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SEX AND PSYCHIATRY
The word "psychiatry" (Greek: healing of the mind or soul) is only about a hundred years old, although the notion of a disturbed or disordered mind dates back a great deal further. However, previous ages did not speak so much of "mental illness" as of possession, alienation, lunacy, folly, or madness. Originally, these were not medical terms, but merely described any kind of "abnormal" human behavior which puzzled or frightened its observers. People who were "possessed" or who had "gone mad" were therefore treated not by medically trained "mind doctors", but by exorcists, inquisitors, judges, jailers, and sometimes executioners. It was not before the beginning of the Modern Age that the old dungeons, fools' towers, asylums, or madhouses turned into "mental hospitals". The inmates became "mental patients", and special "medical psychologists", "alienists", or "psychiatrists" took charge of them.
This is not to say that in ancient and medieval times physicians paid no attention to madmen. On the contrary, they often tried very hard to find physical causes and cures for madness, because they suspected it to be the result of some bodily disease. Thus, they believed that in many cases a cure of the body would also restore the mind. Still, where treatment proved unsuccessful, they usually agreed with the clergy that some devil, demon, or evil spirit was responsible for the failure, and that a religious response was required.
In pagan Europe the religious response to demonic possession was usually prayer, but sometimes magic incantations and even the shouting of obscenities were considered useful. Some of the possessed were also forced to drink foul smelling potions, or they were beaten, tortured, or starved. These and other drastic measures were supposed to drive the demons out of their victim's body.
Unfortunately, the arrival of Christianity did not bring an end to these cruel and useless treatments. Quite the opposite. Beginning in the late Middle Ages, the belief in demonic possession was strengthened by theologians, and more victims of such possession were found than ever before. An ever growing number of old, young, sick, crippled, simpleminded, or otherwise helpless people were declared to be "sorcerers" or "witches" possessed by the devil. They were hunted down by professional witchfinders, officially diagnosed, and then killed. However, over the years, some physicians began to oppose this systematic holy slaughter, demanding instead new forms of medical treatment. In their view, a witch was simply a person with a sick mind, and, with increasing medical knowledge, this mind could perhaps be cured. Finally, after several centuries of ideological struggle, the new opinion prevailed. The church lost its power to the state, and the old-fashioned belief in witchcraft was replaced with the modern belief in mental illness.
Today we can see that, for a very long time, this victory of science over religion was more apparent than real. Psychiatrists no longer believed in the devil, but their standards for "correct" human behavior were not very different from those of the church. This was nowhere more obvious than in the area of sexual behavior. Virtually all former sins were redefined in medical terms and declared to be mental diseases. Thus, the various forms of noncoital sexual activity turned from religious "abominations" into medical "perversions". Indeed, psychiatric textbooks often showed a strange resemblance to medieval penitentials, with therapy substituted for penance. The only real difference was this: Where sexual deviants were once believed to have lost their souls, they were now merely said to have lost their minds.
Before the beginning of our own century few psychiatrists bothered to question the religious assumptions behind their approach to sex. However, when the First World War produced a "sexual revolution" in Europe and America, the psychiatric profession as a whole was forced to become more critical. As a result, some of the former sexual "perversions" and "deviations" were reclassified as normal "variations" of human sexual behavior, and the psychiatric list of permissible sexual activities began to grow longer. In short, many of those who before had been called mentally ill were suddenly found to have been quite healthy after all.
On the other hand, the number and influence of psychiatrists increased dramatically, because, even with their reduced catalogue of sexual "perversions", they found more than enough patients. After all, in our sex-negative culture there were still millions of men and women with sexual problems, and for them psychiatric treatment seemed to offer the best hope. In addition, the government remained greatly concerned about sexual deviance and hired psychiatrists to detect and cure it wherever possible. Thus, more and more frequently they appeared as "experts" in courtrooms, prisons, schools, and in the military. Most state legislatures also passed special laws against "sexual psychopaths" which, although basically unsound and unfair, created the need for even more official psychiatric expertise. Indeed, over the years the governmental use of psychiatry became so well established that critical observers began to fear the end of individual liberty and the advent of a totalitarian "therapeutic state".
In view of these developments, various contemporary psychiatrists have demanded another radical reexamination of psychiatric assumptions. Some even reject the whole concept of mental illness as a "myth" and search for new ways of understanding abnormal behavior. (For details see "The Medical Model of Sexual Deviance.")
The following pages may help to illuminate this and several other controversial issues by placing them in some historical and cross-cultural perspective.
