Masturbatory insanity: the history of an idea, revisited

Abstract

In the eighteenth century, masturbation was extended from the moral to the medical sphere and conceptualized as being the cause of various deteriorative physical illnesses. In the nineteenth century, psychiatrists accepted that difficult to control masturbation was a feature of many mental disorders. They also believed that masturbation could play a casual role in a specific type of insanity with a distinctive natural history. In 1962, E.H. Hare published an article on the concept of masturbatory insanity that became an important explication of the masturbation and mental illness relationship in the history of psychiatry. Historical research published subsequent to Hare's article suggests several updates to his analysis. Hare did not note that the masturbation and mental illness relationship was promoted to the general public by quacks peddling quick cures. Hare emphasized psychiatrists’ condemnatory language only, neglecting the aspiration of psychiatrists to treat disorders caused by excessive masturbation, not punish the sin of masturbation. Hare recognized the importance of hebephrenia and neurasthenia to this history but attributed the decline of masturbation related mental illness in part to the rejection of an irrational, unscientific hypotheses about masturbation's causal role. As an alternative, we suggest that before the causal role of masturbation was widely abandoned, the concepts of hebephrenia and neurasthenia gained a competitive advantage and became primary diagnoses for cases that once would have been conceptualized as masturbatory insanity.

To move up in the ranks of the Proud Boys, a North American alt-right organization, members must commit to not masturbating more than once a month. This pledge was initiated by the Proud Boys’ founder who believes that pornography-induced masturbation drains away the life force and makes men weaker, more stupid, and lazy (McInnes, 2015). In his view, we should not be too quick to dismiss old wives’ tales about masturbation and even try to reconstruct some of the traditional practices recommended by ‘Catholics and old priests and old dads.’ Two other contemporary movements that encourage abstinence from masturbation are called No Nut November and NoFap (Dickson, 2019).

In the mid to late nineteenth century, similar views were culturally dominant. Masturbation was viewed as a casual factor for a cluster of disorders ranging from mild to severe. Exhaustion, detachment from others, and physical and mental enfeeblement represented the initial, milder manifestations. More severe outcomes included blindness, insanity, and death. Indeed, Gilbert (1975, 1980) reports that the masturbation hypothesis offered a convenient explanation for medically unexplained disorders.

In this article, we examine historical claims about relationship between masturbation and mental illness. These claims are potentially apt to be misunderstood. For example, it would be incorrect to say that masturbation itself was considered a mental disorder. Physicians knew that masturbation was a common practice which for most people did no permanent damage. Excessive masturbation over which a person lost control and performed to the point of exhaustion, however, was hypothesized to be a causal factor in deteriorative illnesses.

Hare's (1962) article ‘Masturbatory Insanity: The History of an Idea,’ now over 60 years old, is a classic in the field. Hare argued that when the medical dangers of masturbation were first promulgated in the eighteenth century, mental disorders were not prominent among the listed outcomes, but in the nineteenth century the emphasis on physical consequences faded and the emphasis placed on mental disorders increased. A few years after mid-century, psychiatrists such as Skae, Maudsley, and Clouston argued that the insanity of masturbation was a specific disorder that began in adolescence and in the worst cases progressed to dementia. Hare claimed that by the end of the century the view that masturbation caused a particular form of insanity faded in favor of a view that it caused neurosis. In the twentieth century, masturbation as a cause of neurosis was replaced, said Hare, by the view that any harmful effects from masturbation are due to the anxiety occasioned by exaggerated claims about masturbation's negative consequences.

Hare argued that the masturbation hypothesis was a mistake that never should have been accepted, especially because what he called ‘rational’ arguments against it had been in circulation from Pinel onward. This included the claim that masturbation is a symptom rather than a cause of disorder. Also, as noted by the surgeon Hunter (1786) writing about masturbation as a cause of impotence: ‘the complaint .. appears to me to be by far too rare to originate from a practice so general’ (p. 200). Hare asserted that the masturbation hypothesis persisted due to conservatism, the satisfaction physicians gained from being able to explain mysterious ailments, and logical fallacies.

