1. HUMAN SEXUAL DEVELOPMENT AND PARAPHILIAS Prof. MUDr. Jiří Raboch, DrSc. Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague

2. sexual deviationsdelinquents deviant sexual delinquents

3. SEXUAL DEVELOPMENT

4. GONADAL DIFERENTIATION mesoderm Bipotential gonad DMRT1,2, SRY, SOX9 AMH testosterone testis DAXI Estrogens gestagens ovary WT1 NR5A1 Kucinskas and Just, 2005

5. SEXUAL DEVELOPMENT

6. RAT´S BRAIN

7. RAT´S SEXUAL ACTIVITY

8. SEXUAL CENTERS IN THE HYPOTHALAMUS sex center mating center Female area praeoptica Hypothalamus ventralis nc. ventromedialis Male mediobasalis hypothalamus area praeoptica

9. DIFERENTIATION OF HYPOTALAMIC NUCLEI AND EPITHELIAN OF THE 3rd. BRAIN VENTRICLE

10. FETAL TESTOSTERONE LEVELS

11. HOHLWEG´S EFFEKT Kiss1/kisspeptin system Kiss1 gene expression and kisspeptin protein levels in anteroventral periventricular nucleus – higher levels in females Kauffman 2009

12. RESULTS OF HYPOTHALAMOTHOMY

13. SEXUAL DEVELOPMENT

14. SIGMUND FREUD 1856 - 1939 THEORY OF UNCONSCIOUNESS THEORY OF UNCONSCIOUNESS PSYCHOSEXUAL DEVELOPMENT PSYCHOSEXUAL DEVELOPMENT CHILDHOOD SEXUALITY CHILDHOOD SEXUALITY CONFLICTS, COMPLEXES CONFLICTS, COMPLEXES

15. Consequences of early stress and childhood maltreatment (child sexual abuse) …The major structural consequences of early stress include reduced size of the mid-portions of the corpus callosum and attenuated development of the left neocortex, hippocampus, and amygdala… …Early stress alters the development of monoamine neurotransmitters and affects their degree of laterality… Teicher et al., 2003

16. CUMMULATIVE FREQUENCY OF EXPERIENCES WITH FORCEFULL SEXUAL ACTIVITY 174 female students and 137 male students of 1st. Medical School % age (years) Raboch, 1996

17. REDUCTION OF BRAIN STRUCTURES DEPENDENT ON AGE OF THE CHILD STRUCTURE AGE AT CSA HIPPOCAMPUS 3 – 5, 11 – 13 CORPUS CALLOSUM 9 – 10 FRONTAL CORTEX 14 – 16 AMYGDALA No differences Teicher et al., 2008

18. Plasticity of the brain EVOLUTIONARY EVOLUTIONARY REACTIVE REACTIVE ADAPTIVE ADAPTIVE REPARATIVE REPARATIVE SYNAPTIC LEVEL SYNAPTIC LEVEL LOCAL CIRCUITS LOCAL CIRCUITS DISTANT CIRCUITS DISTANT CIRCUITS PROLIFERATION PROLIFERATION MIGRATION MIGRATION DIFERENTIATION DIFERENTIATION CRITICAL (SENSITIVE) PERIODS CRITICAL (SENSITIVE) PERIODS

19. Vaidya a Duman, 2001 HIPPOCAMPUS AND DEPRESSION

20. Neuroanatomical sex-specific differences MALE BRAIN CONTAINS ON AVERAGE 16% NEURONS MORE MALE BRAIN CONTAINS ON AVERAGE 16% NEURONS MORE MALE CORPUS CALLOSUM IS BIGGER MALE CORPUS CALLOSUM IS BIGGER FEMALE TEMPORAL CORTEX HAS ON AVERAGE 11% GREATER DENSITY OF NEURONS FEMALE TEMPORAL CORTEX HAS ON AVERAGE 11% GREATER DENSITY OF NEURONS THE MOST SIGNIFICANT DIFFERENCES - HYPOTHALAMUS THE MOST SIGNIFICANT DIFFERENCES - HYPOTHALAMUS Sickel a McCarthy, 2000

21. Sexual diferentiation of the brain HYPOTHALAMUS HYPOTHALAMUS SDN-POA (sexually dimorphic nucleus of praeoptic area) - rats SDN-POA (sexually dimorphic nucleus of praeoptic area) - rats INAH 1,2,3,4 (interstitial nuclei of the anterior hypothalamus) – human beings INAH 1,2,3,4 (interstitial nuclei of the anterior hypothalamus) – human beings Bed nucleus of stria terminalis Bed nucleus of stria terminalis

22. DEVELOPMENT OF HYPOTHALOAMIC SDN-POA (INAH)

23. SEXUAL DEVELOPMENT

25. BED NUCLEUS OF STRIA TERMINALIS DEVELOPMENT Chung et al., 2002

26. VOLUMES OF BED NUCLEUS OF STRIA TERMINALIS MTF-T – malet to female transsexuals N=6 Zhou et al., 1995

27. Criteria of sexual „normality“ Adequate gender identity Adequate gender identity PREFERENCE OF PREFERENCE OF Heterosexuality (?) Heterosexuality (?) Mature object Mature object Mutual contrived (voluntary) Mutual contrived (voluntary) Adequate interaction technique Adequate interaction technique Other… Other…

28. F64 Gender identity disorders F64.0 Transsexualism F64.0 Transsexualism F64.1 Transvestitism of the double role F64.1 Transvestitism of the double role F64.2 Gender identity disorder in childhood F64.2 Gender identity disorder in childhood

29. F66 Mental and behavioral disorders connceted with the sexual development and orientation F66.0 Sexual maturation disorder F66.0 Sexual maturation disorder F66.1 Ego-dystonic sexual orientation F66.1 Ego-dystonic sexual orientation F66.2 Sexual relationships disorder F66.2 Sexual relationships disorder

30. F65 Disorders of sexual preferences F65.0–Fetishism F65.1– Transvestic fetishism F65.2– Exhibitionism F65.3– Voyerism F65.4– Pedophilia F65.5– Sexual sadism, masochism F65.6– Multiple disorders of sexual preferences

31. Treatment of paraphilias  voluntary  involuntary  out-patient  in-patient Psychotherapy Psychotherapy individualindividual groupgroup CBTCBT Sociotherapy Sociotherapy Pharmacoterapy Pharmacoterapy (estrogens) antiandrogens gestagens lithium neuroleptics LH-RH analogs Operations (?) Operations (?) hypothalamo- thomy castration

32. THANK YOU FOR YOUR ATTENTITION