Masturbatory Insanity

Every generation creates new mythology about the dangers of masturbation. Very few have stood the test of time.

When I was growing up, no one was concerned that masturbation caused hairy palms, blindness, or epilepsy. But there was a common fear in the religious community of my youth that masturbation was addictive. Masturbation was frequently discussed and demonized; a vile sin that would take over lives and prevent healthy sexuality within marriage. “Of course masturbation is addictive!” we thought as we hung our heads in shame—not realizing that almost every other adolescent boy (and most of the girls) were doing exactly the same thing. My parents held the same beliefs, and schools in my state did not mention that masturbation is a natural process. President Clinton even forced his surgeon general to resign when she suggested that kids ought to know that masturbation is normal [1]. Masturbation addiction continues to carry some misguided cultural cachet, though this messaging doesn’t seem to be as relentless as it was in the past [2].

In my parent’s day, many people worried that masturbation would make boys gay. (Fellas, is it gay to touch a penis?) I’m endlessly fascinated by this idea. Were the men who invented and perpetuated this belief part of the rare few that had no personal experience with masturbation? Were they closeted gay and bisexual men who extrapolated their own sexual thoughts onto others? And why weren’t they worried that women were becoming gay through masturbation? This belief seems absurd to most modern Americans, but it still gets occasionally touted in other parts of the world.

My favorite myth is the belief that masturbation is prohibited in the scriptural canon of the Abrahamic religions. It is not. The Hebrew Bible, New Testament, and the Quran are completely silent on the matter. This near ubiquitous behavior was apparently never a great concern to the ancients. Masturbation is a relatively late addition to each of these traditions, and modern teachings within sects of all three major branches vary from full acceptance to complete prohibition.

Now frankly, I find the medicalization of masturbation much more interesting than the moral baggage it’s picked up throughout human history. And in my estimation, no medical connection is more interesting than the centuries-long link between masturbation and psychosis. 

Psychosis—the modern term we would use to describe most cases of “insanity”—is a phenomenon where people experience a severe disconnection from reality that is manifest through hallucinations, delusions, disorganized behavior, and disconnected thoughts [3]. Psychosis can occur for many different reasons, but the most common form of chronic psychosis is a disorder we now call schizophrenia [4].

Historical psychosis was often described in spiritual terms. Many ancient descriptions of demon possession appear to be psychosis, although a number of other disorders could also present with possession-like symptoms. Even today, it is not uncommon for people with psychosis to report a belief that they are possessed by demons. Attempted exorcism remains surprisingly common, though I haven’t seen a reliably documented case where this was successful. The medical connection between demonic possession and psychosis was discarded centuries ago, but the connection between sin and psychosis lived on much longer than many people would have expected.

The English psychiatrist Edward Henry Hare—who I now gratefully summarize from—has argued that masturbation was rarely more than a spiritual consideration before the early 1700s when a book known as Onania began to be widely published in Europe [5]. Onania was primarily concerned with the sin of masturbation, but it is also the first document connecting masturbation to serious medical illness. This document had profound effects on the general populace, (and likely drove impressive sales of the cure it promoted) but was generally ignored by most of the medical establishment of its time. It was only after the 1760 publication of Samuel Tissot’s “L’Onanisme” that the medical consequences of masturbation—including insanity—came into favor among physicians of the day.

Like most moral panics, “L’Onanisme” blamed masturbation for numerous medical conditions. One by one, scientific consensus began to rule out masturbation as the cause of almost all physical illnesses. Psychopathology was not so fortunate. The covert nature of masturbation and the complexity of mental health gave the masturbatory hypothesis a lasting appeal.

In exploring this, I am not attempting to put our modern understanding of chronic psychotic disorders on a pedestal. We currently think of schizophrenia as a brain disorder caused by interactions between biological, psychological, social, and cultural influences. But to this day, we still have no concrete explanation for why almost anyone develops psychosis. Few cases are caused by a single gene or a chromosomal abnormality. Identical twins are much more likely to share the diagnosis than non-identical siblings, but identical genes alone are not enough to predict a shared outcome. Early life experiences are absolutely important, but which experiences matter, and how do they produce these changes? Why is the presentation of psychosis so diverse? How many different illnesses are we actually observing? This is a wicked problem; the failure of any potential hypothesis reflects the complexity of the issue more than naivete alone.

Masturbatory insanity had a provocative logic to it. For example, people experiencing acute psychosis may engage in public masturbation while grossly disorganized or manic. This is an uncommon phenomenon in adults without psychosis, suggesting that masturbation may be contributing to the psychotic experience. Likewise, masturbation usually begins or dramatically increases during puberty. Psychosis is rare in childhood, but often emerges in adolescence.

We rightly look at these correlations and see them as just that: correlation, not causation. The common cause of public masturbation may have been the psychotic experience itself. Puberty precedes both masturbation and psychosis, and could cause both outcomes. But the suspicion of correlation alone is not enough to readily change beliefs. Concrete data must be produced to support an alternative explanation.

Skepticism of the masturbatory hypothesis was published alongside “L’Onanisme,” and thoughtful minds did significantly narrow the scope of the problem. But masturbatory insanity was an influential idea until the end of the 19th century, and continued in less potent forms until the medical link between masturbation and essentially all negative health outcomes died out for good around the time of World War II. Hare offers four observations for why the masturbatory hypothesis of insanity may have fallen out of favor.

