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Archives of Sexual Behavior, VoL 15, No.

4, 1986

Sexual Development and Life of Psychiatric
Female Patients
Ji}i Raboch, M.D., CSe?

Using a structured interview and f o u r questionnaires we examined the sexual development and life in the following groups o f psyehiatrie female patients: 51 with sehizophrenia, 50 with manie-depressive psychoses, 50 with
neuroses, 30 with hysterical psyehopathie personality, and 20 with anorexia
netn~osa. The results were compared with a eontrol group o f 101 gynecologieal
spa patients. The sexual development o f the schizophrenic patients was found
to be retarded, whereas that o f the patients with anorexia nervosa accelerated
in t~ke initial stages. The sexual development o f patients with hysterical personaöty was f o u n d to be disharmonious. No differenees were f o u n d between
patients with manic-depressive psyehoses and the control group as far as the
sex life in adulthood is concerned. However, all the other groups o f psyehiatric
patients showed deereased sexual activity and/or reactivity. Sexual dysfunctions in the female psychiatrie population are frequent, especially with
schizophrenie patients, females with anorexia nervosa, and with hysterieal
personality. The etiologieal faetors responsible f o r these sex disturbanees are
different in the individual groups o f psyehiatric patients.
KEY WORDS: female psychiatric patients; sexual development; sexual activity; mental illness
and sex.

INTRODUCTION
Relationships between psychiatric diseases and sexuality have so far been
rather unknown. The older psychoanalytical schools (Freud, 1954; 1959; 197 t)
considered that a disturbed sexual development led directly to mental disturbances. At present such an unambiguous relationship is no longer assumed.

1Department of Psychiatry, Charles University, Ke Karlovu 11,128 21 Praha 2, Czechoslovakia.
341
0004-0002/86/0800-0341505.õ0/0 © I986 PIenum Publish[ng Corporation

1974). The occurrence of conspicuous sexual behavior in patients in psychiatric wards has been followed (Akhtar et al. Shader and Elkins. Barrabee. and Johnson. Lesko. Segraves.1 years (SD = 8. and Simson. 1981). This group comprised 50 neurotic patients. Kolodny. with an average age of 34. 1960. Specific features of sexuality with various kinds of mental disturbances have been sought (Beaumont. Abraham. Thirty-three women were hospitalized for decompensation of hysterical psychopathic personality. Diagnosis was established independently by two psychiatrists on the basis of clinical examination according to WHO's ICD-9. and Segraves.. The present study investigated the sexual development and sex life of psychiatric female patients with various psychiatric diseases. Vogel. 1. with an average age of 32. Mathew and Weinman. as well as the study of Pinderhughes. their use of contraception (Abernathy. Swan and Wilson. 1963). 13 with depressive neurosis. 1982. 1981. and 14 with neurasthenic neurosis. The latter authors distributed questionnaires to American psychiatrists. even recent textbooks on sexology (Eicher. Puente Silva. from 20 to 50 years of age.7). Stotland. 1982. 1980. Winokur.4 years (SD = 6. Munjack. Story. who were hospitalized at the psychiatric clinic in Prague in the years 1978 to 1983. 1980.Raboch 342 Ever-increasing attention has recently been paid to this problem in the specialized literature. 2. The effects of various psychotherapeutic drugs on the sex life has especially been studied (Blair and Simpson.5). 11 with phobic neurosis. Three of these patients refused examination of their sex life or were unable to undergo it fully. Odergard. 1982. 1958-9. 1979. 1966. However. 1981. 1979). Guze. including 12 patients with anxiety neurosis. and Pfeiffer. . 1980). Forty-five percent assumed that sexuality might hinder the healing of their patients and sometimes recommended sexual abstinence during convalescence. and Ban. All hospital treatments in Czechoslovakia are free of charge and the patients receive compensation for their lost income. 1982. 1977. Hence this group consists of 30 women with hysterical personality structure. 1979). and occurrence of various sexual disturbances (McCullock and Stewart. 1977. Buffum. Winokur and Leonard. and Reyna (1972). 1982. Mitchell and Popkin. 83% answered that sexual activity may contribute to the formation of psychic diseases. 1974. MATERIAL AND METHODS We examined the following groups of randomly selected psychiatric female patients. Masters. 1979). point out that this area has not been investigated sufficiently. Lehman. as weil as family problems (Lavik. 1982. Modestin. Nestoros.

