Poslední úprava: PhDr. Eva Šírová, Ph.D. (28.02.2020)
1. Psychosexual development
1.1. Biological determination of sexual development
Biological basis of sexuality is above all the sexual dimorphism, which is determined by chromosomal sex, gonadal differentiation, hormonal factors, inner reproduction organs and morphology of genitalia. On the chromosomal level, the male sex is distinguished by the genotype 46 XY, the female one by 46 XX, whereas the sexual chromosomes X and Y have the determinant impact on the forming process of initially undifferentiated primary gonades of the foetus. The feminisation end masculinisation of genitalia (which proceeds during the second and at the beginning of the third month of gravidity) is subject to hormonal regulation. The main determining factor of sexual differentiation is testosterone.
The psychosexual evolution of individuals is continuation of embryonal development of sexual structures - physical sexual development constitutes anatomic and functional background for sexual differentiation of behaviour, emotions and mind.
1.2. Determinants of psychosexual development
Development of sexual identification, sexual role, sexual preferences and sexual behaviour can be considered as the basic determinants of psychosexual development.
a/ Sexual identification
Sexual identity, i.e. the feeling of belonging to particular gender, is formed on the basis of genetic and prenatal (hormonal, gonadal) determinants mediated by the organising influence of sexual steroids on central nervous system during the second trimester of the intrauterine development. Its final forming proceeds then after the delivery due to the interaction of this predisposition and the environment. Forming of gender identity is probably mostly determined before the age of 18 months. The basis of sexual identification is a concept of self that is created in the learning process, especially social learning as well as cognitive learning, which is typical for human beings.
b/ Sexual role
Sexual role is the external display of gender identity. Although there are also constitutional factors participating in its formation, cultural and social influences, mediated mainly by family, play the decisive role. Parents are just the main identification figures for their child, important for the development of adequate behaviours as well as the attitudes towards the opposite sex. In the school age, the parental influence on the formation of the sexual role is complemented by the influence of peer groups and other cultural and social influences (school, media, etc.)
c/ Sexual preferences
The mechanism of the development of sexual preferences (the way an individual reaches sexual satisfaction and which objects erotically prefers) has not yet been fully resolved. Most probably, the constitutional factors are the basic ones. Genetic factors may i.g. determine the preparedness to respond to erotic signals of certain kind. Some role can be also credited to a specific "programming" of sexual centres during the crucial phases of prenatal development. Influences of environment assert probably themselves only on the basis of innate mechanisms.
The proof of importance of constitutional factors in the development of homosexual orientation can for example be represented by 40 - 60% concordance of homosexuals in enzygotyc (monozygotyc) twins or hormonal reaction of homoerotically oriented men to providing of oestrogens. Attempts to deduce homosexual orientation for example from familial constellation, defectivity of parental models or from other environmental influences have all failed so far. Similarly, all "therapeutic" (i.g. behavioristic, as aversion therapy, shame therapy etc.) procedures, centred on the change of sexual orientation, have not been successful.
Most disorders in the area of sexual preferences develop only during pubescence or adolescence. Although even in pre-pubertal period, we could observe for example cross-dressing in transvestites, preference of certain fetish during masturbation in fetishists, voyeuristic, exhibitionistic or other unusual sexual practices in individuals with differently deviant development of sexual motivation, it is only in pubescence that the content of sexual fantasies (of i.g. sadomasochistic, exhibitionistic or paedophile character) could show evidence of disorder in sexual preference in the sense of paraphilia.
d/ Sexual behaviour
Capability to genital reaction is present in human beings since babyhood. Genital stimulation together with orgasm was observed in boys and girls since their 6th month and the masturbation of children often persists as the predominant sexual activity until the beginning of partner sexual activities.. According to surveys, majority of boys and a significant percentage of girls are masturbating already in the pre-pubertal period, this behaviour only becomes, gradually with age, less and less visible, more intimate matter.
Sexual games are similarly frequent child activity that appears most often at about the age of five. In general, these are not of erotic character, they are only a display of children’s curiousness. These activities consist mainly in mutual exploration of intimate body parts, often include also imitation of sexual activities of adults, practically only in non-coital forms. Masturbation as well as these sexual games are absolutely natural and innocuous, on the contrary, forbidding or punishing them can have deteriorative impact on differentiation of gender identity and role.
