Freud - Complete Works (79 page)

Sexuality In The Aetiology Of The Neuroses

467

   In other cases our aetiological
theory can help the physician in charge of the institution by
throwing light on the source of failures which occur in the
institution itself, and can suggest to him means of avoiding them.
Masturbation is far commoner among grown-up girls and mature men
than is generally supposed, and it has a harmful effect not only by
producing neurasthenic symptoms, but also because it keeps the
patients under the weight of what they feel to be a disgraceful
secret. Physicians who are not accustomed to translate neurasthenia
into masturbation account for the patient’s pathological
state by referring it to some catchword like anaemia,
undernourishment, overwork, etc., and then expect to cure him by
applying a therapy devised against those conditions. To their
astonishment, however, periods of improvement in him alternate with
periods in which all his symptoms grow worse and are accompanied by
severe depression. The outcome of such a treatment is, in general,
doubtful. If physicians knew that all the while the patient was
struggling against his sexual habit and that he was in despair
because he had once more been obliged to give way to it, if they
understood how to win his secret from him, to make it less serious
in his eyes and to support him in his fight against the habit, then
the success of their therapeutic efforts might in this way well be
assured.

   To break the patient of the habit
of masturbating is only one of the new therapeutic tasks which are
imposed on the physician who takes the sexual aetiology of the
neurosis into account; and it seems that precisely this task, like
the cure of any other addiction, can only be carried out in an
institution and under medical supervision. Left to himself, the
masturbator is accustomed, whenever something happens that
depresses him, to return to his convenient form of satisfaction.
Medical treatment, in this instance, can have no other aim than to
lead the neurasthenic, who has now recovered his strength, back to
normal sexual intercourse. For sexual need, when once it has been
aroused and has been satisfied for any length of time, can no
longer be silenced; it can only be displaced along another path.
Incidentally, the same thing applies to all treatments for breaking
an addiction. Their success will only be an apparent one, so long
as the physician contents himself with withdrawing the narcotic
substance from his patients, without troubling about the source
from which their imperative need for it springs.
‘Habit’ is a mere form of words, without any
explanatory value. Not everyone who has occasion to take morphia,
cocaine, chloral hydrate, and so on, for a period, acquires in this
way an ‘addiction’ to them. Closer enquiry usually
shows that these narcotics are meant to serve - directly or
indirectly - as a substitute for a lack of sexual satisfaction; and
whenever normal sexual life can no longer be re-established, we can
count with certainty on the patient’s relapse.

Sexuality In The Aetiology Of The Neuroses

468

   Another task is set to the
physician by the aetiology of anxiety neurosis. It consists in
inducing the patient to give up all detrimental forms of sexual
intercourse and to adopt normal sexual relations. This duty, it
will be understood, falls primarily on the patient’s trusted
physician - his family doctor; and he will do his patient a serious
injury if he regards himself as too respectable to intervene in
this field.

   Since in these instances it is
most often a question of a married couple, the physician’s
efforts at once encounter Malthusian plans for limiting the number
of conceptions in marriage. There seems to me no doubt that such
proposals are gaining ground more and more among our middle
classes. I have come across some couples who have already begun
practising methods for preventing conception as soon as they have
had their first child, and others whose sexual intercourse was from
their wedding-night designed to comply with that purpose. The
problem of Malthusianism is far-reaching and complicated, and I
have no intention of handling it here in the exhaustive manner
which would actually be necessary for the treatment of neuroses. I
shall only consider what attitude a physician who recognizes the
sexual aetiology of the neuroses had best take up towards the
problem.

Sexuality In The Aetiology Of The Neuroses

469

   The worst thing he can do is
obviously - under whatever pretext - to try to ignore it. Nothing
that is necessary can be beneath my dignity as a doctor; and it is
necessary to give a married couple who contemplate limiting the
number of their offspring the assistance of one’s medical
advice if one does not want to expose one or both of them to a
neurosis. It cannot be denied that in any marriage Malthusian
preventive measures will become necessary at some time or other;
and, from a theoretical point of view, it would be one of the
greatest triumphs of humanity, one of the most tangible liberations
from the constraints of nature to which mankind is subject, if we
could succeed in raising the responsible act of procreating
children to the level of a deliberate and intentional activity and
in freeing it from its entanglement with the necessary satisfaction
of a natural need.

   A perspicacious physician will
therefore take it upon himself to decide under what conditions the
use of measures for preventing conception are justified, and, among
those measures, he will have to separate the harmful from the
harmless ones. Everything is harmful that hinders the occurrence of
satisfaction. But, as we know, we possess at present no method of
preventing conception which fulfils every legitimate requirement -
that is, which is certain and convenient, which does not diminish
the sensation of pleasure during coitus and which does not wound
the woman’s sensibilities. This sets physicians a practical
task to the solution of which they could bend their energies with
rewarding results. Whoever fills in this lacuna in our medical
technique will have preserved the enjoyment of life and maintained
the health of numberless people; though, it is true, he will also
have paved the way for a drastic change in our social
conditions.

