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Defining Sexuality for Holistic Nursing Practice
Fintan Sheerin BNS(Hons) PgDipEd RNMH RGN RNT Research Associate, University of Ulster. and Hugh McKenna DPhil, RMN, RGN, DipN(Lond), BSc(Hons), AdvDipEd, RNT. Professor, Head of School of Health Sciences, University of Ulster.
Ref: Sheerin, F. and McKenna, H. (2000) Defining sexuality for holistic nursing practice: an analysis of the concept, All Ireland Journal of Nursing and Midwifery. 1, (3): 94 – 99.
Fintan Sheerin BNS(Hons) PgDipEd RNMH RGN RNT Research Associate, University of Ulster. Fintan Sheerin is associate lecturer in the School of Nursing and Midwifery Studies at the University of Dublin, Trinity College, Dublin, Ireland. He is currently pursuing postgraduate research studies at the University of Ulster with the support of an All Ireland Nursing Research Fellowship. A board member of the Association of Common European Nursing Diagnoses, Interventions and Outcomes, he is active in the examining the identification of nursing diagnoses in learning disability nursing.
Hugh P. McKenna, DPhil, RMN, RGN, DipN(Lond), BSc(Hons), AdvDipEd, RNT. Professor, Head of School of Health Sciences, University of Ulster. Dr McKenna is professor of nursing and Head of School of Health Sciences at the University of Ulster. He has published over 75 articles in national and international professional and academic journals and has written and co-written 4 books, one of which has been translated into Italian and Portuguese. He is Associate Editor of 'Quality in Health Care' and the International Journal of Nursing Studies. He is also an editorial board member of three other prestigious international journals. He is currently involved in post-doctoral research into evidence-based practice in primary care, smoking and nursing, the health promotion needs of carers of elderly people and nursing skill mix. He is married to a nurse; they have two children and live in Northern Ireland.
Defining Sexuality for Holistic Nursing Practice
Fintan Sheerin BNS PgDipEd RNMH RGN RNT Research Associate, University of Ulster.
And Hugh McKenna DPhil, BSc, DipN, RMN, RGN, AdvDipEd, RNT. Head of School of Health Sciences, University of Ulster. ___________________________________________________________________________ SHEERIN F & MCKENNA H Defining sexuality for holistic nursing practice Sexuality is an integral part of personhood, permeating all aspects of being. Nonetheless, agreement is lacking as to what sexuality actually is. The objective of this paper is to examine the usage and understanding of the term ‘sexuality’, and to extrapolate from these a working definition of the concept in its expressed condition. This is achieved by identifying the defining characteristics of the concept and considering their existence in a particular context. It is proposed that this resultant definition of expressed sexuality represents a move away from the limiting nature of previous understandings towards encompassing many forms of expressed sexuality.
INTRODUCTION It has been suggested that sexuality is an essential part of every person, permeating all other aspects of being (Stuart and Sundeen 1983, Burkhalter and Donley 1978, Shope 1975, Lion 1982). Furthermore, several nurse theorists have identified it as such within their conceptual frameworks (Roper et al 1990, Johnson 1980). That sexuality is relevant to nursing is obvious when considering the ‘holistic’ person (Levine 1971, Roy 1984), for then it becomes an integral aspect of being. Sheerin and Sines (1999) have described this holistic quality of sexuality in their treatise on the 'sexuality-related developmental potentials' of the person. It may therefore be deduced that, if an interdependence exists between the various aspects of the person, as is suggested by the above frameworks, then problems that relate to one aspect may have consequences for another.
Many nursing frameworks, while attempting to describe individuals in holistic terms, proceed to divide them into activities/systems/behaviours for the purpose of systematic assessment (Roper et al 1990, Johnson 1980, Gordon 1994). The end result is that the person is assessed in a segregational rather than an integrational manner, with no attempt being made to reintegrate those parts back into the whole, that being the function of expert practice (Benner 1984, Gordon 1994).
When considering sexuality as the permeating aspect of being, and as that part of personhood that integrates all others, its relevance to nursing becomes apparent, for it is this factor which underpins the entire concept of holism. Such reasoning is however based on an explicit definition of sexuality that is broad and inclusive. Sadly, the nursing literature does not offer such explication; rather the concept of sexuality is almost ignored by nurses (Savage 1990). Using qualitative methods some researchers have investigated the reasons for this (Lief and
Payne 1975, Payne 1976, Roy 1983, Webb and Askham 1987, Webb 1988). In essence, they have found that the crux of the problem is that no one knows what sexuality actually is, and that attempts to define the concept have frequently resulted in further confusion and avoidance (Carr 1995, Savage 1990, Watson 1991).
