REPORT OF TWO CASES

JOANNE D. DENKO, M.D.* | Rocky River, Ohio

ABSTRACT

"Like a cold Coke on a hot day when you're not thirsty-it's still satisfying" is the sensation described by an habitue of klismaphilia (klysma-Gr. for enema; philia-Gr. for to love.) In a case study of the unusual sexual behavior of taking enemas to induce sexual response, the practice seemed the inevitable result of a pathogenic childhood environment. This included excessive and prolonged administration of enemas by the mother and orientation by both parents to the enema as a way of life. A second case is quite different in that the practice developed only in middle adult years, during a period of great stress, and then, apparently, under the tutelage of a sexual partner.

CASE 1

Present Illness

A twenty-sevell-year-old Army officer, married and father of two children, several years ago made an appointment to discuss "breaking a bad habit." He asked for Saturday time because he planned to come a distance of almost 100 miles. He insisted on paying with cash and refused receipts. Only during his last session did he volunteer the information that he had come under an alias, and then he gave me his real name and address.

A good-looking, athletically built, articulate man, he presented his problem as a "compulsion" and a "phobia" about enemas. What he meant was that he found enemas sexually stimulating and considerably more satisfying than coitus. For a number of years he had taken one enema most days, some days none, some days more than one, except for three years when, as an enlisted man, he could not arrange necessary privacy and therefore took none. With the enema he always experienced erection, usually ejaculation. Hi s pleasure was intensified by watching himself in a mirror. Sometimes prior to the enema he also flagellated his buttocks with a hairbrush to the point of erythema. Part of the pleasure came from the "slippery feeling" of the lubricant. While the water ra n in, he thought of himself somewhat as a woman, and one pleasant accompanying fantasy involved visualizing female buttocks with enema apparatus inserted.

Sometimes he would get his wife, or, when he rarely happened to be hospitalized, a nurse to give him his enema. At such times he was able to hide his pleasure from these women. His first approximation was that to him the enemas were "something extra," not diminishing the pleasure of ordinary intercourse, although he acknowledged having no way of knowing what coitus would be like for one who did not take enemas. Later he admitted that by comparison with enemas, the pleasure derived from coitus was trivial.

He added that, while driving to see me the first day, he had wondered for the first time whether this unusual taste meant he was a homosexual He explained that he had always had an "excessive loathing" for homosexuals. This attitude he attributed to his m other's reiterations as he was growing up that he should have nothing to do with them. She found these warnings necessary because it was "common knowledge" that a "homosexual ring" operated in their city, with some sort of "criminal involvement." The pati ent recalled only once having been accosted by a homosexual in a bus station, and he apparently did not react unduly.

The patient had devised a technique whereby in a strange town he would enter a drug store, pick out a pretty girl clerk, and, affecting ignorance, ask her to explain how to work an enema apparatus. He might tell her he had bought a set packaged without di rections. Such discussions he found titillating. Furthermore, he expressed surprise that these clerks ordinarily did not know proper enema-taking techniques and that the average person shows little interest in enemas. He reacted with amazement to the news that most people find them painful and try to avoid them. He seriously suggested that funds for a study of his case might come from a company making enema equipment.

Craving for an enema he likened to a feeling of "hollowness" or "drawing" in the rectum. He recalled an occasion when desire had welled up suddenly as he was backing the car down the driveway. Also, when his wife in bed was telling him she would be out th e following evening, he experienced a wish for an enema related to that opportunity to be alone. When under pressure or tired, the patient often turned to an enema, finding it a "simple, quick, and sure" method to achieve sexual satisfaction and relief of tension. Once he read in Time that a computer, assigned to produce pronounceable combinations of sound, "spit out" the word "enema" and this threw him into a "frenzy" so that he had to read something else to get his mind off his craving. Over the years he had several times attempted to abstain from enemas and found it possible for a time, but then "it was like a dam breaking."

In an effort to learn about his condition and thereby help himself the patient had read about enemas in the erotica section of a university library. He described one book with a title something like The Hollywood Bowel, published in 1926 or 1927. T hat book contained a description of the Romans' use of gold-tipped enema apparatus, presumably for the taking of enemas for pleasure. He recalled also a quotation from Thoreau to the effect that the best trait in a wife is that she can give a good enema. Thus far, I have not found this unusual and elusive book.

The patient had decided to seek medical help at this time because six weeks earlier, when drunk at the Officer's Club, he had told his wife about his deviance after hiding it during four years of marriage. Her comment was that she had noticed that the ene ma bag was often left out. She had related the incident to her general practitioner, who had advised immediate psychiatric intervention "before the marriage suffered." Also, for three months, the patient had experienced an obsessive triggering so that whe n he heard the word "give" he thought "enema," and he feared saying something in conversation that would expose him. Furthermore, he worried that the effect of his practice on his two sons, aged two and newborn, would be that they would want enemas for th e same reason he did. Still, he did not worry enough to eschew enemas for his sons but advised his wife to administer them for constipation.

