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A Medical Study of Sex Adjustment




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Made in the United States of America

Reprinted April, 1949


ies Wisi ke Wises ads Battmorz, Mp., U. 8. A.


HE STUDY OF SEX and of that marriage relatienship which is its most important social manifestation is still recent. On the psychological side, indeed, it was only with the present century that the study of sex was placed on a widely normal and reasonably scientific foundation. Before then it was either ignored, shunned, or taken for granted, with many results that we are beginning to realize. It was in the German-speaking lands that theemodern scientific study of sex may be said to have had its origin, on the one hand among psychiatric investigators like Krafft-Ebing, Moll, Hirschfeld, and Max Marcuse, gradually developing in general medical and sociological directions and leading.on to the popular movements of psychoanalysis; on the other hand among ethnographers, and culminating in the splendid monument of Ploss and Bartels, Das Weib, now in its eleventh edition as edited by Reizenstein in three richly illustrated volumes. But these investigations led to no wide study of normal civilized conditions in the methodically statistical forms which may lead to fruitful conclusions and definite progress. An investigation of sex activities and sex relationships among fairly normal people, on a sufficiently large and systematic scale to be treated statistically, is quite new, and the most carefully conducted and most illuminating studies, as we may probably consider them, have been carried out in what is commonly and perhaps not unreasonably called the Anglo-Saxon culture. We owe them to American investigators who have worked among the people of the United States. There is Dr. Katharine B. Davis with Factors in the Sex Life of Twenty-Two Hundred Women, and Dr. G. V. Hamilton with A Research in Marriage, both these volumes being published in New York in 1929. Dr. Davis began her study in March, 1920, publishing the findings in journal form first; while Dr. Hamilton’s observations were carried on between October, 1924 and April, 1928. These two investigations were unlike in origin, method, and



material. Dr. Hamilton approached the matter as a trained psychiatrist undertaking the examination of persons who were according to ordinary standards normal. His subjects were one hundred married men and one hundred married women (not necessarily husbands and wives to each other), who were well above the average in intelligence and social position. He pre- pared elaborate and systematic series of questions, covering the whole field of the sexual life in much detail, and these questions were submitted to the subjects to be answered under his personal supervision; the subject being, however, left free to answer, without cross-examination and without any physical exploration, so that some questions were left unanswered, some answers were obscure and occasionally contradictory, while the perychie and physical syndromes of the subject were not positively demon- strated. Dr. Hamilton’s elaborate results were treated exhaus- tively, and though the figures are sometimes too small to be conclusive, it is impossible not to admire the judgment and moderation displayed in suggesting conclusions. This investi- gator is profoundly impressed by the genius of Freud, but is cautious with regard to psychoanalytic methods, as he holds to the ideals of scientific realism, accepting subjective phenomena as experienced by the person reporting their occurrence, so that while his conclusions may be admitted by the Freudian who might himself wish to go further, they remain valid for those who criticise psychoanalytic methods, and who will not fail to be impressed by many of the facts brought out, all the more interest- ing since some of them concern almost. the youngest married generation of to-day. Wh

_ Dr. Katharine Davis’ Factors in the Sex Life of Twenty-Two Hundred Women is a non-medical inquiry from the sociological standpoint. Like Dr. Hamilton’s work, it was carried out on presumably normal persons, who were not, however, investigated _ in personal contact but by means of a questionnaire. This, there was ground to believe, was generally answered in.a pains- taking and conscientious manner. The subjects included about a thousand educated married women and about a thousand unmarried college women. The replies were statistically sum-


marised without any desire to prove a thesis, but with a general intention to set out impartially the facts of the sexual situation in women to-day, and to illuminate, if possible, the influence on that situation of the varying kinds of sexual enlightenment or its absence. A number of interesting facts emerged.

