Psychosomatic Medicine 20:145-150 (1958)
© 1958 American Psychosomatic Society

Transvestism and Pruritus Perinei

¹ Department of Psychiatry, University of Illinois College of Medicine, Chicago, Ill.
² Department of Psychiatry, University of Illinois College of Medicine Chicago, Ill.

Many papers have been devoted to pointing out the psychodynamics of various psychocutaneous manifestations. These responses of the skin, either pathological or "normal," may serve the purpose of attracting love, attention, or pity, or may lead to avoidance and rejection by others. In the severely regressed or fixated patient the skin may be the target of self-punishment, self-castration, or self-destruction. Pruritus has been explained as a combination of pleasure and pain, with hostile and aggressive elements being turned inward, leading to "self-destruction" (scratching and tearing). Associated forbidden sexual wishes have been seen to be gratified in part by itching, which is thus looked upon as a masturbatory equivalent.²⁵ Seitz²⁸ demonstrated that there is an unconscious need in these patients to punish themselves by ripiping, tearing, and picking of the skin. The excoriation is so patently self-punishment, according to Seitz, that it hardly justifies the term "symbolic." He adds that, nonetheless, the scratching is erotically gratifying:

...fantasies during scratching almost invariably have to do either with destructive aggressive behavior on the part of the patient, or with wish-fulfilling situations in which he is loved and approved by others, or with both. Dreams which precipitate scratching follow the same pattern of destructive rage in association with frustrated needs for love and approval. [They] suppress feelings of anger and resentment because they experience so much anxiety when hostile emotions are expressed ... and they react to their own repressed rage and guilt. Excessive excoriation appears to be a symptom which both atones for this guilt through self-punishment and also at the time gratifies the need for love through cutaneous erotic pleasure. In addition, scratching probably serves as a muscular release mechanism for the physiological tension created by repressed rage.

Sexual gratification, conflictual and masochistic, associated with skin eroticism and exhibitionism, has been the subject treated by various authors.^{21,24,25,30,32,33} It has been shown that manipulation of the skin represents attempts at gratification of sexual desires, this particular form being a regressive phenomenon from a more genital level. Scratching and other activities involving the skin have been considered autoerotic (masturbatory), and provide regressive gratification of the need for love.

One of the fascinating psychosomatic phenomena seen in the psychocutaneous disorders is the syndrome of pruritus ani et scroti (pruritus perinei). Pruritus ani alone exists primarily in the male. The psychogenesis of this disorder has been the subject of only a few systematic studies, though there are numerous case studies in the literature.^7,19,26,33 In contrast to most authors, Cormia⁶ disputes the role of overt or latent homosexuality in the genesis of pruritus ani, but admits to its importance when describing the combination of pruritus ani and scroti. He cites the fact that the severity of scrotal itching far overshadows that of pruritus ani. He also notes the absence of overt aggressive tendencies and the lack of assertiveness with a distinct submissive tendency. Saul,²⁶ in a report of a case with pruritus ani, demonstrated the development of pruritus in situations which aroused passive homosexual anal wishes. Schilder²⁷ cited a case where the fear of and wish for castration were present together, with the patient desiring to come into a masochistic, passive, and "homosexual relationship with his father and mother." Wittkower and Russell,³³ in a systematic study of patients with pruritus ani, noted that there were latent homosexual trends in a significant number of male patients. Intensification of these trends can precipitate or exacerbate the pruritus ani.

Other sexual disturbances such as premature ejaculation are noted to be common.^{6, 19} Ferenczi⁹ points to severe castration anxiety present in pruritus ani et scroti, with displacement of fears of genital castration to anal and urethral excretory functions. The relationship between recta] and anal masturbation and pruritus ani has been discussed in a number of studies.^{9, 10, 26, 33} Exhibitionism, common to all psychocutaneous manifestations, is also cited as characteristic of pruritus ani, and to a certain extent, functions to allay anxiety of different sources.^{7, 19, 32}

Of particular interest has been the relationship between the precipitation of pruritus perinei and the occurrence of birth or fantasies relating to birth. In one of the cases of pruritus scroti in a study noted above,⁶ the onset of the patient's pruritus coincided with a period of total sexual abstinence during his wife's pregnancy. Macalpine,¹⁹ in a study of patients with pruritus ani, specifically defined the core of the problem as involving the reactivation of an unconscious fantasy "that babies are thought of as growing in the tummy and being born like a stool ... and get inside by food or kissing or by the same route as they are thought to leave the body." Apparently the conclusion is that in the male, anal-pregnancy fantasies are incompatible with his self-concept and with the definition of a man and that if he harbors the persistent fantasy of this capacity to bear babies, it would obviously be incompatible with his self-concept of masculinity. The slightest reactivation of this fantasy would be pathogenic because, in addition to being "fantastic," anal-pregnancy fantasies carry with them a threat to or grave doubt of manhood. Macalpine added that the patient reveals such doubts in himself with the urge to be examined and examine himself. She added that the precipitating situations apparently involved actual childbirth in a wife or relative, and she cited an example taken from Ferenczi, in which defecation had the symbolic significance of giving birth.