In pubescence, there is an integration of gender identity, sexual reactivity and sexual preference. In our population, this happens between 1Oth and 15th year of age, physically girls experience menarche and boys the first ejaculations. Especially in boys this development is joined with an intense increase in sexual need and activity. Psychosexual development is delayed compared with the somatosexual one, in this period, the capability of young people of emotional romantic attachment, pair bonding or their moral and ethical values are only forming.
The development of sexual behaviour is contingent on the development of sexual emotions that are just formed mainly in pubescence and adolescence. It is a case of sexual arousal (whose physiological correlate for men is erection and for women lubrication), orgastic function and sexual satisfaction, and finally of the development of love attachment as an erotic fascination.
2. Sexual deviations (paraphilias)
From the sexological point of view, we can consider as normal such consensual sexual activities that take place between psychosexually and somatosexually mature enough and not lineally consanguineous partners and that do not lead to psychical and/or physical harm.
According to official International Classification of Diseases (ICD) published by WHO in the 10th revision in1992, in the chapter "Mental and behavioural disorders", sexual deviations are included in the section "Personality and behavioural disorders" under code F 65 as "Sexual Preference Disorders", paraphilias. Paraphilias are, according to this classification, characterized by "sexual impulses, fantasies and practices that are unusual, deviant or bizarre". Following conditions belong among general diagnostic criteria of paraphilia as to ICD 10: a) an individual repeatedly experiences intensive sexual desires and fantasies concerning unusual objects and activities, b) the individual either satisfies his/her unusual desires, or is intensively bothered by them, c) the preference is present for at least 6 months.
Sexual deviations (paraphilias) are considered as qualitative sexual motivation system structure disorders. They include a wide range of activities, from harmless but socially difficult behaviour (indecent exposure, cross-dressing) to the most dangerous offences against human dignity, health or life of victims. Socially dangerous sexual deviations can turn out as sexual crime. It is however important to be aware of the fact that by far not all the sexual crimes are committed by deviant offenders (especially in the cases of rapes or sexual abuses of children the perpetrators are more often sociopathic, impulsive or aggressive psychopaths, alcoholics, socio-sexually immature individuals, mentally handicapped, to some extent also psychotics) and at the same time not all deviants commit sexual crimes.
It is very likely that the development of deviation is caused by innate (inborn) predisposition, whereas later circumstances - education, sexual experience, etc. - play only framing role. The exact mechanism of development of the deviant sexual preferences is however not known yet. Nevertheless, we are able, on the basis of specialized therapeutic programmes, to teach a patient to live with his/her disorder - which means above all that they do not harm their surroundings and find a suitable solution of their sexual needs. In some cases we are only able to suppress the patient’s sexuality to the level at which he/she is capable to manage his/her urges by will. The suppression can be attained by long-run administration of anti-androgens or some psychofarmacs reducing sexual appetence of a person, or - in exceptional cases and only upon patient’s request - also by surgical castration.
Basically, we distinguish two types of sexual deviances - deviations in activity and deviations in object. Beside these two basic ones, we distinguish combined or polymorphous deviations (more types of deviant preferences co-existing at the same time). These are above all:
1. Deviations in activity (it means in the way of reaching sexual arousal and sexual satisfaction):
a/ Voyeurism - arousal is reached by observation of intimate behaviour of unaware anonymous subjects (undressing women, copulating pairs), connected generally with masturbation.
b/ Exhibitionism - arousal is reached by exposing genital in front of unknown women or girls, sometimes connected with erection (not every time), whereas exposure of genitalia can take place in front of a lonely woman as well as a group of several women or girls.
c/ Scatofilia (obscene telephoning) -arousal is reached by anonymous phone calls with erotic or lew content.
d/ Frotteurism - arousal is reached by rubbing oneself against anonymous, unknown women in crowds (in queues, in trams).
e/ Toucherism - arousal is reached by touching intimate parts of anonymous females
f/ Pathological sexual aggressiveness (paraphilic rapism) - arousal is reached by repression and minimisation of attacked anonymous women’s resistance, minimisation of their cooperation. In certain sense, we can classify as pathological sexual aggressors also aggressive sadists, that means deviants who in order to achieve sexual satisfaction need to stun or paralyse in other way his victim before (or instead of) intercourse. The majority of sexual murderers belong to this category.
g/ Sadism (excitement is reached by total control over the partner) and masochism (excitement is reached by total commitment of oneself, humiliation) often occur together, we talk therefore about sadomasochism. Sadomasochist activities frequently occur in the form of so-called partner sadomasochism where the needs of both partners are complementary and take place with mutual agreement.