Neither Dr. Hamilton’s study nor Dr. Davis’ involved any physical investigation. But sex is first of all a physical fact, and the relationship of sex is primarily and fundamentally a physical relationship. The report of a gynecologist, even though he is necessarily limited to women who come to him ‘in the first place as patients, becomes, therefore, essential if we are to have an all-round picture of the sexual situation to-day. It is here that Dr. Dickinson comes before us, aided in the presentation of his work by Miss Lura Beam. He brings us up to the same situation as Dr. Hamilton and Dr. Davis, and his conclusions are in the main concordant with theirs, but he approaches from the opposite side. He is in the first place concerned with that phys- ical situation which they were usually compelled to ignore or ‘to take on trust, and his investigation of the accompanying psychic situation is therefore secondary, and, as it were, accidental in relation to the primary investigation, although it may lead up to facts that are essential for the understanding of the woman’s whole situation. Thus it comes about that, notwithstanding a psychic investigation much less thorough and elaborated than that carried out by the other two inquirers, Dr. Dickinson’s presentation of the situation is more comprehensive. It differs importantly in that respect from the studies of most previous gynecologists, who have been content to view more narrowly the problem before them as confined to the state of the sexual organs, and have less broadly envisaged the woman’s whole sexual rela- tionship in life as a member of a civilised community. This alone would serve to impart value to the work here presented.

There is a further important respect in which Dr. Dickinson’s investigation differs from that of inquirers who, however scientific and detailed their exploration, are compelled to limit it to a single momént in the lives of their subjects. No one always feels the game; everyone tends with the course of years to a change of

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attitude, and not only towards the outer world but also towards the inner world. Dr. Dickinson, as a physician, has frequently had the opportunity of questioning the same patient on the same point at intervals of many years. The answers thus received are full of interest, and not least so when, as sometimes happens, they reveal extraordinary discrepancies. Not only do our experiences change with the years but our opinions and beliefs concerning those experiences change; and we cannot attain to a true vision of the sexual life, or of life generally, unless that fact is present to our minds. We may here trace the evidence for it.

Beyond its value as a large collection of precise data on both the physical and psychic sides by a distinguished gynecologist of long experience, it is the attitude toward life, here revealed, on which I should especially like to insist. When I was‘a student, as I have often recalled, not only was the gynecological instruc- tion I received strictly confined to the physical aspect of the subject but the further outlook of my teacher was obviously narrow; I recall that he only once went beyond the physical sphere of gynecology and then it was to warn us of the evil effects of contraception, not yet called by that name. Nothing was said of any discrimination here to be exercised, not a word as to any advice we should be able to give to those embarked, or about to embark, on the difficult and dangerous sea of matrimony. Indeed, in the gynecological outlook of these days—and, I am assured by students, still frequently in that of to-day—it ‘was assumed, without question, that the whole matter was very simple, and that there was here a “normal” path too well known to need specifying, though it was still necessary to utter a brief and solemn warning against any deviation to the right or to the left of it. I had to discover slowly and laboriously for myself that this rigid rule of simple normality had no general existence, and that, even so far as it existed, it was often undesirable; that in reality there is a wide natural range of variations all legitimately to be admitted within the limits of normality. So that, so far from the physician’s proper function in this matter being limited to the making of an assumption and the uttering of a warning, it was his duty to be prepared to consider a great number of


possibilities, to give advice which could not fail to touch delicate problems, psychological and social, extending far beyond the sphere of gynecology and medic ine generally. To-day that is beginning to be recognised, though even yet I confess that I experience a shock not merely of pleasure but of surprise when I come on a presentation of these questions so scientific and so sane in its recognition of the real facts, so wise and tolerant in its attitude towards the variations which come within the range of normality, as I find in the searching and comprehensive investigation here presented to the physician.

Perhaps the first instinctive reaction of many readers to this work will be one of sadness and pessimism. The probing of the marriage situation here carried out reveals so much pain and disturbance and maladjustment. In an unforgetable story, “Tes Amants de Toléde,” which Villiers de I’Isle Adam included in his vglume of Histoires I nsolites, we are told how Torquemada, the Grand Inquisitor, married a young and loving couple and had them enclosed in the Chamber of Happiness to spend the first forty-eight hours of the honeymoon together. He told them beforehand that they would bless him for giving them to them- selves, that is to say to God, and so enabling them to live ever afterward the ordinary human life. Thereupon, at the Inquisitor’s orders, the surprised and stupified young couple were swiftly unclothed, bound face to face, pressed together by bands of per- fumed leather, and so left alone, heart to heart, on the nuptial couch, to their intense joy. “Ah! If this could only last through eternity!” they sighed. But the embrace only lasted forty-eight hours. The young couple, livid, haggard and trembling, were given a very necessary bath, and the Grand Inquisitor appeared at the door of the Chamber of Happiness: “My children,” he said, “‘you have now passed the hard test of happiness. I give you to life and to love.” We are told, I seem to remember, that they never sought another embrace for fear it would last as long.

