Psychosomatic Medicine 3:72-86 (1941)
© 1941 American Psychosomatic Society

Sex Hormones and Psychic Conflict a Case Report

¹ Departments of Psychiatry and Medicine, Columbia University New York, N. Y.

The present report has been directed to outlining the factors which influenced the sexual adaptation of a male castrate. The interplay of the treatment situation, reality situation, and inner conflicts, constituted the frames of reference. Intensive psychiatric interviews combined with a relatively lengthy replacement therapy schedule were carried out. In viewing the trajectory of the patient's experiences throughout the observation period, it is evident that during the early periods with androgen there was a definite increase in sexual pace over and above his usual capacity during the last few years, particularly since castration. With the progression of treatment there was a decrease in the effective sexual expression of the patient which required explanation. The following comments are offered in explanation of the mechanisms which underlay the reduction in sexual activity.

Following castration, an alteration in the endopsychic conception of the individual takes place. The intensity and extent of this alteration is variable, essentially unconscious, but may also be consciously expressed. The castration may incline the individual to a femininized conception of himself. This is corroborated by the patient's dream material, especially those dreams dealing with the transference. The transference dreams revealed the emergence of a relatively powerful sexual conflict, i.e., the wish to be taken sexually, and also the repudiation of that wish. Since the homosexual conflict is more intense, there will be a concurrent intensification of the patient's hostility toward father-figures, because, by virtue of the homosexual orientation, the patient's passivity is increased. Since passivity is a challenge to the patient's security as well as to the cultural tradition of being virile, it will naturally produce an aggressive response which may or may not be conscious. In this instance, the major display of aggression was seen in the transference dreams and was directed against the physician.

The sex hormone pushes the individual into greater sexual activity. It induces him to follow a path more or less consistent with his basic personality patterns in line with the modifications induced by castration.

Through the introduction of a more prominent feminine component due to castration, hormonal pressure will intensify the patient's sexual conflicts, i.e., being somewhat more "feminine, " he has a more severe struggle against his passive cravings. He may, therefore, be unable to cope adequately with sexual tension, because of his increased passivity. Thus, we see that after the castration, hormonal treatment may operate eventually to interfere with effective sexuality.

It follows that the patient's altered ego attitudes must be worked through before hormones are too freely administered. An effort to analyze carefully the negative transference attitudes was not made in this patient, as, in the main, the psychiatrist took the part of an observer. But, ideally, neglect to analyze such material would appear to be one of the most serious technical oversights for the success of treatment.

The next problem is the effect of the wife's illness and her unattractiveness. This may legitimately disturb the patient's heterosexual expression, and since he is married and not completely equipped sexually, the difficulties of an extra-marital affair are quite real. In support of the greater prominence of inner conflict over the external factors, one must realize that the patient, though married, did not hesitate previously to have relationships with women to his own satisfaction, if he wanted them seriously enough.

Hence, the weight of evidence tends to throw the balance in the direction of inner conflict and altered ego attitudes. One must also bear in mind that in the last year the patient's attitude toward his wife improved considerably when his own sexual interests became less strong, along with the elimination of the hormone. Thus, although the administration of the male sex hormone temporarily produced a period of sexual rejuvenation, probably capable of repitition, it became evident that the patient's most effective psychic equilibrium was maintained after the discontinuation of hormonal therapy.

Note:
This study was made possible by a grant of the National Committee on Maternal Health through funds from the Sex Biology Gift to Columbia University.