In this article, we revisit this history to extend Hare's analysis and explicate some points in more detail. In part this is made possible by the broadening of the historical picture provided by extensive scholarship produced subsequent to Hare's work, much of which has not been reported in the psychiatric literature (Comfort, 1969; Darby, 2005; Gilbert, 1975, 1980; Hall, 1992, 2003; Laqueur, 2003; Stengers & Van Neck, 2001; Stolberg, 2000, 2003). Our own reading of many of the primary works also affords us the opportunity to emphasize some points that Hare did not.

We extend his analysis in three main ways. First, Hare did not discuss the panic about masturbation that occurred throughout Europe and the U.S. and more importantly the role played by ‘quacks’ in advertising the dangerous consequences of masturbation in order to peddle quick cures. Second, Hare primarily emphasized the negative aspects of this history. The condemnatory language used by physicians in the eighteenth and nineteenth century is disquieting in the light of contemporary professional mores. Hare, however, neglected the benevolent features of medical practice– many physicians aspired to treat disorders, not punish crimes and believed that with proper and humane treatment some patients could make a full recovery. Third, Hare emphasized the gradual acceptance of what he called rational arguments against the masturbation hypotheses. We will give more emphasis to the introduction of two replacement concepts, hebephrenia and neurasthenia, both of which gained enough of a competitive advantage to shrink the diagnostic niche which the insanity of masturbation could occupy.

Quackery: the role of scaremongering and peddling cures

Hare claimed that the masturbation-illness relationship was potentially initiated by quackery. Let us examine this in more detail than he did.

Onania or the Heinous Sin of Self- Pollution was first published by an anonymous author in 1716. The term Onania is a reference to Onan from the Hebrew bible, who was struck dead by God for spilling his seed rather than doing his family duty and impregnating his deceased brother's wife. The title page describes Onania as providing ‘spiritual and physical advice to those who have already injured themselves by this abominable practice.’

Stolberg (2000, 2003) reports that in England a religiously inspired anti-masturbation campaign beginning in the late 1600s sowed the ground for this book but Onania introduced a medical slant into the campaign. A few years prior to Onania's appearance, a surgeon named John Marten published a treatise on venereal disease in which he also discussed the harmful consequences of masturbation. Marten's passages about masturbation were reprinted in Onania. Laqueur (2003) argues that John Marten was the anonymous author of Onania.

According to the author of Onania, it is alarming that so many people of both sexes regularly engage in this dangerous practice yet are not aware of the grave risk at which they are putting themselves. Its visible signs were enfeeblement and wasting away – including a pale complexion, loss of strength, and emaciation. Among the frightful consequences that could result from masturbation described in the book were epilepsy, consumption, impotence, imbecility, and death.

In the 4^th edition, first published in 1718, the anonymous author claimed that there are effective medicines for some of the ills consequent to ‘self-pollution’ such as discharges unrelated to venereal disease^†1 and impotence. The author reported that he had intended to insert the prescriptions into the book but the ingredients were costly and hard to prepare. Rather than compelling users to admit their sin and ask an apothecary to make the medicines – perhaps imperfectly, the author had the medicines made by a trusted and competent physician. The author also asked this physician to distribute the medicines freely and to run some trials with them. After two years the medicines had been proven to work, but the physician was put at considerable expense. As a result, the author conferred to this physician the power to dispose of these medicines as he wished. Readers were informed that the medicines can be purchased in London at one of the bookshops where Onania was sold – and the author confided to the readers that he had forgone any share in the profits that might accrue.

Publishing pamphlets and newspaper advertisements that described ailments and then marketed medicinal cures was a common practice in eighteenth and nineteenth century England (Laqueur, 2003; Stengers & Van Neck, 2001). Despite its obvious association with quackery, aided by continual advertisements in various publications, thousands of copies of Onania were sold and the term ‘onanism’ became synonymous with masturbation. The book also became the inspiration for imitators peddling their own cures.