Further.4 years (SD = 7. The control group consisted of 101 gynecological patients examined during their cure in the Frantigkovy Läzn~ spa to complete their after-treatment subsequent to gynecological operations and inflammations. There were 50 women with manic-depressive psychoses (MDP). 1982). Sexual Function of Women (SFW. the course of their disease and of its treatment. and 3 were suffering ffom the pseudoneurotic form.6 years (SD = 8. 4. modified by Mellan.3). 1 was hebephrenic. 3. 1978b.Sexual Development of Female Patients 343 The women from the first two groups were seht by outpatient psychiatrists to a specialized department of the psychiatric clinic to be treated intensively. after instruction. All the above groups of women were examined using a structured interview consisting of 23 questions concerning personal data.8 years (SD = 3. Raboch and Ho~ej~i. 6. female sexual activity and . and the bipolar form in 19. Sexual Knowledge and Attitude Test (SKAT.7). with higher stores representing an acceleration and lower scores a retardation o f sexual development. 1982). All had regular menstruation.9). constituted this group. values o f 71 to 93 are considered average. partner and family problems. and had never consulted a physician either for psychiatric or sexual complalnts. A group of 57 patients were hospitalized with schizophrenia. Values lower than 70 indicate more restricted attitudes toward sexuality. Monopolar depression was found in 29 cases. As the anorectic patients were substantially younger than the other groups of women. Twenty women suffering from anorexia nervosa. The anorectic patients were then compared with this reduced control group with an average age of 26. with an average age of 23. the patients. The average value of this test lies between 2. 1972. by means of ten iterns. All the patients were treated with neuroleptics in doses flora 14 to 956 mg of chlorpromazine. Lief and Reed.6 years (SD = 7. 1980a). Raboch and Ho~ej~i. and gynecological and sexological history. MeUan.0. answered the following questionnaires: Heterosexual Development of Women (HTDW. which utilizes 12 items to examine the sexual development o f women. malnly by group psychotherapy. 12 frorn the simple form.7). The average age in this group was 30. 5. Their average age was 32. 50 women were selected from the control group so that their age corresponded to this group of patients. Mellan. which studies.9 years (SD = 5. 1980b. monopolar mania in 2 cases. had been delivered o f at least one child. had a permanent sexual partner. recalculated according to Hollister (1976). Six patients were unable to undergo the sexological examination or refused it.1 to 3. average age 34. Thus this group comprised 51 female schizophrenics. which examines sexual attitudes and opirfions in 22 items.1). In 35 cases the patients were suffering flora the paranoid form.

0. and in others significantly retarded (the first permanent friendship. It can be seen that schizophrenic patients are significantly delayed in their sexual development compared with the other groups of women. This acceleration was statistically significant regarding the initial erotic interest in boys. Patients with MDP lived in balanced partner relationships more often than the psychiatric patients of the other groups. the first date. schizophrenics were delayed in most points compared with the control group. Data on education. Hoon. the average score is between 1. Sexual Arousability Inventory (SAI. The individual items of the HTDW questionnaire have also been tested statistically (Fig. 1976. All examinations. family situation. and Wincze. Average values are between 2. the total number of eoital partners). 1978b). with a lower score reflecting decreased sexual arousability. of 1 to 2 hr duration. and the number of hospitalizations are given in Table I. It can be seen that the level of education is similar for all the patients examined. . were carried out by the same physician who answered any questions during the session. Lower values indicate decreased sexual activity and also the occurrence of sexual dysfunction. RESULTS The scores of the questionnaires and the data on the occurrence of coitally orgastic women are given in Table II. which evaluates the degree of female sexual arousability with 20 different stimuli. Hoon. modified by Mellan. Schizophrenics and especially patients with anorexia nervosa were more often single and without a constant partner relationship.344 Raboch the occurrence of sexual dysfunction. in some points it was significantly accelerated (coitus with the second male partner. We found that patients with MDP and neurotic patients did not differ from the control group. The women were instructed to describe their sex life during the year prior to their hospitalization. No other statistically significant difference among the groups has been found in the overall score of the HTDW questionnaire. 1978a. the first marriage). the duration of the disease. Patients with hysterical personality exhibited disharmonic sexual development. Both of these groups are younger than the other women examined. and the first falling in love. In other items their sexual development was accelerated.8 and 3.1. the total number of friendships. however. I). the existence and quality of partner relationships.2 and 3. Anorectic patients were significantly more often single.

