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 personaty 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
0004-0002/86/0800-0341505.0/0 I986 PIenum Publish[ng Corporation

Raboch

342

Ever-increasing attention has recently been paid to this problem in the

specialized literature. The occurrence of conspicuous sexual behavior in patients in psychiatric wards has been followed (Akhtar et al., 1977; Modestin,
1981), as weil as family problems (Lavik, 1982; Odergard, 1980), their use
of contraception (Abernathy, 1974; Puente Silva, 1977; Vogel, 1979), and
occurrence of various sexual disturbances (McCullock and Stewart, 1960;
Swan and Wilson, 1979). Specific features of sexuality with various kinds of
mental disturbances have been sought (Beaumont, Abraham, and Simson,
1981; Nestoros, Lehman, and Ban, 1981; Mathew and Weinman, 1982;
Winokur, Guze, and Pfeiffer, 1958-9; Winokur and Leonard, 1963). The
effects of various psychotherapeutic drugs on the sex life has especially been
studied (Blair and Simpson, 1966; Buffum, 1982; Lesko, Stotland, and
Segraves, 1982; Mitchell and Popkin, 1982; Munjack, 1979; Segraves, 1982;
Shader and Elkins, 1980; Story, 1974). However, even recent textbooks on
sexology (Eicher, 1980; Kolodny, Masters, and Johnson, 1979), as well as
the study of Pinderhughes, Barrabee, and Reyna (1972), point out that this
area has not been investigated sufficiently. The latter authors distributed questionnaires to American psychiatrists; 83% answered that sexual activity may
contribute to the formation of psychic diseases. Forty-five percent assumed that
sexuality might hinder the healing of their patients and sometimes recommended sexual abstinence during convalescence.
The present study investigated the sexual development and sex life of
psychiatric female patients with various psychiatric diseases.

MATERIAL AND METHODS

We examined the following groups of randomly selected psychiatric

female patients, from 20 to 50 years of age, who were hospitalized at the
psychiatric clinic in Prague in the years 1978 to 1983. All hospital treatments
in Czechoslovakia are free of charge and the patients receive compensation
for their lost income. Diagnosis was established independently by two
psychiatrists on the basis of clinical examination according to WHO's ICD-9.
1. This group comprised 50 neurotic patients, with an average age of
32.4 years (SD = 6.7), including 12 patients with anxiety neurosis, 11 with
phobic neurosis, 13 with depressive neurosis, and 14 with neurasthenic
neurosis.
2. Thirty-three women were hospitalized for decompensation of
hysterical psychopathic personality. Three of these patients refused examination of their sex life or were unable to undergo it fully. Hence this group
consists of 30 women with hysterical personality structure, with an average
age of 34.1 years (SD = 8.5).