These imitators were the main focus of Comfort's (1969) examination of masturbatory panic in nineteenth century England. According to him, through the volume of their output, the pamphleteers had a greater influence on public opinion than did physicians. Comfort says the sheer volume of noise they generated drowned out less dire perspectives. In addition to charlatans drumming up panic about masturbation and promising a speedy cure – for a price, Comfort noted that some physicians joined the trade to take advantage of the easy profits that could be gained.

The pamphleteers helped both spread and maintain beliefs about the harmful effects of masturbation. Psychologically, if a claim is repeated enough, people assent to it. Even if the claim is unbelievable at first, as repetition leads to increasing consensus, the claim can seem increasingly rational (Hertwig, Gigerenzer, & Hoffrage, 1997). When what is being repeated is a speculative causal theory, and it is further ‘supported’ by clinical lore and experience, it could even seem self-evident.

Darby (2005) also documents how much of the anxiety regarding masturbation was moral panic focused on protecting children from the harmful consequences of ‘self-abuse’. Indeed Hall (1992) reports that the height of public anxiety about masturbation occurred in the decades prior to and just after 1900.

Many physicians who specialized in the treatment of mental illness and accepted the masturbation hypotheses as rational also condemned the pamphleteers as quacks. For example, Drysdale (1861) in criticizing ‘mercenary’ claims for cures, asserted that it is a disgrace to medicine that the disorders related to masturbation have become the trade of unscientific men, and even some physicians. Clouston (1883) criticized what he labeled ‘shameful quack advertisements’ for fattening the vilest of mankind, aggravating those who suffer only minor effects of the vice, and introducing evil thoughts to those who would otherwise be free of them. Also writing about advertisements that ‘defile our walls and newspapers,’ Yellowlees (1892) reported that these imposters ‘trade on the fears of their victims in order to empty their pockets.’ They painted, he claimed, a frightening picture of the dangers of masturbation - including permanent insanity, but promise that a cure is available with the ‘priceless medicine that they alone can supply.’ (p. 784).

Hall (1992) also provides references to letters and editorials in The Lancet The Editors (1870) and The British Medical Journal The Editors (1892) that call attention to the problem of quack advertisements which create panic and then take advantage of readers by selling them cures. Interestingly, by the 1870s, these advertisements had become disreputable in London but continued to have success in rural newspapers. One editorial specifically criticized the newspaper publishers for being willing to print deceptive claims as long as those claims brought in advertising dollars.

Treating disorders not punishing crimes

The bridge between Marten's Onania and general medical practice was a 1760 book by the Swiss physician Samuel Tissot titled L'Onanisme.² It was translated into English as Onanism: or, a Treatise upon the Disorders produced by Masturbation. An elite and well-connected physician, Tissot was a respected expert on smallpox and later became a celebrity throughout Europe as the author of the 1761 book Advice to the People About Health.

Tissot (1760/1766) distanced himself from Onania by presenting his book as a medical, not a clerical tract. He said that his purpose was to write about the disorders occasioned by masturbation and emphasized loss of control over the habit throughout the book.

Tissot brought the danger of masturbation squarely into respectable medical discourse, in part by disputing contrary views that viewed masturbation benignly. Stengers and Van Neck (2001) report that from the Middle Ages on, moral condemnation of masturbation was common, but there is almost no reference harmful physical consequences until the eighteenth century. In fact, in Galenic medicine, a primary concern was the danger of bodily fluids being corrupted – and the importance of evacuating them. Tissot disputed this view, arguing instead that the ‘seminal liquor’ is an essential humor. When first produced it is responsible for the production of secondary sex characteristics and increased vigor and if it is lost, the body cannot restore itself. The reason Eunuchs do not waste away like masturbators, said Tissot, is that their bodies have never benefited from the positive effects of the seminal fluid and therefore are not impoverished by its loss.