I have never been so vividly reminded of that parable of the Lovers of Toledo as when reading some of Dr. Dickinson’s true histories. We see, again and again, the conjugal partners shut


up in the Chamber of Happiness to enjoy what is conventionally supposed to be the most intimate of all relationships. And often they are found to be merely two strangers, bound together in a forced familiarity which is apt to be extremely awkward and painful for one or both parties, especially when they are too shy and too embarrassed to discuss the situation in which they find themselves, even though sometimes a few words would make the whole position easier. ‘‘If I had only known!”’ is the exclamation we are constantly meeting. “If I had only known!”

As that exclamation alone reveals, our final impression will not be pessimistic. It may be true, as Keyserling has argued, that there must always be an element of tension—though we need not, with Keyserling, call that tension ‘‘tragic’—in so intimate a relationship as that of marriage. Yet the largest part of the troubles of marriage and of the perils of sex is due merely to ignorance and superstition. And as it is to go large an extent women who are the victims of this ignorance and these false traditions, a precious instrument for good is placed in the hands of the gynecologist who understands the full scope of his functions. It is indeed a constant source of wonder to find how easily a few understanding words can lift a weight of suffering from an unfortunate patient who for years has been befooled by some false notion of “sin” or “abnormality.” Life must always be an art, but in no sphere is this more true than in that of love and sex; nowhere else do rigid, unnatr-al, and immoral (that is to say anti-social) notions prove so disastrous as in this; nowhere else is the sensitive flexibility of art more wholesome and more life-giving.

It is scarcely necessary nowadays to emphasize this general proposition. Even in the sphere of sex it is becoming recognised. In many of the instructive cases presented in this volume, ex- tending back to a past generation, we can trace unhappy ways of thought and feeling which we recognise as not belonging to our own time. That fact is not only an assurance for the future but the guarantee that the wise and skilful counsels based on a long experience, which are embodied in the investigation before us, deserve our full confidence. The old notion that the physician

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must limit himself strictly to the cure of diseased conditions, and refrain from approaching those wider matters which, as he more and more clearly realises, are intimately related to diseased conditions, is now receding into the past. As Goldberg has recently said (in the Zeitschrift fur Sexualwissenschaft): “If the physician limits himself to the treatment of disease he is leaving undone a large and splendid part of his work for the welfare of the community. It is far more praiseworthy to prevent disease and to act as medical adviser in the education of the whole people.” This first considerable medical analysis of marriage in its widely human relationship, here presented, concerns every

"physician whois called upon to give advice in matters of sex,

in or out of marriage. , Havetock ELLs. Herne Hill, London,

20 A pri 1931


cr IS FORTUNATE that detailed study of marriage began with normal people, and not, like the early case histories of sex behavior, with the abnormal, the Krafft-Ebing psychopaths. The marriage study thus sounded a note of felicity and success where the other roused echoes of repugnance. Thus the analysis by Katharine Davis of the anonymous answers from a. thousand wives of an educated class reported happiness in eighty-seven per cent. Let us repeat it. Unequivocal happiness in eighty- seven per cent. The Hamilton group, though it was over- weighted with the maladjusted, yet showed three-fourths who, knowing what they knew, would wish to marry if unmarried; and more than two-thirds who, if they could press a button and find they had never been married to the spouse, would not press the button. This new Dickinson-Beam series presents no average picture. It is overloaded on the side of trouble by the number _ who came for advice for marital predicaments; nevertheless it should leave the reader with the feeling that a large part of the difficulties are preventable, and call aloud for such action as will help forestall the blundering and misunderstanding that riddle these histories. Indeed, from the standpoint of the physician, if it fails to produce some results in action, the study is waste paper.

As part of its general program the Committee on Maternal Health considered that it was time to make an experimental beginning on an intimate study of. marriage, even though the material available for analysis comprised somewhat haphazard and rather imperfect collections. Such experiment was felt to be warranted whenever there was at hand any long series of medical histories containing a goodly number of reports on conjugal adjustments, because such a collection is believed to be rare. Therefore the Committee, after studying the four groups of long-period records offered, selected the most careful and most detailed, the one on which this book is based.