First—and as we’ve observed above—observers noticed that mental illness itself may be causing masturbation, and not the other way around. I do not want to dismiss how subtle this idea is. Dualism was the philosophy of the day. Neither physicians nor the public broadly appreciated that consciousness arose from the brain. Thoughts and emotions were derived from the spirit, and sinful insults to the soul were bound to cause psychic problems. Even today, many people are uncomfortable with the idea that their experience is the product of a corporeal existence. We, like our forebears, are products of our time and culture.

Second, masturbation was discovered to be common within healthy communities. This was not a banal observation. No one actually knew how common masturbation was until the late 19th century, when researchers reported that more than 90% of boys and 60% of girls masturbated—findings that have been repeatedly replicated across western cultures over the last 150 years. If masturbation was such a common experience, then why did so few go on to develop psychosis?

Third, it was impossible to objectively know how often a patient masturbates. Self-report is inherently challenging, and becomes even more suspect when there is religious and medical stigma regarding a behavior. A patient with psychosis who reports frequent masturbation serves as confirmation bias. But what if that same person reports that they never masturbate? You can easily dismiss their report as a shame-driven lie. Your assumptions catch you in a loop you cannot escape without humility [6]. This fallacy is sometimes known as Morton’s fork: either observation leads to exactly the same conclusion.

Finally, the masturbatory hypothesis had a major physiological flaw. Why did people who primarily engaged in masturbation develop psychosis, but not people who participated solely in partnered sex? These physicians were not generally worried about the total number of orgasms that the patient experienced; they believed that there was something uniquely different about masturbation compared to all other forms of sexual activity. But how would these experiences differentially impact the development of the brain? Could my religiously scrupulous patient with psychosis who abstains from masturbation as often as possible be truly differentiated from the man on the pew next to me who has sex with his wife every night? Removal of the moral implications of masturbation revealed no significant physiological difference between the two acts. 

Like most advances in knowledge, reason and data alone was not enough to produce immediate impacts. It took generations to change the scientific consensus. Changes to our cultural understanding will take even more time. Because although we now recognize that masturbation is by and large a harmless act, there is still a push to add false medical risks to normal human behavior [7].

Footnotes:  

[1] Joycelyn Elders is a badass. Her words ring just as true today as they did almost 30 years ago: “I feel that we have tried ignorance for a very long time and it's time we try education.”

[2] Some communities—such as r/NoFap—explicitly attempt reductions in masturbation. Others say very little outwardly on the subject, and instead talk about addiction to porn. In reality, most “porn addiction” groups worry about both porn and masturbation. Few people are suggesting that “porn addicts” use their imagination when they masturbate, as shame about masturbation remains a core belief in “sex addiction” communities. (I don’t want to dismiss concerns about compulsive sexual behavior outright, but I’ve never found sex addiction to be a useful construct. Even among those who really believe they are addicted to sex, self-reported behavioral change tends to follow acceptance and anti-shame beliefs. This is an axe I plan to keep grinding. You’d better believe I’ll be talking about it more in the future.)

[3] Psychosis is actually a lot harder to define than this. For example, many people hear an occasional, non-bothersome voice talking to them. Or in a time of bereavement, they may see or feel the presence of a deceased loved one. These experiences alone are not signs of mental illness. Psychosis requires much more, and includes significant distress or gross impairment. This trips up a lot of my medical students, but they tend to accept that the phrase “non-psychotic hallucinations” is just another one of the nonsensical things that psychiatrists like to say.

[4] From here on out, I’m going to use schizophrenia and psychosis interchangeably. It’s actually much more complicated than this, but it’s a reasonable approximation for today.

[5] Edward Henry Hare wrote “Masturbatory Insanity: The History of an Idea” in 1962. It’s a provocative article. Historical research has no doubt advanced since that time, but Hare’s writing is thoughtful and entertaining. For example, Zachar and Kendler provide an update to Hare’s treatise in a recent article. Although many of their points appear implied in my reading of the original article, I appreciate both their perspective and their accounting of more recent historical research. 

[6] Similar behaviors still occur today. Patients who test positive for amphetamines often report that they have not used anything in this class of drugs (e.g. methamphetamine, Adderall, and Vyvanse). Many well-meaning doctors will interpret this response as a lie, and the denial as proof that the person has a substance use disorder. The reality is much more complicated. This test is known to have many false positives, and cannot be considered accurate unless it is confirmed by patient report or a more specific test for the drug. Assuming lies in truthful patients is an age-old medical error. I’ll have to talk more about urine drug screens in the future, as their use and misuse is worth discussing.

[7] Where are the caveats to the statement that “masturbation is by and large a harmless act?” Well, I’m just pedantic enough to point out that there are some uncommon, but fairly obvious risks. The use of harmful physical implements and masturbation in the presence of non-consenting individuals would be top of the list. There is also understandable concern that masturbation to harmful stimuli (such as media portraying child sexual abuse) could result in the reinforcement of dangerous beliefs, emotions, and behaviors regarding children. Frequently choosing masturbation over sex with a partner may also be detrimental to a relationship—although that would also be true of any number of non-sexual activities that distract from connection.