Various distinguished physicians, especially in Germany, have proclaimed the duty of the doctor to recommend sexual intercourse to his patient whenever he considers it desirable. Gyurkovechky, for instance, has fully discussed this question, and answered it in the affirmative. Nyström (Sexual-Probleme, July, 1908, p. 413) states that it is the physician's duty, in some cases of sexual weakness, when all other methods of treatment have failed, to recommend sexual intercourse as the best remedy. Dr. Max Marcuse stands out as a conspicuous advocate of the unconditional duty of the physician to advocate sexual intercourse in some cases, both to men and to women, and has on many occasions argued in this sense (e.g., Darf der Arzt zum Ausserehelichen Geschlechtsverkehr raten? 1904). Marcuse is strongly of opinion that a physician who, allowing himself to be influenced by moral, sociological, or other considerations, neglects to recommend sexual intercourse when he considers it desirable for the patient's health, is unworthy of his profession, and should either give up medicine or send his patients to other doctors. This attitude, though not usually so emphatically stated, seems to be widely accepted. Lederer goes even further when he states (Monatsschrift für Harnkrankheiten und Sexuelle Hygiene, 1906, Heft 3) that it is the physician's duty in the case of a woman who is suffering from her husband's impotence, to advise her to have intercourse with another man, adding that "whether she does so with her husband's consent is no affair of the physician's, for he is not the guardian of morality, but the guardian of health." The physicians who publicly take this attitude are, however, a small minority. In England, so far as I am aware, no physician of eminence has openly proclaimed the duty of the doctor to advise sexual intercourse outside marriage, although, it is scarcely necessary to add, in England, as elsewhere, it happens that doctors, including women doctors, from time to time privately point out to their unmarried and even married patients, that sexual intercourse would probably be beneficial.
The duty of the physician to recommend sexual intercourse has been denied as emphatically as it has been affirmed. Thus Eulenburg (Sexuale Neuropathie, p. 43), would by no means advise extra-conjugal relations to his patient; "such advice is quite outside the physician's competence." It is, of course, denied by those who regard sexual abstinence as always harmless, if not beneficial. But it is also denied by many who consider that, under some circumstances, sexual intercourse would do good.
Moll has especially, and on many occasions, discussed the duty of the physician in relation to the question of advising sexual intercourse outside marriage (e.g., in his comprehensive work, Aerztliche Ethik, 1902; also Zeitschrift für Aerztliche Fortbildung, 1905, Nos. 12-15; Mutterschutz, 1905, Heft 3; Geschlecht und Gesellschaft, vol. ii, Heft 8). At the outset Moll had been disposed to assert the right of the physician to recommend sexual intercourse under some circumstances; "so long as marriage is unduly delayed and sexual intercourse outside marriage exists," he wrote (Die Conträre Sexualempfindung, second edition, p. 287), "so long, I think, we may use such intercourse therapeutically, provided that the rights of no third person (husband or wife) are injured." In all his later writings, however, Moll ranges himself clearly and decisively on the opposite side. He considers that the physician has no right to overlook the possible results of his advice in inflicting venereal disease, or, in the case of a woman, pregnancy, on his patient, and he believes that these serious results are far more likely to happen than is always admitted by those who defend the legitimacy of such advice. Nor will Moll admit that the physician is entitled to overlook the moral aspects of the question. A physician may know that a poor man could obtain many things good for his health by stealing, but he cannot advise him to steal. Moll takes the case of a Catholic priest who is suffering from neurasthenia due to sexual abstinence. Even although the physician feels certain that the priest may be able to avoid all the risks of disease as well as of publicity, he is not entitled to urge him to sexual intercourse. He has to remember that in thus causing a priest to break his vows of chastity he may induce a mental conflict and a bitter remorse which may lead to the worst results, even on his patient's physical health. Similar results, Moll remarks, may follow such advice when given to a married man or woman, to say nothing of possible divorce proceedings and accompanying evils.
Rohleder (Vorlesungen über Geschlechtstrieb und Gesamtes Geschlechtsleben der Menschen) adopts a somewhat qualified attitude in this matter. As a general rule he is decidedly against recommending sexual intercourse outside marriage to those who are suffering from partial or temporary abstinence (the only form of abstinence he recognizes), partly on the ground that the evils of abstinence are not serious or permanent, and partly because the patient is fairly certain to exercise his own judgment in the matter. But in some classes of cases he recommends such intercourse, and notably to bisexual persons, on the ground that he is thus preserving his patient from the criminal risks of homosexual practices.