Family History

This man is the older of two brothers born to parents in comfortable circumstances. The father was one of 13 children in a very poor family, married while in college; he had worked his way up to manager of a branch office, and was frequently transferred a round the country. As a result, the, patient's family had had 22 different addresses. When the father got ulcers, he took a demotion to retail salesman so as to work under less pressure, and other salesmen, according to the patient, stole his sales. He wa s a conscientious father, played hockey with his sons, and took them hunting.

In all discussions, however, the father was eclipsed by the patient's mother, who "made medical history by having the first successful operation for an excess 18 inches of bowel," according to the patient. Prior to that surgery she had had "frequent enema s." She was one of three children brought up by her mother after her banker father's death, which left the family without financial resources. After her husband's untimely death, the mother (patient's grandmother) studied a profession to support her child ren and rose to national prominence in her field.

The patient's mother always felt her children came first, so if one of the boys wanted attention, she would immediately lay aside whatever she was doing and devote a half hour or 45 minutes to her child. When asked about discipline, the patient said, "She made us mind, too." The patient's wife believed that his mother showered them with presents because of "insecurity" and was "subtly domineering," especially of the younger brother. Although it sounded to me as though the mother must have dominated the fa ther, the patient adduced as evidence to the contrary the fact that for ten years the mother had wanted a new house but the father had stood pat so she did not get it.

The twenty-five-year-old brother is a shadowy figure. Once, while playing ice hockey, my patient injured his brother, causing him to be unconscious for a week and hospitalized six weeks for a depressed skull fracture. The patient attributed his brother's 4-F status to his head injury. There is now little contact between the two. The officer knows of no unusual habits in his brother, but the brother does not know about the patient's habit either.

Past History

The patient had many recollections about enemas, which apparently were a way of life in his family. His father told the boys a funny continued bedtime story about a family of chickens that lived on an island and got their nightly enemas. At the end of eac h evening's episode the father would say, "Time to go upstairs to your mother now for your enema!" The patient recalled liking the enema sensation even when he was only three and attempted to give himself one by means of sitting on an oilcan with a spout.

At the age of four he was hospitalized for nephrosis. There a nurse gave him an enema. Seeing a bulb syringe on his stand, he dipped it into water in a drinking glass and again tried to give himself an enema. He was tormented by fears that his parents wou ld not return to the hospital, even though his mother visited almost daily. He also experienced and recognized fear of death at this time when a twelve-year-old boy on the ward died of lockjaw. At the age of six the patient loved his teacher and entertain ed a fantasy consisting of half hope, half fear that she would come to his home and catch him giving himself an enema, which he had learned to do by this time. That same year several older boys attempted rectal intercourse with him. He recalled no pain or fear, just embarrassment. His mother administered enemas to him until he was at least in the seventh grade. At that time he hoped his father would not know because he would think it "too intimate."

The patient volunteered various incidents involving spanking on the buttocks. He was "switched for playing on a log partly in quicksand." Once he "yelled at and taunted" two strange girls slightly older than himself, so they spanked him. When left in the care of middle-aged women, he would try to get them mad at him but still control them so that they would not spank him. In high school he rarely dreamed about girls and when he did only saw their buttocks.

During high school and college the patient tinkered with cars, raced them up and down mountains, and once almost crashed. He also unofficially broke a speed record on a dangerous stretch of road. In college he did poorly in engineering. At that time he wa s tested and, he told me, he had an I.Q. "between 126 and 129." (Information from his family physician gave an I.Q. of 118 [P 112, V 121] for that test. Projective tests elicited concern about homosexuals but the examiner did not mention anal preoccupatio n. The subject impressed the examiner as trying to get out from under a career choice in which he had no basic interest.) He changed to a business major but made the Army a career. The worst disappointment of his life was not being able to become a career pilot in the Air Corps because of myopia.

In high school the patient had wanted to experiment with sex but feared venereal disease. He had casual sex relations with many girls, mostly prostitutes, primarily in Europe, and he usually enjoyed accompanying fantasies of enemas. He had tried to learn "good sex technique" from prostitutes to make his wife happy some day. He felt a strong preference for German girls whom he considered more "natural" and less artificial and bejeweled. At one time he had hoped to marry a Norwegian girl. He believed that " most men prefer aggressive women of the type found in Mickey Spillane novels" and that "most American girls are hard and grasping."

He considered women as existing primarily to satisfy men's sex drives. He resented the indirect reasoning, machinations, and maneuverings of women, preferring the straightforwardness and candor of men. His wife, he felt, was more "natural" than other Amer ican girls. He described her as "extroverted, therefore a teacher." Their nine months' courtship was "comfortable." He calculatingly persuaded her to have intercourse with him before marriage because he wanted to assure himself that she put him above her virginity since he was determined to be dominant. Still, he acknowledged her fear of pregnancy and avoided having an ejaculation, even after withdrawal. When asked whether she enjoyed such an experience, he said, "I didn't even enjoy it myself!"

His attempts at proving himself "lord and master" sounded like a twoyear-old's obstinacy. If she asked him to hurry home at night because she had to go out, he would purposely be late. When she asked him how his therapy was progressing, he would reply, "I 'll tell you when I tell you!" Sexually, the couple was never very active, and at the outset of therapy the patient felt that both of their interests in sex were deteriorating. He had the immpression that his wife achieved orgasm with difficulty and found it "a lot of work." Then, too, she was busy nursing the new baby. Later he commented that his wife believed her sexual response was improving. His own lack of interest he first blamed on hairs around her areolae and over her buttocks. He had tactfully hi nted that she remove the breast hairs, but he was reluctant to pursue the idea when she did not understand or failed to comply.