Historical Background
Present psychiatric attitudes toward sexual deviance cannot be understood without some knowledge of history. Unfortunately, many psychiatrists themselves lack such knowledge and therefore fail to see the true implications of their professional activity. Thus, it does not occur to them that some of their "therapeutic" interventions may be harmful not only to their patients, but to society at large. By the same token, possible beneficial uses of psychiatric knowledge may sometimes remain unexplored. It might therefore be very useful if psychiatrists were trained to look beyond their own immediate place and time.
Needless to say, within the scope of the present book we cannot discuss the entire history of psychiatry. Instead, we have to restrict ourselves to a single limited aspect of it. A few selected examples may show what, through the ages, "regular" physicians and psychiatrists have thought and done about sexual deviance.
Ancient Times
In ancient times people did not distinguish between physical and mental illness or between doctors for the body and doctors for the mind. Indeed, there was no distinction between medicine, magic, and religion. All forms of human suffering were ascribed to spirits, gods, or God, and no treatment could be successful unless it somehow dealt with these superhuman forces. When someone became sick or started to behave in strange ways, he was brought to a priest, shaman, witch doctor, wizard, or magician who performed some sacred ritual. Very often this ritual also included the administration of "medicine", but it was always clear that human actions alone could not effect a cure. Both sickness and health depended on the divine will. Thus, for example, the ancient Israelites were told by Yahweh: "I am the Lord that heals you" (Exodus 15; 26) and "I kill and I make alive; I wound and I heal" (Deuteronomy 32; 39).
In support of this view, the Bible describes how Yahweh sends plagues over Egypt and causes various illnesses in those Israelites who disobey his commandments. He also despatches an "evil spirit" to torment King Saul who therefore becomes subject to recurring black moods and finally ends up committing suicide (I Samuel). A similar fate can befall anyone else who displeases Yahweh, as the Bible warns: "The Lord will smite you with madness" (Deuteronomy 6; 5) and "The Lord shall smite you with madness, blindness, and astonishment of heart" (Deuteronomy 28; 28), Curiously enough, in the biblical view, deviant sexual behavior as such is not symptomatic of madness. However, it may be punished by a loss of certain physical or mental faculties. For some forms of sexual deviance the proper treatment is execution. (For details see "Natural—Unnatural.")
The Greeks of preclassical times also believed in the supernatural cause of human illness and therefore went to their temples for treatment. Their most important early "health cult" was that of Aesculapius, the god of medicine. However, with Greece's "golden age", a critical spirit began to arise, and the old religious beliefs were gradually amended or supplanted by systematic observation. The greatest of the new Greek physicians, Hippocrates (460-377 B.C.) set out to find natural causes for every physical and mental affliction. For example, he declared that epilepsy, which before him had been known as the "sacred" or "divine malady" was, in fact, produced by a diseased brain. Therefore, magical incantations were useless in treating it. Hippocrates and his followers assumed that the normal functioning of the brain depended on the perfect balance among four essential bodily humors: blood, black bile, yellow bile, and phlegm. (These were related to the "four elements" [air, earth, fire, and water] as well as to the "four temperaments" [sanguinic, melancholic, choleric, and phlegmatic]). Any imbalance of the four humors could produce various diseases and abnormal behaviors. The cure required a proper diet, rest, and, in some cases, sexual abstinence. On the other hand, sexual activity was recommended for females suffering from "hysteria", a condition allegedly caused by a "wandering uterus". (Ancient Greek anatomical teachings were still more fanciful than factual.)
The second great ancient physician was Claudius Galenus, today better known simply as Galen (131-200 A.D.). Galen was born in Pergamum, but spent much of his life in Rome where he had a successful practice and won fame as a writer on medical matters. His teachings followed closely those of Hippocrates, although he also made new discoveries of his own. While he believed in a divine creator, he was nevertheless convinced that physical and mental disorders could be explained rationally. Thus, he reemphasized the importance of the brain and the balance of the essential bodily humors. Galen also developed several striking theories about reproduction and sexual health. For example, he assumed that both sexes produce seminal fluid, and that both men and women can ejaculate this fluid during their sleep. He considered such spontaneous responses natural and necessary, because unreleased semen could become poisonous. Prolonged sexual abstinence could therefore produce serious disorders, such as hysteria, hydrophobia, trembling, convulsions and madness. In view of this danger, Galen recommended moderate, but regular sexual activity. Where coitus was impossible, masturbation was just as useful. Indeed, Galen explicitly praised the example of Diogenes (that famous Greek philosopher with the lamp) who had been known to masturbate frequently for the sake of his health.
