The sexual question

by Auguste Forel

A sadist or a sexual pervert addicted to assaults on children consults a doctor and confides to him his morbid appetite. It is obvious that the doctor has to do with a dangerous individual and is at the same time in a difficult position. In this case extreme measures are bad. The doctor who simply treats the patient without concerning himself about the possible victims, contravenes his duties. The one who replies to the patient, "you are a beast; go away or I shall denounce you," acts in a still worse manner. The one who simply denounces the patient also puts himself in the wrong. In my opinion, the doctor should first of all make a thorough examination of the mental and sexual condition of the patient, so as to establish the degree of perversion and satisfy himself whether he has to do with an honest individual worthy of pity, who strives to overcome his morbid appetite; or, with a crafty egoist with no conscience, who only consults the doctor to escape from temporary difficulties into which his perversion has led him, and who indulges his morbid appetite without scruple, constituting a perpetual danger to society. Unfortunately, the latter cases are very common, and the doctor is usually consulted from interested motives only. Under these circumstances medical secrecy renders the doctor the accomplice of the criminal.

Between the honest patient and one who is absolutely perverse, there are many transitional stages. In these cases the doctor should always make a careful examination before forming an opinion. If he feels uncertain, he should call in a specialist in mental disease, and then act accordingly. If he is convinced that the patient has made the resolution to overcome his morbid appetite, and has so far resisted the temptation to injure any one, he should strengthen the patient's resistance by doing everything possible (except marriage) to rid him of his malady; he should make him aware how dangerous his condition is to himself and to others; he may even recommend either castration or masturbation in case of urgency, in order to avoid crime; he should make him promise to come immediately for internment in an asylum, as soon as he can no longer resist. Under these conditions he may respect medical secrecy and at the same time save the existence of the unfortunate patient, while protecting society.

In more severe cases, when the doctor is convinced that the patient is incapable of controlling himself or does not wish to, or that he has already committed crimes, he should act as follows: He must explain to the patient that it is impossible for him to take the responsibility and that he must be immediately sent to an asylum, in default of which information will be given against him. We must make him understand that he is a danger to society and goes beyond the limits of what is licit, but that if he voluntarily submits to rational treatment, offering all requisite guarantees on both sides, he (the doctor) is disposed to avoid any legal action.

The duty of medical secrecy ought never to go so far as to render the medical man an accomplice of dangerous individuals or criminals. The lunatic asylum in such cases is the natural refuge for the patient, as the lazaret is for cases of smallpox or cholera. These cases, however, require public asylums which are not too large, well organized, with divisions for different cases, and provided with a sufficient medical staff.

I have chosen as the first example one of the worst kind of cases which endanger the public safety. But there are other cases such as that depicted by Brieux in "Les Avariés." A syphilitic subject wishes to marry before he is cured, and consults his doctor. Does the whole duty of the doctor consist in dissuading the patient from marriage? Has he actually the right to be silent when the patient will not listen to him, and thus allow an innocent young woman to be contaminated, through respect—or rather idolatry—for medical secrecy? Is it not rather his duty to say to the patient: "Beware! If you do not promise to obey me, I will immediately denounce you to your fiancée and her parents, and will tell them the state of affairs." It seems to me that this is his duty. In this case the doctor does not denounce the patient without his knowledge; he threatens him face to face, and may speak to him as follows: "You have confided in me. I am, it is true, under the obligation of medical secrecy toward you, so long as you do no harm to any one. But if, in spite of all my explanations and warnings, you attempt to marry in your present state, rendering yourself guilty of infamous deceit toward a family and an unfortunate young woman whose health you will ruin, trusting in the obligation of secrecy which ties my tongue, I must inform you that I have a much higher duty than that of a doctor toward his patient—my duty toward society, which I shall fulfill, and so prevent an innocent person from becoming your victim."

This is my view of the duty of a conscientious doctor who upholds the dignity of his profession. An analogous case came under my observation: A young tuberculous subject affected with several "white swellings" wished to marry. He refused to listen when I declared that he would be guilty of a crime toward his fiancée. Thereupon I told him that I should tell everything to the young girl. I did this at once and so prevented the marriage. This egoist succeeded later on in capturing the heart of another young girl, whom I also warned, but who married him out of pity. At any rate I consider that I did my duty.

In my opinion, this is also our duty in cases of chronic gonorrhea, insanity, and hereditary or constitutional sexual perversions, etc. Formerly, when sexual inversion was regarded as an acquired vice, it was attempted to cure it by marriage. Such a social monstrosity is even seen at the present day, and certain ignorant doctors recommend it. We sometimes meet with inverts who desire to procreate homosexual beings like themselves. As sexual intercourse with the objects of their perverted passion cannot give them this pleasure, they marry in order to procreate children by some poor woman whom they have victimized, without in the least renouncing their homosexual orgies. Their wives play the part of housekeeper or servant, whose accessory function is to breed young inverts! Is it necessary to say that any self-respecting doctor who is aware of this state of affairs should never countenance such marriages? Here again, his duty is to threaten the invert with immediate denunciation to his fiancée, when he appears determined to accomplish his crime.

Again, the doctor may be consulted with regard to certain hereditary taints, or possibly only a bad ancestral history, and whether marriage is advisable under the circumstances. In some cases there may be some doubt and it is necessary to know the opinion of the other party concerned, and whether this party is also affected in a similar way, etc. The first duty of the doctor is to demand absolute frankness and to say, "under this or that condition and in such and such circumstances, you may perhaps marry, but under no pretext have you the right to conceal the truth from your betrothed. It is to your own interest to be frank, for no marriage founded on deceit can be happy. Give me permission to discuss the matter with your fiancée (or fiancé). We shall then see what is best to be done."

In my experience, the person who consults a doctor usually accepts this proposal, and we can thus avoid many misfortunes and do much good.

It is impossible to fix a general rule. According to the degree of hereditary taint or the nature of the infirmity, we allow marriage with or without children, or do not allow it. In such cases it is rarely necessary to have recourse to the threat of denunciation, but this may be required in the case of egoistic or vicious individuals. On several occasions a betrothed couple have come to me for advice as to their proposed marriage, and have freely disclosed their most intimate relations and antecedents. This is as it always should be, if men were more loyal in sexual matters and understood better their true interests. In this way the doctor's task is greatly facilitated. When the public is more enlightened on the whole question it will become more and more easy to arrive at a just conclusion, even without the doctor's help.