Sexual and Gender Identity Disorder.pptx

• Human sexuality is complex
phenomenon that includes:
• Psychological in origin and occur in the
absence of any pathological disease.
• Discussions about sex and sexual
problems have always been covered in
privacy and prohibited.

ICD 10 Classification:
 F52 Sexual dysfunction not due to a substance or known physiological condition
 F52.0 Hypoactive sexual desire disorder
 F52.1 Sexual aversion disorder
 F52.2 Sexual arousal disorders
 F52.3 Orgasmic disorder
 F52.4 Premature ejaculation
 F52.5 Vaginismus not due to a substance or known physiological condition
 F52.6 Dyspareunia not due to a substance or known physiological condition
 F52.8 Other sexual dysfunction not due to a substance or known physiological condition
 F52.9 Unspecified sexual dysfunction not due to a substance or known physiological condition

ICD 11 Classification:
• 1. HA00-HA4Z: Sexual dysfunction
• - HA00: Desire disorders (e.g., hypoactive sexual desire disorder)
• - HA01: Arousal disorders (e.g., erectile dysfunction, female sexual arousal
disorder)
• - HA02: Orgasmic disorders (e.g., premature ejaculation, female orgasmic disorder)
• - HA03: Pain disorders (e.g., dyspareunia, vaginismus)
• - HA04: Other sexual dysfunction (e.g., delayed ejaculation, female sexual
interest/arousal disorder)

• 2. HB00-HB4Z: Sexual preference disorders
• - HB00: Pedophilic disorder
• - HB01: Fetishistic disorder
• - HB02: Voyeuristic disorder
• - HB03: Exhibitionistic disorder
• - HB04: Other sexual preference disorder
3. HC00-HC4Z: Gender incongruence
- HC00: Gender incongruence of childhood
- HC01: Gender incongruence of adolescence and
adulthood
4. HD00-HD4Z: Sexual exploitation disorders
- HD00: Sexual exploitation disorder (e.g., sexual
abuse, sexual exploitation)

Any impairment in normal sexual response cycle
1. Sexual Dysfunction
Unusual or deviant sexual behaviour
2. Disorder of Sexual Preference (Paraphilias)
Persistent identification with opposite sex and discomfort in own
sex
3. Gender Identity Disorder
CLASSIFICATION OF SEXUAL DISORDERS

PSYCHOPATHOLOGY (PSYCHODYNAMICS) SEXUAL
DISORDERS
Exact cause of sexual disorders is not known.
Psychodynamic theory: Psychosocial and cultural factors:

Genetic factors
Psychoactive substances and drugs
Hormonal

SEXUAL DYSFUNCTIONS
• Impairment of normal sexual interest, enjoyment and/or performance.
• Impairment can occur at one or more points of the normal sexual
response cycle-desire, arousal (or excitement) and orgasm

Classification of sexual dysfunctions
 Appetitive
dysfunction
 Impaired genital
response
 Orgasmic
dysfunction
 Pain during sex
 Hypoactive sexual desire disorder
 Sexual aversion disorder
 Female sexual arousal disorder
 Male erectile disorder (impotence)
 Inhibited female orgasm (anorgasmia)
 Inhibited male orgasm (retarded ejaculation)
 Premature ejaculation
 Vaginismus (female)
 Dyspareunia (both female and male)

ETIOLOGY OF SEXUAL DYSFUNCTION
1. Psychosocial and Cultural
Factors
 Ignorance and
misinformation
 Conflict of values
 Fears and trauma
 Psychodynamic Theory
2. Relationship Factors
3. Organic Factors
4. Psychoactive Substances
and Drugs

SPECIFIC DISORDERS SEXUAL DYSFUNCTION
1. Sexual Arousal (Desire) Disorder
Sexual arousal (desire) disorders are of two types (DSM-5). It is characterized
by the persistent problems in sexual activities which lasting more than six
months.
Female Sexual Interest/ Arousal
Disorder:
Absent or reduced interest in sexual
activity, thoughts or fantasies, excitement
or pleasure and arousal.
Male Hypoactive Sexual Desire Disorder:
Reduced or absent of sexual thoughts or
fantasies and desire for sexual activity.