Needless to say, neither Hippocrates nor Galen ever regarded noncoital forms of sexual intercourse as signs of mental illness. The ancient Greeks and Romans were sexually very tolerant, and this tolerance was reflected in their medical beliefs. Interestingly enough, many of these beliefs survived well into the Middle Ages and beyond. As a matter of fact, in the Western world Galen remained the supreme medical authority for more than 1500 years. However, given the Christian condemnation of "lust", his sexual theories were largely neglected, then dismissed, and finally forgotten.
The Middle Ages
With the fall of the Roman empire and the arrival of the so-called Dark Ages much ancient medical knowledge was lost. Instead, Europe came again under the influence of magical and demonological beliefs. The Christian church preached the old biblical concepts of health and disease. Abnormal behavior was explained as diabolical possession, and exorcism, prayer, confession, and repentance were the only effective remedies. Sexual behavior was normal only when it could lead to reproduction. However, "deviant" types of sexual activity, such as self-stimulation, homosexual intercourse, and sexual contact with animals were seen not in medical, but religious terms. They were declared to be grave sins.
Beginning in the 7th century, the faith of Islam spread throughout the Middle East and Northern Africa and eventually also reached Spain. The Muslims had great respect for learning and therefore preserved and studied the works of their Creek and Roman predecessors. Since they were especially interested in medicine, they surveyed the entire body of ancient medical writings and soon produced many great physicians of their own. Perhaps the two most important of these are Rhazes (860-930), the "Persian Galen", who created the first "mental ward" at the Baghdad hospital, and Abu Ali Al-Hussein Ben Abdallah Ibn Sina, today better known under his Latinized name Avicenna (980-1037). Avicenna believed with Galen that moderate sexual activity was necessary for the preservation of health and that unreleased semen could turn into poison. He further declared that a man's penis would shrink unless it was strengthened by regular use. On the other hand, excessive sexual intercourse could weaken the eyes and lead to a loss of hearing. It could also produce trembling, insomnia, baldness, and epilepsy. The exact definition of "excess" was different for different people, because some were much stronger than others. Avicenna also provided a first short list of diseases which could impair normal sexual functioning. Among these were hermaphroditism, priapism (a painful, permanent erection), and passive male homosexuality. This latter disease was caused by a certain physical weakness, either inherited or acquired, which made normal coitus impossible. These homosexuals were spiteful, ill-tempered, effeminate and incapable of gaining or regaining a healthy masculine strength. Any attempt to cure them was therefore doomed to failure.
Condemnatory theories such as this reveal that Islamic medical research was not entirely free of religious bias. After all, for Islamic physicians the Koran was the final authority on every important question. They were further, handicapped by a prohibition to cut or dissect human bodies, and they were forbidden to look at a naked woman. Under the circumstances, their scientific advances had to remain limited. Nevertheless, on the whole and compared to their Christian colleagues, they were remarkably objective and open-minded. Certainly their treatment of "madmen" was more humane, because they believed that madness was inspired by Allah rather than by some evil demon or devil.
The high quality of Islamic scholarship and medical practice came to be recognized even in Christian Europe, especially when, in the 13th century, the intellectual emperor Frederick II of Hohenstaufen assembled scholars from various countries at his court and became interested in the writings ot the Arabs. He actively supported the University of Salerno and granted it the sole right, in the bounds of the Holy Roman Empire, to grant medical degrees. The physicians trained in Salerno profited from the Arabian preservation of Hippocratic principles and thus had no use for magic or religious ritual. The rediscovery of ancient writers and a growing respect for knowledge soon led to the founding of new European universities. Within the next two centuries, the universities of Padua, Paris, Vienna, Oxford, Cambridge, Prague, and Heidelberg (among others) were established. In short, a rational attitude towards human problems seemed to be gaining ground.
In actual fact, however, progress was difficult and slow. Several eminent Christian physicians who tried to challenge the prevailing demonological beliefs with Greek, Roman, or Arabian clinical observations were accused of heresy or even condemned to death by the Inquisition. Most members of the clergy as well as the laity remained superstitious and ignorant. During the same period there also appeared various bizarre mass movements, such as tarantism and flagellantism, in which great numbers of people all over Europe danced wildly through the streets or whipped themselves bloody in public orgies of self-humiliation. A sense of guilt and sinfulness began to pervade all spheres of life and occasionally led to violent outbursts against Jews, Gypsies, heretics, and other social scapegoats. It also seems that the late Middle Ages developed a strange fear and hatred of women who were increasingly condemned as the vile, wanton, wicked, and lustful sex, a constant temptation for men and their eventual ruin. Females were often seen as instruments of the devil, and, in the course of time, this, together with other frightful fantasies, developed into a new, universal witch craze.