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, malnly by group psychotherapy.
3. Twenty women suffering from anorexia nervosa, with an average
age of 23.9 years (SD = 5.1), constituted this group.
4. There were 50 women with manic-depressive psychoses (MDP),
average age 34.6 years (SD = 8.9). Monopolar depression was found in 29
cases, monopolar mania in 2 cases, and the bipolar form in 19.
5. A group of 57 patients were hospitalized with schizophrenia. Six patients were unable to undergo the sexological examination or refused it. Thus
this group comprised 51 female schizophrenics. In 35 cases the patients were
suffering flora the paranoid form, 12 frorn the simple form, 1 was
hebephrenic, and 3 were suffering ffom the pseudoneurotic form. The average
age in this group was 30.4 years (SD = 7.7). All the patients were treated
with neuroleptics in doses flora 14 to 956 mg of chlorpromazine, recalculated
according to Hollister (1976).
6. The control group consisted of 101 gynecological patients examined
during their cure in the Frantigkovy Lzn~ spa to complete their after-treatment subsequent to gynecological operations and inflammations. All had
regular menstruation, had been delivered o f at least one child, had a permanent sexual partner, and had never consulted a physician either for psychiatric
or sexual complalnts. Their average age was 32.6 years (SD = 7.3).
As the anorectic patients were substantially younger than the other
groups of women, 50 women were selected from the control group so that
their age corresponded to this group of patients. The anorectic patients were
then compared with this reduced control group with an average age of 26.8
years (SD = 3.7).
All the above groups of women were examined using a structured interview consisting of 23 questions concerning personal data, the course of
their disease and of its treatment, partner and family problems, and
gynecological and sexological history. Further, the patients, after instruction, answered the following questionnaires:
Heterosexual Development of Women (HTDW; Mellan, 1980b; Raboch
and Ho~ej~i, 1982), which utilizes 12 items to examine the sexual development o f women. The average value of this test lies between 2.1 to 3.0, with
higher stores representing an acceleration and lower scores a retardation o f
sexual development.
Sexual Knowledge and Attitude Test (SKAT; Lief and Reed, 1972,
modified by Mellan, 1980a), which examines sexual attitudes and opirfions
in 22 items; values o f 71 to 93 are considered average. Values lower than
70 indicate more restricted attitudes toward sexuality.
Sexual Function of Women (SFW; MeUan, 1978b; Raboch and Ho~ej~i,
1982), which studies, by means of ten iterns, female sexual activity and

344

Raboch

the occurrence of sexual dysfunction. Average values are between 2.2 and
3.0. Lower values indicate decreased sexual activity and also the occurrence
of sexual dysfunction.
Sexual Arousability Inventory (SAI; Hoon, Hoon, and Wincze, 1976;
modified by Mellan, 1978a, 1978b), which evaluates the degree of female
sexual arousability with 20 different stimuli; the average score is between
1.8 and 3.1, with a lower score reflecting decreased sexual arousability.
The women were instructed to describe their sex life during the year
prior to their hospitalization. All examinations, of 1 to 2 hr duration, were
carried out by the same physician who answered any questions during the
session.
Data on education, family situation, the existence and quality of partner relationships, the duration of the disease, 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. Schizophrenics and especially patients with anorexia nervosa were
more often single and without a constant partner relationship. Both of these
groups are younger than the other women examined. Patients with MDP lived
in balanced partner relationships more often than the psychiatric patients
of the other groups.

RESULTS
The scores of the questionnaires and the data on the occurrence of coitally orgastic women are given in Table II. It can be seen that schizophrenic
patients are significantly delayed in their sexual development compared with
the other groups of women. No other statistically significant difference
among the groups has been found in the overall score of the HTDW questionnaire.
The individual items of the HTDW questionnaire have also been tested
statistically (Fig. I). We found that patients with MDP and neurotic patients
did not differ from the control group; however, schizophrenics were delayed
in most points compared with the control group. Anorectic patients were
significantly more often single. In other items their sexual development was
accelerated. This acceleration was statistically significant regarding the initial erotic interest in boys, the first date, and the first falling in love. Patients with hysterical personality exhibited disharmonic sexual development,
in some points it was significantly accelerated (coitus with the second male
partner, the total number of friendships, the total number of eoital partners), and in others significantly retarded (the first permanent friendship,
the first marriage).

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Sexual Development of Female Patients

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Fig. 1. The course of the sexual development of schizophrenics, patients with anorexia nervosa, and the control group.
Table II also shows the results of the SKAT questionnaire, examining
attitudes toward sexuality. Schizophrenic patients were significantly more
restrictive in their attitude than females suffering from anorexia nervosa (p
< 0.05) and patients with hysterical personality (p < 0.05). However, no
group of psychiatric patients differed significantly from the control group.
Patients with MDP did not differ from the control group on any
parameter examined except the acute phase of the disease (Table II). However,
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 and anorectic
patients have lower values on the SFW test and a lower coital orgastic capacity. Females with hysterical personality and schizophrenic patients exhibit
lower values on the SFW and SAI tests and a lower coital orgastic capacity.
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). 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. However, anorectic patients thus
selected still had lower scores on the SFW and SAI tests, neurotic patients
had lower capacity to attain orgasm during coitus, and patients with hysterical
personality had lower values on the SFW test and less coital orgastic capacity.