The present volume is built on the very full private histories taken down in person by a specialist in obstetrics and diseases of women who kept the point of view of the family doctor. These records cover nearly half a century, with entries running from childhood to old age, the average couple having been watched for seven years. It draws on a city practice wherein the typical individual is a well educated American married to a professional man and having two children. The histories had been very completely indexed and were freely illustrated with drawings, and wherever questions of the sex life were concerned, the anonymity had been carefully preserved through separate recording. In personal quality and vividness this material differs somewhat from returns drawn from a questionnaire.

The general health and circumstances and fertility of wife and husband are studied, and symptoms and diagnoses, pelvie dis- orders and labors are classified. Attention not found elsewhere is given to anatomical variations in internal and externai genital organs and concerning the interrelation between local findings and any particular sex practice. Among the figures on averages and extremes of sex behavior the data on intercourse show some novel material, such as duration of intromission and orgasm. Control of conception, and abstinence, and their aftermaths appear, as well as the proportion of responsibility undertaken by one or the other partner.

The various groups are classified according to their adjustment to marriage. Each group is worked over with a detail that covers conditions of living, health and fertility, past sex history and present mental and physical qualifications for success or failure, with rather numerous quotations of the expressions used to de- scribe attitudes and actions, and with sample histories to close each chapter.

The first group to be studied are the beginners, the brides, with their frequent erotic confusions, less in these days than of old. Next the frigid woman and passionate woman are analyzed very fully, because the hundred of the one kind and the thirty of the other are held to furnish the best explanations or clues to the situations at any point along the scale between—or, as the author

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would prefer to say, at any point along the circle of feelmg,— ‘inconsistent, life-long, fluctuating” feeling. Capacity for sex response and its dependence on earlier life, on premarital in- struction, ‘on the amount of common knowledge possessed by husband and wife and on his skill and technique, are some of the pressing problems investigated.

The chapters grouped under the he ading, “The Affirmative” take up “Adjustment in Marriage,” ‘‘Fertility” and “Widows.” Then two hundred wives in a control group are considered. “The Negative’’ has to do with “Fear,” “Substitution and Com- pensation,” ‘““The Conflict of Education,” and “Separation and Divorce.” Part V is the ‘Interpretation,’ recurring again to passion and frigidity, the alternations between the two and their significance, and the relation between special sensation and the woman-as-a-whole. A summary winds up the book, with in- terpretative conclusions.

The question of how much detail is desirable has been an- swered by following the example of celebrated medical scientific authors.

A relevant principle seems to be that studies in new fields— or even studies in old fields carried on by a variant in method— call for a goodly degree of elaboration. Whenever an inquiry enters into territory never systematically surveyed, or takes up a collection of records novel in kind or number, the data on which deductions are based or plans of action formulated should be rather fully presented. Osler insisted on submission of all the facts. Cullen published his notebooks on cancer and on fibroids, Schottlander printed a thousand histories of uterine cancer, and Cushing made elaborate use of case histories in describing pitul- tary disturbance. ‘These are notable examples of a method which enables others to evaluate the material and check up on the con- clusions. Such treatment is particularly desirable in any matter involving age-long tradition or religious dogma, general reticence or emotional attitude, personal bias or an individual experience that must necessarily be limited. ;

The bearing of these considerations on the presentation of the results of analysis of hundreds of sex histories is evident.” They

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influence three difficult decisions. One has to do with fullness of

circumstance regarding sex behavior. The second is concerned with relative completeness of individual “‘type’’ histories. ‘The third involves discovery of a formula for adequately presenting such data with a minimum of danger of revealing identity on the one hand; or of distortion of the picture, on the other, through removing so much context and background that the sex factors are given undue prominence.

A middle ground has been sought for this presentation of a complex subject. At one extreme is restriction to colorless and complicated tables of statistics, or to schedules of elaborate lists of answers. From such books the teacher of morals or health has usually to evolve for himself a scheme of diagnosis or in-

- struction. Authors who avoid even tentative conclusions are

nearly as unsatisfactory as the writers of the elaborate stock text-books on sexual morality. Our middle ground is an attempt at investigation, and conclusions after investigation, couched in language as reserved and technical as is consistent with ade- quate submission of evidence and clarity.