Sexuai Development of Female Patients II (o ° d~ 345 ~ ~~ ~~ =~ .

« ° ~o~ ~ .346 Raboch ~o 6 v# 6 o ~q O 8 £ S 8 o °~ m w'~ .-. ~ s ~ ~ ~ VV .

no group of psychiatric patients differed significantly from the control group. . . However. Table II also shows the results of the SKAT questionnaire.05) and patients with hysterical personality (p < 0.o. . .--- FEMALE SCHIZOPHRENI~S • eo** FEMALES WITH ANOREXIA NERIrOSA ]}{{ °2 24 23 ] o° 22 21 / : 2O t9 i8 J 17 . .. . .Sexual Development of Female Patients 347 CONTROL GROUP Affe IN ITAItS . . However.o. Different results were obtained when those women were selected from the group who stated that they had lived in satisfactory partner relationships during the year prior to the examination (Table III). Females with hysterical personality and schizophrenic patients exhibit lower values on the SFW and SAI tests and a lower coital orgastic capacity. 1. Schizophrenic patients were significantly more restrictive in their attitude than females suffering from anorexia nervosa (p < 0.'° 14 13 .. .. anorectic patients thus selected still had lower scores on the SFW and SAI tests. »~. The data on the adult sex life for the patients with both types of endogenous psychoses (schizophrenia and manic-depressive psychosis) did not differ and sexual activity and reactivity were within the norm.. The course of the sexual development of schizophrenics. .._ FIRST FIRST FIRST FIRST LONGER TOUCH TOUCH COITUS FRIEND" OF OF SHIP B R E ~ T GENITALS [ I COITUS F I R S T W I T H A MARRIAGE SECOND MAN Fig. and the control group. in all the other groups the sexual activity and/or reactivity was lower compared with the M D P patients and the control group.. . neurotic patients had lower capacity to attain orgasm during coitus. I I FIRST FIRST I N T E R E S T DATE IN BOyS I I FIRST KISS FIRST FALL IN LOVE I I [ L. Patients with MDP did not differ from the control group on any parameter examined except the acute phase of the disease (Table II). Neurotic and anorectic patients have lower values on the SFW test and a lower coital orgastic capacity.05). However. examining attitudes toward sexuality. . . patients with anorexia nervosa. . and patients with hysterical personality had lower values on the SFW test and less coital orgastic capacity..**" 18 i5 BOWaI°~~ • .

