[Reprint from the alienist and neurologist, April, 1897. Psychical Hermaphroditism. A Few Notes on Sexual Perversion, with Two Clinical Cases of Sexual • ' - . v . Inversion* By WILLIAM LEE HOWARD, M. D., Baltimore, Md, [Reprint from the ALIENIST AND NEUROLOGIST, April, 1897.] PSYCHICAL HERMAPHRODITISM. A Few Notes on Sexual Perversion, with Two Clinical Cases of Sexual Inversion. By WILLIAM LEE HOWARD, M. D., Baltimore, Md. nPHE poet says that some truths had better be kept be- * hind the screen. This statement may be applicable to the writings of the poet, but the scientist wants the verity of life. The truth is, the evils are, with scarcely an exception, old. That which is new is the intelligence which discerns and the humanity which renders them. Sexual per- version has always played an important role in human life. Nor is it confined to the modern life alone. Few general practitioners realize the prevalence of distorted genesic in- stincts to day, or the important bearing it had on the life of the ancients. When this psychical condition is studied by the light of history we can congratulate ourselves that this vice, and often disease, is no longer a factor that can 1 2 William Lee Howard. be insiduously admitted as part of a nation’s foibles or prac- tices, or that it has any role in the life of the normal human being. The ancient history of vice and disease is as inter- esting to the scholar as its aetiology and pathology are to modern medical men. The history of sexual perversion will be a source of pleasure to the optimist and instructing to the pessimist. Before coming to the clinical study of sexual perversion as we see it to-day let us take a cursory glance of the sub- ject from an historical point of view. Von Krafft-Ebing * has ably shown the influence that sexual life exercises on religion, art and poetry. According to his statements there does not exist a real work of art without a sexual basis, and he has properly called attention to the fact that great poets and great artists, and 1 might add, great writers, are mostly of a sensual nature, and 1 will further indite, often this sensuality partakes of a perverted feeling. There are a large number of men that feel themselves attracted to other men and boys. This attraction for individuals of the same sex is designated under the name of homo-sexuality, in distinction to the term hetero-sexuality, which designates the normal attraction. The name Lesbian designates the love of woman for woman, and was used in this sense by Sappho. Westphal t employs the expression sexual per- version (Contrare Sexualemfin dung) which allows of a great- er latitude in dealing with the subject. Westphal’s idea is that it is not always a question of deviation from the in- stinct itself, but of the sensations that make many an in- dividual feel that his personality is entirely estranged from the sex to which he belongs. We will see this fact clearly demonstrated later on in one of my cases. This writer is also of the opinion that sexual perversion embraces also those cases in which, the sexual instinct remaining normal, the individual presents certain tendencies belonging to the opposite sex. It is well here to have a clear understanding between perversion and perversity. There is an incised and rigorous distinction, and as laid down by Krafft-Ebing it is as follows: “We speak of perversion when the sex- ual instinct is a perverted instinct, while we speak of per- * Psychopathia Sexualis. t Arch, fur Psychiatre, II, paije 74. Psychical Hermaphroditism. 3 versity when it is a question of a perverse action, without taking into account the motive that has determined that ac- tion, whether it be a perverse inclination or any other mo- tive, a criminal action for example.” Perversion is an in- clination independent of the will, and for which no one can be held responsible, at least in the eyes of an impartial judge; on the contrary, perversity, which is manifested in the action, must often be placed to the account of the in- dividual. Pederasty is often used by modern writers when speak- ing of homo-sexual love, but this is incorrect so far as it only relates to the act which involves imissio penis in annm. Pederasty comes from paiods erastes, “lover of boys;” and it is by this term that the ancient Greeks designated, in a general way, whether the sexual act was involved or not, lovers of boys and young men. Sexual perversion exists to-day to a much greater ex- tent than the general practitioner realizes. A proper under- standing of this abnormal condition is of great scientific im- portance and medico-legal interest. The medical man who has a clear understanding and conception of the psycholog- ical conditions governing the mental and physical attitudes of these perverts and inverts, who is known to understand their morbid desires, and appreciates their moral palsy, will be astonished at the number which will seek him for relief. I do not refer to the vicious, to the morally depraved, to the male prostitute, to that class which comes under police notice, or to the degenerate whose actions are decidedly anti-social. Space prevents me from showing where the rigorous line should be drawn between these banal and vicious classes and the unfortunate psychical pervert. It is certain that in sexual perversion we have to deal with well- defined pathological phenomena occurring under conditions that vary only in circumstances and environments, which have always existed at all periods and in all countries. Natural laws govern all the phenomena from the first appear- ance of sexual life, through its various phases to decadence. A close study of the history of cases will show analogies which will convince the most skeptical. The invert and the 4 William Lee Howard. pervert is to be found among the class. A marked feature of this anomaly is the precocity of the sexual instinct. Ninety per cent, of these abnormal individuals are engaged in artistic