Use of enemas for sexual stimulation has been observed and named klismaphilia. Some klismaphiliacs indulge their taste for enemas in otherwise normal sexual settings. Others combine it with fetishes, excretory and otherwise, or with masturbation. Still others practice klismaphilia in homosexual or sadomasochistic settings or in group sex. Among the myriad of extragenital modes whereby persons derive sexual gratification is the enema, either taking or giving or both. A psychiatric patient espousing this preference led me to investigate the condition, to report two case histories, and to name it klismaphilia (1). Two aspects of that report were puzzling--the dissimilarities of the two persons described and the inconclusiveness regarding pathogenesis. Library searches and perusal of the old classic works on deviant sex by Krafft-Ebing and Havelock Ellis unearthed no comparable case. A detailed history of the enema since antiquity (2) failed to mention explicitly erotic functions of the enema, although such bizarre details were included as their use during court audiences of Louis XIV and even poisoning via the enema route. A short popularization of the Lieberman study in the medicine section of Time (3) referred to Moliere's lampooning the enema health craze of his day. Searches of the psychiatric literature have unearthed several reports (4-6) of severe sexual psychopathology following traumatic experiences with enemas in childhood. In none of the ten cases reported, however, did klismaphilia characterize the adult problem. One of Bettelheim's (7) children showed her acute regression to autism following a period of traumatic enemas and forced feeding. In therapy, she gave her doll enemas. Freud (8) published the case history of a severely neurotic man for whom "the world was hidden in a veil.... This veil was torn only at one moment--when, after an enema, the contents of the bowel left the intestinal canal; and he then felt well and normal again." Freud's interpretation was that in receiving the enema the patient identified with his mother, while the man administering the enema represented his father. The enema repeated the act of copulation, and the momentarily well patient emerged from the experience as a newborn "excrement infant." A specific sexual response in the patient was not described. Kinsey's study on the female (9) mentions the enema as a masturbatory device, but the study on the male does not mention it at all. Medical Aspects of Human Sexuality (10-12) has recently dealt with three questions on the enema. Recent fiction (13) has contained references to the practice. Popular and underground publications have included questions and discussion concerning "enema freaks." How-to books and pornographic enema pictures are sold--at a high price. Commenting on my article, Dietz (14) detailed a number of variations on the klismaphilia theme that he had discovered on a search through "adult book" sources. He drew attention to sociologic interest in the public's reaction to a new form of sexuality. Several paperback books contain case reports. I am told that a recent movie, "The Devil and Miss Jones," has a bathtub enema scene. An "enema bandit" has been apprehended who gives his victims enemas. My feeling that klismaphilia is probably endemic was confirmed when several letters arrived from other klismaphiliacs who resembled, in many ways, my first patient. They had discovered my first article by following medical indices for references to "enema" in hopes of learning more about their condition as well as improved techniques for gratification. More than one suggested that they had thought themselves unique in carrying the burden of so strange a taste and were relieved to learn that there were others. One man worried that his wife might deduce his true reason for enema taking if she should happen upon material on klismaphilia. Another sent photocopied material from the underground press regarding klismaphilia. Several approved my not attempting to change my patient. Several expressed appreciation for my serious attempts to understand a situation that had plagued and puzzled them and for giving it a name, and thereby making it tangible. Several offered personal material to help in further elucidation of klismaphilia. METHOD Letters from these correspondents suggested further study. A member of a consciousness-raising group of sadomasochists proposed that I advertise for first-person accounts from klismaphiliacs in an underground newspaper thing advertisements from those with atypical practices and offered to put me in touch with the editor. My correspondent advised that the best response would be likely to result if I were billed as a "qualified female researcher" rather than as a psychiatrist because klismaphiliacs want gratification, not therapy or cure. They are wary of the helping professions. Due to a misunderstanding, however, the advertisement was carried as follows: / WANTED-for scientific study by a qualified psychiatrist first person accounts of use of enemas with or instead of sex. I am particularly interested in the first such experience and how it developed, whether enemas were administered by parents, and connection of the practice with other non-coital forms of eroticism. If you are willing, please include identifying data so I can contact you to clarify obscure points. If not willing to be identified, please send your account anyway. Dr. J. D. Denko, M.D., M.S. 21160 Avalon Drive Rocky River, Ohio 44116 This advertisement brought reports from persons quite dissimilar to both patients in my original study. They were much more accepting and open about their klismaphilia and, in some cases, their other sexual deviances. They were fully aware of other klismaphiliacs, knew some personally, and, in some cases, took enemas together with them. Their associated sexual deviances were usually quite pervasive in that they affected their entire lives. To each correspondent I wrote for amplification of areas he might have slighted originally. Several hoped I was a klismaphiliac contact and sent or offered pictures of their practice. They soon lost interest in supplying further data because, as one man put it, they were more interested in action than talking. Others who accepted the bona fide nature of my advertisement even sent photocopies of other printed material concerning erotic enemas, appearing in slick or underground publications or paperbacks about sex. Material derived from this correspondence forms the basis of this report. What fish did this net catch? Thirteen new klismaphiliacs were discovered. Case reports of these plus the two previously reported comprise the 15 cases of this article. In general, they fall into three categories: (1) those who perceive their klismaphilia as ego-alien, whether it occurs alone or in combination with other deviances (Group A); (2) those who have grown to accept