It seems to me that there should be no doubt whatever as to the correct professional attitude of the physician in relation to this question of advice concerning sexual intercourse. The physician is never entitled to advise his patient to adopt sexual intercourse outside marriage nor any method of relief which is commonly regarded as illegitimate. It is said that the physician has nothing to do with considerations of conventional morality. If he considers that champagne would be good for a poor patient he ought to recommend him to take champagne; he is not called upon to consider whether the patient will beg, borrow, or steal the champagne. But, after all, even if that be admitted, it must still be said that the physician knows that the champagne, however obtained, is not likely to be poisonous. When, however, he prescribes sexual intercourse, with the same lofty indifference to practical considerations, he has no such knowledge. In giving such a prescription the physician has in fact not the slightest knowledge of what he may be prescribing. He may be giving his patient a venereal disease; he may be giving the anxieties and responsibilities of an illegitimate child; the prescriber is quite in the dark. He is in the same position as if he had prescribed a quack medicine of which the composition was unknown to him, with the added disadvantage that the medicine may turn out to be far more potently explosive than is the case with the usually innocuous patent medicine. The utmost that a physician can properly permit himself to do is to put the case impartially before his patient and to present to him all the risks. The solution must be for the patient himself to work out, as best he can, for it involves social and other considerations which, while they are indeed by no means outside the sphere of medicine, are certainly entirely outside the control of the individual private practitioner of medicine.
Moll also is of opinion that this impartial presentation of the case for and against sexual intercourse corresponds to the physician's duty in the matter. It is, indeed, a duty which can scarcely be escaped by the physician in many cases. Moll points out that it can by no means be assimilated, as some have supposed, with the recommendation of sexual intercourse. It is, on the contrary, he remarks, much more analogous to the physician's duty in reference to operations. He puts before the patient the nature of the operation, its advantages and its risks, but he leaves it to the patient's judgment to accept or reject the operation. Lewitt also (Geschlechtliche Enthaltsamkeit und Gesundheitsstörungen, 1905), after discussing the various opinions on this question, comes to the conclusion that the physician, if he thinks that intercourse outside marriage might be beneficial, should explain the difficulties and leave the patient himself to decide.
There is another reason why, having regard to the prevailing moral opinions at all events among the middle classes, a physician should refrain from advising extra-conjugal intercourse: he places himself in a false relation to his social environment. He is recommending a remedy the nature of which he could not publicly avow, and so destroying the public confidence in himself. The only physician who is morally entitled to advise his patients to enter into extra-conjugal relationships is one who openly acknowledges that he is prepared to give such advice. The doctor who is openly working for social reform has perhaps won the moral right to give advice in accordance with the tendency of his public activity, but even then his advice may be very dubiously judicious, and he would be better advised to confine his efforts at social reform to his public activities. The voice of the physician, as Professor Max Flesch of Frankfort observes, is more and more heard in the development and new growth of social institutions; he is a natural leaders in such movements, and proposals for reform properly come from him. "But," as Flesch continues, "publicly to accept the excellence of existing institutions and in the privacy of the consulting-room to give advice which assumes the imperfection of those institutions is illogical and confusing. It is the physician's business to give advice which is in accordance with the interests of the community as a whole, and those interests require that sexual relationships should be entered into between healthy men and women who are able and willing to accept the results of their union. That should be the physician's rule of conduct. Only so can he become, what to-day he is often proclaimed to be, the leader of the nation."[[98]] This view is not, as we see, entirely in accord with that which assumes that the physician's duty is solely and entirely to his patient, without regard to the bearing of his advice on social conduct. The patient's interests are primary, but they are not entitled to be placed in antagonism to the interests of society. The advice given by the wise physician must always be in harmony with the social and moral tone of his age. Thus it is that the tendency among the younger generation of physicians to-day to take an active interest in raising that tone and in promoting social reform—a tendency which exists not only in Germany where such interests have long been acute, but also in so conservative a land as England—is full of promise for the future.
