpose served by masturbation (may be useful behavior).
4. Examine pattern in which behavior occurs.
5. Intervene when degree of functioning in other daily life activities is impaired.
1. Remain calm, accepting, but nonsanctioning.
2. Promptly help clarify client's feelings, thoughts, at stressful time.
3. Review precipitating events.
4. Be a neutral "sounding board"; avoid evasiveness.
5. If unable to handle situation, find someone who can.
6. For clients who masturbate at inappropriate times or in inappropriate places:
1. Give special attention when they are not masturbating.
2. Encourage new interests and activities, but not immediately after observing masturbation.
3. Keep clients distracted, occupied with interesting activities.
7. Health teaching: explain myths and teach facts regarding cause and effects.
6. Evaluation/outcome criteria:
1. Acknowledges function of own sexual organs.
2. States sexual experience is satisfying.
3. Views sexuality as pleasurable and wholesome.
4. Views sex organs as acceptable, enjoyable, and valued part of body image.
5. Self-image as fully functioning person is restored and maintained.
2. HOMOSEXUALITY
1. Definition—alternative sexual behavior; applied to sexual relations between persons of the same sex.
2. Theories regarding causes:
1. Hereditary tendencies.
2. Imbalance of sex hormones.
3. Environmental influences and conditioning factors, related to learning and psychodynamic theories.
1. Defense against unsatisfying relationship with father.
2. Unsatisfactory and threatening early relationships with opposite sex.
3. Oedipal attachment to parent.
4. Parent who is seductive (incest).
5. Castration fear.
6. Labeling and guilt leading to sexual acting out.
7. Faulty sex education.
4. Preferred choice as a lifestyle.
3. Nursing care plan/implementation:
1. Nurse needs to be aware of and work through own attitudes that may interfere with providing care.
2. Accept and respect lifestyle of a client who is gay (man who is homosexual) or lesbian (woman who is homosexual).
3. Assess and treat for possible sexually transmitted infections and hepatitis.
4. Health teaching: assess and add to knowledge base about alternatives in sexual behavior.
4. Evaluation/outcome criteria: expresses self-confidence and positive self-image; able to sustain satisfying sexual behavior with chosen partner and avoid at-risk behaviors for STIs.
3. SEX AND THE PERSON WHO IS DISABLED
1. Assessment parameters:
1. Previous level of sex functioning and conflict.
2. Client's view of sex activity (self and mutual pleasure, tension release, procreation, control).
3. Cultural environment (influence on body image).
4. Degree of acceptance of illness.
5. Support system (partner, family, support group).
6. Body image and self-esteem.
7. Outlook on future.
2. Analysis/nursing diagnosis: sexual dysfunction associated with physical illness related to:
1. Disinterest in sexual activity.
2. Fear of precipitating or aggravating physical illness through sexual activity.
3. Use of illness as excuse to avoid feared or undesired sex.
4. Physical inability or discomfort during sexual activity.
3. Nursing care plan/implementation:
1. Approach with nonjudgmental attitude.
2. Elicit concerns about current physical state and perceptions of changes in sexuality.
3. Observe nonverbal clues of concern.
4. Identify genital assets.
5. Support client and partner during adjustment to current state.
6. Explore culturally acceptable sublimation activities.
7. Promote adjustment to body image change.
8. Health teaching:
1. Teach self-help skills.
2. Teach partner to care for client's physical needs.
3. Teach alternate sex behaviors and acceptable sublimation (e.g., touching).
4. Evaluation/outcome criteria: attains satisfaction with adaptive alternatives of sexual expressions; has a positive attitude toward self, body, and sexual activity.
4. INAPPROPRIATE SEXUAL BEHAVIOR
1. Assessment: public exhibitions of sexual behaviors that are offensive to others; making sexual advances to other clients or staff.
2. Analysis/nursing diagnosis: conflict with social order related to:
1. Acting out angry and hostile feelings.
2. Lack of awareness of hospital and agency rules regarding acceptable public behavior.
3. Variation in cultural interpretations of what is acceptable public behavior.
4. Reaction to unintended seductiveness by person's attire, posture, tone, or choice of terminology.
3. Nursing care plan/implementation:
1. Maintain calm, nonjudgmental attitude.
2. Set firm limits on unacceptable behavior.
3. Encourage verbalization of feelings rather than unacceptable physical expression.
4. Reinforce appropriate behavior.
5. Provide constructive diversional activity for clients.
6. Health teaching: explain rules regarding public behavior; teach acceptable ways to express anger.
4. Evaluation/outcome criteria: verbalizes anger rather than acting out; accepts rules regarding behavior in public.

^* Marcus, IM, & Francis, JJ: Masturbation from Infancy to Senescence. International Universities Press, New York.