klismaphilia so that it is now ego-syntonic and accompanied by normal sex (Group B); (3) those with other deviances who perceive their atypical sexual patternsas ego-syntonic (Group C). Not himself a klismaphiliac but a self-avowed sadomasochist, the editor of the underground paper contributed his experience. He had wanted to "try everything" so he took plain enemas without reaction. When he added liquid detergent, he was able to react with an orgasm. Later "when playing topman in a bondage scene, I used enemas and got no reaction myself, but they did, even if they hadn't been into enemas before." (Their previous, experience may have been rectal, however.) RESULTS Group A--Ego-Alien, Compartmentalized Type CASE I This thirty-two-year-old married man (physicist employed in industry) reports that although he would like to take an enema daily, opportunity arises only once a week. Unless he masturbates with the enema (three times out of five) he does not experience orgasm. He does not use enemas to cope with increased stress or fatigue or other bodily complaints. He denies any other "hang-ups, like mirrors or girls' buttocks" as in my first reported case. He has achieved his preference of having enemas administered by girls or women in a variety of ways. When he was a student, he would get an enema from a nurse in the university clinic. Once he talked a physician's receptionist into giving him the number of the visiting nurses' association, which sent out a pretty young nurse to administer the enema. Later he found an ad for "colonic irrigations" in the yellow pages of the phone book and he has returned to the pleasant elderly nurse who told him she has many regular patients. Several times a year, under the guise of constipation, he can get his wife to administer his enema. He plans to stop asking her, however, because she might some day see an article like mine and deduce his abnormality, which he feels she could not "understand"; and her intolerance would probably "wreck the marriage." When her doctor advised enemas during her pregnancy, he enjoyed administering them to her, despite the fact that they hurt her. He enjoys sex with his wife and feels they have a good sex relationship as well as a happy marriage, with three young daughters. For him, too, an enema is not a substitute for sex but an additional sex-related experience, although in his case enemas and sex are not temporally contiguous. Although he has never had any homosexual experience, he has wondered whether his taste for enemas relates to latent homosexuality. He denies worrying particularly and does not wish to change. His parental home was happy and stable. His mother took frequent enemas only for constipation. A woman doctor is said to have ordered a daily enema until he was a year old. Thereafter, they were given less often, and, after he was six, only for illness such as measles. Until he was nine, he hated and fiercely resisted enemas, but then, in a secluded upstairs bathroom at his grandparents', while sitting on the toilet, he opened a drawer where he saw an infant two-ounce syringe. Unable to say why, he filled it six times and injected it into his rectum. To his great (at least conscious) amazement, he enjoyed it and was fascinated to observe an erection, which he puzzled over since he had never seen it before. He began giving himself regular enemas when the house was empty. He "covered my tracks" by memorizing the exact location of thc bag and putting it back in the identical spot. Because he found it the same way he concluded that he was the only family member using the bag. He believes his younger brother and sister did not take enemas. Until he saw my article he had never told anyone of his habit and thought his klismaphilia was sui generis. With trembling hand he wrote that he could communicate with me because I was not a man but akin to a faceless computer. He commended the fact that I did not try to change the first patient, a stance taken by several other correspondents. His letter was anonymous because he feared accidental disclosure. CASE 2 This twenty-seven-year-old married law student entertains three stimulating fantasies about enemas: (1) a woman giving herself an enema; (2) a woman giving him an enema; (3) his giving a woman an enema. As he indulges these fantasies, he either masturbates or takes an enema, usually clear since he fears soap may be injurious. While taking the enema, he imagines himself as a woman and tries to empathize with her reaction to the enema as the tube is inserted. He enjoys the stimulation of the nozzle with Vaseline smeared on it. He finds attendant cramping unpleasant and minimizes it by keeping air out of the tubing. He would prefer for all enemas to be given by someone else, but only rarely can he get his wife, who does not know about his taste and does not like administering them, to give him one, nor would she let him give her one when he tried to promote the idea. He is stimulated by constipation, enema bags, enema nozzles. A picture of a filled enema bag, preferably red, produces an erection. He responded to the ad of a couple who use a champagne solution to cause pain from the bubbling. He is fascinated by their tastes for "B/D, S/M, Golden Shower, French, Greek, mild spankings, rubber garments, small bulb enemas, high colonic irrigations, diaper training, bare bottoms. I don't know what that all involves but I would like to try it at least once, but not again if it caused pain." He writes also: "Somehow I find it extremely difficult to acknowledge the fact that a woman, any woman, knows of the existence of enemas. I, therefore, find it extremely satisfying for a woman to admit to me that she is aware of enemas! For this reason, I frequently do what your army officer patient does. ÜI initiate a conversation about enemas in drugstores or wherever else possible with pretty girls." He related seeing a teenage girl buying a Fleet's disposable enema and for days fantasized her giving it to herself. He does not recall receiving an enema from his mother, although she occasionally took one herself. Despite memory probing, he cannot explain the first enema he received at the age of nine or ten. He may have read a story in Redbook or Mc Call's about a mother giving an enema to a daughter. Living at home or in the army, he could take enemas only rarely because of the lack of privacy, but when he could, he would smear the enema nozzle with Vaseline and insert it. At the time of his first sexual experience at nineteen, he tried to promote enemas with his girl friend, but she rejected the idea. This was his first indication that not everyone shared his taste, despite the fact that he concurrently is unable to acknowledge that women even know of them. "My interest in enemas and my interest in women have, unfortunately, never managed to converge." He considers his wife, who is "an intelligent and pretty