KEY CONCEPTS & DEFINITIONS

 Biological sex: Chromosomes, gonads, hormones, internal/external genitalia.

 Sexual arousal state: of coital readiness brought on by a variety of stimuli.

 Masturbation: sexual stimulation by self.

 Oral sex: stimulation of genitals with mouth.

 Anal Sex: Sexual stimulation of anus

 Petting: Sexual activities other than intercourse

 Pornography: depiction of sex or sex organs in an erotic manner through audiovisual

stimulation.

 Prostitution -commercial sex

 Necrophilia -sex between a living human and a human corpse

 Bestiality -humans having sex with non-human animals

 Gender: Socially constructed roles/behaviours/attributes considered appropriate for
men, women, and gender-diverse people.
 Gender identity: One’s internal sense of being male, female, a blend of both, neither,
or otherwise.
 Gender expression: External presentation (clothes, voice, mannerisms) that may or
may not conform to societal expectations.
 Cisgender: Gender identity aligns with sex assigned at birth.
 Transgender: Gender identity differs from sex assigned at birth.
 Non-binary/Gender diverse: Identities beyond the male–female binary (e.g.,
genderqueer, agender, bigender).
 Intersex: Congenital variations in sex characteristics.
 Sexual orientation: Enduring pattern of emotional/romantic/sexual attraction
(heterosexual, homosexual, bisexual, pansexual, asexual, etc.).
 Sexual health: A state of physical, emotional, mental, and social well-being related to
sexuality.
 Sexual dysfunctions: Clinically significant disturbances in sexual desire, arousal,
orgasm, or pain causing distress/impairment.
 Paraphilic interests vs. Paraphilic disorders: Atypical interests are not disorders
unless they cause distress/impairment or involve non-consenting persons/risk of harm.
  Gender dysphoria: Distress due to incongruence between one’s experienced gender
and assigned sex; not the same as being transgender.

Terminology note: “Gender Identity Disorder” is obsolete; current terms are Gender
Incongruence (ICD-11) and Gender Dysphoria (DSM-5-TR) when distress/impairment is
present.

DEVELOPMENT OF HUMAN SEXUALITY (BIOPSYCHOSOCIAL, LIFESPAN)

Prenatal & Early Biology

 Chromosomal sex determined at conception (XX/XY or variations such as XO, XXY,

etc.).
 Gonadal differentiation (weeks 6–12); hormonal milieu (androgens/estrogens)
influences internal/external genitalia.
 Brain sexual differentiation influenced by prenatal hormones and genetics.

Infancy & Early Childhood (0–5 years)

 Body awareness, curiosity; gender labeling emerges ~2–3 years; gender constancy by
~5–7 years.
 Attachment, caregiver responses, cultural norms shape early gender expression and
comfort with bodies.

Middle Childhood (6–11 years)

 Consolidation of gender roles; modesty; peer norms. Early signs of orientation may
begin as preferences.

Adolescence (12–19 years)

 Puberty: secondary sexual characteristics; surge in sexual interest.

 Identity exploration: orientation, gender identity, consent boundaries; influence of
peers, media, online spaces.
Adulthood & Older Age

 Sexuality continues across the lifespan; influenced by relationship quality, health

conditions, medications, menopause/andropause, chronic illness, disability.

Psychosocial & Cultural Determinants

 Family beliefs, religion, media, education, law/policy, stigma/discrimination.

 Minority stress model: Chronic stress from stigma -> higher risk of depression,
 anxiety, substance use, suicidality in sexual and gender minorities.

SEXUAL AND GENDER IDENTITY DISORDERS

INTRODUCTION

Human sexuality is a complex interplay of biological, psychological, social, and cultural

factors. While sexuality is a normal aspect of human life, disturbances in sexual functioning,
preference, or identity can cause significant distress, impairment in functioning, or conflicts
with societal norms. Such disturbances are classified as sexual disorders or gender identity-
related conditions in psychiatric nosology.

Sexuality

Human sexuality is the way people experienced and express themselves sexually. It is an
important part of who you are.
 Sexuality is not about whom you have sex with, or how often you have it.
 Sexuality is about your sexual feelings, thoughts, attractions and behaviours towards
other people.
Or
It is the sum total of one’s sexual feeling, behaviour, gender consciousness and sexual nature.

DEFINITION

 Sexual Disorders: Disorders characterized by disturbances in sexual desire, response,

performance, or behavior, which cause distress or interpersonal difficulties.
  Gender Identity Disorders (old term): Conditions in which an individual
experiences incongruence between their experienced gender and assigned biological
sex.
 Gender Dysphoria (newer term in DSM-5): Distress due to the incongruence
between one’s experienced/expressed gender and assigned sex at birth.
 Paraphilic Disorders: Intense, persistent sexual interests in atypical objects,
activities, or situations that cause harm or distress.

HISTORICAL PERSPECTIVES

 19th Century: Early psychiatrists like Krafft-Ebing described "psychopathia

sexualis," categorizing homosexuality, fetishism, sadism, and masochism as
pathologies.
 DSM-I (1952): Classified homosexuality as a sociopathic personality disturbance.
 DSM-II (1968): Still considered homosexuality a sexual deviation.
 1973 (APA Decision): Homosexuality was declassified as a disorder, marking a
major shift in psychiatric understanding.
 DSM-III (1980): Introduced "Gender Identity Disorder" and broadened sexual
dysfunction and paraphilia categories.
 DSM-5 (2013): Removed "Gender Identity Disorder" → replaced with "Gender
Dysphoria" to reduce stigma.
 ICD-10 (1992): Retained categories like "Gender Identity Disorder" and
"Paraphilias."
 ICD-11 (2019): Significant shift — moved "Gender incongruence" out of mental
disorders section → into conditions related to sexual health.

CLASSIFICATION IN DSM-5

DSM-5 organizes sexual and gender identity–related conditions under three broad categories:

1. 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
 Other specified / unspecified sexual dysfunction

2. Gender Dysphoria

 Gender dysphoria in children

 Gender dysphoria in adolescents and adults
 Other specified / unspecified gender dysphoria

3. Paraphilic Disorders

 Voyeuristic disorder
 Exhibitionistic disorder
 Frotteuristic disorder
 Sexual masochism disorder
 Sexual sadism disorder
 Pedophilic disorder
 Fetishistic disorder
 Transvestic disorder
 Other specified / unspecified paraphilic disorder

CLASSIFICATION IN ICD-11 (2019/2022 IMPLEMENTATION)

ICD-11 has grouped sexual disorders, gender incongruence, and related conditions in
Chapter 17 instead of Mental & Behavioural Disorders (as in ICD-10).

