17. Developmental delay and inhibition, feminization in males, and sexual perversions.

The concept of developmental delay or inhibition

If a male reaches the normal age of sexual development, but his genitals remain in a pre-pubescent state, or if his testes have not developed by the age of 14 and he lacks any signs of puberty, or if his sexual development is delayed by 1.5 to 2 years, then male sexual development delay should be suspected. If a male is over 20 years old and still has not developed, it is called "sexual development inhibition".

Delayed sexual development and inhibited sexual development are two completely different concepts. The former is simply a delay in the age of sexual development, but normal puberty will still eventually occur. The latter is inhibited sexual development, and puberty will not occur without treatment.

Most cases of delayed sexual development are constitutional. Malnutrition, zinc deficiency, parasitic infections, chronic diseases, hypothyroidism, and hypothalamic-pituitary disorders can all cause delayed sexual development. Male sexual development delay often has a family history of developmental delays, possibly related to hypothalamic-pituitary defects. Besides the lack of development of secondary sexual characteristics and genitalia, male sexual development delay also manifests as lag behind children of the same age in other aspects such as height, age, and gonadotropin levels.

A major cause of male sexual development inhibition is genetic disorders: Incomplete testicular development, also known as congenital hypogonadism. Another important cause is cryptorchidism. In cryptorchidism, the cells contain an extra X chromosome. These individuals have underdeveloped testes, no pubic hair, no beard, sparse body hair, a high-pitched voice, and smooth skin, resembling a woman. Although they possess male external genitalia, because their testes do not continue to enlarge after puberty, the seminiferous tubules do not develop, and they do not produce sperm, they are infertile. In cryptorchidism, the testes remain in the abdomen and do not descend completely, resulting in hypogonadism and impaired development.

Early diagnosis of delayed or suppressed sexual development is significant for clinical treatment. Those who are late bloomers or lack male sexual characteristics after puberty often experience psychological stress due to ridicule or discrimination, leading to feelings of inferiority or inadequacy. Constitutional delayed sexual development can be improved by treating the underlying disease and strengthening the body. Early zinc supplementation is also beneficial for promoting development, but the use of sex hormones should be avoided. If a male has not developed sexual characteristics by age 17, and suppressed sexual development is suspected, a small amount of human chorionic gonadotropin (hCG) can be used for treatment. However, this only improves the development of the external genitalia and secondary sexual characteristics; ultimately, fertility will not be achieved.

Delayed or suppressed male sexual development is more common in males, and it is hoped that this will draw the attention of parents and doctors of boys so that early diagnosis and treatment can be carried out.

Physiological factors of male feminization

We often see teenagers distressed about what they perceive as femininity. Some believe they have a "high-pitched voice and no facial hair," while others think they have a "full figure, like a woman." Still others feel embarrassed by "enlarged breasts," and so on. But do these concerns truly constitute feminization in men? And how can these phenomena be prevented and treated?

We know that puberty can transform a child from a confused, undeveloped individual into a robust young man or a graceful, beautiful young woman. This change is due to a sharp increase in sex hormones. Studies show that during puberty, boys experience a dramatic increase in testosterone secretion from their testes, with plasma testosterone levels rising up to tenfold. These male hormones gradually develop a boy's muscles, broad shoulders, narrow hips, deeper voice, facial hair, and the development of adult male genitalia. However, some boys experience a high-pitched voice, lack facial hair, armpit hair, and pubic hair during puberty, and their genitals resemble those of a young child. This indicates insufficient male hormones in their bodies, and puberty has not yet begun; it is not necessarily abnormal. The age of puberty is influenced by various factors such as genetics, physical condition, nutrition, and geographical environment, resulting in significant individual differences. If a boy is over 14 years old and shows no signs of puberty, or if more than five years have passed between the onset of puberty and the completion of reproductive organ development, it should be considered delayed puberty. In most adolescents, this delay allows them to eventually reach normal development. Only a small number of boys experience hypogonadism due to a disorder of the hypothalamus-pituitary-gonadal system. This condition is often difficult to resolve without treatment.

So, how can we determine if puberty development is normal? A simple and easy method is to regularly measure the testicles. We know that the earliest physical change in boys during puberty is in the testicles. In childhood, each testicle contains only 2-3 milligrams of glucose, begins to enlarge at 8-10 years old, and exceeds 5 milligrams by 10-12 years old. During puberty, a boy's testicles enlarge rapidly, reaching 15-25 milligrams, indicating normal development. However, if any of the following conditions are present: ① No signs of puberty by age 16; ② Testicles less than 2 milligrams or penis shorter than 3 centimeters; ③ Genital malformations such as hypospadias or cryptorchidism; ④ Congenital heart disease or other physical abnormalities such as breast hyperplasia, a medical examination should be sought immediately.

What kind of "feminization" does some young men with developmental abnormalities exhibit? These individuals generally have increased fat in their chest and buttocks, which is actually simple obesity. Their penis and testicles are deeply embedded in fat, but upon close examination, their size is found to be no different from that of normal men of the same age. However, excessive fat can affect the balance between male and female hormones in the body, which is the main cause of male feminization. In addition, due to fat deposition, the increase in female hormones in the body can lead to male breast hyperplasia, which can also result in "feminization." Therefore, these individuals should control their diet, increase physical exercise, and lose weight. Of course, a small number of young men with hypogonadism may also have a "full-figured, feminine" physique.

At this point, we know that the so-called "feminization of men" problem that plagues some male teenagers is mostly a misunderstanding of normal puberty development. A small number of cases are indeed pathological, and they should seek medical attention in time. After the disease is cured, they will still be dignified men.