pursuits. They are found among the painters, musicians, poets, and the writers of erotic fulmination. Among Havelock Ellis’ thirty-three cases, two were physicians. Female perverts depart to a greater degree from the normal than do the male. There are more female preverts than inverts in my experience. These cases of true sexual perversion, can seldom, if ever, be seen in hospitals and dispensaries. (1 use the word per- vert to cover all abnormal sexual desires, while invert is strictly applied to designate the love of one sex for an individual of the same sex. In speaking in a general way of the subject, perversion covers all cases). The practi- tioner, while he may have them in his office to be treated for some extraneous trouble, will not often be made the confident of the pervert. These individuals are secretive, reserved and obmutescent. As they recognize the fact that unless understood they will be avoided, shunned with dis- gust, and finally met with social degringolade, it is not strange that their abnormality is seldom recognized except by those of similar psychical desires, and to the specialist, with whom they are pitiably frank, honest and hopefully confident. The genital organs of the pervert are almost without an exception normal in appearance and function. The condition of these individuals is a decided psychical morbid entity. Some of them do not realize that their passions, desires and thoughts are abnormal. It is not easy to appreciate the role that external impressions and acci- dental environments have played in the individual develop- ment of these cases. 1 do not believe that true inversion is ever an acquired condition; it is congenital. I will not here go into this interesting branch of the subject, but will give fully the history of two cases in which 1 have been able to get at definite basis of facts as regards heredity. The first case I requested to write out for me, in his own words, his history, physical condition, and mental attitude Psychical Hermaphroditism. 5 and desires. This will better enable us to understand the moral status of these unfortunates. CASE 1.—H. W. F., 1 am thirty years old. Ever since 1 was a small boy of eight or nine 1 have practised the habit of self-abuse. For many years 1 had no idea that it was wrong or injurious; when my eyes were opened 1 loathed myself, and have had no self-respect. 1 have hon- estly resolved time and again to break this habit. One summer, four or five years ago, I remember how earnestly 1 tried to refrain, and was most miserable. 1 had nocturnal emissions, which proved far more weakening than the indul- gence; had a cough, was melancholy and despondent. 1 never had advice, I have simply drawn my own inferences; my experience taught me that 1 could not overcome the habit unaided. 1 could not then, and doubt if 1 could now, go to my doctor and tell him what 1 write for you. To-day 1 transgress more than ever; the result: 1 have never weighed as much; eat well. I sleep about nine hours nightly, and have very few spells of that awful despon- dency. 1 believe that I have a goodly amouut of conscien- tiousness. 1 loath the practice, but somehow there seems to be a hungering, burning desire, crying for appeasement so loudly that the voice of reason is drowned. It seems almost as if 1 had two beings. When I am my rational self 1 say to myself “the right is well-defined; the proper course is simple,” but when the fit is upon me, there seems to be only one word, MUST. It must be gratified regard- less of consequences. The object of my imagination is man. 1 suppose that men who practice this habit have as the idol of their imagination woman. But it is not so with me. 1 think that I have the same regard for men as a healthy man has for woman. 1 have loved men passion- ately. I idolize them. Any licentious thought in regard to such 1 regard as a sacrilege. That love is just as real to me as the love of a young man for a woman, though my better s. If would tell me how preposterious it was; yet I seem incapable of any other. 1 can define my disposition no better than to say that I seem to be a female in a per- fectly formed male body, for, so far as 1 know, I am a well-formed man, capable of performing all of man’s func- tions sexually. Yet as far back as I can remembei, surely as young as five years, I seemed to have the strongest pos- sible desire to be a girl, and used to wonder if by some peculiar magic 1 might not be transformed. I played with dolls; girls were my companions; their tastes were my tastes; music, flowers and millinery interested me and do 6 William Lee Howard. to this day. I have had little sympathy with boys or men. It has always been a topic for thought and speculation, the abnormal development of man. Any such thought or con- versation kindles the fire of passion in my brain. My love for a woman is the same that 1 have for a work of art; for a statue. 1 believe that Venus herself would not excite a bit of emotion in me. Yet a handsome man throws me into a passionate and emotional fit. In the romances that I draw for myself I always picture myself as a beautiful girl. This is not a forced imagination; such dreams and fancies come uncalled for in my mind. My childhood was loveless, and 1 often used to reason that 1 longed for love and sympathy. When I first heard that twins were born I wondered if I had not lost my mate, such was that ever present longing. In my mother’s family there were four girls and one boy. He was connected with many women; having three wives, all living. He was very erratic. Of the four girls, two never had children, though married young. The husband of one of them told me that his wife could never have children. 