Furthermore, the search for and understanding of the natural history of sex union ;—of the physiology of bodily expression of enduring love;—of the norm of the growth and the maintenance and the decline of passion, call for case records containing rather full entries of recalled feelings as well as of findings at examina- tion. These entries must be made at reasonable intervals; say not longer than five years apart. They should cover the life- times of very many individuals, husband and wife together. The critical stages, such as sex education, first arousing, en- yagement, first year of marriage, the danger zones of financial burden and child guidance,—and the opposite, wealth and irresponsibility,—need to be subjects of special report. So also. should such failures as divorce and adultery. The story seems to put a quietus on the claim that here ‘Nature is sufficient guide.”” Such was standard teaching when the gathering of these records began and the results may be noted. The inhibitions of the newer generation and its shocks are notably fewer. This, however, excuses no physician from failing to offer or provide

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premarital instruction to those young people to whom he stands in the relation of advisor.

There still remains to be undertaken much study of first-hand material about marriage, in couples observed for lifetimes. It is time physicians with well balanced qualifications made in- quiry into human pelvic anatomy and sex physiology; into health and sickness and mental and emotional adjustment in their bearing on marriage customs and intimate behavior—conducting such inquiry by modern methods of full clinical records, and in a way which permits such medical analysis to be related to social, religious and educational studies.

Phe stress of such studies must fall on the search for the factors

that make for successful monogamy. This the books in our

“series attempt to do by their inquiry into attitudes of mind,

adaptations, varieties of methods of adjustment, and, above all, reports on end results wherever known. ‘Two goals are always in mind: one of general sex education; the other a specific program for conjugal hygiene.

Upon a foundation of physical fact, bound up with wholesome emotional and spiritual experience, rest those positive and con- structive forces which alone can minimize divorce, adultery and prostitution. A hygiene of marriage, as one section of public health work and preventive medicine, can do its part in training people in sane choice of mates, can lend aid in adjustment to marriage and, above all can further stability of union.

The present book is one of a sequence. It forms part of the plan of the National Committee on Maternal Health, Inc. to study those medical aspects of human fertility which present urgent and relatively neglected problems. In the past eight years the Committee has initiated or fostered a number of laboratory researches and many clinical studies, and carried on a steady investigation and clearing house service in its chosen subjects by personal inspections here and abroad, by corre- spondence and study of the literature, and other records. Some eighty current reports have been issued, and a dozen volumes


are either published, in press, or well advanced toward pub- lication, dealing with the following topics:

I. The actual sex life of sociali, 1 srmal persons, married and single, as revealed in medical case histories, studied from the point of view of preventive medicine. (Three volumes).

II. Human sex anatomy and physiology. (One volume)

III. The application of the foregoing to premarital medical instruction and conjugal adjustment. (Three hand- books)

IV. The medical control of fertility; including contraception; sterilization, therapeutic and eugenic; abortion; and the care of involuntary sterility; with consideration in each of history; indications; technique; clinic ad- ministration; together with medico-legal and medical- social aspects. (Five volumes, including four hand- books and a source book.) .

The committee wishes here to acknowledge with deepest appreciation the generosity of its supporters, the small group of individuals who, led by Mrs. Minturn Pinchot, have helped it from the beginning in 1923, and the Bureau of Social Hygiene, Inc. whose subsidies in 1925, 1929, 1930 and 1931 have made its steady progress possible.

This book is a treatise on diagnosis, a medical study of symp- toms of disorder, not therapy. Before education to avert mal- adjustment can be discussed with profit, the evidence from the study of the single woman must be submitted. Thereafter, the practical applications and programs drawn from these studies will need a separate volume on prevention and treatment. (These books are well advanced.)

To this book R. L. Dickinson contributed the material in the form of his carefully recorded observations, and he wrote Chapter IV. L. E. Beam contributed the analysis of the material; its structural organization, the writing of all but the single chapter; and an interpretation influenced by professional study and ex- perience in the field of education. Practically the authors


accept in each other frequent divergence in opinion. Theoreti- cally they accept equal responsibility.

Editorial responsibility, including the preparation of tables and charts and seeing the manuscript into the publishers’ hands and through the press, belongs to Dr. Bryant, Executive Secre- tary of the Committee, who was aided by Mrs. Cecile H. Matschat.

The manuscript was submitted to the Directors, who voted their approval and permission to issue the volume as a committee publication. A number of other persons, medical and lay, saw the manuscript, so that in all thirty individuals read it. The text in its final form was approved by a sub-committee on publication: *

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GrorGcr W. KosMAk. RosBERT T. FRANK. Ransom 8S. HooKER.


