life, such abstention being valuable, not only for the conservation and transformation of energy, but also to emphasize the fact that life contains other matters to strive for beyond the ends of sex. Redlich (_Medizinische Klinik_, 1908, No. 7) also, in a careful study of the medical aspects of the question, takes an intermediate standpoint in relation to the relative advantages and disadvantages of sexual abstinence. "We may say that sexual abstinence is not a condition which must, under all circumstances and at any price, be avoided, though it is true that for the majority of healthy adult persons regular sexual intercourse is advantageous, and sometimes is even to be recommended."
It may be added that from the standpoint of Christian religious morality this same attitude, between the extremes of either party, recognizing the advantages of sexual abstinence, but not insisting that they shall be purchased at any price, has also found representation. Thus, in England, an Anglican clergyman, the Rev. H. Northcote (_Christianity and Sex Problems_, pp. 58, 60) deals temperately and sympathetically with the difficulties of sexual abstinence, and is by no means convinced that such abstinence is always an unmixed advantage; while in Germany a Catholic priest, Karl Jentsch (_Sexualethik, Sexualjustiz, Sexualpolizei_, 1900) sets himself to oppose the rigorous and unqualified assertions of Ribbing in favor of sexual abstinence. Jentsch thus expresses what he conceives ought to be the attitude of fathers, of public opinion, of the State and the Church towards the young man in this matter: "Endeavor to be abstinent until marriage. Many succeed in this. If you can succeed, it is good. But, if you cannot succeed, it is unnecessary to cast reproaches on yourself and to regard yourself as a scoundrel or a lost sinner. Provided that you do not abandon yourself to mere enjoyment or wantonness, but are content with what is necessary to restore your peace of mind, self-possession, and cheerful capacity for work, and also that you observe the precautions which physicians or experienced friends impress upon you."
When we thus analyze and investigate the the three main streams of expert opinions in regard to this question of sexual abstinence--the opinions in favor of it, the opinions in opposition to it, and the opinions which take an intermediate course--we can scarcely fail to conclude how unsatisfactory the whole discussion is. The state of "sexual abstinence" is a completely vague and indefinite state. The indefinite and even meaningless character of the expression "sexual abstinence" is shown by the frequency with which those who argue about it assume that it can, may, or even must, involve masturbation. That fact alone largely deprives it of value as morality and altogether as abstinence. At this point, indeed, we reach the most fundamental criticism to which the conception of "sexual abstinence" lies open. Rohleder, an experienced physician and a recognized authority on questions of sexual pathology, has submitted the current views on "sexual abstinence" to a searching criticism in a lengthy and important paper.[95] He denies altogether that strict sexual abstinence exists at all. "Sexual abstinence," he points out, in any strict scenes of the term, must involve abstinence not merely from sexual intercourse but from auto-erotic manifestations, from masturbation, from homosexual acts, from all sexually perverse practices. It must further involve a permanent abstention from indulgence in erotic imaginations and voluptuous reverie.
When, however, it is possible thus to render the whole psychic field a _tabula rasa_ so far as sexual activity is concerned--and if it fails to be so constantly and consistently there is no strict sexual abstinence--then, Rohleder points out, we have to consider whether we are not in presence of a case of sexual anæsthesia, of _anaphrodisia sexualis_. That is a question which is rarely, if ever, faced by those who discuss sexual abstinence. It is, however, an extremely pertinent question, because, as Rohleder insists, if sexual anæsthesia exists the question of sexual abstinence falls to the ground, for we can only "abstain" from actions that are in our power. Complete sexual anæsthesia is, however, so rare a state that it may be practically left out of consideration, and as the sexual impulse, if it exists, must by physiological necessity sometimes become active in some shape--even if only, according to Freud's view, by transformation into some morbid neurotic condition--we reach the conclusion that "sexual abstinence" is strictly impossible. Rohleder has met with a few cases in which there seemed to him no escape from the conclusion that sexual abstinence existed, but in all of these he subsequently found that he was mistaken, usually owing to the practice of masturbation, which he believes to be extremely common and very frequently accompanied by a persistent attempt to deceive the physician concerning its existence. The only kind of "sexual abstinence" that exists is a partial and temporary abstinence. Instead of saying, as some say, "Permanent abstinence is unnatural and cannot exist without physical and mental injury," we ought to say, Rohleder believes, "Permanent abstinence is unnatural and has never existed."