The Modern Age
Today, the witch craze is often seen as a medieval phenomenon. However, the most intense and systematic European witchhunts began at the height of the Renaissance and continued well into the 18th century. It is true that the belief in witches dates back to medieval and even ancient times, but it was not until the end of the 15th century that this belief was shaped into a comprehensive, coherent doctrine. In 1486, just a few years before Columbus discovered America, two German Dominicans, Jakob Sprenger and Heinrich Kramer, published the definitive handbook on witches under the title Malleus Maleficarum (The Witches' Hammer). This work soon found the official backing of the church, the state, and the community of scholars. It was read and accepted in every European country and, over the next 250 years, went through more than 30 editions.
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Bizarre Mass Movements in Medieval Europe
In the Middle Ages, Europe saw several mass movements which in later times have often been described as symptomatic of mental illness.
(Left) Flagellants. Flagellants were bands of people who wandered from place to place whipping themselves bloody in public orgies of self-humiliation. It can be assumed that for many of them the practice had sexual connotations. Indeed, flagellation had a second flowering in 18th- and 19th-century English brothels where customers paid handsome fees for being whipped by prostitutes. Thus, a preference for sexual whippings also became known as “the English vice”. (Woodcut from the Nuremberg Chronicle.)
(Right) The Burning of Witches. The belief in witchcraft and the persecution of witches reached their height towards the end of the Middle Ages and persisted well into the 18th century. Women who were suspected of being witches were tortured until they confessed and then burned. A closer study of the trial records reveals that the witch craze had strong sexual undertones. (16th-century woodcut.)
The book cannot be discussed in detail here. Suffice it to say that it is one of the most depressing documents of bigotry, cruelty, ignorance, and fanaticism in human history. The text first "proves" that witches exist (those who reject the proof are witches themselves), then describes how they can be discovered, and finally lays down the rules for their trial and execution. Apart from a morbid interest in sexual matters, the authors also reveal an obsessive hatred of women. Thus, they emphasize that a woman is more likely to be a witch than a man. They further declare that "all witchcraft comes from carnal lust which in women is insatiable" and that "those among ambitious women are more deeply infected who are more hot to satisfy their filthy lusts".
Witches were possessed by the devil and often had sexual intercourse with him. They could cause crop failure, disease in cattle, death in small children, infertility in women, impotence in men, and many other disorders, disasters and calamities. The unmasking and extermination of witches was therefore essential for the safety and health of society. Furthermore, the Bible itself was unmistakably clear on the subject: "Thou shalt not suffer a witch to live" (Exodus 22; 18). Within a few years, professional witchhunters, sometimes aided by physicians who were trained to search for a special "devil's mark" on the witch's body, began to roam the land and to arrest dozens, hundreds, and eventually thousands of innocent men, women, and children as witches. These unfortunates were tortured until they confessed and then publicly burned to death. The confessions usually implicated relatives, neighbors, and friends, and thus the whole horrible movement fed on itself.
It is important to remember that this movement was equally strong in both Catholic and Protestant countries. The witch craze became truly ecumenical and international, and there was hardly a voice of doubt or protest to be heard anywhere. Still, a few courageous individuals tried to stem this new tide of barbarism, mostly with medical arguments. For example, in 1563 the German physician Johann Weyer published a treatise De Praestigiis Daemonum (On the Deceptions of Demons) in which he argued that the diseases attributed to witchcraft were, in fact, due to natural causes and that many of the "poor, perplexed women" called witches were instead mentally ill. Therefore, they should be cured rather than killed. However, this view was rejected by most of Weyer's contemporaries, and the church put his work on the index of prohibited books. Only the Spanish Inquisition, which was busy enough persecuting heretics, jews, and sodomites remained reluctant to try and execute witches. In Spain the Islamic heritage of caring for the insane was still alive, and thus people accused of witchcraft were often simply declared to be mad and committed to a monastery or asylum.