scientist doing independent research," to be sexually inhibited since she wants love-making only at the time of her period but will "accommodate" him at other times. He pursues any references to enemas he can find in libraries. There was no way to communicate further with him because he explained that his future political aspirations led him to write anonymously, lest someone burglarize my office, as in the case of Daniel Ellsberg's psychiatrist. He would not like to see his political opportunities jeopardized as with "poor Thomas Eagleton." CASE 3 This thirty-two-year-old single woman's therapist wrote that she had been admitted to a medical ward with severe abdominal cramps, tests had been negative, and she was given a diagnosis of "psychoneurotic hysteria with masochistic tendencies." After two weeks of psychotherapy on a psychiatric ward, she revealed that she felt guilt and shame over the fact that since the age of fifteen, she had taken enemas three times a week, while masturbating. Thereafter, her cramps quickly subsided. Attempts to contact her therapist for further details were unfruitful. CASES 4 AND 5 These men, an army officer and a lawyer, were the subjects of the earlier report (1). They both had wives and each practiced klismaphilia privately, although one had engaged in mutual enemas with an earlier paramour. The officer had accompanying mild masochism (beating his buttocks with a hairbrush), and the lawyer had accompanying coprophilia (smearing of feces). CASE 6 This twenty-three-year-old married man (B student in high school, now employed as a mechanic in a gas station) reports taking solitary enemas, consisting of three quarts of soapy water, at the rate of four per week. While doing this, he thinks about women, sometimes wears women's underpants, fantasizes himself as a woman giving herself a douche, and masturbates thereafter. His wife is unaware of his practice, and he believes his sex life with her is normal. He comes from an intact family where sex was a taboo subject and considers his childhood normal, except for the fact that he spent much time with his mother because the children in the neighborhood were all considerably older than he was. He received his first enema at the age of five: "It made my belly feel weak, and this was the feeling I hated." Until he was nine or ten, his mother administered frequent enemas, always with a 10-ounce syringe "with black nozzle." He tried to prevent the inflow of water with crossed legs, but she "always won." One of his bitterest memories of childhood consisted of a visit by a neighbor's nephew, aged ten. This older boy pulled down the four-year-old's pants despite his screams, pushed him to the floor, pried apart his buttocks, spit into his anus, and stuck his finger up the rectum, leaving him crying on the floor and thinking the tormentor had departed. He returned, however, with an old sponge, which he tore up and pushed piece by piece up the rectum, as he sat on the boy's back. To add insult to injury, he called the boy "a little sissy girl." When the mother returned, she found him hysterical, but no punishment was ever meted out to the attacker. Nineteen years later, the patient still has nightmares about this event. He recalls that at the age of six he envied little girls their pretty clothes and underwear. At seven, he thought his mother, in a white panty girdle, so and that he wanted one like it so he could look just like her. At fifteen, he inadvertently found a douche bag and vaginal nozzle. Despite self-scrutiny he has never been able to explain to his satisfaction why he then took a one-quart enema. He found the erstwhile detestable "weak feeling in then belly" now pleasurable, and it led to masturbation. At eighteen, he began wearing women's underpants prior to the enema. While in high school, he was ridiculed for his figure: very tall and thin with hips and buttocks disproportionately large. He had never divulged his taste and maintained the fiction that he was "one of a kind," despite the fact that he had seen a publication containing advertisements for "enema freaks" and even placed an advertisement for "bondage and discipline" partners. He was disappointed when only men answered, since he is not interested in "the gay thing." He expressed considerable relief and appreciation that I now know of his klismaphilia. Group B--Ego-syntonic, Pervasive Type, Monodeviant CASE 7 This forty-one-year-old married man (degree in agriculture, happily and successfully employed in food processing quality control work, and with a tested IQ of 114 at the age of twenty-three) reports marital sex is more enjoyable when preceded by a mutual enema. This development is new to the past three years, however, because for the first 15 years of his marriage he kept his taste a secret, took his enemas alone, or got his wife to administer them for trumped-up reasons. Three years ago, he became confident that she could accept his anal eroticism with the help of a sort of scrapbook he compiled of photocopied letters (50 or 60) from klismaphiliacs to underground publications. She reacted as he had hoped, and now she gives and takes enemas with him during sex. He summarizes his perceptions of the various forms of sexual gratification: "Masturbation is a poor substitute for coitus but is used occasionally when relations are impossible. An enema alone is very helpful in physical fatigue and it arouses me sexually. If I masturbate in conjunction with the enema, I have a higher intensity sexual release than without the enema. Coitus without anal involvement is about equal in intensity of orgasm to masturbation and enema combined; the ultimate is relations with my loving wife with the enema used as a form of foreplay and continued prostatic stimulation during coitus. An interesting after effect is that I find the insertion or involvement of anything in my rectum or anus after ejaculation extremely annoying. At the time of release, it is tremendous but immediately after, the enema or anal insertion has to be removed as it detracts from the afterglow." He uses enemas also for headache or fatigue. Although he has received enemas since earliest infancy, the first enema he remembers was given to him when he was four. Crying, he was placed across the lap of his mother who assured him that it was just to wash out the bowel movement. When she inserted the tip, he experienced an erection and a tingling sensation in his anus that ran all the way up to the base of the skull, which he now calls a "mini-orgasm." Until he started school he had about two enemas per month, given by his mother or aunt, and always enjoyed them. As his mother stopped giving them, he began taking them by himself. Aware that there was something clandestine about them, he would discuss them furtively with boy and girl playmates, only on a one-to-one basis and only in a clinical setting, that is, when playing