It is impossible not to feel as we contemplate this chaotic mass of opinions, that the whole discussion is revolving round a purely negative idea, and that fundamental fact is responsible for what at first seem to be startling conflicts of statement. If indeed we were to eliminate what is commonly regarded as the religious and moral aspect of the matter--an aspect, be it remembered, which has no bearing on the essential natural facts of the question--we cannot fail to perceive that these ostentatious differences of conviction would be reduced within very narrow and trifling limits.
We cannot strictly coordinate the impulse of reproduction with the impulse of nutrition. There are very important differences between them, more especially the fundamental difference that while the satisfaction of the one impulse is absolutely necessary both to the life of the individual and of the race, the satisfaction of the other is absolutely necessary only to the life of the race. But when we reduce this question to one of "sexual abstinence" we are obviously placing it on the same basis as that of abstinence from food, that is to say at the very opposite pole to which we place it when (as in the previous chapter) we consider it from the point of view of asceticism and chastity. It thus comes about that on this negative basis there really is an interesting analogy between nutritive abstinence, though necessarily only maintained incompletely and for a short time, and sexual abstinence, maintained more completely and for a longer time. A patient of Janet's seems to bring out clearly this resemblance. Nadia, whom Janet was able to study during five years, was a young woman of twenty-seven, healthy and intelligent, not suffering from hysteria nor from anorexia, for she had a normal appetite. But she had an idea; she was anxious to be slim and to attain this end she cut down her meals to the smallest size, merely a little soup and a few eggs. She suffered much from the abstinence she thus imposed on herself, and was always hungry, though sometimes her hunger was masked by the inevitable stomach trouble caused by so long a persistence in this _régime_. At times, indeed, she had been so hungry that she had devoured greedily whatever she could lay her hands on, and not infrequently she could not resist the temptation to eat a few biscuits in secret. Such actions caused her horrible remorse, but, all the same, she would be guilty of them again. She realized the great efforts demanded by her way of life, and indeed looked upon herself as a heroine for resisting so long. "Sometimes," she told Janet, "I passed whole hours in thinking about food, I was so hungry. I swallowed my saliva, I bit my handkerchief, I rolled on the ground, I wanted to eat so badly. I searched books for descriptions of meals and feasts, I tried to deceive my hunger by imagining that I too was enjoying all these good things. I was really famished, and in spite of a few weaknesses for biscuits I know that I showed much courage."[96] Nadia's motive idea, that she wished to be slim, corresponds to the abstinent man's idea that he wishes to be "moral," and only differs from it by having the advantage of being somewhat more positive and personal, for the idea of the person who wishes to avoid sexual indulgence because it is "not right" is often not merely negative but impersonal and imposed by the social and religious environment. Nadia's occasional outbursts of reckless greediness correspond to the sudden impulses to resort to prostitution, and her secret weaknesses for biscuits, followed by keen remorse, to lapses into the habit of masturbation. Her fits of struggling and rolling on the ground are precisely like the outbursts of futile desire which occasionally occur to young abstinent men and women in health and strength. The absorption in thoughts about meals and in literary descriptions of meals is clearly analogous to the abstinent man's absorption in wanton thoughts and erotic books. Finally, Nadia's conviction that she is a heroine corresponds exactly to the attitude of self-righteousness which often marks the sexually abstinent.