In the early eighteenth century, physicians shifted from viewing the physical basis of mental disorders as humoral to speculations about intestinal fermentations (‘the vapors’ and ‘the spleen’) and nerve vibrations. In the second half of the century, their focus shifted almost entirely to disorders of the nerves. In this vein, Tissot also noted that the continual obsession with masturbation fatigues the brain. He also added that the negative effects of masturbation were not inflicted equally on all, but more so for with those who inherited vulnerable constitutions.

One feature that stands out in the subsequent medical discourse, as emphasized by Hare, is the use of condemnatory language. For instance, Ellis (1838) referred to masturbation as a vice and a disgusting habit, opining that the resulting wretchedness of those who practice it is the just reward of their own misconduct. Writing from the perspective of degeneration theory, Maudsley (1868), stated that physicians should not suggest that a conformed masturbator marry and have children because ‘… if he be not entirely impotent, what an outlook for any child begotten of such a degenerate stock! Has a being so degraded any right to curse a child with the inheritance of such a wretched descent? Far better that the vice and its consequences should die with³ him’ (p. 158). Kellogg (1887) declared of masturbation: ‘It is worse than beastly…The most loathsome reptile, rolling in the slush and slime of its stagnant pool, would not bemean itself thus…A boy who is thus guilty, ought to be ashamed to look into the eyes of an honest dog’ (p. 339).

On the other hand, a point that Hare did not emphasize is that many physicians saw themselves as medical doctors who had a duty to care for patients. Religious and moral aversion to masturbation manifestly colored people's interpretations. However, whatever their moral qualms, some physicians saw it as their duty to treat the unwell. This tradition begins with Tissot, who, although referring to masturbation as ‘odious,’ ‘filthy,’ and an ‘abomination,’ claimed that he explicitly tried to avoid what he termed entering upon the moral part.

Such an attitude has an interesting parallel with the diagnosis of same-sex sexual attraction as a mental disorder in the mid-twentieth century. Even psychiatrists who were morally opposed to homosexuality, viewed their profession as having played a progressive role in defining it as a disorder rather than a criminal act subject to prosecution (Bayer, 1981). A similar attitude regarding masturbation was stated most explicitly by Tissot who claimed he set out to write about the disorders occasioned by masturbation, not about the crime of masturbation. In doing so, Tissot established the framework for many subsequent thinkers.

For instance, writing about the negative consequences of compulsive masturbation, Drysdale (1861) begins by quoting a passage from the French physician Lallemand: ‘Instead of blaming these unfortunates, ought we not rather to pity and still more to relieve them?’ (p. 89) Drysdale then states that that path of the true physician is to reverence and love every human being irrespective of their actions. Physicians, he asserted, should not hate, reproach or despise these individuals, but seek to benefit them to the utmost of their power.

It is also important to not divorce condemnatory language from its context. Certainly, the physicians were condemnatory about excessive masturbation. More in context, consider Ellis's above referenced claim about the wretchedness that results from masturbation being a ‘just reward.’ In the preceding sentence Ellis clearly stated that this what he would like to say to young people if he could take them on his daily rounds in the asylum and show them what awaits them if they continue this practice. It was as much a warning off as a condemnation.

Writing about young people who are vulnerable to developing a habit of hard-to-control masturbation, Clouston (1883) refers to medical men as teachers of the truths of medico-psychology and physiology who can help them with counsel and knowledge, but unfortunately, he wrote, our help is too seldom called in. If these habits could be reduced among the rising generation, Clouston said, then ‘…life would be elevated in a large degree, self-respect would be increased, social intercourse would be sweetened, and its pleasures intensified, while the sting of self-accusation and remorse would be far fewer…’ (p. 342). Moreover, Clouston emphasized that although many cases do not recover, a majority of cases are treatable.⁴

The insanity of masturbation replaced with successor diagnostic concepts

Inspired by the Toulmin's (1972) ideas about conceptual diversity and intellectual selection, Mace (2002) argues that psychiatry can be identified with a shared pool of diagnostic concepts that have undergone transformation, division, combination, and replacement. In replacement, new conceptual variants are proposed, gain a competitive advantage, and supplant existing concepts. In this section we will suggest that some cases which once would have been diagnosed as masturbatory insanity were instead diagnosed with two new concepts – hebephrenia and neurasthenia.