He admitted that throughout the marriage he feigned sexual interest to keep her from suspecting the enemas, and he fantasied enemas while having intercourse with her, too. He tried intermittently to increase his interest in sexual relations per se by avoi ding enemas, and he tried to abstain from fantasies about enemas during intercourse, but both attempts were without success because he always eventually returned to the enemas. He and his wife had agreed to have only two children, close together for compa nionship in a family scheduled for frequent moves.

Personality

If his attitudes toward women sounded victorian, so did his feelings about men. Like many career servicemen, he enjoyed spending evenings at the Officers' Club, with all the men at one end, the wives at the other. Most career servicemen he considered "hen pecked," like a friend of his who was given household chores when his wife was due to deliver. He preferred the company of men, who, if something is wrong, will come right out and say what is bothering them rather than indulging in gossip and subterfuge. His subordinates apparently respected him and put themselves out for him, and he and his fellow officers agreed that he showed more "compassion" than most officers. He worked late and apparently took up the slack for other less motivated officers. He spen t a great deal of time discussing with me a functionally illiterate subordinate whom he could not bring himself to scrub. His army talk was interlarded with Madison Avenue neologisms like "rumorwise" and "ratiowise."

Intermittently, several phobias made problems for this man. Although he was not afraid of flying and would have been an Air Force pilot if possible, he feared high places with grids through which one could look down. He was uncomfortable in "places where strangers see you"-for example, restaurants and theaters. This caused minor problems in living, since his wife would have enjoyed going to such places, and they had done so only once in the past two years. His defenses included obeying regulations rigidly , for instance, not deviating in any particular from the exact uniform of the day. He commended the Army for its "esprit, order, spit and polish, and toughness." In short, he admitted liking the Army because it made him "feel like a man." He expressed gui lt, however, over having "let down" the Army by his habit.

His tastes included solitude, and one daydream involved owning enough land in Wyoming to be able to ride on horseback in one direction for an entire day. He developed his own pictures. Although at a desk job, he expressed preference for infantry because h e liked strategy, as in chess. In one fantasy, his drab, peacetime installation was attacked by bombers and he worked out the defense. He considered himself an expert on World War II, particularly German bombers, and had an extensive library on the subjec t. He regaled me with descriptions of these, including their statistics, despite my rather bookish suggestion that he might be avoiding more personal issues. Later I realized that he was demonstrating affection for me by treating me like another Arrmy off icer. He once tested me by describing the average person as "dull and unthiliking" and acted surprised when I agreed rather than spring to the defense of the man in the street, as most patients seem to expect psychiatrists to do. On another occasion he re lated how he became an atheist because his prayers to lose the wish for enemas went unanswered.

Therapy

I saw the patient once a week for five months. Therapy was easy with this intelligent, articulate man. My first consideration was to ascertain his real feelings about enemas and his real hopes regarding therapy. If removal of klismaphilia rated top priori ty, I might have considered sending him to a more experienced therapist, perhaps an analyst. I worried that to try to remove the symptom and fail would not only discourage him but also jeopardize any subsequent efforts to eradicate the symptom. Another co mplicating factor was his fear that a male doctor might consider his problem "akin to homosexuality." (His comment: "No offense, but I consider you sort of neuter-not a man doctor, obviously, and not like the usual woman-more like a computer with answers. " He was my only patient at that time who was not grossly disturbed by my pregnancy and delivery during the course of therapy.) And I knew of no available woman psychiatrist in the area whom I considered more competent than myself.

He would have liked to have hypnosis take the symptom away painlessly. He stated that he had always looked upon being enema-free as an improvement for the future and had assumed he could give up enemas as soon as he wanted to badly enough. In fact, his disappointment over never being able to fly was greater than his disappointment over being a slave to this habit, which he assumed would go away some day with waning libido. He imagined that a switch to only ordinary sex would be like a switch he had recently made from cigarettes to cigars: the latter are harder to get pleasure from, require planning over when to smoke so as not to start and then have to stop, therefore providing pleasure less often, but producing greater pleasure when it comes. Thus he considered ordinary sex hard but probably more rewarding. He had come to me at his wife's behest, on her physician's recomniendation. He was also worried that his sons would find out about his enemas but his precise fear was not that they would be ash amed of him but that they would want enemas themselves when they found out how much pleasure was involved. Still, although he apparently felt a normal paternal love for the children, and although he had good reason to fear enemas, he recommended to his wife that she give them to the boys. All of this did not sound like a man desperate to be free of enemas, but a man at best ambivalent.

Only on his first visit were a panicky fear and general anxiety apparent; subsequently the patient appeared able to compartmentalize this entity, which did not interfere significantly with his everyday life. Once he commented that he was "horribly apprehensive" I would suggest giving him an enema so as to observe his reaction. The next session he described having experienced, when he said that, a sensation of thick phlegm in his throat at what he interpreted must have been a pleasurable reaction in me.