If we turn to Freud's penetrating and suggestive study of the problem of sexual abstinence in relation to "civilized" sexual morality, we find that, though he makes no reference to the analogy with abstinence from food, his words would for the most part have an equal application to both cases. "The task of subduing so powerful an instinct as the sexual impulse, otherwise than by giving it satisfaction," he writes, "is one which may employ the whole strength of a man. Subjugation through sublimation, by guiding the sexual forces into higher civilizational paths, may succeed with a minority, and even with these only for a time, least easily during the years of ardent youthful energy. Most others become neurotic or otherwise come to grief. Experience shows that the majority of people constituting our society are constitutionally unequal to the task of abstinence. We say, indeed, that the struggle with this powerful impulse and the emphasis the struggle involves on the ethical and æsthetic forces in the soul's life 'steels' the character, and for a few favorably organized natures this is true; it must also be acknowledged that the differentiation of individual character so marked in our time only becomes possible through sexual limitations. But in by far the majority of cases the struggle with sensuality uses up the available energy of character, and this at the very time when the young man needs all his strength in order to win his place in the world."[97] When we have put the problem on this negative basis of abstinence it is difficult to see how we can dispute the justice of Freud's conclusions. They hold good equally for abstinence from food and abstinence from sexual love. When we have placed the problem on a more positive basis, and are able to invoke the more active and fruitful motives of asceticism and chastity this unfortunate fight against a natural impulse is abolished. If chastity is an ideal of the harmonious play of all the organic impulses of the soul and body, if asceticism, properly understood, is the athletic striving for a worthy object which causes, for the time, an indifference to the gratification of sexual impulses, we are on wholesome and natural ground, and there is no waste of energy in fruitless striving for a negative end, whether imposed artificially from without, as it usually is, or voluntarily chosen by the individual himself.
For there is really no complete analogy between sexual desire and hunger, between abstinence from sexual relations and abstinence from food. When we put them both on the basis of abstinence we put them on a basis which covers the impulse for food but only half covers the impulse for sexual love. We confer no pleasure and no service on our food when we eat it. But the half of sexual love, perhaps the most important and ennobling half, lies in what we give and not in what we take. To reduce this question to the low level of abstinence, is not only to centre it in a merely negative denial but to make it a solely self-regarding question. Instead of asking: How can I bring joy and strength to another? we only ask: How can I preserve my empty virtue?
Therefore it is that from whatever aspect we consider the question,--whether in view of the flagrant contradiction between the authorities who have discussed this question, or of the illegitimate mingling here of moral and physiological considerations, or of the merely negative and indeed unnatural character of the "virtue" thus set up, or of the failure involved to grasp the ennoblingly altruistic and mutual side of sexual love,--from whatever aspect we approach the problem of "sexual abstinence" we ought only to agree to do so under protest.
If we thus decide to approach it, and if we have reached the conviction--which, in view of all the evidence we can scarcely escape--that, while sexual abstinence in so far as it may be recognized as possible is not incompatible with health, there are yet many adults for whom it is harmful, and a very much larger number for whom when prolonged it is undesirable, we encounter a serious problem. It is a problem which confronts any person, and especially the physician, who may be called upon to give professional advice to his fellows on this matter. If sexual relationships are sometimes desirable for unmarried persons, or for married persons who, for any reason, are debarred from conjugal union, is a physician justified in recommending such sexual relationships to his patient? This is a question that has frequently been debated and decided in opposing senses.
Various distinguished physicians, especially in Germany, have proclaimed the duty of the doctor to recommend sexual intercourse to his patient whenever he considers it desirable. Gyurkovechky, for instance, has fully discussed this question, and answered it in the affirmative. Nyström (_Sexual-Probleme_, July, 1908, p. 413) states that it is the physician's duty, in some cases of sexual weakness, when all other methods of treatment have failed, to recommend sexual intercourse as the best remedy. Dr. Max Marcuse stands out as a conspicuous advocate of the unconditional duty of the physician to advocate sexual intercourse in some cases, both to men and to women, and has on many occasions argued in this sense (e.g., _Darf der Arzt zum Ausserehelichen Geschlechtsverkehr raten?_ 1904). Marcuse is strongly of opinion that a physician who, allowing himself to be influenced by moral, sociological, or other considerations, neglects to recommend sexual intercourse when he considers it desirable for the patient's health, is unworthy of his profession, and should either give up medicine or send his patients to other doctors. This attitude, though not usually so emphatically stated, seems to be widely accepted. Lederer goes even further when he states (_Monatsschrift für Harnkrankheiten und Sexuelle Hygiene_, 1906, Heft 3) that it is the physician's duty in the case of a woman who is suffering from her husband's impotence, to advise her to have intercourse with another man, adding that "whether she does so with her husband's consent is no affair of the physician's, for he is not the guardian of morality, but the guardian of health." The physicians who publicly take this attitude are, however, a small minority. In England, so far as I am aware, no physician of eminence has openly proclaimed the duty of the doctor to advise sexual intercourse outside marriage, although, it is scarcely necessary to add, in England, as elsewhere, it happens that doctors, including women doctors, from time to time privately point out to their unmarried and even married patients, that sexual intercourse would probably be beneficial.