2. Orgasmic disorders
• Orgasmic disorder now referred to as
female orgasmic disorder.
• It is characterized by the difficulty or
inability of a woman to reach orgasm during
sexual stimulation.
• At the diagnosis for men is erectile
dysfunction, premature ejaculation or
delayed ejaculation.
• The symptoms must be present for a
minimum duration of 6 months without any
organic pathology.
TREATMENT
1.Sexual counselling
and therapy
2.Psychotherapy
3.Pharmacotherapy

3. Sexual Aversion Disorder
• It refers to a near total avoidance
of sexual activity and may be
associated with extreme fear,
anxiety or contempt.
• Lack of libido is a common
symptom of psychiatric disorders
especially depression, and should
be excluded.

4. Male Erectile Dysfunction (Impotence)
It is characterized by the inability of
a person to get an erection during
sexual activity, inability to maintain
an erection long enough to finish a
sexual act and inability to get an
erection that is as rigid as
previously experienced.

Ejaculation occurs during sexual
activity within one minute after
vaginal penetration and before the
individual wishes it (DSM-5).
5. Premature Ejaculation

6. Inhibited Male Orgasm
• Person fails to ejaculate following an adequate phase of sexual excitement or activity.
7. Vaginismus
• There is involuntary spastic contraction near the vaginal entrance.
• It is a conditioned response of the muscles around the introitus.
8. Dyspareunia
• Psychogenic pain during sexual intercourse.
9. Dhat syndrome: Dhat syndrome is a one of common condition found in the cultures of South
Asia including India and Pakistan in which male patients report premature ejaculation or
impotence and believe that they are passing semen in their urine.
• IMP: In most of psychosexual dysfunctions, psychotherapy is effective treatment.

DISORDERS OF SEXUAL PREFERENCE (PARAPHILIAS)
AND HOMOSEXUALITY
• Paraphilias are characterized by an excitement stage of sexual activity,
fantasies that are associated with sexual objects, stimulus or
orientations.
• The stimulus may be a woman's shoe, a child, animals, instruments of
torture or incidents of aggression.

'Sexually arousing fantasies,
urges or behaviours that are
recurrent, intense, occur over a
period of at least six months, and
cause significant distress or
interfere with important areas of
functioning.’

Classification of Disorders of Sexual Preference
1. Abnormal preference of sexual objects
o Fetishism: Reliance on inanimate objects, e.g. clothing or shoes, for arousal
and gratification.
o Transvestism: Wearing of clothes of the opposite sex to obtain sexual
excitement.
o Pedophilia: Sexual preference for pre-pubertal children.
o Other objects of sexual preference: e.g. animals (zoophilia or bestiality),
dead bodies (necrophilia), persons with particular attributes, e.g., a deformity,
amputated limb, etc.

2. Abnormal preference of sexual acts
o Exhibitionism: Persistent tendency to expose genitalia to people in public
places, usually for sexual excitement, but without attempts at closer contact.
o Voyeurism: Observing sexual activities of others for one's own sexual
arousal.
o Sadomasochism: Sexual activity involving imposing pain on others
(sadism) or experiencing pain oneself (masochism).
o Frotteurism: Excitement gained from rubbing genitalia against strangers in
crowded places.

Etiology
• Early relationship problems.
• Disrupted development of sexuality.
• Repressed unacceptable heterosexual feelings.
• Excessive shyness or harbouring fears about
relationships with the opposite sex.
• Learning theory: Stated that sexual arousal in this
way is a learn behaviour and conditioned response.
• Psychoanalytic theory: Stated that it is symbolic
presentation of repressed homosexuality or oedipal
conflicts.

Treatment
of Sexual
Preference
Psychotherapy
Behaviour
therapy
Medications:
Antiandrogens
or oestrogens
Other
Medications:
Selective
serotonin
reuptake
inhibitors
(SSRIs)

Role of Nurse in Primary Prevention
 Identify maladaptive coping among patients.
 Teach socially acceptable coping skills
(assertiveness skills).
 Regular evaluation of sexual development
component, i.e., genders identity, sexual
responsiveness and the ability to establish
relationships with others.
 Accurate assessment and early intervention.