This latter approach gained wider acceptance in the 18th century and was finally endorsed by the emerging psychiatric profession. The new "mind doctors" took their cue from Weyer and saw the witch craze simply in medical terms. After all, in their confessions the "witches" usually claimed to have performed impossible feats, such as flying through the air, assuming the shape of animals, and causing death by means of a curse or "evil eye". This, together with the openly sexual character of much of their testimony, seemed proof enough that they were, in fact, unrecognized "mental cases" and that "witchcraft" was nothing more than a misunderstood and mishandled "mental health" problem.
Still, nonpsychiatrists pointed out that all confessions were obtained under torture or the threat of torture, and that the court records were kept by the inquisitors, not by their victims. The bizarre sexual fantasies or "hallucinations" ascribed to witches therefore said less about them than about their accusers. However, this argument was quickly seized upon by some writers of medical history who then declared that all participants in the witch trials— witchfinders, witches, and executioners—had been mentally ill.
There is no doubt that the early "alienists" or "psychiatrists" were motivated by a geniune compassion for society's misfits. They not only rescued many of the "possessed" from the clutches of the Inquisition and claimed them as patients for medical science, but also treated these patients more kindly than had been the custom before. Enlightened men like Pinel in France, Chiarugi in Italy, Langermann in Germany, and Rush in America reformed the asylums, freed the inmates from their chains and fetters, and advocated more humane forms of therapy. Unfortunately, however, with regard to deviant sexual behavior the new psychiatric "enlightenment" proved somewhat less beneficial. In the course of the 18th century physicians discovered the alleged health hazards of masturbation, and by the time of the American and French revolutions these hazards came to be seen as extremely serious. Where Galen once had recommended the periodic release of semen as a matter of hygiene, it was now denounced as the cause of nearly all physical and mental disorders. Masturbation weakened the body, softened the brain, and led to impotence, general lethargy, madness, and finally death. Within the next few decades, "masturbatory insanity" became a major threat to humanity's mental health and therefore another compelling reason for preventive psychiatric care. As a result, the psychiatrists became more important and more influential than they had ever been in the past. (For details on the antimasturbation crusade see "Types of Sexual Activity—Sexual Self-Stimulation."}
The prudish 19th century gave rise to various new psychiatric theories about the dangers of masturbation and other forms of sexual deviance. For example, it began to be believed that the weakening habit of "self-abuse" was itself the result of some inherited psychological weakness. In other words, masturbators were already born sick and then could hardly help aggravating their sorry condition. In 1843 a Russian physician named Kaan published a book under the title Psychopathia Sexualis (Sexual Sickness of the Mind) in which he explained this double jeopardy of masturbation. (This book, although written in Moscow and dedicated to the personal physician of the Czar, was printed in Germany where it greatly influenced psychiatric thinking. Indeed, more than 40 years later the Austrian psychiatrist von Krafft-Ebing used Kaan's book title for a new, even more famous study of deviant sexual behavior.)
According to Kaan, nearly all human beings were afflicted with a certain "phantasia morbosa" (sick imagination) which predisposed them towards sensual excess. It took only the accident of a faulty diet, a soft mattress, tight clothing, or even mere idleness to trigger the inevitable chain of events. In addition to this dismal theory, Kaan also offered a first list of other, comparatively minor sexual "aberrations", such as the love of boys, homosexual mutual masturbation, the violation of corpses, coitus with animals, and sexual contact with statues. This short list of sexual "psychopathologies" was, of course, soon expanded by other psychiatrists. Furthermore, the ever growing number of new aberrations eventually reduced the once all-important disease of masturbation to second rank. Nevertheless, Kaan's belief in the possible heredity of sexual deviance retained its appeal and was, in fact, strengthened in subsequent years.
Before we turn to these further "scientific" developments, however, it may be useful to comment briefly on the concept of "sexual psychopathology" itself. Quite obviously, in the beginning it was nothing more than the secular version of an old religious dogma. It is hardly a coincidence that Kaan's sexual "aberrations" are virtually identical with the "abominations" of the Bible. Moreover, the parallel of his inherited "phantasia morbosa" to Augustine's "concupiscence" is striking. In short, as Kaan's efforts made clear, science, as the "new religion", was still preoccupied with protecting the old sexual taboos. (For further details compare "Sex and Religion—Historical Background.")