This paper aims to rectify the current situation, providing a definitive analysis of sexuality as an expressed concept through using the approach proposed by Walker and Avant (1995). It will further examine this re-definition of sexuality by applying the defining attributes to two conceptual aspects of it, namely gender and sexual-identity. This exercise will form a basis for providing a holistic, inclusive definition of sexuality as an expressed concept.
Defining the concept 'expressing sexuality' The Oxford Paperback Dictionary (1990) defines 'sexuality' in terms of 'belonging to one of the sexes' and as 'sexual characteristics or impulses' (p.744). It further defines sex as i) the categorisation of living things into one of two gender groups; ii) the act of sexual intercourse; iii) sexual feelings or impulses; and iv) the mutual attraction between members of the two sexes. Dorland's Illustrated Medical Dictionary (1988) focuses on the reproductive, attitudinal and activational characteristics associated with membership of either of the two sexes.
Therefore, on the basis of these definitions, one might describe sexuality as referring to characteristics, feelings and impulses attributed to persons belonging to either one of the two sexes. The Oxford Paperback Dictionary (1990) defines the action 'to express' as making known feelings or qualities, putting thoughts into words, squeezing out and symbolically representing something. To 'express oneself' is defined as "to communicate one's thoughts or
feelings" (p.281). Considering this in conjunction with the description of 'sexuality', one may conclude that 'expressing sexuality' may be defined as making known/communicating those feelings, qualities and impulses attributed to persons belonging to either one of the sexes. There is a tacit implication in all of the above definitions, however, that these qualitative aspects of person-hood are defined solely in terms of heterosexuality (mutual attraction between members of the two sexes). In contemporary society the rights of bisexuals and homosexuals are being formally ratified, and the acceptance of other forms of sexual expression is being slowly realised. Therefore, a definition of sexuality that does not explicitly define sexuality in terms of mutual attraction among members of the two sexes, must be seen to be wholly inadequate.
Sexuality as an expressed concept in the professional literature A comprehensive literature search strategy was employed to uncover theoretical and research work pertaining to sexuality and the meaning attributed to the concept. As well as hand searching, Medline, Cinahl, Psychlit, the Cochrane and CRD databases were explored. While a large number of sexuality ‘hits’ were identified our focus was directed at those sources that pertained to human expression of sexuality.
Much of the literature investigating nurses' attitudes towards sexuality has tended to address the concept from a behavioural point of view (Lief and Payne 1975, Payne 1976, Roy 1983, Webb and Askham 1987, Rose and Holmes 1991). This is evidenced by the frequent use of the Sex Knowledge and Attitude Test (SKAT) (Lief and Reed 1972, cited in Payne 1976) which focuses on behavioural aspects of sexual expression (Payne 1976). Although some of these authors define sexuality in terms of the integration of values, feelings and personality (Roy 1983, Webb and Askham 1987), they fail through their use of the SKAT to address
nursing attitudes from this perspective and so they demonstrate ambiguity in their explanation of the concept.
The identification of 'sexuality' as an integral part of the whole person has permeated the theoretical nursing literature, with the concept being related to identity (Stuart and Sundeen 1983) and interpersonal relationships (Shope 1975). Hogan (1980) describes it in terms of that which makes one human. More recently Lion (1982) and Carr (1991) echo this sentiment.
The issue of gender-identity has been linked closely to sexuality in nursing literature. Shope (1975) suggests that sexuality reflects one's gender orientation. Behi and Behi (1987) and Savage (1990) explore the gender issue further through their identification of body-image and body awareness as being important aspects of sexuality. Woods (1987) emphasises the centrality of sexual self-concept to sexuality. This is supported by Weston (1993) who describes it as involving a continual process of recognising, accepting and expressing ourselves as sexual beings. These concepts have been widely expanded upon within gay literature, which provide a number of approaches to addressing sexual identity (Rust 1996, Udis-Kessler 1996, Plummer 1975, Ponse 1978, Troiden 1979). An interdependence between sexuality and self-identity is suggested by Troiden (1988) in his four-stage model of homosexual identity formation. The complexities of sexual identity are teased out further by Shively and De Cecco (1977), who identify the following components: biological sex, gender identity, social sex-role, and sexual orientation. Friend (1987) employed this framework of sexual identity in his discussion of sexuality and human diversity, thus proposing an interesting rationale for the normalisation of such diversity.