Foreworp. By Have.ock ELLIs......- ey hae eet ee rr er no vil INTRODUCTION. ...2s-ceceececesessenneesensneneenees ate ee eee —eeeetee eee XVil


TPs BOUROES ci. -cxcus ces =vapents sousperrsasger eras snnpees tents le* 3 a ee Se ere eR rs ee i as pai es a 21 TIT. HBALTH....---ceseeeneceeees ee ee rena ri Py ttre cee 38 IV. ANATOMICAL EVIDENCE OF Sex EXPERIENCE....--+---s00eeeeeresreee 49 V. Inppx TO MARRIAGB.....--++-- i text Chee NT Fe tie ee 56


VI. BRIDES... .. <4 -000-¢225 Se ae page aan Tier aaa TER Ee Oe VII. FRIGIDITY. .......-22e0eeeeeee ree atelier es re eee ees 100 VIII. PasSION....----«0+5: Se | cage Vee enn coe ema 5 oN Sa . 143 TX. DysPAREUNIA....--0---eeeceereseeeree pe Bea aera Pe Tee ee 167 . PART THREE. THE AFFIRMATIVE XK. ADJUSTMENT.......0002eececee rennet ee Sa ee ee 203 XI. FerriuiTy........-: Ss ere a ey ST pee 246 WEES Wiow6icc i desta ne conten Seen es epee ss re ee eS 270 XIII. Contron GROUP....----+-+ss800" Be tare ee RT aE ce 288 PART FOUR. THE NEGATIVE Bea tice he i en tee ae WEY... FEAR, «0000s sec ome Speer Hat SPA TST a tse a dik TEE ine ooo XVI. SuBsTITUTION AND COMPENSATION....-- She taal e RE TY 346 Be oe Consul oe GG RE ee ae eee XVIII. SEPARATION AND DIVORCE....-:e0-eercerrresseer ne Eee PART FIVE. INTERPRETATION XIX. Passton AND FRIGIDITY....---+-0+s-srreeres ope alee 2 417 Ri ME, SUMMARY: ccec vce es oe Since eareee ss Se ey eg er 433 APPENDIX......:c-ecereceeecseerees indy tudis Wake vee Puen hn o's pee. nies , 449 A Topicat ANALYSIS OF CHAPTERS..----+->> eee ieee eanwosnee ds ee ce Wee 5 oscean cp ames et Rc eeee eer on isan enuaeeneees Ae eee 477


J. Length of Observation 1,008 PatientB.......................-5.. 24 IA. Summary by Patient and Patient-Years in Five Year Groups.... 24 II. Ages of Patients When First Seen, (940 cases)................... 26 III. General Occupational Grade of Patients Compared with Census of City and United States (632 Couples)........................ . 28 IV. Occupational Class Distribution of Patients as Compared with General Population of United States.(433 husbands and 229 Wives Ah SOG eae tcc tt OR ic i, ey Ai elioc eae eee 31 V. Occupational Distribution of 433 Husbands...................... 32 VI. Occupational Distribution of 228 Wives.......... Pear er ale amas 34 VII. Problem Presented at First Visit by 1,050 Patients. ............. 40 VIII. Frequency of Coitus Reported in 526 Cases..........".......... 58 IX. Length of Intromission Before Ejaculation...................... 59 X. Wife’s Experience with Orgasm in Coitus as Reported in 442Cases. 62 XI. Frigidity and Fertility.............., Shea edn CON ee eee 116 XII. Fertility Record of Thirty Women Grouped as Passionate’....., 146 XIII. Fertility Records of 158 Patients with Dyspareunia.......... eee | XIV. Age of Wives Adjusted Without Complaint. First Visit (315 cases) 205 XV. Age of Marriage of 253 Wives Adjusted Without Complaint...... 206 XVI. General Health of Adjusted Wives and Occasion of First Visit (307 IGBOS ONL OE BONN. Fb ese ee idee. eee a eek. 2 eee EPS. 208 XVII. Fertility in Wives Adjusted Without Complaint, (Pregnancies, Abortions, Deliveries at Term in 315 out of fi} iets ee tee a. Oe det 210 XVIII. Fertility and General Health of Adjusted Wives (334 out of 363).... 211 XIX. Pregnancies and Results Reported by 184 Fertile Couples Control- ing Conception.......... enikteas cota wingteery neh a Sere ee 250 XXA. Deliberate and Accidental Pregnancies and Termination Reported by Couples Using Specified Methods of Contraception......... 251 XXB. Summary of Fertility Record Comparing Methods of Control..... 252 XXI. Main Causative Factors in Sterility Distributed in Terms of Sex Responsibility... Oa Pe eer, Se ee ek ee eet ee 255 XXII. Wives Reporting Pregnancies, Abortions and Live Births........ 258 XXIII. Results in Abortions and Live Births According to Number of PIOMDANING Ses Son edeengpin en Re Ee tees OO XXIV. Incidence of Abortion According to Order of Pregnancy Among Women Reporting Two or More Pregnancies and One or More AE ALINE 5.05. os sea 1s Se Ee 263 XXV. Relative Fertility, Groups Below and Over Forty: 0c 5s 264 XXVI. Fertility and General Health and Nervous Balance Measured by Pregnancies, Abortions and Delivery at Term............2.... 265 XXVII. Fertility Record According to Adjustment in Marriage.......... 267 XXVIII. Period of Observation for Forty Widows... .<2 32. ee 212 XXIV