The unacknowledged religious bias of psychiatry became even more evident when, in 1857, the French psychiatrist Morel turned to the concept of degenerescence for the explanation of madness. Morel, who earlier in his life had pursued theological studies, came to the conclusion that, progressive "degeneracy" was the cause of most physical and mental illness. The first man (whom the Bible had called Adam) had been of a healthy "primitive type". However, after his nature had become corrupted at some early date, man found himself subjected to weakening external and internal influences. As a result, today we no longer see the original perfect "primitive type", but various imperfect human races as well as a great number of "degenerates". These degenerates usually suffer from hereditary sexual "perversion" and are destined to die out. ,
Not surprisingly, in the course of time Morel's theory came to be seen as too openly biblical by many of his colleagues, and thus they recast it in more fashionable "objective" terms. It began to be assumed that degeneracy could appear in the course of an otherwise progressive evolutionary process. Still, degenerates retained their basic characteristics, and they, together with their offspring, were inevitably doomed. These ideas were further popularized by great 19th century dramatists like Ibsen and Hauptmann, who described the effects of degeneracy in their most depressing details. Indeed the novelist Emile Zola presented the "natural and social history" of a whole family, the Rougon-Macquarts, as a case of hereditary progressive decay. The notion of an inborn pathological disposition towards madness and sexual deviance continued to dominate psychiatric thinking up to the time of Sigmund Freud, who finally replaced it with the concept of a traumatic (and largely unconscious) individual life history.
In this context it should be remembered that the 19th century also laid the "scientific" foundations of modern racism. The term "degeneracy was all too easily applied to whole social or ethnic groups which were unpopular for some reason and which could now be labeled biologically inferior. Needless to say, such labeling also always implied the charge of sexual perversion The logical implications of racism, in turn, led to "eugenic" policies, i.e, official attempts to improve the biological health of the population by preventing the breeding of degenerates. On the other hand, it was felt that the superior races did not breed enough. There was a widespread fear that, sooner or later, the whole of mankind might become degenerate and die out. (This fear seems especially grotesque today when one looks a the population curve between 1800 and 1900.) At any rate, growing racial pride, nationalism, and a rapidly expanding industry prompted many governments to demand a population increase. Procreation was again confirmed as the only "correct" goal of sexual intercourse.
Psychiatry took another important step forward when, in 1883, the German psychiatrist Kraepelin published a textbook offering the first systematic classification of mental diseases. While he remained convinced that all of them had physical causes, he was careful to describe each disease as a distinct entity with its own set of symptoms and prospects of cure. Kraepelin's work became the basis for all later psychiatric categorizations. Inspired by this example, other psychiatrists soon felt encouraged to be ever more specific. Thus, among other things, they drew up new, detailed lists of sexual "abnormalities" or "perversions". These lists sometimes went to extraordinary lengths and, in fact, breathed a medieval spirit of casuistic scholasticism. At any rate, they shared the basic assumptions of traditional Christian moralists: Only coitus between "approved" partners is right; all other forms of sexual expression are wrong. However, as a concession to the modern, secular world, these value judgments were now expressed in medical rather than religious terms. (For details see introduction to "Sexual Maladjustment.")
Curiously enough, towards the end of the 19th century the psychiatric crusade against masturbators began to lose its momentum. Instead, the attention turned to a new group of sexual deviants—persons attracted to members of their own sex. Same-sex behavior had, of course, long been condemned by both Jews and Christians, but it had never before been regarded as a symptom of mental illness. (The medieval Muslim Avicenna had ascribed it to a physical disorder.) However, now this behavior was discovered to result from a specific psychological "condition" which afflicted a certain number of people, and for this condition the new term "homosexuality" was invented. For some time there was a debate whether homosexuality was an outright "perversion", a sign of "degeneracy", or merely a mild "personality disorder" without wider implications. Sigmund Freud did not consider it an " illness", but still saw it as a symptom of "arrested development". Some of his followers became again more severe and called it an indication of "immaturity" or a neurotic fear of the opposite sex. At any rate, in America the "condition" continued to be listed in the "Diagnostic and Statistical Manual of Psychiatric Disorders" (DSM) until 1973 when the American Psychiatric Association finally decided to remove it. Since then, American homosexuals have been officially healthy again. Now only those who are disturbed by their sexual orientation are said to need psychiatric treatment for "ego-dystonic homosexuality". (See also "Homosexual Intercourse" and "The Sexually Oppressed—Homosexuals".)
(Note: The preceding section is based not only on the standard American histories of psychiatry by Alexander/Selesnick and Zilboorg/Henry [see "Reference and Recommended Reading"], but also includes some historical information from the untranslated German study Formen des Eros [2 vols] by Annemarie and Werner Leibbrand, Freiburg Br., München 1972).