But what about his marriage, the concern of the physician who sent him? No prospect of divorce threatened. His wife apparently made few sexual demands and had not even detected anything wrong during four years of marriage. Her reaction when he told her was astonishingly bland. But now that she had thought about it, would she resent playing second fiddle to the enema bag? Perhaps he had picked a spouse who could coexist with his abnormality. I felt I should see her, and I did, but only after I had decided to encourage him to accept his habit with dignity. A down-to-earth, somewhat athletic-looking woman, with lined face and prematurely graying hair tied in an efficient but collegiate fashion (that is, she was "natural," not "artificial" as he found most American girls), she would have preferred that he not take enemas, but felt it was "not the greatest tragedy" and she would rather he take them than pursue an expensive, uncertain course of therapy. She was quick to blame herself for perpetuation of this problem, feeling that she should stimulate him sexually more. She also commented that the enemas were better than another woman.

She did not seem to belittle, attack, or downgrade him. In general she liked him, particularly with some of the changes he and I had worked on: sharing of interests instead of separate orbiting. (In the past they had taken alternate Sundays to go bicycling, but now they went shopping together.) She also liked his career choice with frequent moves. She too related increased interest in sex since onset of his therapy, because she had felt freer to communicate with him and had advised him "not just to hop on and off." By then she claimed she "looked forward to it." From the standpoint of her husband her sexual arousal might not be an improvement since it could lead to other marital problems. But at that time, the patient, his wife, and I all agreed things we re going well and therapy should terminate. I warned her to avoid enemas for the boys.

Another aspect of my treatment was to help him consider how to take enemas without risk of discovery. He could see that he must avoid his ancillary modes of stimulation such as the drug store trips, because of the danger of apprehension and publicity. Although he had never been a problem drinker, he had to be helped to recognize the role of alcohol in his original "confession" to his wife. Most important, he had to keep his secret from his sons as they grew up, not because they would want enemas but because they would be ashamed. I tried to strengthen his ego control in the direction of greater secrecy and away from outbursts of id-produced revelation. (At the same time I was treating a transvestite, one of whose problems was hiding his women's clothing in men's sizes from his wife. By comparison, my patient's having to put away an enema bag that his wife knew about was a trivial problem. This middle-aged man's lifelong transvestitism had apparently not affected his daughters adversely, both of whom were happily married, so I could hope for the same for my klismaphiliac's sons.) During the five months of his treatment my patient gradually became aware that I respected him as a person and found him intelligent, interesting, and worthwhile. Acceptance by someone who knew of his abnormality permitted self-acceptance and thus was the most important feature of his treatment.

On the final treatment day he produced three dreams and specified that the interval between the second and third was twice that between the first and second. In the first he attempted intercourse with the new girl friend of another officer who acted "provocative and kittenish," but he could not penetrate. In the second dream a horribly mangled animal, possibly a dog, was chasing a rat. Finally, in the last dream, he took an enema. Apparently that was the safe way.

A last but not insigificant outcome of his therapy was growth on the part of the therapist. Whereas at the outset I acknowledged to myself feelings of revulsion over something grotesque, nevertheless, as we worked together, I gradually became able to place his problem in perspective, unfortunate but not unbearable and really not diminishing the patient's good qualities. When this attitude was communicated to him indirectly, he could accept it as his own.

Attempts at follow-up through his former address and general practitioner have failed. I would not try to find him through Army channels for fear of attracting attention to him. Therefore his current functioning is unknown.

CASE 2

A second case has been brought to my attention by an author friend, through whom I have corresponded (anonymously by means of sealed envelopes) with the ex-wife of a klismaphiliac lawyer. This woman has prepared a sketch of her life with her ex-husband and her knowledge of his earlier life as reported by the man himself and his family. She has also answered specific questions. Although embittered by her marriage, she has evidently tried to deal fairly with him and give him credit for his strengths. Her material shows internal plausibility.

Present Illness

This seventy-year-old disbarred lawyer's full-blown condition combined self- or partner-administered enemas with fecal smearing, self-induced vomiting, and hot baths. His third wife (my informant) learned of his abnormality by finding a filthy bathroom soon after their marriage when the lawyer was fifty-nine. At first she attributed this to carelessness and explained the enemas as necessitated by constipation resulting from tension (for instance, when he had to defend a case without merit). In the beginning the enemas were irregularly spaced and seemed to result in a feeling of well-being. Soon she observed that he always carried an enema set whenever he traveled. Never (in this marriage) able to attain a firm erection, he gradually became aware that he w as unable to achieve ordinary sexual relations and stopped trying. As he became involved in a criminal proceeding that led ultimately to his being disbarred (see below) he settled into a three-enema-a-week pattern and added vomiting to his regimen. This he accomplished by drinking a pint or more of salt water and inserting down his throat a table knife which he kept in the bathroom cabinet for this purpose. To his program he added hot baths which seemed unrelated to cleanliness because his personal hygiene was poor.

As the marriage progressed, his wife occasionally would be awakened by his working his tongue in and out of his mouth and sucking on it. He once asked her whether she derived satisfaction from sucking. He would also sob in his sleep, explaining that this was for a "little red-haired boy" (a son who died over 20 years before). After a sister gave him a small picture of his mother (who had died when the lawyer was a child of eight), he began focusing grief and thought on her.