The nursing literature therefore identifies several aspects of expressed sexuality: sexual behaviour; holistic integration; self-awareness; gender orientation; self and sexual identity; communication of identity; and self-acceptance. There appears however, to be an ambivalence in the attitude of nursing towards sexuality as a concept. Whilst, on one hand, there is a recognition of the holistic nature of human sexuality, practice and research appears to return to a functional definition of the concept in terms of sex behaviour.
Sexuality as an expressed concept in society The popular understanding of sexuality is that which is promulgated through the media of magazines and films. This is usually expressed in terms of sexual behaviours that have as their goal self-gratification through sexual intercourse. Although this may appear to be an oversimplified approach to the expression of sexuality, it does introduce important aspects not yet discussed.
Morris (1994) approaches the human expression of sexuality in evolutionary terms. In this, sexual behaviours such as dressing up, flirting and dating echo the courtship rituals of other species. These behaviours, allied to the hormonal and pheromonal aspects of physiology as well as the erogenous nature of certain anatomical zones, serve as a preface to the pleasurereinforced behaviour of coition. The primal force behind these behaviours is the continuation of the human species. Morris (1994) suggests that these expressions of sexuality now have a different focus, evidenced by the fact that much of the sexual behaviour of modern humans does not lead to coition. Greer (1991) and Reik (1975) would contend that the male aim, according to cultural modelling, is self-gratification, whereas the female aim includes gratification of the other person. Llewellyn-Jones (1990) supports this in his discussion of the experiences of bisexual women.
Within the Irish context, it is interesting to examine the Gaelic translation of 'sexuality'. De Bhaldraithe (1959) provides the word collaíocht as the equivalent to 'sexuality'. When translated back to English in Ó Dónaill's (1977) dictionary, this also translates as 'carnality', which equates with the Gaelic word for 'lust' - drúisiúil. In Gaelic terms, therefore, it may be argued that sexuality represents solely an expression of carnal and presumably, animalistic urges.
Fashion and dance may be among the purest forms of expressing sexuality. Fashion design seldom focuses on the functionality of the garment. The garment itself does not express sexuality. It does however, serve as a medium for expression when worn by a person. When chosen as such, it becomes a statement of personal preference, and may through its design and colour emphasise more intimate aspects of person-hood, such as feelings, beauty, selfconcept and gender-orientation.
DEFINING ATTRIBUTES Having considered the uses of sexuality as an expressed concept, both in the literature, and in common usage, it is now possible to identify the defining attributes of the concept. These are:
A conscious perception and acceptance of one's sexual identity at a given time; Communication of feelings, impulses and qualities associated with this sexual identity; Reception, interpretation and reciprocation of these feelings, impulses and qualities on the part of other(s);
Context: gratification of self and/or other(s).
Demonstration of model cases, a borderline case and a related case It has been suggested that cases representing the concept are useful in the clarification of the defining attributes for that concept (Chinn and Kramer 1991). To this end, model, borderline and related cases shall be demonstrated. The situations which are described do not recall actual experiences, but do relate to perceived realities.
Model case A model case is one in which all of the defining attributes are present. It is therefore a definitive occurrence of the concept (Walker and Avant 1995). The first model case examines the experience of sexuality as an expressed concept, within a person to person relationship. Although a heterosexual relationship is described, diverse relationships could be similarly presented as model cases.
Patrick has been living with Emer for three years. They feel very strongly attracted to each other. Tonight they are going out together. Pat dresses up in his best clothes and, after shaving, puts on the aftershave, which he knows Emer, loves. She too wears the outfit he finds most arousing. They go to a nightclub, where they have a few drinks and dance. Emer responds positively to Pat's attempts to impress her, as does he to hers and they kiss and fondle each other as they dance. It is late when they get out of the club, and they walk home together. During the night they make love. Conscious of each other's needs and desires they both achieve sexual release.
In this model case, all of the defining attributes are present. Both of the individuals consciously perceive and accept their sexual identity, through their feelings of attraction to each other. They communicate their identity-specific feelings and impulses to each other
through each one's behavioural and cosmetic attempts to arouse the other. These feelings are received by the other and interpreted, as evidenced by their reciprocative behaviour. The situation is set within the context of mutual sexual satisfaction.