Blocks under Chapter 17 relevant to Sexual Disorders:

1. Sexual dysfunctions

(6A20 – 6A24)

 6A20 Hypoactive sexual desire dysfunction

 6A21 Sexual arousal dysfunction
 6A22 Orgasmic dysfunction
 6A23 Premature ejaculation
 6A24 Other specified sexual dysfunctions not due to a substance or medical condition

2. Paraphilic disorders

(6D30 – 6D3Z)

 6D30 Exhibitionistic disorder

 6D31 Voyeuristic disorder
 6D32 Pedophilic disorder
 6D33 Coercive sexual sadism disorder
 6D34 Frotteuristic disorder
 6D35 Other paraphilic disorder involving non-consenting individuals
  6D36 Paraphilic disorder involving solitary behaviour or consenting individuals (e.g.,
fetishistic disorder, sexual masochism)
 6D3Z Paraphilic disorder, unspecified

3. Gender incongruence

(HA60 – HA6Z)

 HA60 Gender incongruence of adolescence and adulthood

 HA61 Gender incongruence of childhood
 HA6Z Gender incongruence, unspecified

4. Other conditions related to sexual health

 HA70 Compulsive sexual behaviour disorder

 HA71 Other specified conditions related to sexual health
 HA7Z Conditions related to sexual health, unspecified

CHARACTERISTIC OF SEXUALLY HEALTHY PERSON

 The person who has the knowledge about sexuality and sexual behaviour.
 One who has the positive attitude towards body image.
 Ability to express one's full sexual potential.
 Ability to make autonomous decisions about one's sexual life.
 Experience of sexual pleasure as a source of physical, psychologic, cognitive and
spiritual well-being.
 Right to make free and responsible reproductive choices.
 Ability to access sexual healthcare.
 Maintain balance between life style and sexual behaviour.
 Capacity to develop effective interpersonal relationship.

PHASES OF SEXUAL RESPONSE CYCLE

Sexual Response Cycle (Masters & Johnson Model, 1966) – the classical framework for
understanding human sexual functioning.

Phases of Sexual Response Cycle

 1. Desire (Appetitive Phase)

 Psychological interest in sexual activity.

 Initiated by fantasies, attraction, or stimuli.
 Involves limbic system activity and hormonal influences (testosterone, estrogen,
dopamine).

2. Excitement (Arousal Phase)

 Physical and emotional changes occur.

 Men: Penile erection.
 Women: Vaginal lubrication, clitoral swelling.
 Increased heart rate, blood pressure, muscle tension.

3. Plateau Phase

 Sexual tension builds further.

 Heightened arousal just before orgasm.
 Men: Full erection, pre-ejaculatory fluid.
 Women: Vagina expands, orgasmic platform develops.
 Breathing and pulse rapid.

4. Orgasm Phase

 Peak of sexual pleasure.

 Involuntary muscular contractions.
 Release of tension via rhythmic contractions (penile ejaculation in males,
uterine/vaginal contractions in females).
 Neurochemical release: oxytocin, prolactin, endorphins.

5. Resolution Phase

 Body returns to baseline.

 Relaxation and well-being.
 Refractory period in males (temporary inability to achieve another orgasm).
 Females may experience multiple orgasms without refractory period.

FACTORS AFFECTING SEXUAL HEALTH

The factors affecting sexual health are:

 Biological factors
 Psychological factors Environmental factors
 Hormonal factors
 Sexual health history
 Stress

I. Biological Factors

 Congenital abnormalities
 Injuries (affecting nerves, physical or reproductive system, etc.)
  Less secretion of hormones or reasons related to endocrine glands
 Pain, fatigue, etc.
 Old age

II. Psychological Aspects

Pre-disposing Factors
 Disturbance/obstacles in family relationships Incomplete sexual knowledge
 Initial sexual experience being bitter
 Disinterest or disliking for partner.

Assisting and Maintaining Factors

 Unnecessary hopes and expectations from the partner
 Tension and pressure
 Sense of guilt regarding sexual relationship
 Death of beloved one
 Wrong notions and superstitions regarding sexual relationships.

III. Environmental Factors

 Change in lifestyle
 Lack of poor place and privacy
 Religious &culture

IV. Hormone/Genetic Factors

 Can affect sperm quality

 Production and ovulation (e.g. failure to ovulate regularly, or irregular menstrual cycle,
may be caused by problems with the hypothalamus and pituitary gland)
 Congenital factors may impede ability to conceive (e.g. born without uterus).

V. Sexual Health History

 Lack of understanding of one's own reproductive biology and a lack of awareness of

factors that can impact fertility.
 Multiple sexual partners increase the risk for STI's, pelvic inflammatory disease and
cervical cancer.
 Sexually transmitted and pelvic conditions, if left untreated, can cause conditions in both
males and females which can impair fertility.

VI. Stress

 Psychological stress (e.g. depression, difficulty sleeping, anxiety)

 Physiological stress (increased muscle tension, lack of energy, nervousness) affect libido
 Stress affects the ability to make healthy lifestyle choices (e.g. alcohol, other substance
use, smoking, decrease in physical activity or sedentary living, poor nutrition) which in
turn also affects fertility.
SEXUAL DISORDERS

I. SEXUAL DYSFUNCTIONS (DSM-5-TR; DURATION ~6 MONTHS;

DISTRESS REQUIRED)

 Male: Hypoactive Sexual Desire Disorder; Erectile Disorder; Delayed Ejaculation;

Premature (Early) Ejaculation.
 Female: Sexual Interest/Arousal Disorder; Female Orgasmic Disorder; Genito-Pelvic
Pain/Penetration Disorder (vaginismus/dyspareunia spectrum).