doctor. From the age of eleven or twelve, he used school and public libraries in an attempt to learn more about enemas. When he was in college, he discovered Index Medicus, but he credits his "breakthrough" in understanding in the past year to "semipornographic" columns such as "It's Our Bag." He is glad to have discovered his erotic sensitivities and feels that they add another dimension to sexuality. He is happy, too, that his wife, though less anal erotic than himself, knows and can share his pleasure in enemas to some extent He would not be displeased if his children too have this condition, though they, at the ages of nine and sixteen, after several enemas each for intestinal cramps, diarrhea, and hives, have shown no particular reaction. He believes they are in every way an average middle-class family. He sent me photocopied material about klismaphilia including case reports from popular books answering sex questions, expressed great enthusiasm for my study, wished to help, and said he would have done such a study himself except that he lacked credentials. He compares society's current attitude to enemas with the Victorian attitude toward sex and masturbation. CASES 8 AND 9 This thirty-five-year-old husband (apparently a hospital worker) and wife take enemas in the marital situation. The correspondent brags that despite weighing only 135 pounds, he can hold three-and-a-half quarts of plain water, whereas his wife, weighing 125 pounds, can hold two-and-a-half quarts. He has to send his wife for enema equipment because he finds that negotiating about its purchase produces an "embarrassing erection." Homemade equipment consists of a gallon glass jar and surgical tubing, the advantage of which is the pleasure of watching the solution level fall. He states that "retention devices" are available only in hospitals, but I don't want to become a thief to acquire one even though I could get away with it." Therefore, he has adapted acigar tube as a nozzle but this keeps slipping out, which he found "a nuisance if you're having intercourse or masturbating. He has also carved Ivory soap into an hourglass-shaped nozzle for the enema to run through, causing chemical stimulation of the anus which is quite painful and, therefore, not recommended for "the intrepid or the novice." He intends to make a collection of commercial enema products. He hopes to procure a remote shutter release in order to take and develop his own enema pictures. He calls his habit "lifelong." He finally worked up the courage to introduce the idea to his wife, who was cool at first, finally acceded to his request to give him painful enemas, and eventually began taking them with him. She gives the impression of being a rather reluctant participant-observer. The remarkable thing about this man, however, is that he makes a way of life around pursuit of the perfect enema. He had, in fact, received 100 replies to an ad in the underground paper, requesting enema experiences. Because of the unexpected volume, he duplicated a form letter of response, a copy of which he sent to me. The material included mainly recipes, nothing relevant to the development of their habit. Instead, he quoted in cookbook detail how he prepares his Ivory soap solution and how its effect compares with that of Epsom salts. He believes, furthermore, that "soap and turpentine/egg yolks works as well as any thing going and it will produce as much pain as the most dedicated masochist could desire when mixed strong enough. It mixes well with the intestinal contents, causes good cramping, and is irritating to the anus." He continued: "All sorts of solutions were suggested by recent correspondents, but I have not tried them because no one bothered to list the exact ingredient combinations, and I am a little afraid of killing myself. These included ice water, beer, soda water, coffee, vodka and water, wine, lemon juice and water, soapy water and lemon juice, milk and molasses. Asafetida has no effect. I can't find ox gall. Let me have your favorites so I can add them to my recipe collection." He analyzed his responses and found that 80% were from men, 20% from women, which he attributed to his observation that women are less inclined to experiment sexually. He found that 50% used other masochistic devices (spanking, bondage, compelled retention, and so forth), while 20% combined klismaphilia with urine or excrement fetishes, or both. He noted that 40% were just "coming out of the closet," namely, passing, relative to shame and secrecy, from Group A to Group B or C. He concluded: "There should be more acceptance of enemas as a perfectly legitimate form of erotic activity. I can remember the years of my life that were filled with fear and uncertainty about my propensity for enemas. This harmless fetish is neither a disease nor a crime, and suppressing it is a useless absurdity. More people should stop feeling guilty and join the fun. We need a national publication, and from my writer's cramp, I'm beginning to feel I've begun one." CASE 10 This divorced man of unknown age and occupation likes either taking or being given enemas, and he is stimulated by the texture of the rubber, the sight of the apparatus, and the sensation of the insurge of liquid. He also favors sleeping naked with his "pipe" and enema bag which he uses to masturbate. Of his collection, the red bag is his favorite, and he dislikes hard enamel cans or "combination types." As a child, he suffered constipation relieved by an enema, administered with a "small hand syringe." This corrected the constipation, but his "feeling-love" for the enema bag persisted. He would experiment with friends' enema equipment. Finally, he acquired his own bag and has happily given himself enemas ever since. He did not respond to questions about his marriage. He works at least part time writing articles on atypical sex for the underground press. A reprint He enclosed advanced the concept of the normality of sadism and masochism. CASE 11 This twenty-five-year-old man, apparently unemployed, longs for and fantasizes a girl who will "touch my ass and mean it." Meanwhile, he writes about enemas, rambling endlessly, and stopping to masturbate as his urge requires. He did not react to the one "short" enema from his mother. The enema about which he ruminates constantly occurred when, at eight, he was one of the youngest students in a boarding school. Suffering from a headache, he went to the nurse-housemother, who, he later learned, had a reputation among the boys for enjoying administering enemas for a variety of complaints. He managed to convey very well the feelings of a shy eight-year-old boy: "She asked if what I wanted was an enema. I was very taken aback and not used to that sort of talking. I sort of nodded and shook my head trying to say I didn't know but would rather not." He appreciated her gentleness because "I was in the bottom grade