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Beyond the usual perversions Freud described and psychiatric nosography, some new sexual behaviours are nowadays coming to light, with a view to overstepping limits, and this in a mood for provoking, if not transgressing! As with classic perversions, the very play, the ambiguity with sexual difference, seems to be the very game and not the classic denial of this difference.
Perverse incentives in drug development, research, marketing and clinical usage can be illustrated by considering the example of the so-called 'atypical' neuroleptics which have grown to become a standard - indeed expanding - part of psychiatric practice despite their probable inferiority to older sedative agents. There is now ample evidence to suggest that neuroleptics (aka. anti-psychotics and major tranquillizers) are dangerous drugs, and patients' exposure to them should be minimized wherever possible. This clinical imperative applies whether neuroleptics are of the traditional type or atypical variety, albeit for different reasons since the traditional agents are neurotoxic, while atypicals are mainly metabolic poisons. Usage of traditional neuroleptics seems indeed to be declining progressively, but the opposite seems to be happening for 'atypicals', and new indications for these drugs are being promoted. Yet the atypical neuroleptics are a category of pharmaceuticals which are close to being un-necessary since there are safer, cheaper and pleasanter substitutes, such as benzodiazepines and the sedative antihistamines (e.g. promethazine). If 'atypical' neuroleptics did not exist, it would not be necessary to invent them. Analysis of how such expensive, dangerous and inferior drugs as the 'atypicals' have nevertheless come to dominate clinical practice casts light on the perverse incentives which now motivate the pharmaceutical industry in an era of massive state regulation. The lack of positive incentives to deploy off-patent drugs is longstanding, but there is a new disincentive in the widespread but erroneous belief that only randomized controlled trials (RCTs) can provide valid 'evidence' of effectiveness. Consequently, those who control RCTs now control clinical practice. It sometimes makes commercial sense to develop and market new drugs that are inferior to existing agents, since new drugs are patent-protected and can be promoted on the back of a mass of new RCTs funded and 'owned' by the pharmaceutical corporations. The current regulatory and patenting situation, therefore, requires major reform if drug efficacy and patient safety are to become higher priorities. Given that psychiatric practice is apparently 'locked-in' to prescribing atypicals, and if (as seems likely) most informed individuals would wish to avoid neuroleptics for themselves and their loved-ones except as a last resort; then in the short-term it may be wise for patients and their families to explore the possibilities of increased self-management of psychiatric problems using over-the-counter drugs, such as the sedative antihistamines. In the long-term, there need to be legal reforms to change the regulatory and commercial framework of incentives relating to drug development. These might include new forms of short-term re-patenting of old drugs.
Unlike the intrapsychic mechanism for self-esteem regulation in males as a basic component of perversion--extrapsychically (compensationally) culminating in an output of sexual impulses--a functional stabilization of the female self-concept seems more likely if conflict drives were to be focused on reproductional aspects and not on sexuality. It therefore seems more suitable to use a new expression in linguistic analogy to perversion: "reproversion." The case history gives an example of a clinical manifestation of "reproverse" symptom formation. The general survey describes the main points of view in regard to clinically oriented differentiation, i.e., intensity, ego-proximity in the personality structure, and one's own self-acceptance within "reproverse" symptom formation. Underlying personality disturbances are also discussed. The significance of reproversion is relevant to many different specialized medical fields. This is explained in conclusion, using the examples of denied pregnancy and infanticide at birth based on initial empirical results.
The history of ideas about perversion is considered, along with an examination of whether the concept is clinically useful. Three cases of varying degrees of severity are presented, illustrating the clinical value of the concept in the analytic situation. All three cases are women, and the particular usefulness of the concept of perversion for women is noted. The place of aggression and the pleasure resulting from its expression are highlighted.
An attempt is made to place bestophilia in cultural, clinical, and theoretical perspective. Archeological and anthropological documentation and records of the widespread appearance in mythology of this practice are cited. This archaic form of perversion is still practiced in rural environments and isolated communities. The treatment of a man who grew up in such an environment gave the author the opportunity to study this form of perversion. The correlation of clinical findings with culturally sanctioned bestophilia provides a bridge between the understanding of psychopathology and anthropological variation.
The author summarizes and develops some of her viewpoints on the perversions (outlined in several of the books and articles she has written). For her all the perversions, whatever their content, develop against an anal sadomasochistic backdrop. Their aim is to destroy reality. Reality, from a psychosexual perspective, may be defined as resulting from the existence of the father separating the mother and the child. This may be formulated in another way: reality is recognition of sexual and generational differences. Or, yet again: mother and father have a procreative sexuality, whereas the child does not. This leads to the idea that the destruction of reality is equivalent to destruction of the paternal universe. Clinical case illustrations are provided, one of which centers on the assassination of an old man who, besides representing a paternal oedipal image, also represents reality itself. This case illustrates in concrete form the murder of the father, and hence of reality, accomplished by the pervert when he eradicates the paternal dimension of psychosexuality by regressing to the anal sadomasochistic dimension.
