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Course: Fundamentals of Nursing�Topic: Sexual Health

The Nurses International Community

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Module Goals

Learners will be able to:

Discuss changes in sexual development across the lifespan.
Discuss alterations of sexual health, including infertility, STIs, abuse, and dysfunction.
Discuss cultural considerations related to assessment of sexual health.
Identify the nurse’s role in the maintenance of sexual health.

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Sexual Health Definition

World Health Organization [WHO], n.d.

“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”

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Sexual Development 0-2 years old

Learns about love and trust through touching and holding¹.
Becomes very responsive to physical touch¹.
Picks up non-verbal/verbal messages that begin to help them understand their own sexuality¹.
Explores their own body parts^1,2.
Becomes more aware of their bodily functions (toileting) and the messages from parents and others about these functions¹.
Becomes interested in people’s bodies, especially others in their family.
From birth, boys have erections and girls lubricate vaginally

it is not a sexual response, sensitive organ’s normal reaction to touch³.

Alberta Health Services, n.d.
National Sexual Violence Resource Center, 2013
Gill, 2020

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Sexual Development 3-5 years old

Begin to develop a base or foundation for their gender identity¹.
Continue exploring body parts, may touch their own genitals.

Occurs as a soothing behavior, not for sexual pleasure^1,2.

Playful exploration with children of the same age^1,2(e.g role play).
May show curiosity in regard to adult bodies (e.g., wanting to go to into the bathroom with parents, )².
May ask questions about sexuality or reproduction, such as, “Where do babies come from?”².
Continued lack of inhibition around nudity².
Uses slang terms for body parts and bodily functions².

Alberta Health Services, n.d.
National Sexual Violence Resource Center, 2013

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Sexual Development 5-8 years old

Deeper understanding of gender roles. May act in a more “gendered” manner as expected behaviors and norms associated with gender are learned (e.g., girls may want to wear dresses)²
Still explore their own body¹
Sex play or activities that explore sexuality and bodies may occur with same- and opposite-sex friends of same age
Continued use of slang words, “potty humor” or jokes to describe body parts and functions.
Masturbation- Some children may touch their genitals for the purpose of pleasure.

Happens more often privately rather than in public.

National Sexual Violence Resource Center, 2013

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Sexual Development 9-13 years old

Begins to notice the physical changes of puberty¹.

In boys: the penis grows, pubic hair appears.
In girls: pubic hair appears, breasts develop, may menstruate^1,2.

Increased need for privacy and independence is often expressed².
Interest in relationships, may want to have a girlfriend or boyfriend².
May express curiosity about adult bodies².

Could involve the child trying to see people naked or undressing or involve looking for media (such as TV, movies, websites, and magazines) with sexual content.

As social norms around masturbation become clearer

Masturbation will likely occur in private^1,2.

Alberta Health Services, n.d.
National Sexual Violence Resource Center, 2013

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Sexual Development 13-15 years old

In girls:

Breasts continue or begin to grow.
Pubic hair thickens and darkens, and underarm hair thickens.
begin to menstruate, possibility of pregnancy.
White mucus-like discharge from vagina.

In boys:

Penis, scrotum and testes get bigger,
Pubic hair thickens and darkens, and underarm hair thickens
Able to have erections and ejaculate,
May have swelling under the nipples (usually goes away by the end of puberty)

Alberta Health Services, n.d.

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Sexual Development 16-18 years old

A new desire for sexual experiences, brought on by hormone changes.
Become interested in or develops romantic relationships.
Early on dating relationships don’t usually last long, as they’re more social and experimental.
Feel more sexual desire and have more fantasies (may masturbate).
More interest in sexuality—sexual fantasies are a way to prepare for and understand their sexual roles.
May be attracted to or have a sexual experience with someone of the same sex.

However, this does not mean that’s their sexual orientation.

As they get older, dating relationships have a deeper involvement, with real concern for their partner.

Alberta Health Services, n.d.