Cross-cultural Perspectives
Psychiatrists in other countries do not necessarily share all the professional assumptions of their American colleagues. Especially with regard to sexual deviance psychiatric opinion and practice differ widely from one culture to another. Not surprisingly, the fewest such differences are found in the Western so-called capitalist countries which share a common cultural heritage and political philosophy with the United States. In the so-called communist countries, on the other hand, psychiatry is often assigned functions which would be rejected by most of its Western practitioners. Again, the treatment of sexual deviants offers the most striking example. To a Western observer it is obvious that the present communist societies, whatever their economic or political claims, cling to the sexual standards of the capitalist Victorian bourgeoisie.
Unfortunately, the scope of the present book does not permit a detailed discussion of this phenomenon. Nevertheless, the following few brief notes may help to outline its dimensions.
Western Europe
In Western Europe the practice of psychiatry is quite similar to that in the U.S., although there are fewer psychiatrists, and thus their overall social influence is not as great. After all, it must be remembered that in the 1930's and 1940's many leading European psychiatrists were driven into exile by the rise of fascism. Especially those of the psychoanalytic school found themselves persecuted in every country that came under Nazi domination. The psychoanalytic theory itself was officially condemned as "Jewish science", and all psychoanalytic writings were banned or even publicly burned. In addition, the various European movements for sexual reform were ruthlessly destroyed.
It was not until after the end of the Second World War that European psychiatrists could try to regain their former position of leadership. However, first they had to rediscover their own past, and thus the 1950's and 1960's produced a renaissance of psychoanalysis which, at least with regard to sexual deviance, still dominates European psychiatric thinking at the present time. This becomes manifest especially in official and semiofficial European sex education books and programs which, to this day, are conceived from a strictly Freudian viewpoint. It is interesting to note, however, that most contemporary European psychoanalysts honor the older Freud's critical intentions and are comparatively reluctant to apply the "sickness" label to deviant sexual behavior. (On the whole, they see Freud more as a philosopher and social critic than a clinician.) At the same time, they also feel obliged to question the prevailing "normal" sexual standards.
Naturally, to a certain extent this broadmindedness reflects the more tolerant European legal approach to sex. Generally speaking, there is very little prosecution of victimless sex crimes, and therefore the psychiatric involvement in the legal system is kept to a minimum. Still, where sex crimes do have victims, psychiatric treatment of the offender may be encouraged by the courts. Such treatment is rarely based on psychoanalytic concepts, but normally involves various drug therapies, so-called behavior modification techniques, and even castration and new types of brain surgery (so-called psychosurgery). In the meantime some of these treatments have aroused widespread skepticism as the theories of "radical" American psychiatrists have begun to gain some influence. A further challenge of traditional psychiatric assumptions has come from the Europeans themselves. Perhaps the best known of these recent critics is the British psychiatrist Ronald D. Laing. (For further details see "Critique of the Medical Model.")
The Soviet Union
We know that today in the Soviet Union psychiatry is often used as a means of suppressing political dissent, and that Soviet mental hospitals house all kinds of nonconformists, many of whom would not be considered ill in Western countries. We also know that the present Soviet government espouses a very restrictive sexual morality.
This has not always been the case. On the contrary, in the first years after the revolution the Soviet Union pursued the most liberal and progressive sexual policies in the world. Thus, among other things, it replaced the repressive Czarist sex and marriage laws with a whole body of modern legislation based on the then available findings of Western sex research. Moreover, the Communist Party worked hard to overcome sexual prejudice. For example, the articles on sexual deviance in the Great Soviet Encyclopedia were based on the work of Freud and Hirschfeld. At the same time, Soviet scientists also engaged in new research of their own and conducted experiments in nonrepressive education. The best known of these experiments is perhaps that of the psychoanalyst Vera Schmidt who founded a special children's home in Moscow. In this home the children were left free to satisfy their natural sexual curiosity or to masturbate whenever they felt like it. As a result, they grew up without any sexual guilt feelings and developed friendly and responsible attitudes towards each other.
Naturally, in the early years the Soviet example was a source of pride and inspiration for Western sex reformers who held it up as a model to their own governments. Unfortunately, soon all of this came to an end. In the early 1930s the odious Czarist law against male homosexual behavior was revived and the old bourgeois sexual values were officially reinstated. Premarital chastity was praised and the nuclear family with its traditional sexual roles was again set up as the ideal. At the same time, Stalin started a new wave of general political repression whose effects continue to be felt to this day.