A. Male Hypoactive Sexual Desire Disorder

 Causes:
• Psychological – stress, anxiety, depression, relationship conflict
• Biological – low testosterone, chronic illness, medications (SSRIs,
antihypertensives)
 Symptoms: Persistent lack of sexual thoughts/fantasies, reduced initiation of sex
 Diagnosis: Clinical interview, sexual history, hormone evaluation
 Management:
• Psychotherapy (CBT, couples therapy)
• Hormonal therapy (testosterone replacement if deficient)
• Lifestyle changes (reduce stress, exercise, limit alcohol)

B. Female Sexual Interest/Arousal Disorder

 Causes: Hormonal changes (menopause, low estrogen), depression, past sexual

trauma, poor partner relationship
 Symptoms: Lack of sexual interest, absent arousal, reduced genital sensations
 Diagnosis: Sexual history, gynecological exam, hormone tests
 Management:
• Sex therapy and counseling
• Hormone therapy (estrogen, testosterone)
• Lubricants for dryness
• Addressing underlying relationship/psychological issues

C. Erectile Disorder

 Causes:
• Organic – diabetes, hypertension, vascular disease, neurological disorders
• Psychological – performance anxiety, depression
• Medications (antidepressants, antihypertensives)
 Symptoms: Persistent inability to attain/maintain erection
 Diagnosis: Nocturnal penile tumescence test, vascular studies, hormone levels
  Management:
• PDE5 inhibitors (Sildenafil, Tadalafil)
• Vacuum erection devices, penile implants
• Psychotherapy, relaxation therapy

D. Female Orgasmic Disorder

 Causes: Inadequate stimulation, relationship conflict, anxiety, trauma, SSRIs

 Symptoms: Delay/absence of orgasm despite adequate stimulation
 Diagnosis: Clinical history, exclusion of medical causes
 Management:
• Sex therapy (directed masturbation training, sensate focus)
• CBT, couple therapy
• Medication review

E. Genito-Pelvic Pain/Penetration Disorder

 Causes: Vaginismus, pelvic floor dysfunction, endometriosis, trauma history

 Symptoms: Pain during penetration, fear of intercourse, involuntary muscle spasm
 Diagnosis: Gynecological exam, pain mapping
 Management:
• Pelvic floor physiotherapy
• Vaginal dilator therapy
• Counseling for trauma-related anxiety
• Lubricants

F. Premature (Early) Ejaculation

 Causes: Anxiety, performance pressure, prostatitis, genetic predisposition

 Symptoms: Ejaculation within 1 min of penetration, inability to delay
 Diagnosis: Based on history (>6 months duration, distress present)
 Management:
• Behavioral techniques (stop-start, squeeze technique)
• SSRIs (Paroxetine, Sertraline)
• Topical anesthetics (lidocaine spray)
• Counseling

Etiology: Multifactorial—biological (vascular, endocrine, neurologic), psychological

(anxiety, depression, trauma), relational (conflict, communication), iatrogenic (medications),
sociocultural (guilt, misinformation).

Management (interprofessional):
  Education & sensate focus exercises; cognitive-behavioral and mindfulness-based sex
therapy; couples therapy.
 Address comorbidities; medication review (e.g., switch SSRI or add adjunct like
bupropion for SSRI-induced dysfunction under prescriber guidance).
 Pharmacologic options: PDE-5 inhibitors for ED; topical anesthetics/behavioral
techniques for premature ejaculation; hormonal therapies when indicated (e.g.,
estrogen for GSM under gynecologic care); flibanserin/bremelanotide
(context-specific where available); pelvic floor physiotherapy and dilator therapy for
genito-pelvic pain.
 Lifestyle: exercise, sleep, alcohol/smoking reduction; manage chronic disease.

II) PARAPHILIC DISORDERS (ONLY A “DISORDER” IF

DISTRESS/IMPAIRMENT OR HARM/NON-CONSENT RISK)

 Examples: Voyeuristic, Exhibitionistic, Frotteuristic, Sexual Masochism/Sadism,

Pedophilic, Fetishistic, Transvestic.
 Assessment: Risk (self/others), consent, compulsivity, legal issues; co-occurring
conditions; forensic considerations when applicable.
 Management: Specialized psychotherapy (CBT, relapse prevention),
social/occupational rehabilitation, pharmacologic adjuncts (e.g., antiandrogens/SSRIs)
under specialist care; safeguarding and legal compliance.

A. Voyeuristic Disorder

 Causes: Early sexual experiences, reinforcement by masturbation, impulse control

deficits
 Symptoms: Sexual arousal from observing unsuspecting individuals
undressing/engaging in sexual activity
 Diagnosis: Psychiatric evaluation; must cause distress/impairment or involve non-
consenting person
 Management:
• CBT (aversive conditioning, relapse prevention)
• SSRIs, anti-androgens in severe cases

B. Exhibitionistic Disorder

 Causes: Social isolation, poor social skills, learned behavior

 Symptoms: Sexual arousal from exposing genitals to unsuspecting persons
 Diagnosis: Clinical history of recurrent urges/acts for ≥6 months
  Management:
• Psychotherapy, group therapy
• Antiandrogen medication (medroxyprogesterone) in severe cases

C. Frotteuristic Disorder

 Causes: Poor impulse control, early conditioning

 Symptoms: Sexual arousal from touching/rubbing against non-consenting persons
 Management: Similar to exhibitionism – CBT, aversion therapy, SSRIs

D. Sexual Masochism Disorder

 Causes: Childhood trauma, conditioning through fantasies

 Symptoms: Sexual arousal from being humiliated, beaten, or bound
 Management: Psychotherapy, aversive therapy; SSRIs

E. Sexual Sadism Disorder

 Causes: History of abuse, antisocial traits, impulse control disorder

 Symptoms: Sexual arousal from physical/psychological suffering of others
 Management: Psychotherapy, anger management, medications (SSRIs,
antiandrogens)

F. Pedophilic Disorder

 Causes: Neurodevelopmental abnormalities, early abuse, personality disorders

 Symptoms: Sexual fantasies/urges involving prepubescent children (≤13 years)
 Diagnosis: Persistent >6 months, acted upon or causes distress
 Management:
• Intensive psychotherapy (CBT, relapse prevention)
• Pharmacological – SSRIs, anti-androgens, GnRH agonists
• Legal interventions

G. Fetishistic Disorder

 Causes: Conditioning – sexual arousal paired with non-living objects (shoes, leather,
underwear)
 Symptoms: Recurrent sexual fantasies/urges involving non-genital body parts or
objects
 Management: CBT, aversive conditioning, SSRIs

H. Transvestic Disorder

 Causes: Sexual arousal linked to cross-dressing; reinforced by masturbation

 Symptoms: Intense arousal from dressing as opposite gender, causing distress
  Management: Psychotherapy, support therapy; rarely medical treatment needed
unless comorbid with gender dysphoria

III) GENDER DYSPHORIA / GENDER INCONGRUENCE

 Distress from incongruence between experienced gender and assigned sex.