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Sexual Development Age 19 - 30 years

Possibility of masturbation
Decision making about partnerships, marriage, family life, and careers
Possibility of pregnancy, childbirth, and/or parenting
Possibility of contraception and /or sex safety decisions
Possibility of ending a relationship

Island Sexual Health Community Health Center, n.d.

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Sexual Development Beyond Age 30

Possibility of masturbation.
Decision making about partnerships, marriage, family life, and careers.
Possibility of pregnancy, childbirth, and/or parenting.
Possibility of contraception and/or sex safety decisions.
Possibility of ending a relationship.
At age 42-64, menopause occur in female, andropause may occur in male.
Age 65 onwards, body responds sexually but slowly,

Possibility of masturbation,
Possibility of sexual activity
Need for physical affection

Island Sexual Health Community Health Center, n.d.

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What Would a Nurse Do?

Mr. Smith and Mrs. Jones are elderly, widowed, and live in separate rooms in an assisted living facility. The nurses aide reports to the nurse that she has just seen the couple kissing and holding hands. The nurse aide then begins to laugh. What is the best correct nursing action?

Instruct the nurses aide that older adults still experience sexual pleasure.
Call the families and inform them of the couple's action.
Remind the couple that their actions are not appropriate.
Tell the nurse aide to relax because sexual activity is highly unlikely between the residents.

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When is Behaviour a Concern?

National Child Traumatic Stress Network (2009) states following childhood sexual behaviors that indicate more than harmless curiosity:

Are clearly beyond the child’s developmental stage (for example, a three-year-old attempting to kiss an adult’s genitals).
Involve threats, force, or aggression.
Involve inappropriate or harmful use of sexual body parts (for example, inserting objects into the rectum or vagina).
Involve children of widely different ages or abilities (such as a 12-year-old “playing doctor” with a four-year-old).
Are associated with strong emotional reactions in a child—such as anger or anxiety.
Interfere with typical childhood interests and activities.

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When is Behaviour a Concern? continued….

Sexual behavior problems tend to continue even after the child has been told to stop or limit the behavior.

These behaviour pose a risk to the safety and well-being of the child and other children.

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Causes of Problematic Sexual Behaviours in Children

National Center on the Sexual Behaviour of Youth states following as some of the factors related to children with problematic sexual behaviour:

May have been sexually abused.
Witnessed violence or have been physically abused.
Have experienced other kinds of traumatic or frightening events without positive, healthy ways to cope.
Have problems following rules and listening to their parents, teachers, or caregivers at home, in school, and in the community.

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Causes of Problems in Children’s Sexual Behaviours

Have parents who struggle to provide close supervision

E.g depression, substance use, the need to hold multiple jobs, or simply nervousness or insecurity about parenting.

Resulting in poorly monitored television and video games access to children.

Have problems making friends their own age.

instead play with much younger children and act out sexual activities with them.

Or, may or may not have had any prior sexual or physical abuse.
Multiple factors may contribute to the development of problematic sexual behavior.

National Center on the Sexual Behaviour of Youth, n.d.

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Other Issues with Sexual Health Development

Research in many countries shows majority of teenagers report experience with sexual intercourse by eighteen years of age.
It is generally argued that young adolescents:

Are generally not “cognitively ready” for safe and consensual sexual interactions.
Are generally more impulsive.
Are more sensitive to social pressure.
Often have less knowledge about sexual risks, and tend to be less confident and assertive during interactions with partners.

Boislard, 2016

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Other Issues with Sexual Health Development

As a result young adolescent are vulnerable to sexual risks like:

Early initiators are more likely to have condomless sex.
Accumulate more sexual partners throughout adolescence.
Be vulnerable to sexual exploitations, have non-consensual sexual experiences.
Contract sexually transmitted infections (STIs).
Become pregnant as a teenager.