XXIX. Incidence and Cause of Fears Recorded in 219 Cases According to

Adjustment in Marriage. .....--.-++++-sserrrrcreer steer 337 XXX. Shocks in 150 Wives... ..------er eee cssrese ret et tenets es ... 340 XXXI. Source of Sexual Shock Reported by 150 Wives. .....-.-+-+--++++ 340 XXXII. Autoerotism: Facts and Hypotheses and Methods. ......-------- 349

XXXIII. Factors of Sexual Maladjustment Among Thirty-Nine Separated and Divorced Couples. ...-..+++-+-+++: pee eek caw ecen ge 401

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LIST OF FIGURES 1. Observation Time for 1,098 Patients Studied for Adjustment in Marriage. 25 29

2. Occupational Grade of Patients. .....---++-----ssssssrrrn BA pepe 3. Occupational Distribution of Husbands and Wives......------++s+s59": 30 4. Occasion of First Visit by Patients Studied for Adjustment in Marriage... 39 5. Age at First Menstruation Reported by 386 Patients...--------- es 43

6. Basic Health and Nervous Balance of 1,098 Gynecological and Obstetrical Patients Studied for Adjustment in Marriage....-------+-- 5 +s7700"7"* 45 7. Frequency of Coitus Reported by 526 Couples. ....----+-+--serrrtrtets 57 8. Controlled Fertility. .....--+++-----.srrrereesnen ee 253 9. Responsibility for Involuntary Sterility. 0.0.2 esse seese seen neesrteee 256 10. Total Fertility Records of Patients.....-.---+-----s.srrrsrrten 257 11. Pregnancies and Outcome. ..-------- Tiptree SL hegie tases aerate h ene 260 12. Relative Fertility According to General Health and Nervous Balance... - 266 13. Effective Fertility and Marital Adjustment.....-..-+--sserrserer terre 267 14, Marital Adjustment and Fertility....-------+-++*-* x eee oh ge 268

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CHAPTER I THE SOURCES Durine forty-seven years’ practice a physicvan gathered evidence about the interrelation of sex experience and pelvic disease, combining detailed observation of genital anatomy and listening and questioning upon the intimate life. Copious data of medical interest were filed,

indexed and used in gynecology and anatomical research. Thetr

collection was influenced by a highly personal setting. Therefore, without formal psychological framework, much subjective evdence given in times of emotional crisis and colored by a sympathetic appreciation accumulated. Data from married women were gather

during a period which witnessed important changes in social tradi- tion and behavior. They are classified into brides, widows, sepa- rated or divorced women, and those wives who had presumably arrived at an equilibrium in marriage. Half of the last group makes no complaint about sexual adjustment; the others cite difficulty, usually their own coldness. edical history and gynecological treatment are abbreviated in favor of selective abstracts bearing

directly on marital adjustment. The reliability of these data is of

three kinds: The subjective narratives, told spontaneously at the peak of experience, are illusive. They are profoundly true though they may be superficially false. The objective facts are of the ordi- nary statistical worth. The interpretation 1s sharply separated from these classifications and 18 subordinated to the presentation of facts.

tee which has to do with the inner life explains as a matter of course, the sources and setting upon which interpretation depends. .

Figures are not necessarily true. Neither are classifications, since the mere making of one means that the data must go into» it. The more valid source material is that coming directly fron the patient. But the patient is really the secondary source. Fully to comprehend the human material makes it necessary to



take into account the primary source, the doctor, who is the questioner and recorder. The personal element thus involved corresponds to the statistical process of weighting the data. It acts toward belief as an explanation and a corrective. It puts basic means of evaluation into our hands.