 Not a sexual orientation and not a paraphilic interest.
 Goals of care: Alleviate distress, support identity, reduce dysphoria, improve
functioning and quality of life through gender-affirming care.

 Causes:

• Biological – hormonal influences in prenatal brain development

• Genetic factors
• Psychological – early childhood gender nonconformity

 Symptoms:
• Strong desire to be other gender
• Discomfort with assigned sex characteristics
• Desire to alter body through hormones/surgery
• Distress or social/occupational impairment
 Diagnosis:
• Clinical psychiatric evaluation
• Must persist for ≥6 months with significant distress

 Management:
• Psychological support – counseling, support groups
• Medical treatment – hormone replacement therapy (HRT)
• Surgical treatment – gender-affirming surgery (mastectomy, vaginoplasty,
phalloplasty)
• Social support – legal gender recognition, family education

OTHERS

[Link] Identity Disorders

These disorders are characterized by disturbance in gender identity, the sense of one's
masculinity or femininity is disturbed.
a. Transsexualism
b. Dual role transvestism
c. Intersexuality

[Link] and Behavioural Disorders

 Disorders of sexual development and maturation include disorders where sexual

orientation causes significant distress to the individual or disturbance in relationships.
 The preference as well as the physical and emotional attraction one develops for a partner
of particular gender is called sexualorientation. e.g.
 homosexuality
 Bisexuality

DYNAMICS OF SEXUAL DSORDERS USING THE THRANSACTIONAL MODEL

OF STRESS / ADAPTATION
Affirming Interventions (person-centered, reversible to irreversible):

1. Social affirmation: Names, pronouns, clothing, hair; school/workplace supports.

2. Puberty suppression (adolescents): GnRH analogs (reversible) under endocrine
specialty care.
3. Gender-affirming hormones: Estrogen/anti-androgens; testosterone (partially
reversible changes); monitoring protocols.
4. Surgical options: Chest, genital, facial, voice procedures—based on readiness,
informed consent, and multidisciplinary evaluation.
5. Mental health support: Psychoeducation, coping skills, family counseling, peer
support; management of comorbidities.

VARIATIONS IN SEXUAL ORIENTATION (DIVERSITY, NOT DISORDER)

 Heterosexual, homosexual, bisexual, pansexual, asexual, demisexual, etc.—all are

normal human variations.
 Orientation is not a choice; attempts to change it ("conversion/repair" practices) are
unethical and harmful.
 Nursing role: Affirm identity, address minority stress, screen for mental health
concerns, advocate for safe/competent care.

Factors Influencing Sexual Orientation

Sexual orientation is considered to be the result of multiple interacting factors rather than a
single cause.

1. Biological Factors

 Genetic influences: Twin studies show higher concordance in identical twins than
fraternal.
 Prenatal hormonal influences:
• Exposure to androgens in utero may affect sexual orientation.
• Brain structural differences – e.g., hypothalamic nuclei variations in homosexual
men (LeVay, 1991).
 Neurobiological differences: Studies suggest variations in brain circuits regulating
attraction and arousal.
2. Psychological Factors

 Early childhood experiences and identity formation.

 No evidence that poor parenting "causes" homosexuality; however, supportive or
rejecting environments strongly influence self-acceptance.
 Sexual orientation becomes stable in adolescence, not consciously "chosen."

3. Social & Cultural Factors

 Cultural norms shape how sexual orientation is expressed, not necessarily what it is.
 Social acceptance or stigma influences mental health outcomes.
 In restrictive societies, individuals may suppress orientation, leading to internalized
homophobia.

4. Environmental & Developmental Factors

 Peer relationships and role models may influence sexual identity expression.
 Experiences of attraction during puberty consolidate orientation.

CHALLENGES FACED BY SEXUAL MINORITIES

 Stigma & Discrimination (at school, workplace, healthcare).

 Mental health issues – anxiety, depression, higher suicide risk (due to stigma, not
orientation itself).
 Social isolation.
 Legal & cultural barriers – in some countries same-sex relationships are
criminalized.

DIAGNOSTIC TOOLS
 Clinical psychiatric interview
 Sexual history taking
 DSM-5/ICD-11 criteria
 Questionnaires: Sexual Desire Inventory, International Index of Erectile Function
(IIEF)
 Medical tests (hormone levels, vascular studies, neurological exam when indicated)

MEDICATIONS FOR SEXUAL DISORDERS

For Hypoactive Sexual Desire Disorder (HSDD)

 Flibanserin (for premenopausal women, serotonin agonist/antagonist)

 Bremelanotide (melanocortin receptor agonist, injectable, for women)
  Testosterone replacement therapy (for men with hypogonadism)HRT

For Erectile Dysfunction (ED)

 PDE-5 Inhibitors: Sildenafil citrate (nitric oxide enhancers ), Tadalafil, Vardenafil,

Avanafil, clomipramine, cyprohepatidine
 Intracavernosal injections: Alprostadil, Papaverine, Phentolamine
 Vacuum erection devices
 Hormonal therapy if low testosterone

For Premature Ejaculation

 SSRIs: Dapoxetine (on-demand), Paroxetine, Sertraline

 Topical anesthetics: Lidocaine–Prilocaine cream or spray

For Female Sexual Arousal/Lubrication Disorders

 Topical estrogen (for postmenopausal vaginal dryness)

 Ospemifene (SERM for dyspareunia)
 Lubricants & moisturizers

For Orgasmic Disorders

 Bupropion (antidepressant that enhances dopamine)

 Mirtazapine, nefazodone, Naltrexone
 Psychostimulants (off-label) in resistant cases
2. PSYCHOTHERAPIES

 Cognitive Behavioral Therapy (CBT) – addresses negative thoughts, performance

anxiety.
 Psychodynamic Therapy – explores unconscious conflicts, childhood issues.
 Couples Therapy / Marital Therapy – resolves relationship conflicts impacting
sexual function.
 Mindfulness-Based Therapy – improves body awareness and reduces anxiety.