and had the least privilege. She could have put it in as if she had the right of way there. But she treated me like a very private and worthy person. That was nice." He went on for 20 jumbled pages all written in capital letters, and his phrases included "asshole all bared and ready for her to conquer," "something about her power over me excited me," "that beautiful part of the body called the ass," "like a feeling of overwhelming awe, somewhat like love," "like I was full of somebody's product," "gently ease the glorious tube well into me to make sure the way is paved and parted," "she is like a clothesline from the sky leading down into me," "like an aqueduct leading along the ridge to the tunnels that await it," "those caverns of my insides where so much sensuality waits eagerly to be touched," and "surging home to make the abdomen look pregnant." He has some insight into his psychotic condition and wrote: "I think my sexuality is influenced by my inability to cope with the world.... I cannot compete for a woman's affection, but if I fantasize about a maternal influence (not my mother but a warm loving maternal and protective woman about forty-five to fifty), then I get very enemaprone and I just feel I want her to give me enemas. Yes, there is sexual feeling involved, but it is comfortable and simple." In another section he wrote: "The ass itself is very stimulating. Extra flesh, like a storehouse for stamina, like a camel's hump, without a bone and near the genitals. So with poking inside the hole it is a personal touch, and somehow I feel close to warmth spiritually and one with mother earth and everything I hold precious." In childhood, he played with a nude girl who put her finger up his rectum. He relates a cold relationship with his mother. "Most people that I have run into usually say that they like their mother's enema and wish to have the experience repeated. My mother happens to be very beautiful physically, but she and I did not get along on hugging and warm maternal child embraces. She was too harassed by job and no husband." He has inveigled his local doctor into getting a visiting nurse to come to give him his enema, and he has patronized a "health studio" with enemas by appointment. He states that he had a voluntary vasectomy in 1971, prior to being "devirginated in 1973." He finds ordinary sex hard on his back and his penis easily becomes irritated. Hence, he is looking for his dream girl who prefers the anal region. The fact that talking about enemas causes him to stutter makes him sensitive. He relates that there are untranslated books on "enema torture" of Persian prisoners, ancient and modern, in a large metropolitan library. He states that his "technical IQ" was 121 at the age of seventeen, "with a very poor concrete understanding and very high abstract understanding." He believes he has raised his score with "mental power and vitamins." His borderline functioning is conveyed by this exposition: "I am going to make my life for the next 40 years on ESP. It will become a big industry. Currently medical psychiatric physical laws and those on obscenity and all the space age sciences are almost too barbaric for me to cope with. I am used to a much more developed civilization and find it hard to relate to earthmen's thinking. If people knew my IQ, they would try to make it public and exploit it. I know two geniuses that this happened to. I am good at certain types of reasoning that science now cannot tolerate, too unscientific, too spaced out, too sporadic, too radical." He sent many booklets about health foods and cancer. He had spent four years in a mental hospital but "for a rest, not for psychosis." Group C--Ego-syntonic, Pervasive Type, Polydeviant CASE 12 This twenty-three-year-old divorced woman (scoring at the 99th percentile on the verbal portion of a university entrance exam and urged to go on in languages, "now living on 240 acres of my own land" but formerly a nurses' aide while attending the university) gives and receives weekly enemas in a "gay relationship" with a teacher friend of her own age. Despite a lively correspondence with me showing a high level of awareness and general topicality, she has not sent her history as promised. She has written, instead, about enema underground pornography and drew my attention to the enema bathtub scene in "The Devil and Miss Jones." She informed me that European "specialty brothels" feature enema bags as part of their equipment, along with their whips, harnesses, and the like. She indicates that she knows six klismaphiliacs, all happy and successful, and she suspects that there are more women with this passion than men, her reason being that anyone taking enemas is "into feminine behavior." She wrote to me in Australia: "Odd dream of you the other night. You were over the lap of an aboriginal chieftain being given baptism per annum, calmly taking three quarts for research purposes only, your clip-boarded notebook in hand, and your husband be aiming approval at how internally clean you'd be, for research purposes only! The scene was so incredibly comic that I had to share it with you: you looked like a combination of Margaret Mead and Jane Goodall. The chief was saying to various braves that it was quite unusual for white women to take three quartsÜthe last five anthropologists had only managed two. The witchdoctor was taking notes with a Sony tape recorder." This woman believes I should have stated more succinctly in my original article that "all is not grim and doomed with the enema set." She took a militant stand in favor of an "enema liberation" movement and puckishly foresees demonstrators carrying bags and tubing. She is glad I gave the condition a name and hopes I will write a book. CASE 13 This thirty-six-year-old woman (some graduate education) living in a master-slave relationship, notes that the combination of humiliation and enema always "turns me on." She was introduced to the enema in her mid-thirties at a party given by her master. Two "bisexual girls" insisted that she be cleansed by douche and enema. After a douche, she was placed on her back with her legs brought back and the ankles chained to the wrists. Then one girl held her buttocks apart, the other played with her breasts, and the master inserted his penis into her mouth. The simultaneous surge of two quarts of soapy water into her rectum and her master's ejaculation into her mouth produced her first orgasm, which she related to humiliation. One of the girls plugged her rectum and they alternated mildly whipping her. The pain of the whipping and the retained enema produced her second orgasm. Then they permitted her to go to the bathroom to expel the enema. This is more or less her current pattern. She did not respond to questions about her youth but related that when she came to the metropolitan area, she was exposed to a "swinging sex scene." "Because of a sense