348 Raboch ù~ o o e~ Q o 8 E o o~ ¢.3 ù~ o~ ~~~-~~~oo~ V .

Raboch and Mikota. on the basis of a disturbed partner relationship. 1984) we found that this retardation did not correlate either with the premorbid structure of the personality or with the age at the onset of the disease. 1968. Those schizophrenic patients who lived in subjectively satisfactory partner relationships did not differ sexually from the control group. 1984. The acceleration of the first stages of the sexual development found in our 20 patients with anorexia nervosa is difficult to interpret. These are apparently early manifestations of typical character features of these women-instability and lack of self-restraint.. 1981). 1981. Leckman. 1982. Perhaps a biological factor is operating here. and Mella Majias (1979). Thus it seems that schizophrenia adversely affects sexuality as a secondary effect. Caridad Pou Garcia. Freyhan. Mitchel and . 1980) we found delayed heterosexual development of schizophrenic patients. We did not find any relationship between heterosexual development and the clinical form and the further course of schizophrenia. except for the acute phase of the disease. the sexual development of females with MDP and neurotic patients did not differ from the control group. in contrast to the whole sample of schizophrenic patients.Sexual Development of Female Patients 349 DISCUSSION In agreement with other authors (Chodura. e. in press a. Bowers. On the other hand. b. Thus we have not confirmed the observation of Sosjukalo. and Sturges. In a previous study (Raboch.g.. So far we are unable to explain our findings. Bal~akov. Our finding concerning disharmonic sexual socialization of patients with hysterical personality is in agreement with that of Amaro Gonzales. whereas decreased sexual activity and/or reactivity was found in all other groups of psychiatric patients. 1961. Patients with MDP showed no pathological features in their adult sex life. There is a large amount of data on unfavorable effects of neuroleptics on the sexual life of psychiatric patients (e. Their data did not differ from those for the control group.. Raboch and Faltus.g. For schizophrenic patients we have verified a pronounced relationship between their sex life and the quality of their partner relationships. and Ka~nikova (1978) who assume that the course of sexual development is a modifying factor in the formation of the clinical picture of schizophrenia. Nestoros et aL. immaturity of the dopaminergic system (Leckman et aL. We have found in other articles (Raboch. No group of psychiatric patients differed significanfly from the control sample in their attitudes toward sexuality. 1984) that values of this SKAT questionnaire do not correlate significantly with the scores on the SFW and SAI tests that examine sexual activity and reactivity.

We have also not found sex life differences between various clinical forms of neuroses. Lehman. This raises the question whether this disturbance in the sexual life causes neurotic difficulties. Even in a temporarily balanced partner relationship. We found that in the subgroup of schizophrenic patients with a good partner relationship. this author found that hysterical women are less sexually arousable. a majority of observations deal with male sexual behavior. both in the extragenital and genital regions. t = 0. 1982.g. However. We found that scores on the SFW and SAI questionnaires did not correlate significantly with the amount of neuroleptics administered. similar to Nestoros. The disharmonic personality structure of females with hysterical character apparently disturbs the quality of their sexual relationships as adults. With anorectic patients hormonal disturbances (Kolodny et al. and the number of hospitalizations.49). we found pronounced symptoms of insufficiency in their sexual life. these women are offen dissatisfied with sex. Our findings of the decreased sexuality of these patients are in accord with the physiologically oriented studies of Topia} (1982. In another study we discussed the effects of psychopharmacological treatment on the sexual life of 51 female schizophrenic patients examined by us (Raboch and Smiljani~. their sexual activity and orgastic capacity are decreased. any significant relationship between the amount of neuroleptics administered and the quality of sex life for the female schizophrenic patients. in another study (Raboch and Faltus. With the latter.350 Raboch Popkin. we have not demonstrated. 1979) and low weight may adversely affect their sex life. Ghadirian. 1982.9 mg chlorpromazine per day. On the basis of mammoplethysmographic and vulvoplethysmographic examinations. Lovet-Doust and Huszka. 1982.. 1982) we found that the number of neurotic symptoms and their intensity do not correlate significantly with the quality of the sex life. Degen. In agreement with Kratochvfl and Uhlifovä (1978)we thus feel that imperfect orgastic capacity may be one of the neurosis-causing factors in some predisposed women. 1982). 1985). However. We have not confirmed deterioration in the sex life in relation to the duration of neurosis. In another study (Raboch and Mikota. The amount of neuroleptics administered to them was not significantly different from that administered to schizophrenic patients living in disturbed partner relationships or without a stable partner (304. Only rarely can literature reports be found that concern female patients (e. 1984) we found insufficiencies in sex life even before . 1982). the number of decompensations. Shader and Elkins.. sexual activity and reactivity did not differ from the control sample. 1980).4 or 272. Therefore. and Ban (1980). Topia~ and Flädr. or the neurosis secondarily disturbs the orgastic capacity. and Annable. Chouinard. Even those neurotic patients who lived in good partner relationships reported a lower coital orgastic capacity than the women in the control group.

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