3. HERBS FOR SEXUAL DYSFUNCTION

1. Ginseng (Panax ginseng / Korean Ginseng)

o Improves erectile function by enhancing nitric oxide synthesis.
o Increases energy, stamina, and libido.
o Acts as an adaptogen, reducing stress-related sexual problems.
2. Ashwagandha (Withania somnifera)
o Enhances libido and fertility.
o Reduces stress and anxiety (which worsen sexual dysfunction).
o Improves testosterone levels and sperm quality.
3. Maca Root (Lepidium meyenii)
o Increases sexual desire and fertility.
o Boosts stamina and energy.
o Improves sperm count and motility.
4. Ginkgo Biloba
o Enhances blood circulation to sexual organs.
o Useful in erectile dysfunction related to poor blood flow.
o Improves mood and reduces antidepressant-induced sexual dysfunction.
5. Tribulus terrestris
o Increases testosterone production naturally.
o Enhances libido and sexual performance.
o Traditionally used in male infertility and erectile dysfunction.
6. Safed Musli (Chlorophytum borivilianum)
o Powerful aphrodisiac in Ayurveda.
o Improves semen quality and sperm count.
o Boosts vitality and reduces premature ejaculation.
7. Shilajit (Asphaltum)
o Rejuvenator and natural aphrodisiac.
o Enhances testosterone and energy levels.
o Improves fertility and reduces fatigue.
8. Yohimbe (Pausinystalia johimbe) (used more in Western herbal medicine)
o Improves erectile function by dilating blood vessels.
o Increases sexual arousal.
o Must be used cautiously due to possible side effects (high BP, anxiety).
CLINICAL ASSESSMENT IN SEXUAL & GENDER HEALTH

Principles

 Normalize the topic; ensure privacy; obtain informed consent; be trauma-informed

and inclusive.
 Use person’s name and pronouns; avoid assumptions; use open-ended questions.

Frameworks

 5 Ps sexual history: Partners, Practices, Protection from STIs, Past STIs, Pregnancy
plans (plus: Pleasure, Problems, Coercion/violence).
 PLISSIT model: Permission → Limited Information → Specific Suggestions →
Intensive Therapy.
 BETTER model: Bring up, Explain, Tell, Timing, Educate, Record.

Standards & Ethics: Follow contemporary professional standards (e.g., WPATH SOC;
DSM-5-TR/ICD-11 alignment). Ensure informed consent, confidentiality, documentation,
and harm-reduction.

SEX THERAPY (MASTERS & JOHNSON APPROACH)

Definition

Sex therapy is a specialized form of psychotherapy that helps individuals or couples

address sexual problems such as low libido, erectile dysfunction, premature ejaculation,
orgasmic disorders, pain during intercourse, and intimacy issues. It is usually short-term,
structured, and solution-focused.

Goals of Sex Therapy

 Improve sexual functioning (desire, arousal, orgasm, satisfaction).

 Reduce anxiety, guilt, or shame related to sex.
 Enhance intimacy and communication between partners.
 Resolve sexual dysfunction caused by psychological or relational factors.
 Educate about normal sexual response and healthy sexuality.
Techniques Used in Sex Therapy

1. Education & Counseling

o Teaching about human sexuality, anatomy, sexual response cycle.
o Correcting myths and misconceptions.
2. Behavioral Techniques
o Sensate Focus Exercises (Masters & Johnson) → gradual, non-demand
physical touch to reduce performance anxiety.
o Stop–Start Technique → used in premature ejaculation.
o Squeeze Technique → pressure at the base of penis to delay ejaculation.
o Systematic Desensitization → for vaginismus and sexual anxiety.
3. Cognitive-Behavioral Therapy (CBT)
o Identifying and modifying negative thoughts related to sex.
o Reducing guilt, shame, or unrealistic expectations.
4. Couple/Relationship Therapy
o Enhancing communication and emotional bonding.
o Resolving conflicts affecting intimacy.
5. Relaxation & Mindfulness
o Reducing anxiety and stress.
o Focusing attention on sensations rather than performance.

NURSING MANAGEMENT (COMPREHENSIVE)

General Principles of Nursing Management

 Holistic care: Sexuality is multidimensional—biological, psychological, social,

cultural, and spiritual.
 Therapeutic relationship: Build trust with a non-judgmental, empathetic attitude.
 Confidentiality: Protect the patient’s privacy regarding sexual concerns.
 Individualized care: Each client’s values, cultural background, and life experiences
must guide interventions.

SEX EDUCATION

 Start early (5–8 years) → with simple body awareness & safety.

 Expand during adolescence (13–18 years) → detailed sexual and reproductive health.

 Continue into adulthood → responsibility, family planning, sexual well-being.

Components of sexual health education

[Link] aspects;

 Anatomy and physiology of the reproductive organs

 Physical, emotional and psychological changes during puberty
 Contraception, pregnancy and childbirth
[Link] aspects;

 Sex drive or sexual feelings in childhood and adolescence.

 Emotional development- teenage excitement and emotional stress.
 Personal identity (self-esteem).
 Social relationship (with parents, siblings, peers of either sex)
 Gender roles.
 STD/HIV.

[Link] education at school

Sex education in the school has best extension than it is provide at home
 Teaching should be scientifically correct.
 It should be a two-way dialogue.
 The group of students should be homogenous in age and cultural background.
 Groups should be over two members. Otherwise, two-way communication is difficult.
 Talks should be supported by AV aids.
 At least one trained teacher.
 Support of administration.

NURSES ROLE IN SEXUALITY AND SEXUAL HEALTH

ROLE OF THE NURSE

In Public health centres nurse should be able to:

 Foster comfort and trust between clients and providers.
 Explore underlying issues that affect clients' needs.
 Improve both client and provider satisfaction
 Keep the community knowledgeable and support the community's role in influencing
sexuality and gender dynamics for achieving and maintaining healthy sexual and
reproductive behaviours.

As a school health nurse, she should be able to:

 Help to increase sexual and reproductive health knowledge and promote sharing of
information.
 Help to understand changes in their bodies throughout their life cycle.
 Improve their knowledge about safe sex practice and provide help to psychological
and physical issues involved with sex.