of docility in my nature, I gravitated to the B & D scene and after about a year of this, it became my permanent way of life." She sent a picture of herself nude except for her slave chain, called the enema "a punishment and pleasure device," and signed herself "sincerely and submissively." CASE 14 This sixteen-year-old only child (sophomore in the upper sixth of her class and with an IQ of 118) has parents who belong to "swingers' clubs," in whose publications her mother places ads for "women to teach me the arts of love, bondage, and discipline. "Women ranging in age from twenty to forty-five are each given "a chance," although some demur over her being a minor. According to this informant, "Most of it is the usual: 69, me licking their asses clean, them feet foot-fucking me." She prefers women who "are romantic and kiss first." Her preference is receiving "two enemas (prefer ice water) at a time and then my Mom eating my cunt and our maid eating my ass." She states she will "do anything for a woman if I can drink her urine." "Most of the enema action is when they give it to me up my ass and let me shit on my Mom. Then I get to lick it up." She disclaims pain, says she would quit if it hurt. This menage dates back to when the girl was nine, at which time her aunt gave her an enema for constipation of a week's duration. She was "scared and hated the warm water." Her aunt massaged her abdomen to "loosen things up," then manipulated the child's vulva, and inserted her tongue up the child's vagina. The subject was confused at first, then "loved it,', moved her bowels all over the bed, and finally entered a secrecy pact with her aunt. Over the years, she gave enemas to the aunt and received douches. At fourteen, the girl was caught douching by the maid, who offered to teach her how to get "turned on," took an enema herself, and straddled the girl's head, ejecting water and urine, which, according to the girl, 'tasted so good that I drank most of it." They were caught by the mother, who averred that if her daughter could do this to the maid, she could accommodate her own mother similarly. The father was called in to watch, and subsequently the child was introduced to the "swingers' clubs" mentioned above. The girl related in detail how she and her gym teacher mutually seduced one another. She writes in a schoolgirl scrawl of her favorite rock musicians and how she has "to fight off boys because I am good looking." She has girl friends, but "none that I have sex with." Although bright, she denies being future oriented and has no career plans. She sent a vulgar photo which she bragged had been "taken by a professional," but had to have this returned immediately since her father needed it for her future connections. She expressed disappointment that I was "straight" (which she inferred from the fact that I did not respond to her offers to come visit me) and indicated that she had always wanted to "go to a gay woman gynecologist and let her seduce me." CASE 15 This forty-year-old man (IQ 150, with an M.A., who had been teaching hut inanities in college at twenty, got a Ph.D. at twenty-three, now in business) who customarily "passes" as a female and has assumed a woman s name calls himself a "thorough-going erotic fetishist" and indicates a preference for "sex with genetic females regardless of gender orientation, in the role of male-to-female, as epitomized by the act of cunnilingus with no need for reciprocal behavior on my partners part." Clothing is, surprisingly, not involved "though I must admit I believe it would lend spice to the situation should the session also involve my looking like a female." He also favors bondage and discipline with "frills"Üthat is, a device to insert and inflate after the enema to hold the contents until his partner decides he can be relieved. The liquids he prefers include ice-cold club soda, mineral oil, and tomato juice. He has also experienced an "enema hook-up" devised by an acquaintance, in which enema fluid is expelled from one klismaphiliac to the next. His enema history dates to those administered by his physician-mother, who also dosed him with malt dietary supplements. As a child, he discovered the pleasure of the "tickle of penetration, the warm inflation, as well as the evacuation." He learned to take advantage of being "sickly" to get enemas. Left with his aunt most summers, he started "experimenting with the hose." She had a "nice red rubber unit of douche bag style." When a slightly older playmate accomplished rectal penetrations and seminal "deposit," the subject states that he "instinctively" went home to his hose and bag to "douche" per rectum after sex! That same summer, he "budded as a cross-dresser"Ünamely, put on a show for his aunt by modeling her kimono and gushed urine all over the floor in his excitement Thereafter, he began masturbating by sliding the enema "pipe" in and out of his rectum. As a pubescent youth, he reamed from his mother's texts how to give large "high" enemas and introduced castile soap, producing "delightfully sensuous cramps." As a university student, he discovered the colonic tube that could "slither round the bend"' and learned the exquisite torture of two quarts to be held tightly while masturbating to orgasm." At that time he also made contact with a woman who would accept him in his female garb and who also enjoyed enemas. A B&D relationship ensued, and she would tie him up before his "douche" with forced retention until she decided he could be relieved. This pattern has persisted, more or less, in subsequent relationships. The subject spends much time perfecting his appearance as a female. He suspects that klismaphiliacs are characterized by high intelligence, as, indeed, his contacts are. DISCUSSION During the course of this study, I learned that klismaphilia, though not common, falls somewhere between rare and unusual. As my correspondents informed me, klismaphilia is catered to in "specialty brothels," in "enema spas," and under the rubric of "colonic irrigations." Also the ruse of inveigling a physician into having a public health nurse dispatched to administer an enema was admitted by several subjects, and, from the opposite standpoint, a public health nurse of my acquaintance told of a similar instance in her work. Articles and letters in popular publications devoted to the various aspects of sexuality deal with klismaphilia. Underground sex publications contain advertisements for others with whom to engage in this practice, and pictures and handbooks on the erotic enema are offered for sale. A variety of liquids is recommended, ranging from soapsuds to ice water to alcoholic beverages to urine (called the "golden enema" to parallel the "golden shower"). Techniques combining this practice with sadistic and masochistic practices, digito-manual-rectal stimulation, and so on occur in profusion. Others combine it with a variety