1 have two sisters and one brother; both sisters married over twenty years and childless. Their doctor told me that neither of them could have children. My mother died when I was six years old. My father was addicted to the morphine habit, and wished to be left alone. Yes; 1 love man in. the sexual sense; unsatisfac- torily? not wholly so; but the voice that haunts, the fire that burns, are stilled and quenched for the time, but only for a time. Men who have known men thus extraordinarily favored are common. * * * When 1 see some men my face flushes; I tremble; my voice seems unsteady and harsh; the nerve strain is acute; only by a mighty effort do I keep a semblance of coolness. * * * Should I meet a man who said that he was the favored one I would throw discretion to the winds; I’ll follow impulse regard- less of consequences, though I should lose my position and be forever disgraced. Indulgence will restore me quickly to my mental equilibrum. 1 desire to have the penis placed where the female organ would be if it existed. * * * I wanted to be an artist but the opposition was greater than the determination. I now paint and design during my leisure moments. The quality of my voice has been so frequently remarked as to annoy me. 1 have quite a stong falsetto voice of considerable compass. I once knew a man who would entice boys to his room and expose him- self and fondle them. I have no desire that way. I desire only handsome and robust men. 1 do not think that I Psychical Hermaphroditism. 7 look twice at a man wholly shaven. 1 do not always entertain lascivious thoughts toward them, I feel if I could only caress, kiss and “love” them it would be the acme of happiness. We see in this case a peculiar congenital condition, which differs from the generally conceived idea of a sexual pervert, in the fact that the idea of sodomy (immissio penis in anum) is repulsive. This condition was first pointed out by Casper in the Vierteljahrschrift in 1852. We also have in F’s statement the idea and suggestion of a female soul in a male body. This phantasy (anima muliebris in copore virili inclusa) is an old one, first expressed by Carl Hein- rich Ulrich, but is an original conception with F; of this 1 am reasonably certain. Such a specious explanation, while it satisfies the psychical longings of the pervert, has no scientific psychological basis. CASE II.—Mr. W.: age 38 years; occupation, artist; referred to me by Dr. C. G. Chaddock, of St. Louis, Mo. His father v/as a prominent physician who died when W. was about twenty years of age. He had been a hard drink- er; and during the latter part of his life was addicted to taking large doses of chloral, and died in an insane asylum. W.’s mother died of paresis when W. was an infant. A brother is a steady drinker, and another died insane. He has rea- sons to believe that one of his sisters is a victim of sexual disturbances. In fact we have a history of a family en- dowed with superior mental capacity yet exhibiting lycan- thropic stigmata throughout its whole existence and person- nel. When W. was about eight years of age the question of sex differentiation arose in his mind, and he questioned his father regarding the subject. He was erroneously in- formed that there was no difference, and from this mislead- ing and injudicious instruction W. dates back the psychical twist in his sexual character. At school he practiced mut- ual masturbation, but went no further in physical contact with his schoolmates. He has never had any normal inter- course with, or mental pictures of women or girls. So for- eign to him is the*ordinary attraction of women to men that he expresses no desire to be placed in such a mental con- dition as to realize this attraction. He wishes to be relieved from a very depressing and annoying nervous irritation which inevitably culminates in excessive masturbation, and is accompanied by salacious thoughts regarding those of his 8 William Lee Howard. own sex. These attacks occur at intervals of about four weeks, an interesting pathological fact, and immediately cease after he has manually relieved himself. For several days preceding this psychical explosion he is a different person; irritable, unable to rest or sleep, and oblivious to his other personality. We have here a disordinated conditioh of the mind, or what Prof. Newbold calls an “amorphous mind,” the dis- ordination producing an imperative and uncontrollable desire to masturbate; the impulse to act being forcibly accentuat- ed by hallucinations regarding the male genital organs. During these periods he has no clear consciousness of the existence of his normal body, or rather no lucid conscious- ness belonging to that body. When he is W. he realizes that he is a man, and has all the habits and instincts of a man aside from sexual desires, which are then negative. When in this condition, if he has any sexual suggestions, auto or otherwise, he is transformed psychically into the opposite sex. This derangement of personality, with sexual inversion as its motif, I do not remember having ever met with before. It offers a new field for studies which involve the most perplexing of psychological and physiological problems. Treatment.—There is but little to be said regarding the treatment of the true sexual pervert. As 1 have stated the condition is a congenital one. In the two cases given above, and in several others, 1 have been able to abolish the habit of masturbation, subdue the intense despondency, and suppress hysterical tendencies, by the use of hypnotic suggestion. This mode of treatment has brought about a better physical and mental condition, and aside from the inverted sensibility, but which now partakes more of the social and sentimental aspect, the patients are well and re- signedly contented. Drug medication in these cases is ab- solutely useless. Suggestion, avoidance of surroundings which are apt to produce emotional feelings: such as music, art galleries or the theatre, and substantial but nourishing diet is all that can be done; and this only with the idea of keeping them free from vicious habits and placing them in a condition of mental equilibrium, although they still re- main psychically inverted.