Role of the nurse in hospital setting:

 Along with imparting knowledge she should take care of various sexual concerns of
theclient.
 Nurse should be sensitive to the cues of the sexual needs of the clients.
 Assist in various procedures to improve sexual health and provide family planning
services to the client
 Assist in various procedures to improve sexual health and provide family planning
services to the client
 Provide privacy to the client with his partner.
 Reproductive and sexual health careincluding abortion and reproductive and genetic
technologies an integral part of individual, family and community services provided by
professionals and others at the health care system.
 Nurses have aprofessional responsibility to provide high quality, nonjudgemental
reproductive and sexual health care five their clients.

NURSING TASKS

 Sexual and contraceptive history taking/assessment including HIV and initiate Partner
Notification via index cases.
 Understand and be able to discuss different sexual activities and sexualities
 Ability to challenge stigmas and discriminations
 Supply emergency hormonal contraception (EHC)
 Supply and administer other methods of contraception apart from IUD, IUS and SDI
 Supply and administer all forms of contraception/refer for SDI/IUS/TUD
 Pre-conception advice (folic acid/rubella vaccination; assessment of gestation of
pregnancy)
 Pregnancy testing: interpreting and giving results
 Abortion: Familiar with legal requirements and referral pathways
 Abortion care
 Breast awareness
 IUD/IUS/SDI insert and removal
 Menopause advice
 Testicular and prostate awareness
 STI screening: Ct, GC, BBV and syphilis screen
 HIV testing, BBV risk assessment and vaccination
 HIV pre-and post-exposure prophylaxis
 Management of rape/sexual assault cases
 Cryotherapy Microscopy, Recognize Signs and Symptoms of STIs: Diagnose and manage
simple presentation, e.g. urethral and vaginal discharge, treatment of STIs and
epidemiological treatment of STI contacts via PGD; perform cervical cytology.

TEACHING SELF-EXAMINATION

 Monthly breast self-examination for women and monthly testicular self-examination for
men. Clients need to be assured that most lumps discover are not cancerous, but that it is
essential that all the lumps or other detected abnormalities be checked by the client's
primary care provider for accurate diagnosis.

 For BSE a regular time is best: Such as 1 week following menstruation, when breast
tenderness and fullness caused by the fluid retention subsided, or on the same day of the
month for postmenopausal women.

 TSE should also be performed on same day of each month, starting at the age of 15. The
best time for the TSE is after a warm bath or shower when the scrotal sac is relaxed.
 SEXUAL EDUCATION AND COUNSELING

 Nurses can assist clients to understand their anatomies and how their bodies function.

 The importance of open communication between partners should also be encouraged.

 Details about physiological changes. For example, puberty, pregnancy, menopause and
male climacteric on sexual function.

 Parents often need assistance to learn ways to answer questions and what information to
provide for their children starting in preschool year.
SEXUAL AND REPRODUCTIVE TRACT INFECTIONS

 Advise sexual abstinence (including oral sex) or condom use where an STI is suspected,
until treatment has been undertaken.

 for at least one week after treatment, and, ideally, until treatment has been proved
effective.
 Nurses need to find their own way of eliciting a patient history without being
judgmental or trying to force their own sexual morals onto the patient.

 Motivational interviewing and counselling skills can be useful tools, particularly when a
lot of information and advice needs to be supplied within a short time.

DISEASE S\S IN MALE S\S IN FEMALE

Primary chancre, usually on glans Primary: chancre, usually
penis, which is painless and heals in occurs at the site of infection,
4-6 weeks, highly infectious during which is painless and heals in 4-
this stage. Secondary symptoms: 6 weeks, highly infectious
skin eruptions (especially prevalent during this stage. Secondary:
Syphilis on palms and soles), low grade rash occurs which involves the
fever, sore throat, headache. trunk, extremities, including
latency: infectious lesions may palms of the hand and soles of
occur, otherwise asymptomatic, feet. Tertiary syphilis: Affect
reactive serological tests. Tertiary: multiple organs
Affect multiple organs
Painful urination, urethritis with May be asymptomatic or
watery white discharge, which may vaginal discharge, pain and
Gonorrhoea become purulentSlight itching, urinary frequency may be
moisture on top of penis Itching present
and redness o skin

Single lesion or Cluster of lesions Certain stains of HPV have

growing beneath or on the foreskin, been linked to cervical cancer.
at external meatus, or on the glans Lesions appear at the bottom
Trichomoniasis penis. On the dry skin areas: lesions part of the vaginal opening, on
 are hard and yellow-grey. On moist the perineum, inner walls of
areas: lesions are pink or red and vagina and the cervix
soft with cauliflower like
appearance
Itching, irritation, discharge, plaque
Red and excoriated vulva.
Genital warts of cheesy material under intense itching of vaginal and
vulval tissues, thick, white,
cheesy or curd-like discharge
Painful urination, urinary Commonly a carrier, usually no
Chlamydia frequency, watery, mucoid urethral s/s appears. May experience
discharge vaginal discharge, dysuria, and
urinary frequency.

LAW RELATED TO SEXUALLITY AND SEXUAL HEALTH

Laws related to sexuality and sexual health vary significantly across countries and regions,
but they typically address issues such as reproductive rights, sexual consent, sexual
orientation, gender identity, sexual education, and access to healthcare services. Here's a
broad overview of some of the key areas where laws intersect with sexuality and sexual
health:

1. Sexual Consent

Age of Consent:
Laws define theminimum age at which an individual can legally consent to sexual activity.
This varies by jurisdiction, but the general range is between 18and 21years.

Consent Standards:Many countriesemphasize that consent must be given

voluntarilyknowinglywithout coercion, and certain legal system have introduced affirmative
consent standards where yes means yes.

2. Reproductive Rights

Abortion Laws:
Abortion laws differ widely. Some countries permit abortion on demand (often within a
specific gestational period), while others restrict it to cases of rape, incest, or health risks.
Some countries completely ban abortion.

Contraception:
Access to contraception is a critical aspect of sexual health. In some countries, laws guarantee
the right to access a range of birth control methods, while in others, restrictions may apply,
particularly f of certain practices or in the case or cultural.

Consent Standards:
Many countries emphasize that consent must be given voluntarily, knowingly, and without
coercion, and certain legal systems have introduced affirmative consent standards where "yes
means yes."

3. Sexual Orientation and Gender Identity

Gender Identity:
In some jurisdictions, individuals have the legal right to change their gender markers on
official documents. Transgender rights and protections against discrimination in areas like
employment and healthcare are also important legal considerations.
4. Sexual Harassment and Assault
Sexual Assault Laws: Laws in manycountries define and criminalize sexual assault,
including rape and molestation, and provide legal recourse for victims. These laws typically
address non-consensual sexual acts and sometimes have specific provisions for various forms
of sexual violence.