2. Deviations in object (it means in object of the erotic desire):
a/ Pedophilia - erotic preference of objects in prepubertal age (of boys and girls without signs of puberty), most often in the age of 5-12. Pedophiles prefer both physical immaturity of the object, i.e. absence of secondary sexual characteristics (lack of pubic hair and breasts in girls, for homosexual pedophiles also absence of ejaculation), and its childlike behaviour (spontaneity, innocence, credulity, dependence).
b/ Fetishism - erotic preference of objects or parts of a human body, which stand for normal sexual object (in certain sense we can classify among fetishistic orientation also zoophilia - the fetish is an animal, necrophilia - the fetish is a corpse, statuophilia - the fetish is a statue, mysophilia - the fetish is dirt, pyrophilia - the fetish is fire, there exists also fetish orientation on rubber, nappies, women shoes, etc.). The most common fetish is women underwear, but it can also be some part of a body (hair, big breasts, legs) - so called partialism.
c/ Transvestism - arousal is reached by dressing into clothes of the opposite sex (cross-dressing) and playing the role of the opposite sex. The feeling of belonging to their own sex (sexual identity) is usually not considerably affected, a man, despite women clothes and behaviour, still feels to be a man.
Diagnostics and treatment of sexual deviants belong basically to the competence of specialized sexologists. TheCzechRepublicis one of the few where this medical specialization exists and which has a developed specialized programme of treatment of these clients. The Czech model of treatment of paraphilics is based on psychotherapy, hormonal supresion by anti-androgens and in the last resort - in the case of the most dangerous and in no other way treatable patients - on the possibility of voluntary surgical desexualisation (castration). Even in the case of delinquent deviants, after a specialized sexological therapy there can be observed only about 17% relapses which ranks the Czech model of sexological treatment among the most successful ones in an international comparison.
3. Transsexualism
Transsexualism is, according to official International Classification of Diseases (ICD 10), included under diagnosis F 64.0 and is defined as a state of an individual who wishes to live and be accepted as a member of the opposite sex. There is a common sense of dissatisfaction with their own anatomic sex or a feeling of its inappropriateness and a wish of hormonal treatment and surgery so that his/her body is congruent (if possible) to the preferred sex. Transsexual identity should last for at least two years, it must not be a symptom of a mental disorder (especially schizophrenia) and it must not be connected with inter-sexual, genetic or chromosomal abnormity.
Transsexualism is the most extreme expression of gender dysphoria. This is considered to be the basic sign of all disorders in gender identity and is defined as the feeling of discomfort, which the person attributes to disaccord between his/her gender identity (internally lived gender) on one hand and his/her gender role and biologic sex (primary and secondary sexual characteristics) on the other hand. Male transsexuals longing for the change of sex are called M to F (male to female), conversely, female ones F to M (female to male).
Transsexuality means in fact the feeling of not belonging to their own sex. Transsexuals have normal chromosomal sex and do not suffer from any so far identified physical (chromosomal) disease. They feel trapped in a false body and feel strong long for the sex reasignment. Clinical definition of transsexualism is based on closed set of characteristics. These include a client´s belief that he/she is a member of the opposite sex, dressing and behaving in the role of the opposite sex, aversion to their own genitals and a wish to its change and lasting desire for the surgical sex reasignment. The primary diagnostic instrument is a non-structured interview and client’s statement.
The integral part of gradual diagnostic process is also RLT (Real Life Test). In this period, the client lives in the opposite role in all aspects of his/her life and his/her adaptability in this role gives relevant information not only from the therapeutic point of view, but is also a significant criterion confirming diagnosis.
The process of the sex reasignment can be divided into following phases:
a) diagnostics (necessity to make and verify the diagnosis),
b) decision-making process (the client must come to the decision about the change of sex),
c) RLT, RLE (Real Life Test, Real Life Experience, i.e. verification of the client’s ability to live in the role of the opposite sex),
d) hormonal therapy (administration of oestrogen to transsexuals M to F and androgens to F to M),
e) surgery (especially ablation of mamms and hysterectomy in F to M and the castration and amputation of penis and creation of neo-vagina in M to F),
f) post-surgical period in which the change of sex in the registry of births is made.