The duty of the physician to recommend sexual intercourse has been denied as emphatically as it has been affirmed. Thus Eulenburg (_Sexuale Neuropathie_, p. 43), would by no means advise extra-conjugal relations to his patient; "such advice is quite outside the physician's competence." It is, of course, denied by those who regard sexual abstinence as always harmless, if not beneficial. But it is also denied by many who consider that, under some circumstances, sexual intercourse would do good.
Moll has especially, and on many occasions, discussed the duty of the physician in relation to the question of advising sexual intercourse outside marriage (e.g., in his comprehensive work, _Aerztliche Ethik_, 1902; also _Zeitschrift für Aerztliche Fortbildung_, 1905, Nos. 12-15; _Mutterschutz_, 1905, Heft 3; _Geschlecht und Gesellschaft_, vol. ii, Heft 8). At the outset Moll had been disposed to assert the right of the physician to recommend sexual intercourse under some circumstances; "so long as marriage is unduly delayed and sexual intercourse outside marriage exists," he wrote (_Die Conträre Sexualempfindung_, second edition, p. 287), "so long, I think, we may use such intercourse therapeutically, provided that the rights of no third person (husband or wife) are injured." In all his later writings, however, Moll ranges himself clearly and decisively on the opposite side. He considers that the physician has no right to overlook the possible results of his advice in inflicting venereal disease, or, in the case of a woman, pregnancy, on his patient, and he believes that these serious results are far more likely to happen than is always admitted by those who defend the legitimacy of such advice. Nor will Moll admit that the physician is entitled to overlook the moral aspects of the question. A physician may know that a poor man could obtain many things good for his health by stealing, but he cannot advise him to steal. Moll takes the case of a Catholic priest who is suffering from neurasthenia due to sexual abstinence. Even although the physician feels certain that the priest may be able to avoid all the risks of disease as well as of publicity, he is not entitled to urge him to sexual intercourse. He has to remember that in thus causing a priest to break his vows of chastity he may induce a mental conflict and a bitter remorse which may lead to the worst results, even on his patient's physical health. Similar results, Moll remarks, may follow such advice when given to a married man or woman, to say nothing of possible divorce proceedings and accompanying evils.
Rohleder (_Vorlesungen über Geschlechtstrieb und Gesamtes Geschlechtsleben der Menschen_) adopts a somewhat qualified attitude in this matter. As a general rule he is decidedly against recommending sexual intercourse outside marriage to those who are suffering from partial or temporary abstinence (the only form of abstinence he recognizes), partly on the ground that the evils of abstinence are not serious or permanent, and partly because the patient is fairly certain to exercise his own judgment in the matter. But in some classes of cases he recommends such intercourse, and notably to bisexual persons, on the ground that he is thus preserving his patient from the criminal risks of homosexual practices.