Borderline case Borderline cases have been defined as "situations in which the concept appears only occasionally or appears under a new set of conditions" (Meleis 1991. p.224). These new conditions, whilst retaining the same defining word, may describe a wholly different experience to that portrayed in the model case (Chinn and Kramer 1991). In the following case, sexuality is expressed but the expression is not consistent with that which is felt by the subject.
Máire has felt strongly attracted to other women for as long as she can remember. She had an encounter with a female college friend, some months ago, but would not pursue a relationship. She knows that she is a lesbian, but having been brought up as a Roman Catholic in a secularist society, she experiences guilt feelings whenever she thinks about 'coming out'. Since that one-night stand she has only dated men, and although she feels that she is living a lie, it is the easiest path for her to follow. She maintains this situation by doing what she can to be attractive to her male friends. She does not enjoy heterosexual lovemaking and often fakes orgasm. She wants to ensure that her 'partner' enjoys making love, so that he does not suspect that anything is amiss.
This case describes many of the defining attributes presented in the model cases, but whereas Máire is conscious of her attraction towards other women, she does not exhibit the feelings and impulses associated with this perceived gender attraction. This creates a discrepancy
between perceived sexual identity and expressed sexuality. She communicates instead, those attributes characteristic of heterosexual femininity, and it is these feelings that are reciprocated by her male partner and friends. The context of gratification is maintained through her ensuring that her partner experiences pleasure during lovemaking.
Related cases Related cases refer to those concepts which do not contain the defining attributes of the concept under study, but which are related to it. In the case described below, none of the defining attributes of sexuality as an expressed concept are present.
Sr.Úna has spent the past six years living within the confines of a monastery. She decided, long ago, that she wanted to spend her life as a virgin consecrated to God. Today, the time has come for her to take her final vows. Wearing her simple religious habit, she approaches the altar, where she pledges her life to God, through her vows of poverty, obedience and chastity.
Here, Sr.Úna is expressing the feelings, impulses and behaviours associated with being a female religious, dedicated to a life of chastity, within a one-sex institution. Sexual identity is not relevant here, and any expression of the attributes associated with her identity is not consciously communicated. Because of this, there is no reciprocation of feelings. The context is not gratification of another, but rather a wish to share, through prayer, "the fatigue, the misery and the hopes of all mankind" (Flannery, 1981. p.666).
Antecedents and consequences Walker and Avant (1995) emphasise the importance of identifying the antecedents and consequences of the concept, so as to provide the social context for its occurrence. Antecedents are described as those events that are required to take place prior to a valid occurrence of the concept, whereas consequences are those events that take place consequent to the concept’s occurrence.
Antecedents The antecedents that must take place, prior to a valid occurrence of the concept are addressed in relation to the defining attributes.
A conscious perception and acceptance of one's sexual identity at a given time.
This attribute demands that the person must have undergone a period of reflection on his/her sexuality. Whilst this may not be a formal conscious process, it could be a normal part of psychosexual and emotional growth, occurring according to the developmental processes of cognitive-social learning theory (Dworetzky 1991). This process of reflection results in selfawareness on the part of the person, attained through a thorough examination of one's feelings and attitudes.
The ability to consciously perceive and accept one's sexual identity may be greatly affected by the contexts of religion, social norms and judicature. It is, for example, of note that homosexual acts are adjudged, to be "acts of grave depravity" by the Roman Catholic Church (Catechism of the Catholic Church 1994. p.505), to be illegal, in many U.S. states (Kosofsky Sedgwick 1994), and to constitute aberrant behaviour, by many societies.
Communication of feelings, impulses and qualities associated with this sexual identity. Reception, interpretation and reciprocation of these feelings, impulses and qualities on the part of other(s).
These attributes demand that there be ability, on the part of the person, to communicate and receive sexual cues. This again depends on adequate emotional-social development and on the mastery of the social skills of communication such as listening, intuition and observing. Communication of sexuality also depends on one possessing the self-confidence to transcend prejudices and conforming needs, so as to be free to express one's true sexuality.
Gratification of self and/or other(s)
The principles of behaviourism propose that behavioural learning may be strengthened by the use of positive reinforcements - stimuli following behaviour, which cause an increased probability of the behaviour reoccurring. Gratification may act as a powerful reinforcing stimulus and, as an antecedent, may increase the chance of sexuality being expressed again.
Consequences The consequences of expressing sexuality relate largely to positive and negative aspects of personal fulfilment and intimacy.