Sexuality In The Aetiology Of The Neuroses

470

   This does not exhaust the
possibilities which flow from a recognition of the sexual aetiology
of the neuroses. The main benefit which we obtain from it for
neurasthenics lies in the sphere of prophylaxis. If masturbation is
the cause of neurasthenia in youth, and if, later on, it acquires
aetiological significance for anxiety neurosis as well, by reason
of the reduction of potency which it brings about, then the
prevention of masturbation in both sexes is a task that deserves
more attention than it has hitherto received. When we reflect upon
all the injuries, both the grosser and the finer ones, which
proceed from neurasthenia - a disorder which we are told is growing
more and more prevalent - we see that it is positively a matter of
public interest that
men should enter upon sexual relations with
full potency
. In matters of prophylaxis, however, the
individual is relatively helpless. The whole community must become
interested in the matter and give their assent to the creation of
generally acceptable regulations. At present we are still far
removed from such a state of affairs which would promise relief,
and it is for this reason that we may with justice regard
civilization, too, as responsible for the spread of neurasthenia.
Much would have to be changed. The resistance of a generation of
physicians who can no longer remember their own youth must be
broken down; the pride of fathers, who are unwilling to descend to
the level of humanity in their children’s eyes, must be
overcome; and the unreasonable prudery of mothers must be combated
- the mothers who at present look upon it as an incomprehensible
and undeserved stroke of fate that ‘
their
children
should have been the ones to become neurotic’. But above all,
a place must be created in public opinion for the discussion of the
problems of sexual life. It will have to become possible to talk
about these things without being stamped as a trouble-maker or as a
person who makes capital out of the lower instincts. And so here,
too, there is enough work left to do for the next hundred years -
in which our civilization will have to learn to come to terms with
the claims of our sexuality.

Sexuality In The Aetiology Of The Neuroses

471

   The value of making a correct
diagnostic separation of the psychoneuroses from neurasthenia is
also shown by the fact that the psychoneuroses call for a different
practical assessment and for special therapeutic measures. They
make their appearance as a result of two kinds of determinants,
either independently or in the train of the ‘actual
neuroses’ (neurasthenia and anxiety neurosis). In the latter
case we are dealing with a new type of neurosis - incidentally, a
very frequent one - a mixed neurosis. The aetiology of the
‘actual neuroses’ has become an auxiliary aetiology of
the psychoneuroses. A clinical picture arises in which, let us say,
anxiety neurosis predominates but which also contains traits of
genuine neurasthenia, hysteria and obsessional neurosis. When
confronted with a mixture of this kind, we shall nevertheless not
be wise to give up separating out the clinical pictures proper to
each neurotic illness; for after all it is not difficult to explain
the case to oneself in the following manner. The predominant place
taken by the anxiety neurosis shows that the illness has come into
being under the aetiological influence of an ‘actual’
sexual noxa. But the person concerned was, apart from that,
disposed to one or more of the psychoneuroses owing to a special
aetiology and would at some time or other have fallen ill of a
psychoneurosis either spontaneously or with the advent of some
other weakening factor. In this way the auxiliary aetiology for the
psychoneurosis which is still lacking is supplied by the actual
aetiology of the anxiety neurosis.

   For such cases it has quite
correctly come to be the therapeutic practice to disregard the
psychoneurotic components in the clinical picture and to treat the
‘actual neurosis’ exclusively. In very many cases it is
possible to overcome the neurosis as well which it has brought
along with it, provided that the neurasthenia is effectively dealt
with. But a different view must be taken in those cases of
psychoneurosis which either appear spontaneously or remain behind
as an independent entity after an illness composed of neurasthenia
and psychoneurosis has run its course. When I speak of a
‘spontaneous’ appearance of a psychoneurosis, I do not
mean that anamnestic investigation shows us no aetiological element
whatever. It may do so, no doubt; but it may also happen that our
attention is directed to some indifferent factor - an emotional
state, an enfeeblement owing to physical illness, and so on. It
must, however, be borne in mind in all these cases that the true
aetiology of the psychoneuroses does not lie in such precipitating
causes, but remains beyond the reach of ordinary anamnestic
examination.

Sexuality In The Aetiology Of The Neuroses

472

   As we know, it is in an attempt
to bridge this gap that the assumption has been made of a special
neuropathic disposition (which, incidentally, if it existed, would
not leave much hope of success for the treatment of such
pathological conditions). The neuropathic disposition itself is
regarded as a sign of a general degeneracy, and thus this
convenient technical term has come to be superabundantly used
against the wretched patients whom the doctors are quite incapable
of helping. Fortunately, the state of affairs is different. The
neuropathic disposition does no doubt exist, but I must deny that
it suffices for the creation of a psychoneurosis. I must further
deny that the conjunction of a neuropathic disposition with
precipitating causes occurring in later life constitutes an
adequate aetiology of the psychoneuroses. In tracing back the
vicissitudes of an individual’s illness to the experiences of
his ancestors, we have gone too far; we have forgotten that between
his conception and his maturity there lies a long and important
period of life - his childhood - in which the seeds of later
illness may be acquired. And that- is what in fact happens with a
psychoneurosis. Its true aetiology is to be found in childhood
experiences, and, once again - and exclusively - in impressions
concerned with sexual life. We do wrong to ignore the sexual life
of children entirely; in my experience, children are capable of
every psychical sexual activity, and many somatic sexual ones as
well. Just as the whole human sexual apparatus is not comprised in
the external genitals and the two reproductive glands, so human
sexual life does not begin only with puberty, as on a rough
inspection it may appear to do. Nevertheless it is true that the
organization and evolution of the human species strives to avoid
any great degree of sexual activity during childhood. It seems that
in man the sexual instinctual forces are meant to be stored up so
that, on their release at puberty, they may serve great cultural
ends. (W. Fliess.) Consideration of this sort may make it possible
to understand why the sexual experiences of childhood are bound to
have a pathogenic effect. But they produce their effect only to a
very slight degree at the time at which they occur; what is far
more important is their
deferred
effect, which can only take
place at later periods of growth. This deferred effect originates -
as it can do in no other way - in the psychical traces which have
been left behind by infantile sexual experiences. During the
interval between the experiences of those impressions and their
reproduction (or rather, the reinforcement of the libidinal
impulses which proceed from them), not only the somatic sexual
apparatus but the psychical apparatus as well has undergone an
important development; and thus it is that the influence of these
earlier sexual experiences now leads to an abnormal psychical
reaction, and psychopathological structures come into
existence.