It seems to me that there should be no doubt whatever as to the correct professional attitude of the physician in relation to this question of advice concerning sexual intercourse. The physician is never entitled to advise his patient to adopt sexual intercourse outside marriage nor any method of relief which is commonly regarded as illegitimate. It is said that the physician has nothing to do with considerations of conventional morality. If he considers that champagne would be good for a poor patient he ought to recommend him to take champagne; he is not called upon to consider whether the patient will beg, borrow, or steal the champagne. But, after all, even if that be admitted, it must still be said that the physician knows that the champagne, however obtained, is not likely to be poisonous. When, however, he prescribes sexual intercourse, with the same lofty indifference to practical considerations, he has no such knowledge. In giving such a prescription the physician has in fact not the slightest knowledge of what he may be prescribing. He may be giving his patient a venereal disease; he may be giving the anxieties and responsibilities of an illegitimate child; the prescriber is quite in the dark. He is in the same position as if he had prescribed a quack medicine of which the composition was unknown to him, with the added disadvantage that the medicine may turn out to be far more potently explosive than is the case with the usually innocuous patent medicine. The utmost that a physician can properly permit himself to do is to put the case impartially before his patient and to present to him all the risks. The solution must be for the patient himself to work out, as best he can, for it involves social and other considerations which, while they are indeed by no means outside the sphere of medicine, are certainly entirely outside the control of the individual private practitioner of medicine.
Moll also is of opinion that this impartial presentation of the case for and against sexual intercourse corresponds to the physician's duty in the matter. It is, indeed, a duty which can scarcely be escaped by the physician in many cases. Moll points out that it can by no means be assimilated, as some have supposed, with the recommendation of sexual intercourse. It is, on the contrary, he remarks, much more analogous to the physician's duty in reference to operations. He puts before the patient the nature of the operation, its advantages and its risks, but he leaves it to the patient's judgment to accept or reject the operation. Lewitt also (_Geschlechtliche Enthaltsamkeit und Gesundheitsstörungen_, 1905), after discussing the various opinions on this question, comes to the conclusion that the physician, if he thinks that intercourse outside marriage might be beneficial, should explain the difficulties and leave the patient himself to decide.
There is another reason why, having regard to the prevailing moral opinions at all events among the middle classes, a physician should refrain from advising extra-conjugal intercourse: he places himself in a false relation to his social environment. He is recommending a remedy the nature of which he could not publicly avow, and so destroying the public confidence in himself. The only physician who is morally entitled to advise his patients to enter into extra-conjugal relationships is one who openly acknowledges that he is prepared to give such advice. The doctor who is openly working for social reform has perhaps won the moral right to give advice in accordance with the tendency of his public activity, but even then his advice may be very dubiously judicious, and he would be better advised to confine his efforts at social reform to his public activities. The voice of the physician, as Professor Max Flesch of Frankfort observes, is more and more heard in the development and new growth of social institutions; he is a natural leaders in such movements, and proposals for reform properly come from him. "But," as Flesch continues, "publicly to accept the excellence of existing institutions and in the privacy of the consulting-room to give advice which assumes the imperfection of those institutions is illogical and confusing. It is the physician's business to give advice which is in accordance with the interests of the community as a whole, and those interests require that sexual relationships should be entered into between healthy men and women who are able and willing to accept the results of their union. That should be the physician's rule of conduct. Only so can he become, what to-day he is often proclaimed to be, the leader of the nation."[98] This view is not, as we see, entirely in accord with that which assumes that the physician's duty is solely and entirely to his patient, without regard to the bearing of his advice on social conduct. The patient's interests are primary, but they are not entitled to be placed in antagonism to the interests of society. The advice given by the wise physician must always be in harmony with the social and moral tone of his age. Thus it is that the tendency among the younger generation of physicians to-day to take an active interest in raising that tone and in promoting social reform--a tendency which exists not only in Germany where such interests have long been acute, but also in so conservative a land as England--is full of promise for the future.