In general, we can state that some phases can be delimited very precisely and concretely by time (i.g. the minimum time for hormonal therapy before surgery), others are in progress very individually as to time (diagnostics). Some phases overlap each other (RLT intervene in both diagnostics and hormonal phase of therapy). Psychotherapy goes trough all mentioned phases.
4. Sexual dysfunctions
Sexual dysfunction (i.e. disorders of sexual capability, activity, need) occur more often than in the case of paraphilias or gender identity disorders. In the last representative research of sexual behaviour of the Czech population, 17% of women and 19% of men stated that they have already experienced some sexual disorder in their life. Men suffer the most often from premature ejaculation and erectile disorders, women from appetence (sexual need) disorders and problems in reaching orgasm.
4.1. Male sexual dysfunctions
4.1.2. Premature ejaculation
If man ejaculates earlier than he wished to or earlier than his partner wishes to, we talk about premature ejaculation (ejakulatio praecox), if he ejaculates even before the imission of penis (entry of penis into vagina), we talk about ejaculation ante portas. This disorder occurs more likely in younger, well arousable men. Therapeutically it is possible to influence this disorder for example by anaesthetic salves or medicaments, sometimes it suffices to use a condom. Postponing the ejaculation reflex can be also reached by training or just by repetition of intercourse.
4.1.2. Erectile disorders
They are either of psychogenic (especially in younger men) or more often of organic (vascular, neurological) origin. At organic erectile dysfunction, besides the lack of erection during intercourse there is also no morning or masturbational erections. Psychogenic disorders of erection are most often caused by anxiety, inexperience or by the fear of failure. At present, erectile dysfunctions can be successfully treated pharmacologically (Viagra, Uprima, Cialis, Levitra) or (especially in the case of psychogenic disorders) by sexual training (e.g. well known Masters and Johnson´s exercises).
4.1.3. Pains during intercourse
These can be caused by phimosis or by too short fraenulum. The treatment in these cases is surgical. There is also a rarely observed so-called induration penis plastica (deformation of penis caused by changes in fibrous tissue).
4.1.3. Sexual appetence disorder
Low sexual need in men is very rare. It can be caused by endocrine gland dysfunction (thyroid gland, adrenal gland), seldom also by insufficient supply of the organism with androgens (i.g. in the case of hypogonadism, castration). Sometimes also some mental disorders, especially depression or bipolar disorder, can couse an appetence disorder.
4.2.Female sexual dysfunction
4.2.1.Low interest in sex (sexual appetence disorder)
It is the most frequent disorder observed in women. The causes may be (analogous to men) psychogenic (mainly mood or affective disorders), but more often emotional and social. If there exist some problems in the partner relations, women considerably more often than men lose their interest in making love. As to biological causes, we can cite hormonal changes of organism during menopause or physical diseases (breast or genital cancer, diabetes, etc.). However, we come across the discrepancy in sexual needs between partners rather than real appetence disorder. In these cases, if there is a cooperation of both clients, the problem is solvable psychotherapeutically.
4.2.2. Anorgasmy
Disorders of sexual arousal and disorder of the orgasmic function can be either primary, i.e. from the beginning of sexual life, or secondary, it means e.g. originating after sexually traumatizing experience, after delivery or as a result of emotional discrepancy and partner’s lack of interest. Almost every tenth woman is not able to reach orgasm or reaches it only rarely. In the therapy of anorgasmy autoerotic practice is important as well as "technical" training of both partners concentrated especially to non-coital activities.
4.2.1. Vaginism
It is a spasmodic and involuntary contraction of the pelvic floor muscles that surround the vagina (introitus), which prevents the entry of penis into vagina and in trying to do so, it provokes strong painful feelings. The causes of this disorder are usually psychogenic (the fear before intercourse due to incorrect sexual education, fear of pregnancy, sexual traumatisation in past). The treatment is based on sexotherapeutical activities connected with gradual relaxation of vaginal muscles during masturbation or other sexual practices.
4.2.2. Dyspareunia and algopareunia
Unpleasant and painful feelings during intercourse can be caused by women’s low sexual arousal (the vagina is not lubricated enough), changes during and after menopause or by different gynaecological complications (inflammations, surgical changes, etc.). Presumption of successful therapy is, in these cases, the treatment of the primary physical cause of difficulties.