of paraphilias, such as urolagnia, coprophilia, and so forth. Really far-out practices include wearing an enema apparatus dangling like a tail until enema-taking is convenient, combining enema taking and vaginal douching, and taking enemas in tandem, from one klismaphiliac to another, as described in Case 15. One couple devised an electrical hookup that added mild tingling to the enema. In some persons, on the other hand, klismaphilia coexists with ordinary, everyday, mundane marital se:;. The persons in this study are all of superior intelligence, as Case 15 suspected, but this is to be expected when persons volunteer for research. In spite of this diversity, however, the subjects for whom I have data fall into three broad types, depending on their reaction to their klismaphilia (rejecting or accepting) and on the presence or absence of other sexual deviance. Group A (Table I) : consists of those who experience their klismaphilia as ego-alien, shameful, and abnormal, and who would, if it were not so pleasurable, like to be rid of the habit or at least more accepting of it in themselves. Some have achieved the latter goal, at least partly, such as the army officer (Case 4) whom I treated. Most of the members of Group A, however, take enemas alone in shame and secrecy, and some are unaware of the existence of the condition in others. Most of them date their habit to childhood. In most cases, their early enemas were administered with medical intent by the mother or female relative, rarely self-administered without previous enema experience, as in Case 2. These klismaphiliacs, when men, characteristically imagine themselves as women when taking their enemas, or at least ask thinly veiled questions about how it would feel to be a woman. Several have either "wondered" whether their habit meant they were homosexual or frankly struggled with fears to this effect. In three cases, there is co-existent, but relatively mild, sexual psychopathology: mild masochism (hairbrush slapping of the buttocks) in Case 4, coprophilia (fecal smearing) in Case 5, and fetishism (women's underwear) in Case 6, a man who also toys with the idea of bondage. These klismaphiliacs keep their condition compartmentalized, and it has little effect on the rest of their work or social lives (including marriage). Group B : consists of klismaphiliacs like those in Group A except that they have accepted their klismaphilia. After therapy the officer in Case 4 came close to this but at that time did not show the same level of acceptance that Case 8 demonstrated following his own working through. With him perhaps, the pendulum had swung too far, with overemphasis on klismaphilia as a hobby and his recipe collection and excessive time investment. Masochism figures in the hospital worker's (Case 8) pleasure. Like Group C members, he flaunts the deviance, but only in the underground press, not socially. His wife (Case 9) sounds like a lukewarm fellow traveler, similar, perhaps, to the wife in Case 7. Like patient 8, patient 7 has worked through his feelings on his own, enjoys his klismaphilia with his wife, and would not regret it if his children adopt the pattern. Group C (Table I) is quite different. Their klismaphilia is ego-syntonic and pervades their life and relationships. They know others with the same tastes and usually take enemas with them. Most also date their klismaphilia to childhood, but the hospital worker (Case 8) discovered it in later life. Their sex life is replete with a variety of paraphilias, including homosexuality and transvestism. Masochism is prominent in two ways in Group C. Patient 15 enjoys the painful cramps of the enema itself, while others describe the enema itself only in pleasurable terms. Still others combine other masochistic devices with the enema, as in the menage a quatre in which patient 13 is the slave. According to patient 8, 50% of his 100 klismaphiliac correspondents relate a masochistic component to their enema taking, but he did not differentiate the masochism inherent in the enema from that of accompanying activities. Urolagnia ("water games" in the underground press) coexists in Case 14, and according to patient 8, these complications are found in 20% Fetishism regarding enema equipment is a major component in Case 10. What can be said about the cause of klismaphilia? Several explanations (such as childhood conditioning to enemas, passivity, masochism) could account for the majority of cases, and the exceptions explained away, if dealt with one by one. This device characterizes the explanatory methods of both scientists and witch doctors and permits the proponent to retain the hypothesis that best fits his personal orientation (15). I believe, however, that different explanations make sense in combinations in different cases, but still the whole answer escapes me. First, since klismaphilia is not unique to either sex, it cannot be attributed to anything anatomically, physiologically, or psychologically, unique to either sex. Two disparate observations in klismaphiliacs serve as a starting point. Some subjects (Case 2) come to enemas voluntarily and without prior conscious knowledge as if satisfying an innate anal craving. Others were given enemas, which frightened them originally and perhaps caused pain, but either on the first occasion (Case 11) or years later (Case 6) they were astonished to observe that they reacted with pleasure. Still others, having experienced a variety of genital and extragenital forms of sexual stimulation, were given enemas with expectation of an erotic response (Cases 7 and 13), and the prophecy was self-fulfilling. The sadomasochistic editor found that he could induce a klismaphiliac response experimentally. These varying routes to klismaphilia suggest that in some persons, nerve endings in the rectum are capable of producing reactions pleasurable and similar to those produced by nerve endings in and around the genitalia, that is, they make cerebral connections in cortical centers where orgasm is experienced. One of my well-informed correspondents (Case 7) had read one "researcher's" estimate that 50% of us are "anal erotic" in this way, but he could not quote his source. These nerve endings may never in a lifetime be put to an enema test, but if they are, klismaphiliac response may or may not be learned. In this way, some persons who have had one or a number of enema experiences may find, without consciously searching, a new and different dimension of sexuality, as some of these cases attest. This new dimension may develop in a masturbatory setting, in a fairly ordinary sexual setting, or in a setting of deviant sexuality. In addition, however, there are others who have learned this rectal reaction as a result of early conditioning (when they were more educable) at the hand of a loving mother or substitute attending to the needs of her child as she perceived them (Case 11). Experience