The physician is usually content to consider his duty to his patient in relationship to sexual abstinence as sufficiently fulfilled when he attempts to allay sexual hyperæsthesia by medical or hygienic treatment. It can scarcely be claimed, however, that the results of such treatment are usually satisfactory, and sometimes indeed the treatment has a result which is the reverse of that intended. The difficulty generally is that in order to be efficacious the treatment must be carried to an extreme which exhausts or inhibits not only the genital activities alone but the activities of the whole organism, and short of that it may prove a stimulant rather than a sedative. It is difficult and usually impossible to separate out a man's sexual activities and bring influence to bear on these activities alone. Sexual activity is so closely intertwined with the other organic activities, erotic exuberance is so much a flower which is rooted in the whole organism, that the blow which crushes it may strike down the whole man. The bromides are universally recognized as powerful sexual sedatives, but their influence in this respect only makes itself felt when they have dulled all the finest energies of the organism. Physical exercise is universally recommended to sexually hyperæsthetic patients. Yet most people, men and women, find that physical exercise is a positive stimulus to sexual activity. This is notably so as regards walking, and exuberantly energetic young women who are troubled by the irritant activity of their healthy sexual emotions sometimes spend a large part of their time in the vain attempt to lull their activity by long walks. Physical exercise only proves efficacious in this respect when it is carried to an extent which produces general exhaustion. Then indeed the sexual activity is lulled; but so are all the mental and physical activities. It is undoubtedly true that exercises and games of all sorts for young people of both sexes have a sexually hygienic as well as a generally hygienic influence which is undoubtedly beneficial. They are, on all grounds, to be preferred to prolonged sedentary occupations. But it is idle to suppose that games and exercises will suppress the sexual impulses, for in so far as they favor health, they favor all the impulses that are the result of health. The most that can be expected is that they may tend to restrain the manifestations of sex by dispersing the energy they generate.
There are many physical rules and precautions which are advocated, not without reason, as tending to inhibit or diminish sexual activity. The avoidance of heat and the cultivation of cold is one of the most important of these. Hot climates, a close atmosphere, heavy bed-clothing, hot baths, all tend powerfully to excite the sexual system, for that system is a peripheral sensory organ, and whatever stimulates the skin generally, stimulates the sexual system.[99] Cold, which contracts the skin, also deadens the sexual feelings, a fact which the ascetics of old knew and acted upon. The garments and the posture of the body are not without influence. Constriction or pressure in the neighborhood of the sexual region, even tight corsets, as well as internal pressure, as from a distended bladder, are sources of sexual irritation. Sleeping on the back, which congests the spinal centres, also acts in the same way, as has long been known by those who attend to sexual hygiene; thus it is stated that in the Franciscan order it is prohibited to lie on the back. Food and drink are, further, powerful sexual stimulants. This is true even of the simplest and most wholesome nourishment, but it is more especially true of flesh meat, and, above all, of alcohol in its stronger forms such as spirits, liqueurs, sparkling and heavy wines, and even many English beers. This has always been clearly realized by those who cultivate asceticism, and it is one of the powerful reasons why alcohol should not be given in early youth. As St. Jerome wrote, when telling Eustochium that she must avoid wine like poison, "wine and youth are the two fires of lust. Why add oil to the flame?"[100] Idleness, again, especially when combined with rich living, promotes sexual activity, as Burton sets forth at length in his _Anatomy of Melancholy_, and constant occupation, on the other hand, concentrates the wandering activities.
Mental exercise, like physical exercise, has sometimes been advocated as a method of calming sexual excitement, but it seems to be equally equivocal in its action. If it is profoundly interesting and exciting it may stir up rather than lull the sexual emotions. If it arouses little interest it is unable to exert any kind of influence. This is true even of mathematical occupations which have been advocated by various authorities, including Broussais, as aids to sexual hygiene.[101] "I have tried mechanical mental work," a lady writes, "such as solving arithmetical or algebraic problems, but it does no good; in fact it seems only to increase the excitement." "I studied and especially turned my attention to mathematics," a clergyman writes, "with a view to check my sexual tendencies. To a certain extent I was successful. But at the approach of an old friend, a voice or a touch, these tendencies came back again with renewed strength. I found mathematics, however, the best thing on the whole to take off my attention from women, better than religious exercises which I tried when younger (twenty-two to thirty)." At the best, however, such devices are of merely temporary efficacy.