The author considers how Freud's original formulation of the sexual drive may be understood in contemporary terms. Parallels between psychoanalysis, art history and the social and natural sciences underline the idea of sexuality as a construct that can be revisited. The nature of sexuality depends on how its irreducible biological basis is interpreted by a particular society at a particular time. The importance of revisiting is illustrated by Klein's concept of a position, which revisits the theoretical construct of a developmental stage. Freud's own construction of sexuality is based on his view of drive as comprising source, aim and object. Freud, in the Darwinian climate of his time, considered the object in terms of whether it served the fulfillment of the aim, but his paradigm can today be understood more broadly than Freud himself was able to. A discussion of perversion shows that psychoanalysis has moved from seeing it as defensive against instinctual derivatives to seeing it as defensive against object-relatedness. This reflects a shift in the analytic conceptualization of sexuality in general. Freud's paradigm for the sexual drive can be reconceived in terms of source, aim and quality of relatedness to object. Such a view of sexuality also has implications for gender issues, for the comparison of male and female perversion, and for the relation between sexuality and love.
The author views psychological perversion as a ubiquitous adaptation which preserves the person's capacity to apprehend reality while changing its meaning at will, in the service of staving off unbearable emotional pain. This is understood as derivative of the infant's horror of the nameless dread uncontained by the tantalizing environment. Whether perceived or actual, parental abdication of their protective responsibility (the meaning of the generational divide) can threaten the child's capacity to learn to contain his affects, and can bring forth the creation of a fetishistic artificial container as a substitute for a reliable connection. In this way, fantasied instant unison might take the place of genuine intersubjectivity. Using clinical examples from the analysis of Mr. A, and Bion's concept of reversible perspective, the author depicts the challenge presented by the patient's rigid and invisible commitment to turn the possibility of an interpersonal connection into yet another incarnation of the familiar script, in which decency and good will are silently and reflexively deformed. In this approach, perversion is seen not simply as the cynical game it frequently becomes, but as a person's last effort to protect himself from anticipated psychological breakdown, in which excitement serves as a smokescreen hiding the internal terror. The technical difficulties arise from the paradox of the patient's adamant refusal of a healthier relationship, which can be useful to see as an imperative form of survival, rather than merely an intrinsic malignancy.
The etiological significance of the actually observed primal scene in fetishism and other perversions is discussed. The impact of the primal scene on the pathology of part object relationships, self and object image, and on the development of superego structures in perversion is stressed.
The patient repeatedly and compulsively made stereotyped telephone calls to her mother and other female protective figures. She had a history of genito-urinary infections and operations consequent to urinary retention. These symptoms were relieved gradually in the course of analysis, in which this was interpreted as a sado-masochistic perversion based on a central fantasy of phallic intrusions on the mother. The fantasy was related to turning passive viewing into active exhibitionism, actively seeking to inflict pain on herself and others in an attempt to overcome early painful medical intrusions, misplaced identification with the father, complementary relationship with the passive, compliant mother, and consequent failed identification with the oedipal mother. In the analysis, she attained a gradual reorganization of adaptive functions which allowed identification with the father through her work, reconciliation with the rivalrous siblings, and enjoyment of her female sexuality in heterosexual intercourse with the use of a fetishistic requirement that the man be uncircumcised. The hypothesis was developed that whether called a symptom or a perversion, the treatment was the same so that it was most useful to think of it as a compromise formation rather than attempting to preserve a distinction largely based on moralistic considerations.
The coexistence of physical malformation and homosexuality and their mutual effects on each other are examined in the context of an account of the early months of an analysis. The material is structured around the hypothesis that this perversion is based on the existence of a perverse pact between the mother and the son, characterized specifically by a particular exchange of disavowals: the typical attribution by the child of phallic completeness to the mother is returned by her in her transformation by disavowal of the son's physical deformity into an image of beautiful fullness and physical normality. The material is set out and developed with a view to corroborating this hypothesis in detail; this account is followed by a brief review of the concepts of narcissism, disavowal and splitting of the ego, which constitute the Freudian theoretical basis for an understanding of the case. Narcissism is observed here from the point of view of the fusion of mother and son and the vicissitudes and difficulties of separation. Disavowal is examined from three aspects: repudiation of the absence of a penis in the mother, of the father's function and of the physical malformation.
The authors have wanted to study the structure and the characteristics peculiar to the perverse speech, on beauty, enjoyment, claiming to be a knowledge on the other one. We have tried to mark the crucial elements of this speech in the portrait of Dorian Gray (Oscar Wilde) and in Othello (Shakespeare) in which the perverse's activity of staging is particularly explicit and contributes to substitute a reality for another one.