Finally, he began behaving increasingly erratically. His temper flared over little or nothing, with shouting and cursing. Occasionally he acted as though out of contact. One evening at a lecture he appeared in a daze, then quoted the wrong color for his own car, got into the back seat and tried to start it, and got lost on roads in an area where he had lived all his life.

For some time he had told such people as the wife's minister that she was not his intellectual peer, but he began to go further afield to find people, such as tenants, with whom to discuss this. Torn between his obvious need of her, her pride, her fears of legal battles with a lawyer, and concern for her own safety, his wife finally stopped wavering and divorced him.

She has heard that he had worked as night clerk at the Y.W.C.A. but either quit or was fired. He lives in an undesirable neighborhood but owns better rental property. He is dirty and unkempt.

Family History

This man is the oldest of three children born to parents both of whom were brought here from Germany in childhood. The father came to this country at nine, never attended school in America, but nevertheless taught himself to read and write commendable English. The household was stormy, the father a domestic tyrant of filthy personal habits, such as spitting tobacco juice on the floor. Bathing was a sometime thing. Enema-giving by the mother seems impossible. Furthermore, the mother died following a miscarriage when this boy was eight, and when he was twelve, a stepmother of twenty-two, nearly illiterate, entered the home. The children were all socially unacceptable to their contemporaries. They were and are intelligent people, all with some artistic ability. The second son is a minister. The other sibling is a woman who models in clay. These two consider the subject the black sheep.

Past History

This man's sex education (as was common at the time) consisted of his father giving him a paperback on the horrors of venereal disease. He attended school nights to get his law degree and passed bar exams creditably but always with the feeling that he did not quite measure up.

He had an "undersanding" with a young woman but wanted to postpone marriage until he had his law degree. She tired of waiting and married someone else. He obtained a position as associate in a law firm with a possibility of later partnership. He became an officer in the local branch of the Ku Klux Klan, where he met a young couple; the wife, twice married, was soon pouring out her problems to him. Soon she was divorced and married to the lawyer, now aged twenty-seven, but he maintained that not only had he not had an affair with her but he had also been virginal at the time of the marriage. Two children came quickly, whereupon the wife insisted on some sort of contraception. He adopted his father's pattern of running the family with a heavy hand. He told my informant that he could never use a condom because it was too tight. (She questioned this because she considered his penis quite small.) The family moved frequently, buying one house after another, finally a farm of 100 run-down acres with a five room house and no indoor plumbing.

In 1946 (when he was forty-seven), while making business calls, he learned on his car radio of the shotgun death of his eight-year-old-son. The lawyer had recently taught his sixteen-year-old son to shoot crows, and both father and son were proud when he killed his first one. The son replaced the gun in the barn without emptying it, and the father did not check it. Two weeks later a neighbor child, playing with it, shot the eight-year-old son. When the lawyer arrived home, his wife hysterically called him a murderer and said she would institute divorce proceedings after the funeral, which she did. The lawyer accepted responsibility for the accident, partly because he could see that he was morally responsible, partly in order that the sixteen-year-old would not have to grow up under that shadow. He contested the divorce three years, until it became final. At that time he tried psychiatric treatment for a short time. Until this time there was no evidence of klismaphilia.

Soon he learned that his former sweetheart had divorced the same husband for the second time. When the lawyer was fifty-two, they were married, but the marriage fell apart, in part, at least, over financial differences. The wife taught school, and the lawyer felt entitled to her earnings, whereas she supported her college-educated son. Other problems resulted from the fact that the wife was accustomed, from her former marriage, to perform fellatio and find her own satisfaction from masturbation. During th is time the enemas started, but my informant considered them "normal" at that time. After four years the lawyer divorced this second wife.

He began looking for another wife and "somehow learned" of a registered nurse in another state. She came to his town, moved in with him and introduced him to the "high enema" with rubber tubing inserted fifteen or eighteen inches. They gave them to each other. There were no masochistic or sadistic sexual practices, to the best of my informant's knowledge. The nurse was addicted to dilaudid. When she was unable to keep food down the lawyer would give her enemas of coffee and raw eggs. She required hospitalization for "a stomach condition." Two hospitals refused to keep her because of her unwillingness to undergo treatment for addiction. For some time the lawyer managed to close his eyes to her addiction even though she kept him drained financially. When he was no longer able to blind himself to her condition, he sent her away.

Not long thereafter, at the age of fifty-nine, he married my informant. The marriage was held together by a peculiar mixture of hostility, pity, pride, fear, and companionship. Although there were loud and violent crises, his wife audited courses he was taking for credit at a nearby college.

While hospitalized for hemorrhoidectomy and repair of an anal fissure, be became suspicious and called his wife and various relatives "to find out my condition." When asked what he found out, he replied "nothing, but now I know." He also demanded that his wife bring to the hospital Metamucil and laxatives, and when she refused, he told her to "go ahead and get your divorce," although she had not brought up the idea of divorce as yet.