348

Raboch

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Sexual Development of Female Patients

349

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

350

Raboch

Popkin, 1982; Shader and Elkins, 1980). However, a majority of observations deal with male sexual behavior. Only rarely can literature reports be
found that concern female patients (e.g., Degen, 1982; Ghadirian, Chouinard,
and Annable, 1982; Lovet-Doust and Huszka, 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~,
1985). We found that scores on the SFW and SAI questionnaires did not
correlate significantly with the amount of neuroleptics administered. We
found that in the subgroup of schizophrenic patients with a good partner
relationship, sexual activity and reactivity did not differ from the control
sample. 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 (304.4 or 272.9 mg
chlorpromazine per day; t = 0.49). With the latter, we found pronounced
symptoms of insufficiency in their sexual life. Therefore, we have not
demonstrated, similar to Nestoros, Lehman, and Ban (1980), any significant
relationship between the amount of neuroleptics administered and the quality
of sex life for the female schizophrenic patients.
Even those neurotic patients who lived in good partner relationships
reported a lower coital orgastic capacity than the women in the control group.
This raises the question whether this disturbance in the sexual life causes
neurotic difficulties, or the neurosis secondarily disturbs the orgastic capacity. In another study (Raboch and Mikota, 1982) we found that the number
of neurotic symptoms and their intensity do not correlate significantly with
the quality of the sex life. We have also not found sex life differences between various clinical forms of neuroses. We have not confirmed deterioration in the sex life in relation to the duration of neurosis, the number of
decompensations, and the number of hospitalizations. In agreement with
Kratochvfl and Uhlifov (1978)we thus feel that imperfect orgastic capacity may be one of the neurosis-causing factors in some predisposed women.
The disharmonic personality structure of females with hysterical
character apparently disturbs the quality of their sexual relationships as adults.
Even in a temporarily balanced partner relationship, these women are offen
dissatisfied with sex; their sexual activity and orgastic capacity are decreased. Our findings of the decreased sexuality of these patients are in accord
with the physiologically oriented studies of Topia} (1982; Topia~ and Fldr,
1982). On the basis of mammoplethysmographic and vulvoplethysmographic
examinations, this author found that hysterical women are less sexually
arousable, both in the extragenital and genital regions.
With anorectic patients hormonal disturbances (Kolodny et al., 1979)
and low weight may adversely affect their sex life. However, in another study
(Raboch and Faltus, 1984) we found insufficiencies in sex life even before

Sexual Development of Female Patients

351

the onset of the disease in 45% of these patients, namely, primary lack of
interest in a sex life or primary anorgasmia. In their communication, Guile,
Horne, and Dunston (1978) described a dramatic improvement in the clinical
picture of an anorectic patient after including sexual education and sexual
desensitization in treatment. We also feel that the problems of sexuality should
be discussed in detail with anorectic patients.
It is predicted that certain conspicuous findings in the sexual sphere can
be detected in future psychiatric patients eren in the premorbid stage: a detay
in heterosexual development in schizophrenic patients, its acceleration in
various stages in patients with anorexia nervosa, and disharmonic development in patients with hysterical character. Sexual dysfunctions are frequent
in the female psychiatric population in adulthood, especially with
schizophrenics, patients with anorexia nervosa, and those with hysterical personality. On the other hand, patients with MDP do not differ in their sexual
life from the control group when not in the acute phase of the disease.
These sexual problems, often unpleasant and annoying for the pafients,
should always be borne in mind and looked for. It is well known that
psychiatric patients rarely speak of them spontaneously (Pinderhughes et aL,
1972).
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,/

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353

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