Kendler and Engstrom (2017) report that in the middle of the nineteenth century Karl Kahlbaum and Ewald Hecker argued that psychiatric diagnostic concepts represent only symptom clusters, not valid disease forms. In their view, diagnosing mania and melancholia is analogous to diagnosing a cough. Instead, they proposed that physicians should attend to natural history, i.e. the typical course of an illness and its outcome. With this in mind, in 1863 Kahlbaum introduced the concept of ‘hebephrenia’ to refer to a disorder that began in adolescence.

According to Kraam and Phillips (2012), a few years later using his own observations and Kahlbaum's notes, in 1871 Hecker published a detailed monograph including several case studies that provided the first actual description of the natural course of hebephrenia, i.e. mood disturbance, followed by excitement and agitation and progressing rapidly to an incurable dementia (i.e. disorganization) (Hecker and Kraam, 2009a, 2009b). Some of Hecker's cases featured masturbation as a precipitant. Kraam and Phillips argue that several attempts to deny the existence of hebephrenia over the next 20 or so years were futile as the concept was too compelling. It became institutionalized beginning in 1893 when Kraepelin incorporated it into his evolving notion of dementia praecox (and later as part of Bleuler's broader notion of schizophrenia).

The person who was the most explicit about a specific masturbation-related syndrome was the Superintendent of the Royal Edinburgh Asylum – David Skae (1863). Similar to Kahlbaum and Hecker, Skae was a practitioner, not a university-based psychiatrist. Like them, Skae claimed that diagnosing acute mania or melancholia is analogous to diagnosing a fever. In Skae's view, these are symptoms of disease, not diseases in themselves. The problem, noted Skae, is that we cannot refer mental symptoms to known diseases processes, but nevertheless by attending to precipitants, causes, course, and probable termination we can identify natural groups.

Skae proposed 25 natural groups, one of which was the mania of masturbation. Although, he claimed that masturbation refers only to the cause, Skae said it is associated with a characteristic natural history. It first manifests as imbecility and shy habits in youth, developing over time into suspicion, fear, dread, and suicidality, gradually progressing to fatuity or dementia. Later, Skae (1874) gave a more elaborate description of the insanity of masturbation in his Morosonian lectures, noting that if treatment begins before the mind has become too impaired to exert self-control, recovery is typical. If patients continue to masturbate after dementia begins, he reported that the prognosis is not hopeful.⁵

Hare (1962) claimed that Skae's description of masturbatory insanity anticipated what would become hebephrenia. Had Skae not selected as a name the mania of masturbation, Hare said he would be remembered for giving one of the earliest descriptions of hebephrenia. This is plausible. Several of Hecker's studies mentioned excessive masturbation as a precipitant. In addition, the natural histories of hebephrenia and the insanity of masturbation are similar, involving onset in adolescence and potentially terminating in incurable dementia.

Hare said masturbation ceased to be seen as a cause of insanity in the final years of the nineteenth century, which implies the ground was passively ceded to hebephrenia. We would like to argue something slightly different, namely, that as hebephrenia became better known, it replaced the insanity of masturbation as the primary diagnosis whether or not one accepted the masturbation hypothesis.

In some respects, however, hebephrenia and the insanity of masturbation differ. For example, Skae's description of the insanity of masturbation included a gradual not a rapid onset. Skae and Clouston both reported that not all cases progress to an uncurable dementia. Clouston (1883, 1888) specifically claimed that the insanity of masturbation is a disorder distinct from other early onset dementias. Masturbation-induced dementia, he said, has a specific character, – being solitary, unsocial, and impulsive. The salience of symptoms related to brain exhaustion, he thought, justify the insanity of masturbation being a primary diagnosis.

Masturbation-induced disorders were broad and protean, but there are a few consistencies that appear across the various descriptions, including Skae and Clouston's distinct insanity of masturbation. From Onania onward, the consequence of excessive masturbation included fatigue, loss of vigor, and wasting away. Masturbation practiced to the point of exhaustion was solitary and self-focused. Sufferers were described as physically emaciated and pale. Furthermore, dementia was only a possible outcome. These core features were not readily captured by hebephrenia.