Sexual Harassment:
Sexual harassment in the workplace, educational settings, and other environments is
addressed by many legal frameworks. These laws typically prohibit unwanted sexual
advances, comments, or behaviours.

5. Sexual Health and Access to Care

Sexual Health Services:

Legal frameworks often regulate access to sexual health services, including testing for
sexually transmitted infections (STIs), HIV prevention and treatment, and public health
campaigns aimed at improving sexual health.

Comprehensive Sex Education:

Many countries have laws requiring the inclusion of sex education in schools, though the
extent and nature of this education can vary widely. Some countries focus on abstinence-
based education, while others emphasize comprehensive sexual health education.

6. Human Trafficking and Exploitation

Anti-Trafficking Laws:
Manyjurisdictions have laws aimed at preventing sex trafficking and exploitation,
criminalizing the buying and selling of sex, as well as coercive sexual practices. These laws
aim to protect individuals from being forced into sex work or sexual exploitation.

7. Pornography and Sexual Expression

Pornography Laws:
Laws aroundpornography often address issues of consent, age verification (e.g., prohibiting
child pornography), and public decency. There are also debates over the regulation of online
pornography and its impact on sexual health and exr¹-+action.

Laws related to Sexual health and Sexuality in India

In India, laws related to sexual health and sexuality are shaped by a combination of
constitutional rights, statutory laws, and judicial interpretations. Here are some key laws:
1. The Indian Penal Code (IPC) - Sexual Offenses:

o Rape (Section 375 IPC):

Defines rape as sexual intercourse without consent or under circumstances that violate a
woman's consent. It has specific clauses on consent, age, and coercion.

o Sexual Assault (Section 354, 354A, 3548, 354C, 354D IPC):

These sections cover offenses like molestation, stalking, and voyeurism.

o Child Sexual Abuse (Section 377 IPC):

Section 377 criminalized non -consensualsexualacts, but in 2018 the Supreme court read
down this provision decriminalizing consensual same sex relation between adult, through
some aspect related to non-consensual acts still exist under this section.

2. Protection of Children from Sexual Offences (POCSO) Act, 2012:

This The law provides protection to children from sexual offenses. It defines sexual abuse in
a broad manner, covering physical, emotional, and psychological harm. It prescribes strict
punishment for offenses such as child pornography and sexual assault.

3. The Medical Termination of Pregnancy (MTP) Act, 1971:

This law governs the conditions under which an abortion can be legally performed in India.
As of recent amendments (2021), it allows abortions up to 24 weeks of pregnancy for certain
categories of women, including minors, survivors of rape, and incest, and women with
physical disabilities, among others.

4. The Family Courts Act, 1984:

This law facilitates the resolution of family-related disputes, including those related to sexual
health, marital rape, and domestic violence. It provides a platform for women to seek
redressal in matters concerning sexual health within marriage.

5. The Domestic Violence Act, 2005 (Protection of Women from Domestic Violence
Act):

This law offers protection to women from domestic violence, which includes sexual violence
within the confines of marriage or cohabitation. It includes provisions for seeking relief
against sexual assault, harassment, and intimidation.

6. The Transgender Persons (Protection of Rights) Act, 2019:

The Act ensures the protection of transgender people from discrimination and violence. It
acknowledges the right to self-identify gender and includes provisions related to the
protection of sexual health and dignity of transgender persons.
7. The HIV and AIDS (Prevention and Control) Act, 2017:

This law seeks to prevent discrimination against people living with HIV/AIDS and ensures
their access to healthcare services. It includes provisions related to sexual health in the
context of HIV/AIDS.

8. The Special Marriage Act, 1954:

• This law allows for the registration of marriages between individuals of different religions
or those who do not follow any religion. It has provisions that pertain to sexual health and the
duties and rights of individuals in the marital relationship.

9. The Criminal Law (Amendment) Act, 2013:

This Act amended the Indian Penal Code to provide stricter punishment for crimes related to
sexual violence, including acid attacks, sexual harassment, and rape.
It also expanded the definition of sexual assault and introduce gender neutral language in
some sections to include transgender persons.

10. Right to Privacy and Sexuality:

Union of India case, the Supreme Court ruled that the right to privacy is a fundamental right
under the Constitution, which has implications for the privacy of sexual choices,
relationships, and sexual health decisions.

11. The Assisted Reproductive Technology (Region) Bill, 2020 (Proposed):

The bill aims to regulate assisted reproductive technologies (ART) in India, ensuring safe and
ethical practices, especially concerning the use of reproductive organs and the rights of
individuals using these technologies.

[Link]+ Rights and Same-Sex Relationships:

The supreme court decriminalized consensual same sex relations between adults by reading
down section 377 of the Indian Penal Code, thus recognizing the right to consensual same-
sex relationships. However, same-sex marriages are still not legally recognized in India.

These laws, along with judicial interventions, contribute to shaping the sexual health and
sexuality landscape in India, although enforcement and cultural attitudes can present
challenges.

NURSING PROCESS APPROACH

A. Assessment

 History taking
o Sexual history (partners, practices, protection, past experiences, satisfaction).
o Onset, duration, and severity of disorder.
o Medical and surgical history (diabetes, hypertension, medications).
o Psychological factors: anxiety, depression, stress, past abuse/trauma.
 o Relationship issues, partner’s perspective.
 Physical examination
o Reproductive and endocrine system evaluation.
o Neurological assessment (if indicated).
 Psychosocial assessment
o Body image, self-esteem, coping mechanisms.
o Family and cultural influences.

B. NURSING DIAGNOSIS (NANDA EXAMPLES)

1. Ineffective sexuality pattern related to lack of knowledge, psychological distress, or

altered body function.
2. Disturbed body image related to gender identity concerns.
3. Anxiety related to fear of rejection or sexual performance.
4. Low self-esteem related to perceived sexual inadequacy.
5. Social isolation related to stigma or internalized shame.
6. Risk for self-directed violence in severe cases of gender dysphoria or sexual stigma.