This paper is a clinical account of a patient whose adolescence was dominated by perverse and antisocial behaviour and who later became ill with severe anxiety symptoms and inability to work. In the analysis the breakdown of his omnipotent defences led to feelings of impotence and depression and delusional fears which he had previously tried to deal with by drugs and perverse sexuality. Both good and bad sexuality were used to compensate for lack of internal and external loving relationships. Analysis helped him to achieve a more stable equilibrium as a result of his becoming more able to become aware of and contain the murderous part of himself, and the growth of good parts and loving feelings.
In this paper I have presented clinical material which emphasized the way a narcissistic part of the personality can acquire a disproportionate power by gaining a hold on the healthier parts of the personality, and I have suggested that it does this to the extent that it can persuade these parts to enter into a perverse liaison. An understanding of these liaisons can help the analyst to resist some of the pressure to act out with his patient. I have tried to show that we are dealing here not with a split between good and bad, but with the consequences of a breakdown in splitting and a reassembling of the fragments into a complex mixture under the dominance of an omnipotent narcissistic structure. In order to free the healthy, sane part of the patient we have to understand the whole situation. I believe this includes the propensity of the patient to present himself as the innocent victim. We have to recognize the sense of helplessness, but also those occasions when a collusion develops and the patient gets a perverse gratification from the domination of the narcissistic organization. Insight into the domination may then not be enough, and the collusion has also to be exposed. If this can be achieved, the patient can sometimes come to accept the existence of a part of himself as truly destructive, which he has to learn to live with, which can be contained and modified but which cannot be disowned.
Case material from the analysis of a fetishistic cross-dresser is reported. The evolution of a transference perversion and treatment impasse, in the form of the recalcitrant symptom of anal flatulence, is described. The patient's contrasting needs to cling perversely and addictively to the analyst, on the one hand, and to provoke an acting out of the countertransference, on the other, are placed in the context of his dread of rejection and potentially suicidal reaction. The author argues in favour of offering psychoanalysis as a lifeline, but with the condition that the psychoanalytic setting and boundaries are maintained and that gratifications are denied. Limited but precise interpretive psychoanalytic work in the transference was maintained. The relatively good outcome is explained in terms of the provision of safety, survival of the analyst and avoidance of countertransference acting out, which, in the author's view, represents an implicit and mutative transference interpretation, the specific factor in bringing about psychic change. This enabled the patient to recognise and accept the analyst as a 'new' object and, as a consequence, to question and reject his idealisation of the anal universe that he inhabited.
This study develops a new explanation for the loss of reality in perversion. It is a speculative effort, and draws heavily on Freud's metapsychology. I have reviewed Freud's concept of the experience of satisfaction, and have described tests of reality implicit in the experience. Freud did not put these forward as reality-tests, but this they logically become from his own arguments. These reality-tests can be shown to be at work in the perverse solution to overwhelming anxiety. In particular, the pervert exploits them to create body or motor hallucinations or delusions which serve to deny castration anxiety and other concomitant traumatic situations.
The so-called Law of Maximum Perversity, generally stated, says that when more than one outcome is possible, that which is the more adverse is the outcome most likely to occur. In medical oncology, the most obvious expression of this law is the fact that all the neoplasms that are most sensitive to cytotoxic drugs and are most curable by chemotherapy, are rare and in numerical terms are not important as causes of cancer-related deaths. Conversely, the most commonly encountered neoplasms that make up the bulk of oncologic practice and that cause over 90 per cent of cancer-related deaths, are all relatively resistant to cytotoxic agents and are virtually never curable by chemotherapy administered in standard (i.e. non-transplant) doses. It is postulated that the biological properties and the normal tissue distribution of the multidrug resistance (MDR) gene and its product p-170 glycoprotein explain the observed incidences and distribution of tumours that are sensitive or insensitive to cytotoxic agents. The normal role of MDR is to protect cells from environmental carcinogens, and the tissues that are most at risk, and most richly supplied with MDR, will produce drug-resistant neoplasms. Current attempts at MDR reversal may facilitate the treatment of some tumours that are resistant to multiple drugs but may cause severe toxic effects as a consequence of abrogating the largely unknown physiologic functions of P-170.
Subtle, nonpsychotic disturbances in thinking may cause significant impairment of intellectual functioning and interfere with a patient's capacity to make use of psychoanalytic treatment. As these come under interpretive scrutiny, the intellectual exchange between patient and analyst may emerge as a theater for the enactment of perverse sexual fantasies. In this paper, the author describes these disturbances in thinking and proposes a model that explains their underlying structure and their link to the associated fantasies. Interpretation and working through of the condensed part-object and whole-object transferences that emerge in the analysis of these forms of thinking may lead to some measure of clinical improvement.