A charter member of a Unitarian group, he was finally elected to his first office as vice-president and chairman of the program committee. His ex-wife described him as "bursting with importance." Every evening he was on the phone from seven until ten. Halfway through the year he had locked horns with the editor of the Unitarian paper. The lawyer tried to insist that his reports be printed exactly as written (and they were longwinded). He also tried to make all speakers submit their talks to him in advance for editing. When the president was away, others were appointed to conduct meetings. As a result, the lawyer sent out a mimeographed letter to the members, complaining about how he had been treated; he also stated that he expected to be re-elected and to have the president and the editor dumped. When the group broke precedent and failed to re-elect the lawyer, he left the group. He told someone at that time that his thinking went beyond the finite into infinity.

Some contact persisted with the nurse, to whom he sent $200 on one occasion. He was arrested for having stolen a pad of prescription blanks from the doctor who had kept the nurse supplied and for having forged several prescriptions for her. As the legal wheels rolled, his use of enemas became more regular. Eventually, the bar association found him guilty of moral tupitude and disbarred him when he was sixty-three. His ex-wite believed that he would have gotten by with a rap on the knuckles except that he had never been friendly with other lawyers. He chose to defend down-and-out and marginal members of society, often winning over the well-to-do clients of other lawyers, who never forgave him. His ex-wife felt he did not treat her fairly for refusing to go elsewhere to live and expecting her to live under this stigma.

He spent the next year trying with little success to collect outstanding bills. Sandwiched in between were odd jobs. He also wrote a book called Romance After Forty and was determined for a time to have it published even if he had to use a vanity press. By then he had returned to college full time to complete his B.A. Because of lack of planning and the fact that he had taken whatever courses struck his fancy, many credits were not allowed, and he had two full years to make up. He graduated when he was nearly sixty-five, 190th in a class of 420. Then he learned that he would be unable to teach in public schools because of the charge of moral turpitude, so he got a job in a parochial school, teaching history, English, and social studies. According to my informant, he was unable either to teach or to maintain discipline. Resentful over the treatment he had received by the bar association he always attacked law and government. He also took opportunities to ridicule "Christianity and decency" and managed to "insinuate and insert" sex into discussions, not in an instructive way, but more like the stereotypic "dirty old man." He earned 30 credits toward a master's before learning he would not be granted the degree because of the charge.

He became obsessed with the idea that he must leave an estate for his grandchildren, children of that eldest son, who apparently grew up normal despite his brother's death.

Personality

A small-statured, mild-mannered man (except when enraged), he was described as dirty in his person. His nails had grime under them. He used old-fashioned barber's razors, which he stropped, but never got a close shave and never washed his face before or after a shave. Apart from hot baths with enemas, he bathed infrequently by dampening his body with a wet wash cloth and then getting under the shower to rinse. The collar on a clean dress shirt would be filthy in an hour. When he practiced law, he put on a clean shirt and socks daily but wore the same shorts for days. His seedy appearance did not matter to his lower class clientele. He was phobic about drafts. I'herefore he always kept car windows closed and eventually had his prescription for eye glasses made in safety-type goggles.

My informant felt that "his attitude toward me was . . . what I would assume might exist between a prostitute and her customer"-no thoughtfulness, consideration, or tenderness. His daughter-in-law (wife of the son) believed the lawyer was a latent homosexual. His ex-wife described him as possessing both an immense conceit and an immense inferiority complex. Solemn, with no lighter side, he would have liked, more than anything else to be considered a "brilliant mind." He seemed abnormally afraid of even the slightest pain, and she felt he was also "afraid of life." At times he displayed a visible tremor. Despite having been a Unitarian, he considered himself an atheist.

DISCUSSION

How unusual is the behavior shared by these two men?

A question from a physician about a similar case of unspecified sex elicited from Bieber ( 1 ) a reply concerning the etiologic role of the enema-giving mother. My efforts to contact the questioner for further information about this patient were unsuccessful. Bieber (2), the consultant, commented that the fad in the thirties for high caloric feeding produced constipation in children, and that frequent use of enemas led occasionally to this aberration. Stekel (3) described and gave case reports of paraphilias in which sexual satisfaction was inextricably linked with either micturition or defecation. Although he mentioned that mothers who give daily enemas predispose their children to anal fixation, he did not report a case of klismaphilia. A social worker told me about a very gifted professional woman friend of hers whose mother had administered daily enemas for 12 years, resulting in pleasure from enemas and feelings of guilt over the pleasure. She had sub sequently undergone analysis, but the results on the enema practice were unknown. Because of the sensitive nature of the problem this social worker was unwilling even to ask her friend to contact me anonymously regarding her experience. Interestingly, both sexes are represented in this group of five known cases: my army officer (M), the lawyer (M), the nurse (F), the professional wolman (F), the subject of the question (unknown sex). This small group seems weighted with persons of above-average intelligence.