GENDER IDENTITY DISORDERS (GENDER DYSPHORIA)

Gender identity is the awareness of
one's masculinity E (maleness) or
femininity (femaleness). Gender
identity disorders occur when there is
inconsistency between anatomic sex
and gender identity.

Definition
Gender identity disorders as a group whose common feature is a strong, persistent
preference for living as a person of the other sex. -DSM-IV-TR

 Transsexualism: Desire to live and be accepted as a
member of the opposite sex, usually accompanied by
the wish to make one's body as congruent as possible
with one's preferred sex through surgery and hormonal
treatment.
Wearing clothes of the opposite sex in order to experience
temporarily membership of the opposite sex in the
absence of any sexual motivation for the cross-dressing
and any desire to change permanently into the opposite
Classification : Gender Identity Disorders (ICD-10)

Gender identity disorder of childhood
 For females: Persistent and intense distress about being a girl and a stated desire to be a boy.
 For males: Persistent and intense distress about being a boy and an intense desire to be a girl.

Transgender
Refers to the broad spectrum of individuals who transiently or persistently
identify with a gender different from their gender at birth.

Prevalence of gender identity disorder is 1 in 30,000 men and 1 in 100,000
women.

ETIOLOGY
Biological Factors:
i. Masculinity, femininity, and gender identity may result more from postnatal life events than from prenatal
hormonal organization
ii. Genetic causes of gender dysphoria are under study but no candidate genes have been identified, and
chromosomal variations are uncommon in transgender populations.
Psychosocial Factors:
iii. The formation of gender identity is influenced by the interaction of children's temperament and parents'
qualities and attitudes.
iv. Culturally acceptable gender roles exist (which are learnt): Boys are not expected to be feminate, and girls are
not expected to be masculine. There are boys' games (e.g., cops and robbers) and girls' toys (e.g., dolls and
dollhouses).
v. Childhood conflicts; mother-child relationship, mother's death, the separation-individuation process

Clinical Features of gender identity disorders
In children or adolescents In adults
 Repeatedly stating intense desire to be of
the opposite gender.
 Insistence that one is of the opposite
gender.
 Cross-dressing.
 Fantasies of being of the opposite gender.
 Strong desire to participate in the games of
the opposite gender.
Strong preference of having playmates (peers)
of the opposite gender.
 A stated desire to be of the opposite gender.
 Desire to live or be treated as the opposite
gender.
 Belief that one has the typical feelings and
reactions of the opposite gender.
 Persistent discomfort with or sense of
inappropriateness in the assigned gender
role.
 Request for opposite gender hormones or
surgery to alter sexual characteristics.

Treatment
Approaches for
Gender Identity
Disorder
Counselling, individual
psychotherapy and
behaviour therapy.
Cross-sex hormones
and gender
reassignment
surgery.
Social and legal
support.

HOMOSEXUALITY
Although homosexuality is not a disorder, psychological problems
associated with conflicts over sexual orientation are commonly seen in
clinical practice.
Definition : Homosexuality refers to sexual attraction toward persons of the same sex.

 Male homosexuality is more common than in females.
 About 5% of the male population is exclusively homosexual.
 10% who may have had homosexual experiences at some time in their
life but are otherwise predominantly heterosexual.

Clinical Features of Homosexuality
• Homosexual patients may present with a number of problems related
to their orientation and lifestyle.
 Uncertainty about Sexual Orientation: Doubt and guilt about
their homosexual feelings or behaviour.
 Adjustment Problems: Unstable relationship Feeling of
discrimination unstable and common fears of partner's infidelity.

Forms of homosexuality
• LGBTQ+ ( Lesbian, Gay, Bisexual, Transgender and Queer or Questioning.)
• Lesbian: A homosexual woman.
• Gay: A homosexual man.
• Bisexual: Attracted to both men and women.
• Transgender: Relating to a person whose sense of personal identity and gender
does not correspond with their birth sex.
• Queer: A person whose gender identity is nonbinary or differs from the sex they
had or were identified as having at birth.

Treatment
Behaviour therapy: Modifying the sexual behaviour of patients
experiencing adjustment problems. For example, covert sensitization or
aversion therapy car be used in treating those who are strongly motivated.

