DSM-5-TR places three separate groups in distinct chapters. They are taught together because each involves sexuality or gender, but they are different concepts: a sexual dysfunction is a problem with sexual response; gender dysphoria is distress about a mismatch between gender identity and assigned sex; a paraphilic disorder is an unusual sexual interest that causes distress or harm to others. Sexual orientation and gender identity are not disorders.

Sexual response cycle (desire, arousal/excitement, orgasm, resolution) involves hormones (testosterone, estrogen), neurotransmitters (dopamine promotes, serotonin inhibits), autonomic function (parasympathetic for erection and lubrication, sympathetic for ejaculation), vascular supply, and relationship and emotional context.

Sexual dysfunctions — present about 75–100% of the time for about 6 months, causing significant distress, and not better explained by another condition, relationship distress, or substance:

Physical contributors: diabetes, vascular disease, hypertension, smoking, obesity, low testosterone, pelvic surgery, spinal cord injury, depression, anxiety.

Gender dysphoria

• Clinically significant distress or impairment associated with a marked incongruence between a person's experienced/expressed gender and gender assigned at birth, lasting at least 6 months
• Adolescents and adults: at least 2 of 6 indicators (e.g., strong desire to be rid of one's sex characteristics, strong desire to be treated as another gender)
• Children: at least 6 of 8 indicators, which must include a strong desire to be, or insistence that one is, another gender
• The diagnosis centers on distress; gender diversity itself is not a mental disorder. ICD-11 uses the term "gender incongruence" and has moved it out of the mental disorders chapter.
• Higher rates of depression, anxiety, and suicidality are linked in part to minority stress (stigma, rejection, discrimination, violence).

Paraphilic disorders

• A paraphilia is an intense, persistent atypical sexual interest. It becomes a paraphilic disorder when it causes distress or impairment to the person, or when satisfying it involves harm or risk of harm to others, including acting on it with nonconsenting persons; duration at least 6 months
• Types: voyeuristic (watching unsuspecting people), exhibitionistic (exposing genitals to unsuspecting people), frotteuristic (touching or rubbing against a nonconsenting person), sexual masochism, sexual sadism, pedophilic (sexual focus on prepubertal children; the person is at least 16 years old and at least 5 years older than the child), fetishistic (nonliving objects or nongenital body parts), transvestic (arousal from cross-dressing with distress)
• More common in males; often begin in adolescence; frequently co-occur with other paraphilias, mood, anxiety, and substance use disorders

Approach for all groups

• Private setting, nonjudgmental tone, plain language; explain why questions are asked
• PLISSIT model: Permission, Limited Information, Specific Suggestions, Intensive Therapy — nurses provide the first levels and refer for the last
• Nurse self-awareness: recognize personal values so they do not affect care

Sexual dysfunction

• Onset (lifelong vs. acquired), situational vs. generalized, relationship context
• Review all current medications first, including over-the-counter and recreational drugs
• Chronic illness, cardiovascular risk, depression, anxiety, alcohol and tobacco use
• A normal nocturnal penile tumescence test (erections during sleep) suggests a psychogenic rather than organic cause of erectile disorder

Gender dysphoria

• Ask the name and pronouns the client uses and record them; use them consistently
• Assess distress, supports, family acceptance, school or work safety, bullying or violence
• Screen for depression, self-harm, and suicide risk
• Current or planned hormone therapy, including non-prescribed hormones
• Use an organ-based approach for physical assessment and screening (e.g., cervical screening for anyone with a cervix)

Paraphilic disorders

• Nature, frequency, and targets of urges and behaviors; whether they involve nonconsenting persons or children
• Legal history, insight, motivation, guilt and shame, co-occurring substance use
• Risk to others — takes priority over confidentiality where law requires reporting

Sexual dysfunctions

• Treat underlying conditions; reduce alcohol and smoking; increase activity
• Sex therapy and couples therapy: sensate focus, communication training; stop-start or squeeze technique for early ejaculation; pelvic floor physical therapy and graded dilators for genito-pelvic pain
• SSRI-induced dysfunction: do not stop the antidepressant abruptly; options include dose reduction, switching to an agent with fewer sexual effects (bupropion, mirtazapine, vortioxetine), or adding a PDE-5 inhibitor — decided with the prescriber