with enemas may set a pattern for a mode of passive sexual gratification not ordinarily available to men. Maxine Fabe, a science writer in one of the underground papers, quoting Otto Fenichel and Felix Boehm, gave the following explanation for men with klismaphilia: located somewhere between the perineum, the rectum, and the root of the penis is an area where men experience passive sexual needs, which can be satisfied by an enema. This does not account for the 20% of klismaphiliacs who, according to patient 8, are women, with an ideal passive sexual anatomic arrangement. Hemmat, a psychiatrist who wrote to one of the underground papers and later to me, believes that, as is generally accepted, women are basically either vaginal or clitoral types, and that men, as is not generally recognized, may be basically seminal rather than penile. Vaginal women and seminal men, according to Hemmat, are candidates for rectal erotogenic stimulation of the type to produce klismaphilia But if this is true, then more women are potential klismaphiliacs because so many are vaginal types. Is patient 12 correct when she predicts more female klismaphiliacs? What other necessary causes must be met? Surely a casual enema experience is not sufficient because most women have babies and few babies are delivered without a preparatory enema, but the incidence of klismaphilia is small. In contrast to this explanation, which considers the erotic enema essentially normal, is the belief of my correspondent from the consciousness-raising group that klismaphilia invariably represents a form of masochism. Several of these subjects refer to painful pleasure, but most experience their enemas as wholly pleasurable. Early enema conditioning seems important in patient 4, but he was the only one whose family made the enema such a way of life. Even those who received a daily enema for a time were not, apparently, put to sleep with chicken enema stories Preoccupation with fantasies about being women by several men of Group A raises the question of gender definition, but in everyday life these men function normally, in contrast to men (and women) in Group C whose general sexual orientation is grossly abnormal. We must conclude that colonic nerve endings occur in at least some of the population capable of producing sexual sensations, when the balance of intrapsychic, social, and exploratory or experimental factors leads to search for this kind of satisfaction. This is identical to the causation of all other kinds of behavior, and it says only what we knew beforeÜthat some people experience sexual gratification from enemas. What is remarkable is that this reaction is possible, since there is no phylogenetic reason for it: that is, it never served the human or other species. Unlike homosexual or masturbatory behavior, klismaphilia would be impossible for a species without hands and technology. The only analogous situation I can think of is the implantation of "pleasure electrodes" in brains of experimental animals. What should be done about klismaphiliacs? An academic question because there is usually no question of "treatment" or "cure" since they do not wish it. Several of my correspondents (those who wrote because they had seen my original article) v voiced approval that I had supported the army officer and had not tried to "change" him. Robertiello (16) believes that sometimes "perversions" represent the best compromise to intrapsychic conflicts, and. in light of our changing social mores with diminished shame or guilt and little or no legal coercion regarding paraphilia, attempts to eradicate them are ill advised. In any case, it would seem to me imperative that desire on the part of the subject to change should be very strong before such attempts be made, and, therefore, careful evaluation of anyone who might present himself for treatment should precede any therapeutic rushing-in. A sensible compromise might be to evaluate with the patient his enema techniques to consider potential harm from either the technique or the chemicals used. Patient 3 had produced severe abdominal cramps requiring hospitalization. Women therapists may be more likely to be presented with this problem Patient 4 selected me on this sole criterion and patient 1 indicated that he would not have written if I had been a man. Even more, women in the role of nurses to say nothing of wives and paramours, may be asked not to treat but to gratify klismaphilia. [Image] SUMMARY Certain persons take enemas as a substitute for, or an auxiliary to. se'; Some persons find their condition (klismaphilia) ego-alien and treat it with secrecy and ambivalence, if not shame. They indulge their taste privately or, at most, try to get others to administer an occasional enema under guise of constipation and attempt to conceal their pleasure from the administrator . A few of these eventually grow accepting of their habit without burdens dens of ambivalence and loss of self-esteem. Another group of klismaphiliacs, with grossly atypical sex patterns generally, indulge in enemas in a variety of homosexual, transvestite, sadomasochistic, and other settings. This group does not want treatment or change With today's great focus on sexual issues generally, klismaphilia Will probably become more widely dis- cussed. REFERENCES 1. Denko, J. Klismaphilia: Enema as a Sexual Preference. Am. J. Psychther., 27: 232, 1973. 2. Lieberman, W. The Enema: Some Historical Notes. Rev. Gastroenterol., 13: 215, 1946. 3. The Clyster Craze. Time, July 1, 1946, p. 48. 4. Siegel, B. L. The Role of the Mouth in the Search for the Female Phallus. J Am. Psychoanal. Ass., 19:310, 1971. 5. Spiegel, N. T. An Infantile Fetish and Its Persistence into Young Womanhood: Maturational Stages of a Fetish. Psychoanal. Study Child, 22:402, 1967. 6. Freytag F. F. Hypnotherapeutic Exploration of Early Enema Experience. J. Ciin. Hypn., 14:24, 1971. 7. Bettelheim, B. The Empty Fortress: Infantile Autism and the Birth of the Self. Free Press, New York;, 1967, pp. 160-161, 205, 221-224. 8. Freud, S. From the History of an Infantile Neurosis (1918). In Collected Papers of Sigmund Freud, Vol. 3. Basic Books, New York, 1959, pp. 471-605 (55; and 581). 9. Kinsey, A. C. et al. Sexual Behavior in the Human Female. W. B. Saunders, Philadelphia, Pa., 1953, p. 163. 10. Bieber, I. Answers to Questions: Enemas and Sex. Med. Aspects Human Sexual, 4:89, 1970. 11. Feigen, G. M. Answers to Questions: Erotic Potential of Enemas. Med. Aspects Human Sexual., 6: 199, 1972. 12. Shapiro, H. A. Answers to Questions: Enemas as Sexual Stimulants. Med. Aspects Human Sexual., 8: 159, 1974. 13. Metalious, G. Peyton Place, Dell, New York, 1957. 14. Dietz, P. E. Letter to the Editor. 28:322, 1974 15. Marwick, M. Is Science a Form of Witchcraft? New Scientist, 63:578, Sep 5, 1974. 16. Robertiello, R C. A More Positive View of Perversions. Psychoanal. Rev., 58:467, 1971. w