GERIATRIC CONSIDERATION
Elderly sexuality and issues related to it
have long been neglected from the
treatment aspect.
The common misconception is that the
elderly are asexual individual.
Physiologic changes in sexual response
occur during old age is normal
physiological responses.

Physiologic Changes in Sexual response during old age.
Phases Male Female
1. Desire / excitement Erection take longer time
and somewhat lost
Longer time than usual
1. Plateau / arousal Extended time Extended time
1. Orgasm Shortened Multiple orgasm is
possible
1. Resolution Increased Rapid

Sexual Disorders among elderly
 Among elderly males, erectile dysfunction is the most common sexual
disorder due to biological changes during old age.
 Among elderly females, arousal disorder is the most prevalent female
sexual dysfunction where psychological aspect plays an important role.
 Vaginal dryness and dyspareunia are the most important factors in
reducing the sexual desire and frequency in women.

Follow-up, Home Care and Rehabilitation
 Offer to be available for support to the child when he/she is feeling
rejected by peers.
 Discuss about anatomy of the sex organs as part of psycho- education.
 Discuss about menstrual cycle, pregnancy, puberty, masturbation,
formation of semen, nightfall, types of sex, stages of sexual
intercourse, normal male and female sexual response cycle.
 Educate the patient/couple about wide variation in the extent and
frequency of feelings of sexual desire.

Cont.…
 Educate the patient about the harmful effects of negative self- talk.
 Promote activities to reduce stigma by increasing awareness regarding
sexuality.
 Need for health-promoting behaviours for early identification of sexual
problems
 Measures to promote gender equality and freedom from all forms of
discrimination based on gender.
 Provide regular follow-up home care.

Assessment
 Evaluate the degree to which the patient believes he/ she is 'in control' of
his/her own behaviour.
 Assess the patient's feelings of comfort and content with his/her own
performance.
 Evaluate recent variations in the patient's behaviour.
 Evaluate the extent to which the patient feels loved and respected by others.
 Assess how competent patients feel about their ability to perform and carry
out their own and others expectations.

1.Nursing Diagnosis
 Situational low self-esteem related to development of a negative
perception of self-worth in response to sexual identity as evidenced by
perceived distress and sexual impairment.
•
 Expected outcomes: Client will
o Verbalize and demonstrate behaviours that indicate self-satisfaction.
o Demonstrate ability to interact with others and a sense of self as a
worthwhile person.

Interventions Rationale
Encourage patient or significant others in healthy expression of feelings or
concerns.
Help the client to identify behaviours or aspects of life he/she would like to
change.
Offer to be available for support to the child when he/she is feeling rejected by
peers.
To enhance patient's group interaction.
Spend time with the patient; set aside enough time so that the encounter is
calm and deliberate.
A trusting relationship is an important factor in building self-esteem.
Provide privacy. Patient feels free to express feelings without being overheard.
Apply active listening and open-ended questions. To convey a sense of respect.
Consider the 'normal' impact of change on self-esteem. Reconstitution of the patient's self-esteem occurs as part of the patient's
adjustment.
Nursing interventions

2. Nursing Diagnosis
 Ineffective sexuality pattern related to actual or perceived sexual dysfunction as
evidenced by sexual aversion, limitations in sexual behaviours and lack of sexual
desire.
 Expected Outcomes
o Client will verbalize positive statements about self, including past
accomplishments and future prospects.
o Patient will relate satisfaction with sexuality and understanding of the ability to
resume sexual activity.

Interventions Rationale
Determine the patient's problem and validate it with the patient. Identifies the cause of sexual dysfunction.
Assess the normal sexual function of the patient. Helps to determine the patient's normal sexual function.
Allow the patient and significant others to express feelings and concerns regarding sexual
issues.
Establishing open communication will help to build a strong intimate relationship.
Allow acceptable expressions of sexuality by the patient. Promote positive and acceptable behaviour and eliminates inappropriate behaviours.
Encourage collaboration with the patient and significant others. To facilitate an understanding between the patient and caregivers.
Evaluate the need for professional counselling when needed. Counselling may enhance communication and agreement of alternative means.
Nursing interventions

Evaluation
o Client verbalizes positive perception of self.
o Patients will verbalize his/her sexual issues/concerns openly in socially
acceptable manner.