Male sexual perversions

Male sexual abnormalities, also known as sexual perversions, are psychological disorders, much like heart disease, liver disease, and stomach disease. They often manifest in the following ways:

1. Naked vagina fetish

This is a relatively common sexual perversion. Patients are mostly adult men. They often hide in dark corners and suddenly expose their genitals to unsuspecting women, sometimes accompanied by various lewd gestures. Psychologically speaking, their behavior is not intended to seduce the opposite sex, but rather to demonstrate their male prowess and release their sexual repression.

2. Observation of vagina

This refers to men repeatedly peeping at unsuspecting women undressing, naked, or exposing their genitals, some even watching others' sexual activity to satisfy their own sexual desires. It can be divided into active and passive types. The so-called passive type is actually a form of nudity fetishism. Most of them lack normal sexual function but rarely use violence against the opposite sex.

3. Fetishism

These patients achieve sexual satisfaction by collecting, caressing, smelling, or biting women's hair, clothing (such as tight shorts, bras, stockings, etc.), and even using women's bedding. They use certain objects to replace normal sexual objects, but do not use them as the purpose of sex. Fetishists are similar to the former, only their sexual release is abnormal and their sexual interests are alienated; they rarely inflict violence on women.

4. Sadists and Masochists

Sadism derives sexual satisfaction from physically torturing a sexual partner, while masochism derives sexual satisfaction from being tortured or abused by others. Mild cases do not necessarily constitute behavioral deviation. However, when it develops into a severe form, it manifests as highly dangerous violent behavior, such as biting or cutting off the victim's breasts or genitals.

5. Homosexuality

This refers to intimate sexual behavior between individuals of the same sex. Homosexuality can generally be divided into five categories:

①Single homosexuality refers to sexual relations between people of the same sex over a long period of time.

②Psychological homosexuality refers to those who have sexual desires but do not engage in actual sexual behavior.

③ Temporary homosexuality refers to temporary homosexuality that occurs when living in a homosexual environment (such as the military or prison) for a long time.

④ Coexistence of homosexuality and heterosexuality refers to the simultaneous existence of both homosexuality and heterosexuality.

⑤ Incest primarily involves sexual intercourse between siblings, or even between fathers and daughters. Because such acts are extremely secretive, the actual incidence may be higher than commonly believed. Most men who commit incest do not exhibit obvious signs of abnormal sexual psychology, possibly due to a lack of normal environments and conditions for interacting with the opposite sex, or an inability to establish a normal sexual relationship with their wives. Most incestuous individuals lack proper education, moral values, and a correct understanding of sex.

In short, there are other manifestations of male psychological abnormalities, such as transvestism and pedophilia, which will not be introduced in detail here.

Correcting exhibitionism

Exhibitionism is a common form of sexual perversion, often causing extremely negative impacts on the physical and mental health of others, and plunging sufferers into unbearable distress. So, can exhibitionism be cured? The answer is yes. Although its treatment and correction are more time-consuming and laborious than those for general medical or surgical conditions, the chances of a cure are quite high if the patient has a strong will to seek treatment, coupled with the correct guidance and procedures from a psychiatrist.

Modern psychiatry generally adopts comprehensive treatment measures, with psychological and behavioral therapy as the main approach and medication as a supplement, and consistent treatment has proven effective.

First, it's crucial to offer positive guidance and persuasion, helping them deeply understand that their behavior contradicts social norms and normal ethics. They must not consider themselves "ill" and believe they can "abstain from responsibility" or allow their behavior to continue unchecked. If these erroneous thoughts are not corrected, they will inevitably be hindered by this powerful "shield" during psychological treatment, preventing effective intervention.

Secondly, patients should be told that while sexual desire is a human instinct and is not inherently wrong, its manifestation must adhere to traditional social moral norms and legal constraints. Patients should strengthen their self-control and never become "prisoners" of abnormal desires.

Third, at the start of psychotherapy, patients should first recall the psychological state and triggering factors of the first instance of this erroneous behavior, including relevant experiences from childhood. When patients can recognize and understand the root of this abnormal psychology and frequently recall the conflicting and guilty feelings they experienced when they first committed the offense, most patients can strengthen their control over it, and in some cases, it disappears completely soon afterward.

Fourth, for some patients who go astray due to disharmony in their sex life, such as their wife's frigidity or the inconvenience of living in cramped conditions, their sexual desire cannot be fully satisfied. If they can receive their wife's understanding, care, and encouragement to improve their sexual desire, their treatment will definitely be more effective.

Fifth, if a patient experiences exhibitionist urges, they should immediately force themselves to silently repeat, "This is an immoral and illegal thought. I, a dignified man, must not become a prisoner of evil lust!" Or they should immediately force themselves to do something beneficial to counteract, dilute, or distract these thoughts. If the urge is particularly strong, one tablet of diazepam (1 mg) or one tablet of perphenazine (2 ml) can be taken on the same day, three times a day for three consecutive days.

Sixth, behavioral therapy. This method is relatively quick and practical, but it should be combined with the aforementioned psychotherapy. The specific method involves having the patient stand in front of a sexually suggestive photograph, exposing their genitals, and then administering a weak electric shock to their hands. This is repeated every other day, with 10 sessions constituting one course of treatment. This utilizes the principle of "aversive conditioning" to gradually eliminate the patient's exhibitionist impulses.

It should be pointed out that family members and colleagues of the patient should never despise him, but should extend a helping hand to help him and persuade him to overcome this evil will.