Boislard, 2016

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Female Genital Mutilation

Female genital mutilation (FGM) involves the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons.
Can cause severe bleeding, problems urinating, and later cysts, infections, as well as complications in childbirth and increased risk of newborn deaths.
Mostly carried out on young girls between infancy and age 15.
FGM is a violation of the human rights of girls and women
World Health Organization is opposed to all forms of FGM, and is opposed to health care providers performing FGM (medicalization of FGM).

World Health Organization, 2020

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Critical Thinking Question

How is knowledge of sexual health important to the nurse’s role?

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How to Promote Sexual Health in Children?

Protective factors that prevent onset and continuation of problematic sexual behaviours are:

Ability of informed adults to talk openly to children about relationships, intimacy, and sexual-education matters.
Close supervision and guidance of children.
Opportunities for children to be involved in age-appropriate activities (for example, sports, boys/girls clubs, after-school activities, and craft activities).
Friends who are caring and who make good decisions.
Warm relationships with caring adults.
Clear, positive messages about modesty, boundaries, and privacy.

National Center on the Sexual Behaviour of Youth, n.d.

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Nurses Role in Maintenance of Sexual Health

Initiate age-appropriate conversation about sexual health in every encounter with the client.
Acquire knowledge and skills to deliver sexual and reproductive health services that have been proven effective in clinical settings.

Includes counseling, behavioral screening, risk avoidance and reduction methods, and STI testing, as well as knowledge of treatment guidelines.

Advocate for youth friendly services, including private nurse–adolescent consultation time during each encounter.

Should ensure confidentiality within the parameters of state law.

Santa Maria et al., 2017

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Nurses Role in Maintenance of Sexual Health

Ensure developmentally appropriate sexual and reproductive health screening and counseling to adolescents and their parents¹.
Identify clients at high-risk for STIs, and ensure appropriate counselling and referral².
Be resourceful and knowledgeable about local care pathways for clients in need for more complex health promotions, specific programmes.
Involve parent in promotion of sexual health of their children.

Santa Maria et al., 2017
Barnes, 2009

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Nurses Role in Maintenance of Sexual Health

Verbally endorse importance of parent–child sexual health communication at each visit¹.

Ensure parents are counselled, if possible beginning before children become sexually active.
Parent-child communication on sexual health/protective practices, parental monitoring of behaviour in order to delay sexual debut.

Some facilitators of the nurse-client interactions are:

A positive attitude and effective communication².
Commend clients in good sexual practices like using condoms².
Clients needs met with ‘non-judgmental and supportive way’².
Maintaining privacy, confidentiality^1,2.

Santa Maria et al., 2017
Barnes, 2009

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Nurses Role Relating to Sexual Health of the Client

Assessment: Obtaining Sex History

Maintain privacy, without parent/friend/partner at some point to enable disclosure of sexual behaviour and possible abuse¹.
Communication method should be appropriate to client’s age.
Request permission to ask more personal questions and explain why you think it is relevant¹.
Information to be obtained:

Sexually active status.
Use of recreational drug/alcohol.
Sex practices (use of condoms, multiple partner, etc).
Current STIs status.

Forsyth & Rogstad, 2015

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Nurses Role relating to Sexual Health of the Client

Assessment:

Client may not voluntarily inform of sexual abuse, so be vigilant for possible signs of physical/sexual abuse:¹

Swelling or redness in the genital area
Pain when going to the toilet
Difficulty walking or sitting
Bruises on soft parts of their body, like buttocks or thighs
Discharge from the penis or vagina
Missed period

Needle stick marks of drug abuse for possible STIs.
Observe for problematic sexual behaviors².

Raising Children Network Australia, 2020
National Center on the Sexual Behaviour of Youth, n.d.

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Nurses Role relating to Sexual Health of the Client

Know national/state/local regulations and legal pathways relating to reporting of sex exploitation/abuse.
Report relevant authority of suspected sexual exploitation or abuse.
Facilitate referral to licensed mental health professional with specific knowledge of:

Child development (including sexual development).
Childhood mental health issues and Child trauma.
The relationship between social environment and sexual behaviors.
Scientific research on treatment for childhood mental health disorders and sexual behavior problems.
Cultural variations in parenting and attitudes toward sexuality.