Gender dysphoria

• Psychosocial care: psychotherapy for distress and co-occurring conditions (not aimed at changing identity), family support, social transition when chosen
• Gender-affirming medical care for adults after multidisciplinary assessment and informed consent (WPATH Standards of Care, version 8):
  • Estrogen with or without an antiandrogen (spironolactone): risk of venous thromboembolism (higher with smoking and older age), raised prolactin; spironolactone → hyperkalemia, polyuria
  • Testosterone: erythrocytosis (monitor hematocrit), acne, lipid changes, blood pressure; it is not a contraceptive and is teratogenic — pregnancy is still possible
  • Fertility preservation counseling before starting — hormones may reduce fertility
  • Gender-affirming surgeries for selected adults
• Minors: puberty suppression and hormones for adolescents are an area of active scientific and legal debate; policies differ widely between countries and US states. Several countries (e.g., Finland, Sweden, England) restricted routine use after evidence reviews from 2020 onward, and US federal policy also changed in 2025; other professional bodies (e.g., WPATH, Endocrine Society) continue to support it for selected adolescents. Nurses follow current local law and institutional policy while giving respectful, supportive care.

Paraphilic disorders

• CBT with relapse prevention: identify triggers and high-risk situations, challenge cognitive distortions (e.g., "this doesn't harm anyone"), victim empathy training, redirect sexual energy into socially acceptable, consensual outlets
• SSRIs to reduce intrusive urges
• Antiandrogens (medroxyprogesterone acetate, GnRH agonists such as leuprolide) for high-risk clients, with informed consent — bone loss (monitor bone density), weight gain, hot flashes, depression, metabolic effects
• Legal system involvement is common

Listed in priority order.

1. Safety
   • Suicide and self-harm risk assessment for clients with gender dysphoria and those with shame related to paraphilic behavior
   • Protect others: follow mandatory reporting laws for child abuse; confidentiality has legal limits when there is serious risk to an identifiable person
2. Therapeutic, nonjudgmental relationship
   • Use the client's chosen name and pronouns; keep information confidential
   • Accept the person while not condoning harmful behavior; express that guilt and willingness to discuss behavior can support change
3. Physiologic causes first in sexual dysfunction — check medications and chronic illness before assuming a psychological cause; if symptoms worsened after starting an SSRI, explain that it may be a drug effect and to discuss it with the prescriber rather than stopping the drug
4. Support identity exploration — for an adolescent with gender dysphoria, the initial goal is to reduce distress, support exploration and self-acceptance, and strengthen family support
5. Family counseling — help parents acknowledge the young person's distress and respond with support; provide accurate information and referral to specialist services
6. Therapy support — reinforce relapse prevention plans and coping strategies; encourage couples communication

• Many medicines affect sexual function — report changes rather than stopping the drug
• PDE-5 inhibitors: never with nitrates (including "poppers") — no nitrate within 24 hours of sildenafil or vardenafil, or 48 hours of tadalafil; seek care for erections over 4 hours or sudden vision or hearing loss
• Limit alcohol and stop smoking to improve sexual function and vascular health
• Hormone therapy: take only prescribed hormones; keep lab appointments; report leg swelling, chest pain, or shortness of breath (clot signs); use contraception if pregnancy is possible on testosterone; stop smoking
• Safer sex and STI testing for all clients
• Paraphilic disorders: follow the relapse prevention plan; avoid high-risk situations; seek help immediately when urges increase
• Family: accept and support the person; distress, not identity, is the treatment target

• Sexual dysfunction criteria: about 6 months, most occasions, with distress
• SSRIs are a leading cause of sexual dysfunction — discuss options with the prescriber, do not stop abruptly
• Assess medications and physical causes first
• Normal nocturnal penile tumescence → psychogenic erectile disorder
• PDE-5 inhibitors: contraindicated with nitrates; priapism over 4 hours is an emergency
• Gender dysphoria = distress from gender incongruence for 6 months; gender identity itself is not a disorder
• Use the client's name and pronouns; screen for suicide risk; supportive family response
• Estrogen → VTE; spironolactone → hyperkalemia; testosterone → erythrocytosis, not contraceptive
• Paraphilic disorder = paraphilia with distress or harm/nonconsent; pedophilic: at least 16 and 5 years older than child
• Paraphilia treatment: CBT to challenge cognitive distortions, relapse prevention, SSRIs, antiandrogens
• Ethics: respect confidentiality but protect others' safety