However, another new concept may have created a diagnostic niche into which the some of the less severe cases of the insanity of masturbation could fit, namely, neurasthenia which was defined by Beard (1869) as exhaustion of the nervous system. Beard emphasized the physical nature of the disease, that it can be acute or chronic, and is more likely to occur in those with a hereditary disposition. That same year a similar description of neurasthenia was offered by Van Deusen (1869).

Book length treatments of neurasthenia were published in England by Campbell (1873) and in the U.S. by Beard (1880, 1881) – each describing a cornucopia of possible consequences of nervous exhaustion. These descriptions included features previously attributed to masturbation such as malaise, blank facial expressions, involuntary seminal loss in men, and even death. They also included new features such increased sensitivity to stimuli and alcohol and drug abuse.

Neurasthenia became better known just about the time that Hare claimed that the insanity of masturbation declined while the masturbation hypothesis found new life by being proposed as the cause of neurosis. For example, Beard (1884) wrote a book called Sexual Neurasthenia (published posthumously) that allowed masturbation to be a precipitant in both neurasthenia and insanity.

Beard's view of masturbation's role, however, was not uniformly shared. Indeed, in his initial description of neurasthenia, Van Deusan asserted that masturbation could not even be considered a predisposing cause in any of the cases he reported.

Short of explicit claims on the part of physicians that what they use to diagnose as less severe forms of masturbation-related mental disorder was actually neurasthenia, however, this replacement notion is speculative. The closest thing we found is a report by Kosenko and Steger (2022) showing how as a medical student, in 1883 Anton Chekhov treated a patient who he considered to have a masturbation induced nervous disorder. Because the disorder did not progress to insanity, Chekov diagnosed it as neurasthenia instead.⁶

Neurasthenia became a faddish diagnosis in the 1880s, increasingly psychological in nature, which sufferers readily self-applied. Wessely (1995) reports that people's willingness to pay for treatment helped the concept of neurasthenia to stay in use long past the introduction of its own successor concepts. The concept's popularity would be another possible reason that neurasthenia could have gained a competitive advantage and become a primary diagnosis, even though masturbation remained a possible precipitant according to some.⁷

The arc of history?

The decline of diagnosing masturbation-induced mental disorder does not mean that ideas about the negative effects of masturbation were suddenly discarded. Watts (1972) reported that when he was a student in Canterbury in the 1920s, boys his age were given the impression that masturbation could result in many dreadful consequences including syphilis, epilepsy, and death. Furthermore, when Kenneth Kendler was interviewing patients with schizophrenia in the West of Ireland for the Roscommon Family Studies in the 1980s, he was struck at the guilt about masturbation in male patients. He recalls that the level of self-repugnance described by many of these patients was painful to listen to and far beyond the scope of any attempts at reassurance.

Hare adopted a somewhat triumphalist tone when he argued that contemporary psychiatry can see beyond the many fallacies that supported the masturbation hypothesis and would not repeat such mistakes. In our view, it would be difficult for the concept of a specific masturbatory mental disorder to regain a competitive advantage over the categories in the DSM and the ICD or the factor analytic dimensions of the psychologists if for no other reason than that introducing new disorders into the classifications require meeting a high bar of validating evidence (Kendler, Kupfer, Narrow, Phillips, & Fawcett, 2009).

In other respects, Hare may have been overly confident about being beyond the errors of the past. This article began by briefly describing the views of contemporary advocates for abstaining from masturbation. The similarity between these views and some eighteenth and nineteenth century views would raise doubts about an assertion that the masturbation hypothesis has been so completely disproven that it is gone for good and beyond resurgence. If some could gain benefits from making seemingly implausible claims about disorders, and they are repeated enough, such claims could seem increasingly plausible. Especially if the claims could be further linked with risks to children, we suspect quack treatments would probably not be far behind.