1. Ineffective Sexuality Pattern related to lack of knowledge, psychological distress, or

altered body function

Assessment

 Patient expresses lack of sexual desire or inability to perform

 Verbalization of guilt, shame, or frustration
 Inadequate knowledge about sexual health, anatomy, or safe practices

Goals

 Patient will verbalize understanding of sexual anatomy, physiology, and safe practices
within 1 week.
 Patient will demonstrate healthier coping with sexuality issues.

Planning / Interventions

 Assess patient’s perception of sexual problem and knowledge level.

 Provide health teaching about sexual function, anatomy, and safe sexual practices.
 Encourage open communication between partners.
 Offer counseling for anxiety, depression, or body image issues.
 Refer to specialist (sex therapist, urologist/gynecologist) as indicated.

Implementation

 Conduct teaching sessions, provide pamphlets, or audio-visual aids.

 Arrange couple’s counseling sessions.
 Encourage patient to keep a diary of sexual thoughts/concerns.

Evaluation

 Patient verbalizes increased knowledge about sexual function.

  Reports improvement in sexual satisfaction.
 Reduction in distress and improved confidence.

2. Disturbed Body Image related to gender identity concerns

Assessment

 Patient verbalizes dissatisfaction with body parts/appearance.

 Expresses desire to alter physical sex characteristics.
 Avoids social interaction due to appearance.

Goals

 Patient will verbalize acceptance of self by end of therapy.

 Patient will demonstrate adaptive coping with body image concerns.

Planning / Interventions

 Assess patient’s feelings about body and self-image.

 Provide a nonjudgmental environment for expression.
 Encourage realistic goal setting for body modification (HRT, surgery if chosen).
 Facilitate support groups with peers facing similar concerns.
 Involve family (if supportive) in education about gender identity.

Implementation

 Conduct regular counseling sessions.

 Refer to endocrinologist/plastic surgeon if patient opts for transition.
 Provide psychoeducation on positive self-image.

Evaluation

 Patient demonstrates improved self-acceptance.

 Reports reduced distress regarding gender incongruence.
 Actively participates in support groups.

3. Anxiety related to fear of rejection or sexual performance

Assessment

 Patient verbalizes fear of being rejected by partner or society.

 Restlessness, palpitations, sweating before intimacy.
 Avoidance of sexual activity.

Goals

 Patient will report decreased anxiety before sexual interaction.

 Patient will demonstrate relaxation skills.

Planning / Interventions
  Assess level and triggers of anxiety.
 Teach relaxation techniques (deep breathing, guided imagery).
 Provide reassurance and supportive communication.
 Encourage gradual exposure to feared situations (systematic desensitization).
 Involve partner in therapy to promote understanding.

Implementation

 Practice relaxation daily with patient.

 Encourage verbalization of fears during sessions.
 Provide couple therapy for performance-related anxiety.

Evaluation

 Patient reports decreased fear and anxiety.

 Engages in sexual activity without distress.
 Demonstrates coping skills learned.

4. Low Self-Esteem related to perceived sexual inadequacy

Assessment

 Patient verbalizes feelings of worthlessness or inadequacy.

 Negative self-talk (“I am not a good partner”).
 Lack of confidence in relationships.

Goals

 Patient will verbalize at least 2 positive qualities about self.

 Patient will demonstrate improved confidence in social/sexual roles.

Planning / Interventions

 Assess patient’s sources of self-esteem and past experiences.

 Challenge negative thoughts and cognitive distortions.
 Provide positive reinforcement for efforts and strengths.
 Encourage patient to participate in enjoyable, confidence-building activities.
 Involve partner/family in supportive care.

Implementation

 Daily self-affirmation exercises.

 Encourage participation in group activities or hobbies.
 Provide CBT sessions to restructure negative beliefs.

Evaluation

 Patient verbalizes improved self-worth.

 Engages in sexual and social relationships more confidently.
5. Social Isolation related to stigma or internalized shame

Assessment

 Patient avoids friends/family gatherings.

 Expresses fear of being judged or ridiculed.
 Loneliness, withdrawal, lack of social support.

Goals

 Patient will increase social interaction with supportive people.

 Patient will verbalize reduced feelings of isolation.

Planning / Interventions

 Assess extent of isolation and factors contributing to stigma.

 Provide emotional support and a safe environment for expression.
 Encourage participation in LGBTQ+ or sexual health support groups.
 Educate family/community about reducing stigma.
 Collaborate with social worker for community resources.

Implementation

 Arrange family counseling sessions.

 Refer to peer-support groups.
 Teach assertiveness and social skills training.

Evaluation

 Patient engages in social activities without distress.

 Reports increased sense of belonging.

6. Risk for Self-Directed Violence related to severe gender dysphoria or sexual stigma

Assessment

 Patient expresses suicidal ideation or self-harm behavior.

 History of depression, hopelessness, or past attempts.
 Severe distress due to stigma or rejection.

Goals

 Patient will remain safe and free from self-harm.

 Patient will verbalize alternative coping strategies.

Planning / Interventions

 Assess suicidal thoughts, intent, and plan.

 Provide constant observation if risk is high.
 Develop a safety contract (no self-harm agreement).
  Teach stress management and problem-solving skills.
 Refer for psychiatric evaluation and possible pharmacotherapy (antidepressants,
anxiolytics).
 Involve supportive family/friends in care plan.

Implementation

 Place patient in a safe environment (remove sharp objects, harmful substances).

 Maintain close supervision.
 Provide crisis intervention and immediate counseling.
 Initiate appropriate medications as prescribed.

Evaluation

 Patient remains free of self-harm.

 Reports decreased suicidal ideation.
 Demonstrates healthy coping strategies.
REFERENCES

 Shabeer. P. basher, Yaseen khan, ‘A concise textbook of Advanced Nursing

Practices,’’1st edition published by Emmess,162-168.
 Kapoor Bimla.(2000).”A textbiik of psychiatric nursing” (Vol. I,II).NewDelhi: Kumar
publishing [Link].336
 Mary C. Townsend. “Psychiatric mental health nursing”;8h edition; jaypee publishers;
page no 599.
 Sreevani R. (2008).”A guide to mental health and psychiatric nursing.”(2 nd Ed.).New
Delhi: Jaypee [Link]. 116-120
 Neeraja KP (2008).”Essentials of psychiatric nursing”(vol.2).New Delhi: Jaypee
[Link] 430
 Ahuja Neeraj.(1995).”A short textbook of Psychiatry” (3 rd Ed). New Delhi: Jaypee
brothers. Pp. 284-285