National Child Traumatic Stress Network, 2009

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Critical Thinking Question

An 18-year-old high-school senior comes to the local family planning clinic requesting birth control pills. When discussing sexual health with the adolescent girl, nurse’s first priority would be to do which of the following?

Urge the teen to practice healthful sexual behaviors.
Inform her about the risk of pregnancy and STIs.
Assess the teen's knowledge of sexuality and reproduction.
Provide detailed information about birth control pills.

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Cultural Considerations

Sexual health education and care provided should be culturally sensitive¹.

Being knowledgeable and aware of client’s cultural values/beliefs, practices surrounding sexual practices.
Be aware of cultural variations in parenting and attitudes toward sexuality.
Level of comfort to talk about personal sexual health issues varies across cultures.

many may not approach voluntarily for guidance.

Factoring in of these cultural values, norms, practices in planning education and care interventions.

Santa Maria et al., 2017

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References:

Alberta Health Services (n.d.). Understanding your child’s development. teachingsexualhealth.ca. Retrieved on September 19, 2021 from https://teachingsexualhealth.ca/parents/information-by-age/birth-to-2-years/

Barnes J. (2009). Health promotion in sexual health 2: how to put theory into practice and empower clients. NursingTimes, 105(19):26-8. https://www.nursingtimes.net/clinical-archive/sexual-health/health-promotion-in-sexual-health-2-nurses-role-in-engaging-with-clients-14-05-2009/

Boislard, M. A., van de Bongardt, D., & Blais, M. (2016). Sexuality (and Lack Thereof) in Adolescence and Early Adulthood: A Review of the Literature. Behavioral sciences, 6(1), 8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810042/

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References:

Forsyth, S., & Rogstad, K. (2015). Sexual health issues in adolescents and young adults. Clinical medicine (London, England), 15(5), 447–451. https://doi.org/10.7861/clinmedicine.15-5-447

Gill, K. (2020). How to care for a baby penis. Healthline. Retrieved from: https://www.healthline.com/health/baby/baby-penis

Island Sexual Health Community Health Center (n.d.). Sexuality through lifespan. Retrieved on September 19, 2021 from https://www.islandsexualhealth.org/sexual-identity/lifespan/

National Center on the Sexual Behaviour of Youth (n.d.). What causes problematic sexual behaviour?. Retrieved on September 19, 2021 from http://www.ncsby.org/content/what-causes-sexual-behavior-problem

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References:

National Child Traumatic Stress Network (2009). Understanding and Coping with Sexual Behavior Problems in Children. Retrieved on September 19, 2021 from https://www.nctsn.org/sites/default/files/resources//understanding_coping_with_sexual_behavior_problems.pdf

National Sexual Violence Resource Center (2013). An overview of healthy childhood sexual development [PDF]. Retrieved on September 19, 2021 from: https://www.nsvrc.org/sites/default/files/2013-01/saam_2013_an-overview-of-healthy-childhood-sexual-development.pdf

Raising Children Network Australia (2020). Signs of sexual abuse in children and teenagers. raisingchildren.net.au. Retrieved from: https://raisingchildren.net.au/school-age/safety/child-sexual-abuse/signs-of-sexual-abuse

Contact info: info@nursesinternational.org

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References:

Santa Maria, D., Guilamo-Ramos, V., Jemmott, L. S., Derouin, A., & Villarruel, A. (2017). Nurses on the Front Lines: Improving Adolescent Sexual and Reproductive Health Across Health Care Settings. The American journal of nursing, 117(1), 42–51. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513155/

World Health Organization (n.d.). Sexual Health. Retrieved on September 19, 2021 from https://www.who.int/health-topics/sexual-health#tab=tab_2

World Health Organization (2020). Female Genital Mutilation. Retrieved on September 19, 2021 from https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation

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