The physician who provides the records for this narrative graduated in 1882, began his work as a general practitioner of medicine, and continued in this field for ten years. Although he started to develop a specialized preparation in obstetrics and gynecology after the first two years, he has always tried to keep . the point of view of the family doctor. From 1884 to 1910, he worked chiefly as obstetrician. During one yeaz of this period he dropped gynecology for an operative service in general and abdominal surgery; and from 1897 to 1924 had a varied experience » in pelvic surgery of women. Since 1924 he has worked only at selected problems, having retired from active practice to the guid- ance of research in medical aspects of fertility.

In a total working period of forty-eight years, of which nearly forty were devoted to work in gynecology and obstetrics, there were forty-two years of service in several large hospitals; seven- teen years of teaching obstetrics and gynecology; much work in hospital organization, and the societies of his specialty; observa- tion of foreign medical procedures; and the writing of papers and medical texts. The major professional interests appear as anat- - omy, pelvic diagnoses, office practice, surgical craftsmanship and hospital and office case records.

The knowledge and technique of all these years were centered upon the patient as an individual. This chapter purposes to show how the personal data come into significance.


One value in any such record lies in the analytical exactness with which material about the patient was observed and recorded.

For some years the patient was required to bring to the first appointment an 83 x 11, four page, closely printed question- naire, filled out, which accounted for family and general history as well as particular illness and special symptoms. (Appendix A.)



During the most active practice the patient was not received until this information was submitted in writing.

As they discussed the symptoms, the doctor underlined in red, important points in the general history which became the basis of a condensed medical history. He noted backgreund, history of the symptoms, diagnosis and treatment, recording fluctuations, visit by visit, as long as the women remained in his care. Nine- tenths of all the records are in his handwriting. Every step of pre-natal care, the stages of confinement and after care, the details of every operation, both technique and result, were set down. The patient often received her diagnosis and later an account of her Operation in writing. Drawings of the anatomy and processes concerned were made from measurements with a view to accuracy and comparability. Five drawings,—the uterus, the cervix, the vulva and two illustrative of the pelvic difficultys—are the minimum; the maximum is sixty-two and the average is estimated as twenty. These are scattered as comment through the whole story. Additions from year to year over 4 long period, reports of laboratory examinations and consultations frequently bring the total history to 3,000 words.

In the course of questions about habits of eating, exercise, hours of sleep, work and recreation, personal matters mingled naturally with purely medical entries. The cause of insomnia and the weight of family responsibility not infrequently had their roots in. the sexual life. The patient could not get married because she had to support her mother and she could not sleep because she was worrying about the break with her fiancé. Her body’s reaction to these burdens seemed to be the painful menstruation for which she wanted relief.

Repetition of this experience made the doctor think of trans- posing the terms, and if the next patient had an unexplained ache he might ask if she had a love affair. It could also happen that a woman alienated by her husband’s misbehavior would burst out angrily with a complete story of her sexual wrongs. A quite soon familiar sequence was the patient, very grateful after confinement, or cure of sterility, finding courage to inquire about other aspects of marriage. The frank speech with which



the tenement house in a large city meets the young doctor was contributing all along to an understanding of the interrelationship of sex and gynecology. Later, whenever it promised to be rel- evant the doctor began definitely to ask for the patient’s sexual experience. Finally, a brief question as to sex adjustment be- came a routine part of the married woman’s history.

Traced carefully case by case, the degree of frankness of the record has some relation, often a direct proportion, to the doctor’s technical skill exercised in a situation which the patient regards as perilous. For example, one of the most complete and notable histories of the sexual life of a couple was written by the husb and while the wife was still in the hospital; he was grateful for a difficult diagnosis proven by the follow-up. .

The first sex history as such was written in 1890. The sex history was a third document, a sheet or set of sheets, written separately from the medical notes, filed elsewhere and hidden under a number, without a name. It was in the doctor’s hand- writing, often in shorthand and by his own special code, and at times in stenography reversed like mirror writing. Only brief notations and matter involving dates and figures were written in the patient’s presence; those of acknowledged sexual malad- justment and of reasons for divorce were exceptions. Details were jotted down between patients or after office hours or when traveling about between cases, always on the same day, and always as much as possible in the patient’s