At the present time the Soviet Union still does not permit its citizens much sexual freedom. Soviet psychiatry also explicitly rejects Freud and denies the existence of sexual interests in "normal" children. Childhood masturbation and sex play are considered signs of "premature development" and as a deviation from the norm. The masturbation of adolescents and adults is still called "onanism". It is regarded as a "vice" which demands correction, because it has a pernicious influence on the mind and weakens the body. Male homosexual behavior is considered to be both criminal and sick. However, now as before, little attention is paid to female homosexual behavior. (See also "Sex and the Law—Cross-Cultural Perspectives.")
Cuba
Among the declared goals of the Cuban socialist revolution are the full equality of men and women and a rational and humane approach to sexual problems. However, in practice the Spanish cultural heritage of a sexual double standard and excessive masculine pride (machismo) have greatly hampered progress in these areas. Furthermore, there is little official tolerance even of harmless sexual deviance. Special targets of governmental repression are prostitution, "pornography", cross-dressing, and homosexual behavior. Indeed, at times large numbers of homosexuals have been sent to special prison farms or forced labor camps where they have been brutally treated in order to be "reformed". When American and European visitors to Cuba became aware of these policies and denounced them in their home countries, the Cuban government became embarrassed enough to soften its approach. Nevertheless, in principle this approach has not changed even today. Homosexuality is still seen as an infectious "aberration" which has to be corrected. Thus, according to the Cuban National Congress on Education and Culture, "homosexual deviations" are "socially pathological" and must be "prevented from spreading". Homosexuals display an "antisocial character" and therefore must be denied any influence on young people through artistic and cultural activities. Instead, they must be "controlled", "transferred", and "relocated" according to their "degree of deterioration". In short, Cuban officials today still use quasi-medical or pseudo-medical arguments to reduce Cuban homosexuals to the status of second-class citizens and to deny them the most elementary civil rights.
The People's Republic of China
The treatment of "mental patients" in the People's Republic of China combines elements of traditional Chinese medicine, Western medicine, and new political techniques. Mental hospitals are not run exclusively by doctors and their staff, but by so-called Revolutionary Committees which include members of the military and various political workers. By the same token, the patients receive not only drugs and acupuncture therapy, but also ideological counseling. They are expected to engage in "productive labor" and to study the thought of Mao Tse-tung. In addition, there is great emphasis on participation in group activities and on "collective help". Indeed, the social and political aspect of mental illness is considered more important than the medical aspect, and therefore psychiatrists do not hesitate to "put politics in command".
The extent to which the Chinese equate sexual deviance with mental illness is, at the present time, difficult to determine. We know, however, that Freud and his psychoanalytical theory are not accepted in China. We also know, for example, that homosexual behavior is not tolerated, although it is seen as a moral rather than a medical problem. (The last Chinese emperor, who later became an ordinary citizen in the People's Republic, was a homosexual. It is therefore possible that in the public mind homosexuality is now associated with feudalism.) Moreover, there is an official Chinese campaign to stamp out masturbation. From all indications, this campaign seems to be quite similar to that in Western countries about a hundred years ago. Thus, just as in bourgeois Victorian Europe, the public is told that masturbation results in an "overstimulation of the brain, dizziness, insomnia, and general weakness". However, in a new twist of the old yarn, it is now also said to "erode the revolutionary will". In order to avoid these dangers, Chinese teenagers are advised to get sufficient physical exercise, to wear loose-fitting underclothes, and to study the works of Marx, Lenin, and Chairman Mao. In the same puritanical spirit young married couples are warned against having too much sexual intercourse. For instance, a recent advice column in an official Chinese newspaper explains to a young woman that intercourse with her husband must not take place more than one to three times a week, because "indulgence will undermine your health".
(Note: Comprehensive and systematic studies of Soviet, Cuban, and Chinese psychiatric practices are difficult to obtain. Most of what can be learned about them in the West is scattered in numerous books and articles written for professional journals. However, some official Soviet and Chinese pronouncements on sexual questions can be found in Steward E. Fraser, ed., Sex, Schools, & Society, International Perspectives, Nashville, Tenn., 1972. The Soviet return to bourgeois sexual values is discussed in Wilhelm Reich, The Sexual Revolution, New York, 1969. Present Chinese psychiatric treatments are also described by Ruth Sidel in Thomas J. Scheff, ed., Labeling Mental ///ness, Englewood Cliffs, N.J., 1975. A discussion of homosexual civil rights in Cuba can be found in K. Jay and A. Young, eds., Out of the Closets, Voices of Gay Liberation, New York, 1974, and in A. Young, Gays Under the Cuban Revolution, San Francisco, 1981.)
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