Our librarian's search of Index Medicus and antecedent indexes dating back to 1896 have failed to unearth other cases. A Medlars search for the years from 1966 to 1969 in English, Russian, and German, failed to disclose references. My own skimming of the index and relevant sections of Krafft-Ebing's (4) and Havelock Ellis's (5) classical works on sex did not produce a comparable case. While one can understand that information may be hard to get from individuals suffering from this problem, I am puzzled by lack of reports of this entity, since it is obviously common enough for me to have heard about four other cases within a year. The condition is not unknown in popular literature, however. Two fleeting mentions of the problem are made in the best-seller of several years ago, Peyton Place by Metalious (6). The general pratitioner in this story (presumably taken from life) commented that a possessive, neurotic mother had produced this condition in her adolescent son, and that it requires hospitalization to correct electrolyte imbalance.

On the other hand, one might wonder why the condition is not more frequent. The pudendal branch of the perineal nerve supplies both penis and lower bowel and prostate. Urologists have noted that prostatic massage produces sexual feelings and reactions. The sexual pleasure of the passive partner of rectal intercourse between homosexuals must be related to klismaphiliacs' sensation of pleasure from dilation of the rectum during an enema. The army officer himself sensed a relation between his problem and homosexuality. The lawyer's daughter-in-law considered him a latent homosexual, and his excessive fear of pain is a trait sometimes attributed to boys who are in danger of becoming homosexual.

Why, one may ask, should a man like the army officer not go on to a more customary marital sexual adjustment? Presumably, early experiences with frequent enemas could condition different tactile nerve endings in the rectum that synapse in the same centers of awareness where penile nerves make their ultimate synapses, thus producing the same cortical sensation of pleasure. When a particular pathway is used frequently, as in a habit, it may become the casiest route to the desired cortical end-sensation. If such a route is habitual, it might be harder to develop a neurohumoral path starting at the penile nerve endings but ending at the identical cortical area where an orgasm is experienced in awareness. This recalls this patient's experience of greater difficulty and less pleasure when the penile nerve endings were stimulated to the cortical sensation of orgasm. When I was no longer seeing him, a reference by Lovshin (7) came to my attention about the fixity of even such relatively mild rectal psychiatric symptoms as pruritis ani. Evidently it was just as well that I did not try to take away his symptom.

For the army officer, the causal role of frequent repetition of enema experiences in childhood at the hand of the loved (and basically good) mother is obvious. The father played his part too with his chickens' enema stories and encouragement of the enema practice. One critical factor in consolidating the symptom was the misfortune that the patient happened to suffer at the age of four a potentially fatal illness, provoking anxiety that could be relieved by the device of the enema, which evidently represented the mother by substituting her behavior for herself. On the other hand, the case of the lawyer demonstrates that klismaphilia does not always stem from childhood since his was learned in adult life following establishment of an at least adequate sexua l response by the usual route.

Association of enemas by the army officer with behavior including self-flagellation of the buttocks, use of a mirror, and conversation with drug-store clerks suggests masochism (in its primary sense), voyeurism-exhibitionism combined (in that the patient takes both roles), and a form of clandestine stimulation in which the other person is unaware of the part she plays. The sensation of phlegm in his throat (that he described having experienced as he talked about the possibility of my giving him an enema) is a symptom that Stekel considered a hysterical upward displacement of ejaculation.

My patient had other neurotic problems in addition to enema-taking. He suffered conflicts over who controls whom-men or women, husbands or wives, little boys or middle-aged women. One service of enemas in his psychic economy was to give him absolute control in at least one area, where he functioned as both giver and taker. Still, his concern over control was not without conflict. Although happy to take enemas himself, he in fact preferred, when possible, to receive them from women (wife, nurses, psychiatrist) as from his mother in the past.

Discovery was another area of conflict. He would have liked to be discovered by his beloved teacher, and he wanted his wife to know at least enough to tell her when his inhibitions were diminished by alcohol. Intellectually he knew the dangers of discovery, because the Army would discharge him, and in the process he might suffer notoriety and disgrace. But his obsessive symptom ("give" produces "enema") seems to represent a wish for discovery akin to exhibitionism. His phobia about crowds may have related to this ambivalence. As I think about it now, I should have made more effort to clarify this wish for discovery, lest he be caught off guard and betray his secret. Another area I should have emphasized to him (as I did to his wife) is how he might have been setting up his sons for a similar problem by encouraging his wife to give them enemas, as his father did to his mother.

This patient's entire life style represented an adaptation to his problem. Selection of a wife without excessive sex drive or demands dovetailed well with his enema practice. Her willingness to let him be dominant and his selection of a service career both served to suppress doubts of his gender. This military adaptation worked in the service of the ego, since he liked his work and was surely an asset with his compulsiveness, drive, and application of intelligence to bureaucratic problems.

In contrast to the army officer's symptom, the lawyer's klismaphilia is less integrated with the rest of his personality and life history. He is a complicated but diffuse individual with a hodgepodge of neurotic, psychotic, and characterologic traits. His combination of idealism (shouldering blame on behalf of his son; practicing law for the poor) and bigotry (Ku Klux Klan leadership) is remarkable. I believe his klismaphilia was an accident, in the original sense.

To an obsessional personality unable to recite the mid-twentieth century refrain "It's not my fault," death of a son and loss of a wife were greater traumata than he could assimilate. In an effort to regain his equilibrium he remarried; the marriage probably did not provide sexual or other satisfaction. With all the complaints against this man, infidelity was never suggested. Therefore in all probability he discovered his own reaction to enemas (which people of that generation seem to take frequently) and gradually slid into the klismaplliliac mode as a substitute for conventional sex in this marriage. Chance is one factor in symptom determination.