Macalpine and Hunter,²⁰ in a paper involving a reevaluation of the Schreber case, looked upon Schreber's psychosis as a quest for procreation, and noted that his wish to change into a woman was not for self-punishment by castration for forbidden homosexual wishes, but for becoming endowed with female reproductive organs in order to procreate. During the psychotic episodes Schreber would wear "sundry feminine adornments such as ribbons, trumpery necklaces and the like," believing he had turned into a woman, and he suffered from many somatic complaints. In a case of pruritus ani cited by Wittkower, the patient in describing the onset of the complaint stated that "suddenly he felt transformed from a man into a woman"; the implications to be drawn can be in the direction of both the passive homosexual role and possibly a fulfillment in fantasy of the wish to procreate by becoming a woman.

The psychodynamic similarities between the aforementioned areas and transvestism are many. The psychodynamics of transvestism have been extensively described, with certain modifications pertaining to individual cases.^{2, 4, 8, 12-15, 17, 23, 31} Gutheil lists 6 psychopathological factors important in the causation of transvestism. They are: (1) latent or manifest homosexuality with unresolved castration complex; (2) sadomasochism, wherein the masochism accentuates the passivity and feminity, and at times results in acts of strangulation; (3) narcissism; (4) scoptophilia; (5) exhibitionism; and (6) fetishism. Fenichel's formulation stresses two components in the transvestite act: (1) an object-erotic or fetishistic component in which the person "lives with" the clothes of the woman, representing his mother. Instead of coitus with the mother or mother substitute, the transvestite enters into a fetishistic relationship with her. The body odor and warmth of the clothes appear significant in addition to the sadomasochistic components; and (2) a narcissistic relationship in which the transvestite identifies with the phallic woman, wherein the love for the phallic mother is transformed into love for the ego. The narcissistic regression manifested extends beyond that seen in the homosexual.

Studies of fetishism have been approached with different degrees of emphasis on the relative contribution made in terms of the libidinal level of psychosexual development. Thus, some authors have paid particular attention to the analerotic and sadistic aspects and noted that coprophilia is an important activity.^{1, 2, 3, 22, 31}

In the case reported here, attention is drawn to the similarities between transvestism and pruritus perinei, with the demonstration that in both there are involved the aspects previously discussed, namely, castration anxiety with anal displacement, passive overt and latent homosexuality, extreme masochism, and the deeper implication in both syndromes of the wish to be a woman and ultimately to procreate. The examples of Wittkower in which the man with pruritus ani felt transformed into a woman, and the Schreber case, in which the psychosis involved the wish to be a woman, further clarify this relationship. In the case summarized, it is seen that, as the patient gratifies and acts out the fantasy of being a woman, the somatic expression of this wish, i.e., the pruritus perinei, disappears, reappearing when the transvestism is not gratified. The pruritus scroti represented an extreme masochistic and eroticized wish for castration, against which, theoretically, the transvestism should act as a defense but which apparently is not entirely the case.

This interesting panorama of symptoms poses many theoretical questions which are beyond the scope of this paper, such as concepts of bisexuality, the choice of symptoms, etc. Certainly in this patient, as masculine demands were made, and especially during the period when his wife was pregnant and giving birth, there was a reactivation of analerotic and other pregenital fantasies. There is evidence that this involved the wish to procreate. With the resultant intensification of anxiety, the wish led to regression beyond somatic expression in the form of pruritus perinei to the more narcissistic, masochistic, and exhibitionistic acting out in the form of transvestism, and ultimately to transsexualism, i.e., emasculation, with the fantasy of transformation.

This patient became more than identified with his "phallic mother." There is a possession or introjection of her which finds its manifestations in the patient's fantasy of transformation into a woman (i.e., mother), thus endowing him with the capacity to procreate.¹¹ Following his mother's death he lived in fantasy the role of replacing her, to the extent of sleeping in bed with his father and wearing female clothes. One can readily postulate his wish for anal impregnation by his father, thereby extending beyond the obvious wish for a passive homosexual relationship with his father. Kubie¹⁸ postulates that "from childhood and throughout life, on conscious, preconscious, and unconscious levels, the psychosexual goal is always and invariably to be both sexes, in varying proportions or emphasis." He adds that the insatiability of this drive results in an "orality" which "may rather be the instrument by which the unconscious goal of being both sexes is to be achieved through incorporation of breasts or penis or the body as a whole." The unconscious demands utilized in the attempt at achieving this bisexual goal have one common goal, namely, a "magical bodily transformation." The psychological study on this patient, done following emasculation, suggests that this patient has relatively few anal (ruminative) characteristics. He is much more the narcissistic, exhibitionistic character, whose emotional relationships are characterized by their dramatic, albeit superficial, quality. His concept of himself as a "sensitive person" is belied by the mock quality of his feelings. His perception of the ideal female endows them with characteristics illustrative of the noblest of the "Dickensian heroines." The two dreams reported in the study indicate the bisexual role this patient embodies. In the first dream, as a woman in the obvious wish-fulfillment function of the dream, and in the second, as a man (the chrome train) involving anal intercourse. The patient's persistent fantasy that his mother gave birth to another child in his first year of life would, if true, have given the patient exposure at that time to the process of pregnancy, which to an infant of 1 year might involve the inference that the baby grows in the mother's abdomen out of food and leaves the body through the anus, and thus in some special way is created and formed of feces.

This paper in its entirety has been concerned only with the psychodynamic aspects of pruritus perinei as it exists in the male. It may well be that in both the male transvestite and male patient with pruritus perinei, the deepest wish is not only to bear a child but to bear their own child, the result of an autoimpregnation.

Note:
Commonwealth Fund Fellow in Psychiatry.