As in many other areas of psychiatric research, new techniques have led to an upsurge of interest in and of findings about the neurophysiological (including chemical) mechanisms involved in many aspects of sexual behavior. Along with this excitement caused by fine experimentation, there is less enthusiasm than ever for investigation of sexuality in the human by clinical methods, especially by collecting data in the supportive environment of proper treatment. I think that nothing but good can come from the increased laboratory work and that nothing but bad can come from ignoring the single case studied in depth.
It will be nice if we can reverse the belief that the clinical method is either so weak (as some laboratory scientists are convinced) or has finished its task (as some psychoanalysts tend to feel). Now, years after the work of such observers as Freud, Krafft-Ebing, or Havelock Ellis, we still need naturalistic observations on sexual behavior, normal and abnormal. The work of Masters and Johnson has convinced us of this. But I am not now referring only to the observation of gross physiological response—which they are doing—but to collecting exact subjective descriptions of the sexual experience, the accompanying fantasies, and the indications of unconscious processes and childhood influences that the psychoanalytic method can gather.
And there may be additional bonuses if we revive clinical research on sexual behavior. For instance, from this neglected area can come great insights into causes of violence, the research of which these days is more to be commended for its volume than its discoveries. It is no coincidence that violently aggressive people usually have bizarre sexual impulses and severe conflicts about masculinity and femininity. And, a second area that sex research may clarify: some legal and moral issues that turn on questions of responsibility and of normality may melt away under the heat of the facts.
Perhaps the group who can give us the most, because (with a few notable exceptions like LaBarre) they have provided the least so far, are the anthropologists. Their acceptance of sketchy, anecdotal material and their failure to develop a method for getting detailed, accurate material on such a private subject as sexual desire have crippled our understanding of human sexuality. We simply cannot do without cross-cultural studies, but we also cannot afford the superficial and opinionated reports they too often have given us. Certainly analysts need their findings to keep us honest, that is, to keep us from generalizing too rapidly from the particular patient we analyze—a member of our culture—to humanity at large.
Finally, it is crucial to remember that we still know very little about the mechanisms or causes of human sexual behavior, normative and variant, normal and abnormal. We still know too little about what affects the unfolding of sexuality after the essential inputs of heredity, constitution, and early environment. We know too little even about what people do, what they think they are doing, what they think while they are doing it, and what they think of what they are doing. However, it may not be too optimistic to say that we are now developing, for the first time, tools and ideas that will enable us to study these issues well.
Chapter J
Variants:
Aberrations That Are Not Perversions
Having oriented the new research to psychoanalytic positions, let us review what evidence there is of a category of aberration that is not perversion. Perhaps a few examples will be enough to make the concept usable. The defining quality in all categories of this group is that, though one finds sexual behavior beyond society’s norms, the behavior is not primarily the result of fantasies that are permutations of hostility.
Genetic and Other Constitutional Factors
We have seen (chap. 2) that in both sexes maleness of anatomy occurs only when androgens are added prenatally. Additionally, prenatal hormones organize the brains of all mammals, including humans, in ways that predetermine sexual behavior (both that behavior adding up to erotic experiences—that using the apparatuses of reproduction—and that connected with the nonerotic, nonreproductive behavior called in humans masculinity and femininity). Regardless of whether the organism is genetically male or female, if androgens are not present at the appropriate periods prenatally, masculine behavior will not occur. This has been the invarying rule in innumerable experiments on lower animals and is also confirmed, though less definitively, in “natural experiments” in humans.
In such cases, aberrant erotic or gender behavior is, thus, the result of brain function determined primarily before birth. For instance, women with androgen insensitivity syndrome are chromosomally males, with testes producing testosterone in normal amounts. However, their tissues are unable to respond to testosterone. The external appearance of their bodies is female (the testes being cryptorchid), and they are invariably heterosexual, feminine women (109). Anatomically normal-appearing men with Klinefelter’s syndrome (XXY) have an unexpectedly high frequency of disorders of gender identity, from homosexuality through cross-dressing to complete gender reversal with desire for “sex change” surgery. Otherwise genetically and anatomically normal females who have been masculinized in utero either by excessive amounts of androgens produced in their adrenals or by progesterone given to their mothers to prevent abortion are more masculine in their interests and behavior than a control group of girls. These, then, are examples of aberrations of sexual behavior in which the dynamics of perversion as defined earlier are not present as a cause.
Postnatal Disorders of Brain Function
There are a handful of cases reported in which aberrant sexual behavior was the result of brain disease. Blumer (5) reviews this meager literature—a few cases of fetishism and cross-dressing in which abnormal temporal lobe foci, sometimes accompanied by the overt manifestations of epilepsy, were found; one case in which a “fetish object (a safety-pin) became the invariable trigger of temporal lobe seizures.... During postictal confusion the patient later on occasionally dressed himself in his wife’s clothing. A left temporal lobectomy, at age thirty-eight, relieved both the epilepsy and the fetishism"; a series of sixty temporal lobe epileptics with two being homosexual and one with “minimal interest in girls . . . and partial erection by putting on his baby sister’s diapers.”* Walinder (151) reviews other evidence for cerebral lesions (especially in regard to “trans-vestism/transsexualism”), including a report in which “transvestism/transsexualism” occurred for the first time in men with senile brain changes.
If an aberration occurs only when brain disorder is present and disappears with treatment of the lesion, there is no point in calling this a perversion, though some do when they try to show that perversions are due to brain, not psychic, dysfunction (16).
Hermaphroditic Identity
Usually, when an infant is born whose genitals appear at birth to be neither unequivocally male nor female, the parents are unable to accept their child as being clearly a male or a female; instead, they feel the child to be in some degree either a mixture of male and female or neither male nor female. A hermaphroditic identity develops, the child believing itself to be of a different sex from the two sexes to which everyone else belongs (134). Such people may then find themselves able to have sexual relations with people of both sexes. But once again, the motivating force for aberrance is not that defined above for perversion but rather results from impulses springing from the bisexual identity, an identity originating in parents teaching their child that it is a hermaphrodite, not from the child’s defense against oedipal and preoedipal dangers.