The gratification attribute, as a positive experience, reinforces the emotional stability and security in the person, by acting as a nurturing force (Plutchik 1980, cited in Dworetzky 1991). If this gratification also has a physical component, it will result in a more generalised experience of satisfaction, a sense of wholeness. Expressing sexuality may also increase
interpersonal closeness, especially where the gratification attribute is a shared experience, or where it is freely given to the other.
When sexuality is expressed, there are risks associated that may result in negative consequences for the individual. One may experience social rejection if one does not communicate the attributes of the most common sexual identity in that social grouping. Rejection of one's sexuality may also be experienced on a one-to-one basis, where a desired partner spurns one's advances. This may result in the development of feelings of inadequacy and dejection (Plutchik 1980, cited in Dworetzky 1991).
Gender rejection may follow the expression of sexuality, through the practice of gender discrimination. This has historically been evidenced by the manner in which male employees received better benefits and positions than their female counterparts (O'Dowd 1986).
A final, possible consequence of expressing sexuality is pregnancy. As such, it is the primal aim of species continuation, as described by Morris (1994).
Empirical indicators McKenna (1997) defines empirical indicators as being "explicit criteria" by which the existence of the concept may be reckoned (p.25). However, as Walker and Avant (1995) admit, the empirical indicators of some abstract concepts may not be easily explicated.
The concept of expressing sexuality must similarly be alluded to, through the identification of outward impulses and qualities normally associated with a particular sexual identity.
However, whereas these may be expressions of one's sexuality, they do not provide an insight into the conscious perception and acceptance of one's sexual identity.
The empirical referents for the expression of sexuality are therefore:
Expression of behavioural norms usually associated with a particular sexual identity;
Wearing sexual identity-specific styles and types of clothing and cosmetics; Developing and/or maintaining open intimate relationships with partners according to one's sexual identity.
An holistic definition of sexuality Whilst the defining attributes have been defined from the perspective of sexual identity, it has been noted above that sexuality is more commonly defined, within society, from a heterosexist, physical-gender perspective. Consideration of this aspect as the principal term of reference for the defining attributes demands that for sexuality to be expressed there must be:
A conscious perception and acceptance of one's physical-gender at a given time; Communication of feelings, impulses and qualities associated with this physical-gender; Reception, interpretation and reciprocation of these feelings, impulses and qualities on the part of other(s) of the opposite physical-gender;
Context: gratification of self and/or other(s).
When these are examined, it becomes clear that this corresponds with the heterosexist paradigm where the perception and acceptance of being physically male or female is considered to be normal. The attributes associated with being biologically male or female (masculinity and femininity) are communicated, with reciprocation being normally made by another of the opposite physical-gender. The implications of this for human diversity are presented in figure 1.
Please insert figure 1 here
It is obvious from figure 1 that within the context of the predominantly heterosexist practices of western society (Innes and Lloyd 1996, Plummer 1998), any deviation is seen to be abnormal and so, is an invalid expression of sexuality. This poses major philosophical problems for the practice of holistic nursing. If, as it has been suggested, sexuality and sexual identity are essential and permeating aspects of personhood being (Sheerin and Sines 1999, Stuart and Sundeen 1983, Lion 1982, Burkhalter and Donley 1978, Shope 1975), then, it is the person's perception of sexuality and not that of society or nursing that is important.
The substitution of sexual identity (as the person's own perception of sexuality) for physicalgender within the defining attributes yields a re-definition of expressed sexuality which is both inclusive and recognisant of the holistic quality of sexuality, thus justifying its presence as the basis for this definition. This inclusive aspect, which is demonstrated in figure 2, is all the more interesting in that, the usage of sexual identity as the basis for approaching a definition of expressed sexuality does not appear to create a stigmatising categorisation of abnormality.
Please insert figure 2 here.
Conclusion Sexuality as an expressed concept is an essential aspect of person-hood, and as such is an important component of the holistic individual (Fuller 1978). It has been shown that sexuality permeates this wholeness and that it finds expression physically, behaviourally, cosmetically, emotionally and æsthetically. However, as an interdependent component of person-hood, its importance is grossly underestimated and often ignored by nurses.
The capacity of the concept to find expression in many ways has been discussed. Conservative interpretations of the term imply that the heterosexist form of expression is the definitive one, and that other forms come, not under a definition of expressed sexuality, but under the heading of aberrant sexuality. An understanding of sexuality as an expressed concept is presented which encompasses many expressive forms of sexuality. Employing ‘sexual identity’ rather that ‘physical-gender’ as the basis for the definition enhances this. Whilst it may still be a limiting definition, it is argued that it bears relevance to the behavioural norms that are current in western society.
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