His association with the nurse was probably not by chance. Someone, possibly the physician, must have known of both their proclivities and brought them together. To everyone's surprise this was the best time of his life. His poor self-image ("never quite measured up") seemed mirrored in his life style (dirty environment and person). He also evidently identified with the down-and-out, to the exclusion of professional peers. His final deterioration suggests a psychotic process. It is tempting to try to link organic brain syndrome somehow with klismaphilia, for example, with repeated insults caused by electrolyte imbalance. I have not heard of such a connection, however, and even if it happened, there were no bouts of electrolyte imbalance severe enough to r equire hospitalization. More likely, ordinary senile deterioration is the explanation.

What is the relationship between klismaphilia and homosexuality? To receive sexual stimulation at one's own hand is a form of masturbation. But to arrange, whenever possible, for an intromission to originate from a woman suggests homosexuality carried one step further to reversal of physiologic sex roles. My patient's sexual ambiguity is illustrated by how he longed to be neuter-freed of sex drives by inevitable loss of libido with age. (The lawyer's retention of enemas after loss of potentia does not bear out this hope.) Loss of libido is an outcome that an occasional guilt- or shame-ridden homosexual or neurotic man looks forward to, and Socrates, I believe, felt freed from the tyranny of his body in later years, so he could devote himself to philosophy, but the usual heterosexual man dreads loss of libido almost more than death, and many homosexuals fear loss of libido and youth even more than the average heterosexual man. The army officer's wish to be desexualized seems related to some extent to feelings of guilt over not being what the Army (and in a larger sense society) wanted. Primarily, however he lived with feelings of shame over not being like everyone else and loneliness over carrying his problem alone. About being alone, too, he was ambivalent and in one way wanted to be physically alone in Wyoming. But as an elderly man he would be physiologically like many other old men, just as now he needed to be accepted as one of the army officers' group. Interestingly, he had no difficulty in emotionally ignoring my impending delivery and making me, too, neuter for companionship.

Meaningful freedom consists in the opportunity to make informed choices. Homosexual groups are finally beginning to demand the option of living their lives in a tolerant society. Similarly, one may reasonably expect social attitudes to change so that persons enmeshed in the practice of one or another uncommon paraphilia, such as klismaphilia, may enjoy options. Just as an obsessive-compulsive may decide he would rather live with his problem than undergo expensive, time-consuming, and uncertain treatment, so a person with an unusual sexual practice may or may not wish to avail himself of what psychiatry has to offer in the way of correction, alteration, or "cure." If he elects to live with his condition, he should at least be able to do so in a social climate that is tolerant enough for him not to feel compelled to conceal it from a prospective wife, with results like those of these two wives who learned of their respective husbands' condition by observation or by "confession" from an intoxicated husband. A woman in this position should also have informed options: to marry despite the abnormality or to decline without malice.

Furthermore, besides taking a more civilized and humanitarian attitude toward the victims of these disorders, we would be behaving more rationally anent our planet's major problem and the problem on which all others hinge: overpopulation. A homosexual recently told me he had difficulty understanding why society tries to make him fit its procrustean bed. Not only is he not burdening the earth with his progeny, but also, by sidestepping the onerous responsibilities of conscientious parenthood, he has both time and energy to devote toward social solutions in his life work.

"The only freedom which deserves the name, is that of pursuing our own good in our own way, so long as we do not attempt to deprive others of theirs, or impede their efforts to obtain it."--John Stuart Mill, On Liberty

SUMMARY

Two case reports are presented of men whose primary sexual behavior consisted of taking enemas. This condition is now called klismaphilia.

Habitual administration of enemas by his loving but overly protective mother, encouragement of the practice by the father, and anxiety related to a life-threatening illness in childhood all served to produce this condition in an army officer. Despite obsessive thinking and phobias, this man's use of compulsive defenses helped him so to compartmentalize his abnormality as to lead an externally normal life. Problems of accepting himself despite this condition and learning to conceal it better occupied most of his therapy. By contrast, a lawyer who had experienced no anal attentions in childhood adopted a habit of klismaphilia in adult life. Multiple characterologic and psychopathic problems overshadowed klismaphilia in this intelligent, complex, and sensiti ve man.

Although this condition is not unknown, it is rarely reported. Its relationship with homosexuality is considered, and broader aspects of sexual deviation in our society are discussed.

REFERENCES

1. Bieber, I. Enemas and Sex. Medical Aspects of Human Scxuality 4:89, 1970. 2. . Personal communication, 1970.

2. -------, Personal communication, 1970.

3. Stekel, W. Pattetns of Psychosexual Infantilism, Washington Square Press, New York, 1966.

4. Krafft-Ebing, R. Psychopathia Sexualis. Enke, Stuttgart, New York, 1907.

5. Ellis, H. Psychology of Sex: A Manual for Students, Emerson, New York, 1935.

6. Metalious, G. Peyton Place, Dell, New York, 1957.

7. Lovshin, L. L. Anorectal Symptoms of Emotional Origin, Dis. Colon Rectum 4:399, 1961.