The physician is usually content to consider his duty to his patient in relationship to sexual abstinence as sufficiently fulfilled when he attempts to allay sexual hyperæsthesia by medical or hygienic treatment. It can scarcely be claimed, however, that the results of such treatment are usually satisfactory, and sometimes indeed the treatment has a result which is the reverse of that intended. The difficulty generally is that in order to be efficacious the treatment must be carried to an extreme which exhausts or inhibits not only the genital activities alone but the activities of the whole organism, and short of that it may prove a stimulant rather than a sedative. It is difficult and usually impossible to separate out a man's sexual activities and bring influence to bear on these activities alone. Sexual activity is so closely intertwined with the other organic activities, erotic exuberance is so much a flower which is rooted in the whole organism, that the blow which crushes it may strike down the whole man. The bromides are universally recognized as powerful sexual sedatives, but their influence in this respect only makes itself felt when they have dulled all the finest energies of the organism. Physical exercise is universally recommended to sexually hyperæsthetic patients. Yet most people, men and women, find that physical exercise is a positive stimulus to sexual activity. This is notably so as regards walking, and exuberantly energetic young women who are troubled by the irritant activity of their healthy sexual emotions sometimes spend a large part of their time in the vain attempt to lull their activity by long walks. Physical exercise only proves efficacious in this respect when it is carried to an extent which produces general exhaustion. Then indeed the sexual activity is lulled; but so are all the mental and physical activities. It is undoubtedly true that exercises and games of all sorts for young people of both sexes have a sexually hygienic as well as a generally hygienic influence which is undoubtedly beneficial. They are, on all grounds, to be preferred to prolonged sedentary occupations. But it is idle to suppose that games and exercises will suppress the sexual impulses, for in so far as they favor health, they favor all the impulses that are the result of health. The most that can be expected is that they may tend to restrain the manifestations of sex by dispersing the energy they generate.
There are many physical rules and precautions which are advocated, not without reason, as tending to inhibit or diminish sexual activity. The avoidance of heat and the cultivation of cold is one of the most important of these. Hot climates, a close atmosphere, heavy bed-clothing, hot baths, all tend powerfully to excite the sexual system, for that system is a peripheral sensory organ, and whatever stimulates the skin generally, stimulates the sexual system.[[99]] Cold, which contracts the skin, also deadens the sexual feelings, a fact which the ascetics of old knew and acted upon. The garments and the posture of the body are not without influence. Constriction or pressure in the neighborhood of the sexual region, even tight corsets, as well as internal pressure, as from a distended bladder, are sources of sexual irritation. Sleeping on the back, which congests the spinal centres, also acts in the same way, as has long been known by those who attend to sexual hygiene; thus it is stated that in the Franciscan order it is prohibited to lie on the back. Food and drink are, further, powerful sexual stimulants. This is true even of the simplest and most wholesome nourishment, but it is more especially true of flesh meat, and, above all, of alcohol in its stronger forms such as spirits, liqueurs, sparkling and heavy wines, and even many English beers. This has always been clearly realized by those who cultivate asceticism, and it is one of the powerful reasons why alcohol should not be given in early youth. As St. Jerome wrote, when telling Eustochium that she must avoid wine like poison, "wine and youth are the two fires of lust. Why add oil to the flame?"[[100]] Idleness, again, especially when combined with rich living, promotes sexual activity, as Burton sets forth at length in his Anatomy of Melancholy, and constant occupation, on the other hand, concentrates the wandering activities.
Mental exercise, like physical exercise, has sometimes been advocated as a method of calming sexual excitement, but it seems to be equally equivocal in its action. If it is profoundly interesting and exciting it may stir up rather than lull the sexual emotions. If it arouses little interest it is unable to exert any kind of influence. This is true even of mathematical occupations which have been advocated by various authorities, including Broussais, as aids to sexual hygiene.[[101]] "I have tried mechanical mental work," a lady writes, "such as solving arithmetical or algebraic problems, but it does no good; in fact it seems only to increase the excitement." "I studied and especially turned my attention to mathematics," a clergyman writes, "with a view to check my sexual tendencies. To a certain extent I was successful. But at the approach of an old friend, a voice or a touch, these tendencies came back again with renewed strength. I found mathematics, however, the best thing on the whole to take off my attention from women, better than religious exercises which I tried when younger (twenty-two to thirty)." At the best, however, such devices are of merely temporary efficacy.