RESEARCH PERSPECTIVE:
1. Vora P., D’souza A., “Gender Identity and Gender Identity Disorder Issues for Clinical
Practice”, Gender dysphoria (GD) is a term coined for "persistent discomfort with one's
biologic sex or assigned gender, replaced the diagnosis of gender identity disorder" in
the Diagnostic and Statistical Manual of Mental Disorders in 2013. The term GD has
received tremendous attention, in recent years, because of many cases coming to the
fore and the problem also emerging in adolescents in the school setting. There is some
reprieve with the term GD as it replaces the earlier terms gender identity disorder (GID)
which gave a mental disorder such as connotation to the condition and transgenderism
which also was not liked in some quarters. The current article provides an overview of
some terms used in GD and related disorders and the clinical dilemmas that may be
seen in these conditions.

2. Cooper K. & et al.(2020) “The phenomenology of gender dysphoria in adults: A systematic review and meta-
synthesis” Gender dysphoria is distress due to a discrepancy between one's assigned gender and gender
identity. Adults who wish to access gender clinics are assessed to ensure they meet the diagnostic criteria for
gender dysphoria. Therefore, the definition of gender dysphoria has a significant impact on the lives of
individuals who wish to undergo physical gender transition. This systematic review aimed to identify and
synthesize all existing qualitative research literature about the lived experience of gender dysphoria in adults. A
pre-planned systematic search identified1491 papers, with 20 of those meeting full inclusion criteria, and a
quality assessment of each paper was conducted. Data pertaining to the lived experience of gender dysphoria
were extracted from each paper and a meta-ethnographic synthesis was conducted. Four over arching
concepts were identified; distress due to dissonance of assigned and experienced gender; interface of assigned
gender, gender identity and society; social consequences of gender identity; internal processing of rejection,
and transphobia. A key finding was the reciprocal relationship between an individual's feelings about their
gender and societal responses to transgender people. Other subthemes contributing to distress were
misgendering, mismatch between gender identity and societal expectations, and hypervigilance for transphobia.

Human sexuality encompasses a range of biological, psychological, social, and cultural
factors. Psychosexual disorders are sexual problems originating from psychological issues
rather than physical disease. Greater access to information has increased awareness and
encouraged more people to seek help. Also, we discussed about:
 ICD and DSM Classifications
 Normal Sexual Response Cycle
 Classification of Sexual Disorders
 Psychopathology of Sexual Disorders
 Specific Disorders: Sexual Dysfunctions, Paraphilias, Gender Identity Disorders,
Sexual Dysfunctions, Paraphilias, Gender Dysphoria, and Geriatric Considerations.
 Nursing Management
 Client/Family Education

Psychosexual disorders are complex and multifaceted,
influenced by a range of psychological, biological, and social
factors. Effective management requires a thorough
understanding of these disorders, including their
classifications, causes, and treatment options. Nursing
management plays a crucial role in supporting individuals with
psychosexual disorders through assessment, education, and
intervention.

BIBLIOGRAPHY
1. Pareek B., Arya S. Textbook of Mental Health & Psychiatric Nursing, 2nd
Edition, VISION,
Psychosexual Disorders, Eating Disorders and Personality Disorders, Page No. 246-253
2. Townsend M.C., Morgan K.I., Psychiatric Mental Health Nursing, 9th
Edition, JYPEE,
Issues related to Human Sexuality and Gender Dysphoria, Pg No. 641-668.
3. Bhaskara Raj D.E., DEBR’S Mental Health (Psychiatric) Nursing, 2017, EMMESS, Sexual
and Gender Identity Disorder, Page No.:513-530
4. Sreevani R., A Guide to mental Health & Psychiatric Nursing, 5th
Edition, JAYPEE,
Nursing Management of Patient with Personality and Sexual Disorder, Page No.: 287-288
5. https://journals.lww.com/indianjpsychiatry/_layouts/15/oaks.journals/downloadpdf.aspx?
trckng_src_pg=ArticleViewer&an=01363795-202163040-00003

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